The therapeutic alliance

Essential to the therapeutic alliance is the client's sense that the therapist is caring, collaborative, reliable, knowledgeable and appreciates their feelings. The alliance has been established when the client realises that the therapist is there to help no matter how hard the going gets; that the relationship will survive any difficult feelings that may arise in the course of therapy. The client's sense of being held by the therapist and trust in her is the key to its achievement.

"Ellie"

It was easy for the therapist to ally himself with the healthy part of Ellie who had suffered emotional abuse in childhood. She was seeking a male therapist to enable her to begin to develop the trust in men that her father had denied her. Her eagerness for therapy was such that the alliance was not in question. It was not necessary to focus upon it even during the most difficult phase of her therapy when the therapist was most challenging. Her sense of trust was damaged but not so damaged as to undermine her ability to form an alliance with the therapist.

"David" 

David was unsure why he had come to see the therapist. He said he had "a general feeling of unease".
He lacked trust in others, including the therapist of course at the beginning, but was not aware of it. It showed in the wariness in his eyes and slight movement backwards when the therapist spoke to him. Whenever he did this or showed other signs of wariness the therapist would comment upon them. He did not respond to these comments in the early sessions but very gradually, with growing acceptance that the therapist was relating to him with care, he was able to reveal more about himself. He realised with the passage of time that the therapist would not judge him whatever he said about himself. He accepted that he and the therapist could work together: the therapeutic alliance had been established. Eventually, his sense of trust and safety enabled him to work through some of his painful issues.

"Wendy"

Wendy sought therapy because she was suffering depression and anxiety. She was largely silent during the early sessions. Her voice was low-pitched and she was listless. It was crucial that the therapist established a holding environment. Feeling held was vital to her gaining a sense of connection to the therapist. This sense of connection grew as she felt less threatened by her. Gradually she felt able to reveal more and more about herself and gained a sense that the therapist would contain her however much pain she experienced. Tentatively, she emerged out of her cocoon and began to reflect on the therapist's comments. She became more receptive to her challenging comments and the therapist knew that the therapeutic alliance had been established.

To foster the therapeutic alliance the therapist must focus on:

• Containing the client to enable them to feel safe.
• Being aware of the client's experience in the here and now.
• Exploring the therapy relationship which both strengthens the alliance and the therapeutic process.

For some clients like Ellie, the therapeutic alliance is present from the beginning; a sense of reliable connection to the therapist is there and does not need to be made explicit. The vital factor for the establishment of alliance is the client's sense of being held from which a sense of trust in the therapist arises.

With David, the therapeutic alliance strengthened as the therapist focused more on the therapy relationship. And for Wendy, once she felt held and contained, her sense of connection to the therapist enabled her to gain confidence in the therapeutic process.