September 17, 2018 11:00 AM
Listening creates a holy silence. When you listen generously to people, they can hear the truth in themselves, often for the first time. And when you listen deeply, you can know yourself in everyone.
-- Rachel Remen
The fact of the matter is that the alliance is our most powerful ally and represents the most influence that we can have over outcome. The alliance is an all-encompassing framework for psychotherapy—it transcends any specific therapist behavior and is a property of all aspects of providing services It calls for your utmost attention and best clinical skills in each and every client encounter—your conscious, proactive efforts to make it happen. Of course, that is what the Session Rating Scale (SRS) is all about.
The alliance is the central filter of all your words and actions: Is what I am saying and doing now building or risking the alliance? Few things are worth risking the alliance. This doesn’t mean that you can never challenge clients; it just means that you must earn the right to do so and must always consider the alliance consequences. At the very least, a discussion with the client about the value of challenge and securing permission is advisable. Our behavior should be designed to engage the client in purposeful work. That is what the alliance is supposed to do.
Bordin (1979) classically defined the alliance with three interacting elements: (a) the relational bond between you and the client—the client’s perception of your empathy, positive regard, and genuineness (thanks to Carl Rogers); (b) agreement on the goals of therapy; and (c) agreement on the tasks of therapy or how the goals will be accomplished, which includes all the accompanying details—topics of conversation, frequency of meetings, handling cancellations, payment, etc.
The Relational Bond
It is helpful to think of each meeting with a client as a first date (without the romantic overtones, unless you want a very short career trajectory), in which you make a conscious effort to put your best foot forward, actively woo the client’s favor, and entice his or her participation. This requires listening intently, staying close to the client’s experience, not steering the conversation elsewhere unless invited, and just plain being likable, friendly, and accommodating. Because clients vary widely in their experience of what constitutes a good relationship, your flexibility is important. Pay attention to what excites clients: When do they lean forward, raise their voice, sparkle their eyes, talk more? What topics and ways of relating raise their activity and engagement?
A useful way to think of your relational responses, as an overall backdrop for your comments, is the concept of validation. Validation reflects a genuine acceptance of the client at face value and includes an empathic search for justification of the client’s experience in the context of trying circumstances—that they have good reason to feel, think, and behave the way they do. Clients are often wary about our judgments. Validation helps them breathe a sigh of relief and know that blame is not a part of our game—we are on their team.
To enhance the relational bond:
- Listen, listen, listen—stay close to the client’s experience.
- Be likable, friendly, and responsive (like on a first date).
- Carefully monitor the client’s reaction to comments, explanations, interpretations, questions, and suggestions; use your alliance filter and the SRS to keep you on track.
- Be flexible: Do whatever it takes to engage the client and ensure his or her experience of empathy, positive regard, and congruence. Use your complexity to fit clients.
- Validate the client. Legitimize the client’s concerns and highlight the importance of the client’s struggle. Appreciate your clients. Let them know that you do.
Bottom Line: There are a lot of ways of understanding and applying relationship skills, and research offers key guidelines regarding what is important to outcome from the client’s point of view. Take on your relational skills as a project and as perhaps the central symbol of your development as a therapist. Watch your outcomes improve as you refine ways to purposefully involve your clients in the work. Keep in mind that the Session Rating Scale is the only way to know for sure whether you are accomplishing your relational efforts.
Watch brief videos about the alliance and the common factors.
Read tips for engaging clients and forming strong alliances in the new PCOMS Manual.
Reliance on the Alliance, Part 2 discusses agreement with the client about the goals and tasks of therapy.