Admittedly, this column tends to focus on the abundant research pointing to the importance of a professional relationship between you and your client.

In the review of literature for this article, I encountered even more data to support this critical counseling element — specifically, what constitutes a relationship; the need to teach relationship basics; and the relation to motivation, particularly low motivation.

The therapeutic alliance does it again

In a National Institute on Alcohol Abuse and Alcoholism (NIAAA) paper (Finney, 2004) written for treatment assessment and process, a small, but significant paragraph was devoted to the therapeutic alliance. In the paragraph, Finney cited reputable research that indicated an alliance between you and a client is a necessary, yet insufficient task (meaning you should have it, but there are other important elements to counseling). If the relationship is well crafted, you will note changes in client proximate outcomes — cognitions, emotions, attitudes and behaviors that should be affected by the treatment strategies you use, shortly after you use them. Those outcomes should, in turn, affect ultimate outcomes, which are the endpoints of treatment.

In addition, Finney noted that when both client and therapist agree the relationship is going well, clients have a better session attendance record, as well as more days of abstinence.
Specifics of the therapeutic alliance

In another paper (Summers & Barber, 2003), authors referred to the development of the alliance as a “technical activity,” and outlined parameters (from other research) to improve the alliance. Some of those parameters included certain therapist qualities, such as: little if any therapist self-hostility (makes sense); more comfort with closeness; and having a social support system.

These authors cited evidence that therapists who were taught to discuss a client’s non-verbal communication and could accurately report a client’s core issues, had better alliance-building scores on appropriate questionnaires. Additional data indicated that the therapist’s ability to repair ruptures in the therapeutic relationship was an essential ingredient for strengthening it.

Lastly, when trained in relationship-building, counselors who demonstrated a greater level of sophistication and complexity of the client and the relationship, had greater comfort discussing a client-therapist relationship, and tended to be able to create better therapeutic relationships. Yet, despite this data, little research has been done on alliance-building pedagogy, which means the teaching and instruction of how to teach relationship-building skills and noting effects is thin (Grist for another column).

Alliance and motivation

It is pretty clear that if a client is motivated to change, the chance for a positive treatment outcome is good; and, it’s pretty clear that clients who have low motivation are strongly related to poor outcomes. In our field, it is no secret that a lot of clients have low motivation. Under these circumstances, what does the counselor do? Some researchers (Ilgen, McKellar, Moos & Finney, 2006) looked at that contingency, noting that motivation plays an important element in the overall recovery process. They further noted that the literature indicates that a stronger alliance contributes to better compliance and outcome. (Hate to beat the drums on this, but there it is again.) They hypothesized that a positive alliance can overcome the consequence of low motivation equating to better outcomes.

From their own research, the authors found, as predicted in the literature, that those clients with better motivation drank less at six months and one year following counseling. In addition, those clients who perceived a stronger alliance from their counselors decreased their drinking at six months. One particular finding noted that a therapist’s rating of the alliance (higher motivation, and a positive perception of the alliance) predicted less alcohol use at six months and at one year. There was an important interaction between clients with low motivation and the therapist’s rating of the alliance.

Essentially, the better the alliance, the better the outcome. This was especially true for clients with low motivation. This same finding did not hold for clients with high motivation. Apparently if you are motivated to change, even a solid alliance isn’t going to dramatically improve that motivation.
The speculation for why low motivation was improved by the strong alliance, and is associated with decreased drinking, seems to center on the therapist’s sensitivity to the needs of the client — how the therapist saw the relationship and made adjustments to improve it.

This research suggests that the quality of the relationship between the therapist and client is more important than the treatment or specific techniques used.

Try it: counseling suggestions

In the second article, the authors suggest that counselors do the following:

• Decrease levels of hostility that he or she might bring to the face-to face encounter with clients. Such hostility could originate with the counselor’s dissatisfaction with doing a good job, hostility from the program itself, or from his or her personal life.
• Become more comfortable with closeness to other humans, and not keeping others at arms length.
• Make sure you have a good support system around you.
• Repair damaged clinical relationships as soon as you can. Try to avoid the “blame game,” sometimes leveled at clients when the relationship turns sour (and sometimes it will).
• Try to avoid simple explanations of why things are going badly between you and your client.

Alternative explanations and more thought toward the problem tends to bring better results.
The practical suggestion from the third article is simple. Work on your alliance skills (e.g., engagement, empathy, respect, etc). It bears repeating that one of the discussion points from Ilegen et al (2006) was that working with low motivation clients, you, the therapist, are in a position to observe your own sensitivity as to how the overall relationship is developing. For instance, should the alliance be developing well, you need to keep your “sensitivity antennas” out, to improve the probability that whatever you’re doing is keeping the alliance healthy. Essentially, keep doing what seems to be working. (Yet, it’s important you know what you are doing in order to keep the alliance positive.) However, if the alliance does not seem to be working particularly well, then your sensitivity needs to be called on to evaluate what’s not going well, so you can correct the situation.

Research you can do

This is the section where some of you may wish to put the suggestions listed above to the test. As always, the research here is not meant to be sophisticated. It is simply something that gets clinicians into the groove of doing measures.  

The suggested research is broad-based, and in two broad categories. First, consider creating a short spreadsheet of the core recommendations above. List on a short scale (e.g., 1-7) of how well you think you are doing on each element. For the more adventurous, ask your clients to rate you, as well. Then make it a point to improve your skills on the same list. This can be accomplished through some local workshops, your own readings, and or help from your supervisor. Following that, re-rate yourself and have your clients re-rate you. Then simply note the differences.

The real proof of improvement might be on measuring other variables, such as noting changes in the level of keeping appointments before and after your relationship training. And, (this is important) are there variations in a set of client proximate variables (e.g., feeling better, feeling more confident) and ultimate outcomes (base levels of pathology decrease) before and after your training. If there were, I suggest you consider writing a short article about it.

References

Finney, J.W. (2004). Assessing treatment and treatment processes. http://pubs.niaaa.hih.gov/publiciations/
Assessing%20Alcohol/Assessing.htm
Ilgen, M.A., McKellar, J., Moos, R., & Finney, J.W. (2006). Therapeutic alliance and the relationship between motivation and treatment outcomes in patients with alcohol use disorder. Journal of Substance Abuse Treatment, 31, 2,157-162.
Summers, R.F. & Barber, J.P. (2003). Therapeutic alliance as a measurable psychotherapy skill. Academic Psychiatry, 27, 160-165.

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