Therapeutic Alliance

The therapeutic alliance is something that we need to pay more attention to. In my mind, it’s the foundation of any successful psychotherapy. When a client and a therapist have a good alliance, it can facilitate a lot of positive growth and change. When the alliance is weak or not present, it can explain why the therapy isn’t progressing.

So what is a good therapeutic alliance? I believe that it consists of two main elements: respect and trust, and these must be mutual. The client must respect the therapist and trust them, more than even liking them, in order for the therapy to move forward in a positive direction. They must also feel that the therapist respects them and trusts them, in order for them to feel safe in the therapy.

I’ve heard of a few situations in which the client liked their therapist but didn’t fully trust them or respect them. I’ve heard of some situations in which the therapist didn’t fully trust or respect the client. Needless to say, these weren’t successful therapies. As therapists, we need not concern ourselves as much with being liked as with instilling that sense of trust in our clients and making sure that there’s mutual respect.

Sometimes, a client really struggles with the therapeutic alliance. Traumatic events from their past can make it difficult for them to trust a person in a position of authority. Their past experiences of disappointment or betrayal can make it challenging for them to respect someone in a caring role.

As a therapist, I’m always watching for signs of a good or not-so-good therapeutic alliance. I look for it in how my patient is responding to me, and also in how I’m responding to them. My reaction to the patient often tells me what they’re unconsciously evoking in me – my counter-transference.

Some therapy clients are ambivalent about treatment. They inadvertently behave in ways that are destructive to the therapeutic alliance. In my many years as a therapist, I’ve seen some of the ways that people unconsciously undermine the therapeutic alliance.

One way is to disrespect the therapeutic “container.” The container is the time and place of the therapy sessions and it’s so important in building respect as well as therapeutic continuity. If the client cancels too many sessions; if they cancel at the last minute one too many times, or if they continually arrive late for their sessions, these are ways that they disrespect the container.

Other ways of disrespecting the therapeutic container is to leave a mess in the office. If they flood the toilet “accidentally-on-purpose,” or leave rotting garbage (or, as I’ve experienced, dirty diapers) in the waste basket, literally stinking up the joint, the therapist has to ask him or herself, “Is this person sending me a message?”

Some clients have other ways that they resist the therapeutic alliance. They maintain a negative transference on the therapist, long after the therapist has demonstrated to them that they’re not the “bad parent” or “bad object” the client fears that they are.

The client can behave toward the therapist as though the therapist was this hurtful person, even when the therapist has been consistent, caring, respectful of their boundaries, and fully present in the sessions. Sometimes, no matter what the therapist does, it’s tremendously difficult for an individual to let go of this negative transference. They’re being driven by powerful inner messages, as opposed to observable outer reality.

Some clients are so afraid that the therapist will hurt, betray or exploit them (in the same way as their parents or parent-figures once did) that they behave in ways that would alienate the therapist. They sabotage the therapeutic alliance by being dishonest with the therapist, by showing up to sessions drunk or high, or by behaving aggressively or threateningly toward the therapist.

I see my job as helping people learn, grow and change, but I don’t believe that as a therapist, I’m required to tolerate abuse. I will address unacceptable behaviors in a therapeutic context, but I’ll make it clear to the patient that no matter how wounded they are, I won’t accept their disrespect or abuse. If they can’t behave appropriately, I make it clear that we won’t be able to proceed with the therapy.

I understand why some people behave in these ways; I simply draw the line on certain types of behaviors. I do this for a number of reasons. One is because if I continue to tolerate mistreatment, I’m likely to become burnt out and perhaps even resentful, and then I won’t be of use to anyone.

Another reason is that I see myself as a role-model for my patients. I’m trying to teach them not to tolerate disrespect or mistreatment from others, for any reason. If I tolerate my patients’ bad behavior I’m being hypocritical, telling them to do as I say, not as I do.

Another reason I won’t accept mistreatment is that I’m teaching my patients accountability. My patients need to learn that no matter how hurt or traumatized they are, they’re responsible for their choices and for the consequences of these choices. If their trauma causes them to break the law, my patients need to know that the police won’t give them special dispensation for their childhood hurts, either.

Often, I can tell that there will be a problem with the therapeutic alliance in my initial intake session with a prospective patient. Rather than demonstrating interest in my background, the person interrogates me about my training or approach to therapy. They behave suspiciously, passively, aggressively or seductively. They make me uncomfortable – a reflection of the discomfort they most likely feel within themselves.

Most often, I choose not to work with such individuals. I see them as not ready to embark upon the difficult journey of psychotherapy. Or perhaps, this individual and I are simply not a good fit.

On many occasions, however, building a better therapeutic alliance is simply a matter of attending to it. Often, I find myself gently inquiring as to whom my patient believes they’re speaking to, when they make an accusatory or hostile remark toward me. I work with my patients to help them see, through my words and my behavior, that I’m not the one who hurt them back when.

Like any relationship, either personal or professional, the therapeutic alliance requires some effort and awareness. And sometimes, through no fault of our own, it’s impossible to establish or maintain. When this happens, we shouldn’t see it as a professional failure. In therapy as in medicine, some people can be helped, some can be helped by a different practitioner and some, unfortunately, are beyond our help.

The views expressed in these blogs are the author’s own and not necessarily reflective of those of Psychotherapy Matters.  Information provided here and anywhere else on is for learning purposes only and should not be used to guide treatment of clients/patients. Copyright © 2018

Marcia Sirota
Marcia Sirota

Dr. Marcia Sirota, MD, FRCPC, is a psychiatrist, coach, author, speaker, and prolific Huffpost contributor. She completed her residency at Maimonides Medical Centre and has over 25 years of experience in health and wellness focusing on long-term results. Dr. Sirota enables people to overcome adversity, obstacles, mental blocks, to improve effectiveness, performance, and leadership. Her achievements include 5 books and hundreds of published articles on personal and organizational development. In 2016, Dr. Sirota was named one of the Top 50 most influential bloggers and communicators in Canada.

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