The Therapeutic Alliance: The Glue That Makes Therapy Work
Therapeutic alliance, irrespective of the field of clinical work, is often referred to as the sine qua non of all successful clinical work. This is true in working with substance abusing adolescents, whether in inpatient, outpatient or residential settings, and regardless of the service delivery mode, whether individual or group counseling. Often counselors and therapists believe that successful engagement with adolescent clients depends upon whether the adolescents desire a relationship with the practitioner; however, success is based more upon the counselor’s or therapist’s approach and his or her desire to develop a therapeutic alliance with the adolescent. In my own work with adolescents and as a consultant traveling through and out of, I utilize the phrase “therapeutic use of self,” meaning using myself as a starting point for engaging and developing the therapeutic alliance. The following are factors that contribute to the therapeutic use of self:
- Understand and like adolescents
- Have clear values about alcohol and drugs
- Remember when you were an adolescent
- Be willing to laugh at yourself
- Remember the power of the peer group
- Be willing to make peace with your parents
- Be sure you have worked through or are working on your own adolescent issues
It is necessary for the counselor to keep in mind that adolescents do not enter treatment on their own and that they will present with other problem behaviors, which interface and interact with their substance use.
An important factor for substance abuse counselors to consider when working with adolescents is that many of their clients cannot recall many positive experiences in their lives and may come from negative circumstances that can ultimately lead to the cognitive schema or belief that adults cannot be trusted and that the world is not a safe place. “I will cope and manage my life on my own terms, because no one cares what I think or feel,” may be their established credo.
The therapeutic alliance is a paradigm that refers to collaboration in the relationship between adolescent therapist and/or substance abuse counselor and client in the context of clinical intake interviewing or inpatient or outpatient substance abuse counselors. Bordin (1979) lists the following components of this collaboration, which are necessary for engagement and work to be accomplished: an agreement about the goals of treatment between the counselor and youth; an agreement about the counseling tasks needed to accomplish those goals; and an emotional bond between the substance abuse counselor and adolescent client, which allows the adolescent to make clinical and therapeutic progress.
Studies and clinical practice have demonstrated that a therapeutic alliance is a powerful tool for engaging adolescents (Brown, 2001), and that even substance abuse counselors with limited experience can—with training, supervision, and a continuing desire to promote positive change in the lives of their adolescent clients—cultivate an alliance that is conducive to that change (Hanna, Hanna, & Keys, 1999).
Strengthening the therapeutic alliance is an important goal to be pursued during therapy. It is important to remember that alliance building is not an event; it is an ongoing process, and little therapeutic benefit will be accomplished in its absence. Myriad studies have provided evidence of the importance of displaying empathy in developing a therapeutic alliance for achieving positive outcomes in general (Sexton & Whiston, 1994).
Wilkes, Belsher, Rush, and Frank (1994) provide ten key principles for doing therapy with adolescents. Each principle provides an opportunity to strengthen the therapeutic alliance. They are:
- Acknowledge the adolescent’s narcissism
- Adopt a mode of collaborative empiricism
- Adopt an objective stance
- Include member of the social system
- Change the affect
- Use Socratic questions
- Challenge the Binary Motif
- Avoid blame
- Operationalize the assistant
- Model for the adolescent
Counselors and therapists are often asked whether there are any specific guidelines for cultivating and developing a therapeutic alliance. The following represent guidelines for counselors to use in cultivating a therapeutic alliance:
- Like adolescents
- Understand adolescent development
- Offer a snack, juice or water
- Allow the youth to occupy his or her hands while talking
- Allow the youth to wear his or her hat (if wearing one)
- Be nonjudgmental
- Don’t be a parent
- Don’t be a peer
- Avoid lecturing
- Don’t trivialize an adolescent’s concerns
- Learn to be quiet and let the adolescent talk
- Be supportive
- Do not tell the adolescent what he or she thinks
- Look for opportunities to affirm prosocial behaviors and/or responses
- Be emotionally and physically present
- Acknowledge the adolescent’s narcissism/strengths
- Chase the affect
- Maintain an objective stance
- Promote self-efficacy
- Offer advice if and when asked
In proposing the aforementioned guidelines for cultivating a therapeutic alliance, below are components which work against the development of the alliance:
- Excessive writing during interview or counseling session
- Not listening
- Lack of warmth
- Lack of empathy for youth’s symptoms or circumstances
- Trivializing the adolescent’s concerns
It is important for counselors to remember that the therapeutic process of change, for the adolescent, begins with four questions in their minds relative to change:
- Why do I need to change?
- Can I change?
- What will change cost me?
- If I change, what will I look like?
Studies have shown that youth and counselor relationships are the most consistent predictor of client improvement. The therapeutic alliance is equally about comfort level and trust. Adolescents want to know that they can trust the counselor to listen and be patient. If adolescents do not believe that their counselors can help them change, they are likely to be resistant to treatment. Adolescent substance abuse counselors should keep in mind that when entering into an interview or counseling session, there is no guarantee that they will see the youth for a second session. Cultivating the alliance must begin during the first session. Studies further show that the therapeutic bond is not highly correlated with the length of services, but rather with a strong adolescent/client-counselor relationship. The importance of a positive therapeutic alliance cannot be underestimated. In my work with substance using adolescents, I observed reductions in substance consumption, increased abstinence rates, better social adjustment, and more successful referrals to treatment—all outcomes that resulted from a positive therapeutic alliance.
The following are strategies substance counselors can use for developing and maintaining a positive therapeutic alliance with substance abusing adolescents:
Support the adolescent’s drive to achieve the goals he or she has set for him- or herself. Review these goals periodically to clarify them and to relate what is being done during the sessions.
Offer understanding and unconditional acceptance of the adolescent client. It is important to develop a genuine liking of the adolescent client in some way. Adolescent clients can sense your dislike of them.
Aid the adolescent in finding and holding on to activities that maintain a positive level of functioning.
Offer a hopeful, but realistic attitude that the counseling goals can be met and that you, as a counselor, are committed to helping the adolescent client attain them.
Recognize and praise the adolescent client who has made progress toward attaining his or her goals.
Find different ways to encourage adolescent clients to express themselves whenever possible. When you as the counselor recognize that there has been a rift in the relationship, acknowledge and directly address it. Not only are you then repairing the alliance, you are also modeling positive, relationship-building behavior.
Carl Rogers, one of the founders of client-centered therapy, once said, “All adolescents need is one person in their lives to be absolutely supportive of them.” Positive change can begin in an adolescent’s life because of the therapeutic alliance with his or her counselor.
Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research, and Practice, 16(3), 252–60.
Brown, S. A. (2001). Facilitating change for adolescent alcohol problems: A multiple options approach. In E. F. Wagner & H. B. Waldron (Eds.), Innovations in adolescent substance abuse interventions (pp. 169–87). Oxford: Pergamon.
Hanna, F. J., Hanna, C. A., & Keys, S. G. (1999). Fifty strategies for counseling defiant, aggressive adolescents; Reaching, accepting, and relating. Journal of Counseling and Development, 77(4), 395–404.
Sexton, T. L., & Whiston, S. C. (1994). The status of the counseling relationship: An empirical review, theoretical implication, and research directions. The Counseling Psychologist, 22(1), 6–78.
Wilkes, T. C. R., Belsher, G., Rush, A. J., & Frank, E. (1994). Cognitive therapy for depressed adolescents. New York, NY: Guilford Press.