One of the most important indicators of positive therapeutic outcome and reduction of symptom severity across different types of therapies and populations is a strong working alliance between therapist and client (Horvath & Symonds, 1991; Raue & Goldfried, 1994). A working alliance, also used interchangeably with the term “therapeutic alliance”, is defined by Norcross (2010) as the “quality and strength of the collaborative relationship between client and therapist,” which can be demonstrated through the emotional bond and mutual agreement on treatment goals and tasks. Bordin coined the term “working alliance”, initially placing the importance of the ‘work’ on the therapist (1979) but later authors refined this definition to put responsibility on both the therapist and client working together as a team (Muran & Barber, 2010). The working alliance cultivates a safe environment for a client to engage in self-discovery and builds the therapeutic pathway needed for adaptive client change and growth (Horvath & Greenberg, 1994).
The development of the working alliance at the beginning of treatment is a robust predictor for treatment outcome (Horvath & Greenberg, 1994). Some factors that can suggest favourable treatment outcome in early therapy sessions include client engagement with their therapist; ability for client to develop trust with the therapist; and shared agreement on treatment goals. Although the working alliance does not need to be immediately established, it is expected that this therapeutic relationship begins as ‘good enough’ in order for it to progressively grow into a strong therapeutic alliance over the course of treatment sessions (Horvath & Greenberg, 1994).
A strong working alliance is key in any treatment modality, including Cognitive-Behavioural Therapy (CBT). CBT is a highly effective, evidence-based treatment modality that helps individuals identify and change unhelpful thinking, adverse emotions, and maladaptive behaviours. One common myth is that CBT is rather cold and manual-based in its approach to addressing client concerns that is void of emotional bond. In contrast, a core principle in CBT is the requirement of a good therapeutic alliance between therapist and client that is achieved through rapport, empathy, non-judgment, and genuine positive regard (Beck, 2011). CBT focuses on collaborative empiricism and Socratic questioning, wherein both therapist and client work as scientists to challenge, test, and promote more helpful thought patterns and behaviours, making it a very collaborative dynamic (Beck, 2011). Research has shown that higher ratings of working alliance was associated with reduced anxiety (Rubel et al., 2019), depression (Cameron, Rodgers, & Dagnan, 2018), and posttraumatic stress disorder symptoms (Beierl et al., 2021).
To summarize, if you are beginning CBT with a new therapist, your appraisal and reaction to your clinician’s sense of concern, commitment, collaboration, and overall emotional bond is imperative to ensuring treatment success and sustainability of treatment gains (Muran & Barber, 2010). It is important to remember that this working alliance may not be established instantaneously, but a reasonable degree of foundational rapport should be developed in the initial therapy sessions. It is possible that your expectations about the therapeutic process may differ from your therapists, thus it is helpful to create a dialogue with your clinician to collaborate in the decision-making process about treatment goals and tasks to increase your overall satisfaction of the therapy experience.
How can the Team at Oakville Centre for Cognitive Therapy help?
At the Oakville Centre for Cognitive Therapy, we have trained psychologists who utilize evidence-based treatment of Cognitive-Behavioural Therapy to address a variety of psychological concerns and are dedicated to developing strong working alliances with their clients. If you are interested in receiving evidence-based treatment, please contact us at: 905-338-1397 or admin@oakvillecbt.ca or via our Contact Us page.
References
Beck, J. S. (2011). Cognitive Behavior Therapy: Basics and beyond. The Guilford Press.
Beierl, E. T., Wiedemann, M., Wild, J., Grey, N., Ehlers, A., Murray, H., Warnock-Parkes, E., Stott, R., & Clark, D. M. (2021). The relationship between working alliance and symptom improvement in cognitive therapy for posttraumatic stress disorder. Frontiers in Psychiatry, 12, Article 602648. https://doi.org/10.3389/fpsyt.2021.602648
Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice, 16(3), 252-260. https://doi.org/10.1037/h0085885
Cameron, S. K., Rodgers, J., & Dagnan, D. (2018). The relationship between the therapeutic alliance and clinical outcomes in cognitive behaviour therapy for adults with depression: A meta-analytic review. Clinical Psychology & Psychotherapy, 25(3), 446-456. https://doi.org/10.1002/cpp.2180
Horvath, A. O. & Greenberg, L. S. (1994). The working alliance: Theory, research, and practice. John Wiley & Sons.
Horvath, A. O., & Symonds, B. D. (1991). Relation between working alliance and outcome in psychotherapy: A meta-analysis. Journal of Counselling Psychology, 38(2), 139-149. https://doi.org/10.1037/0022-0167.38.2.139
Muran, J. C., & Barber, J. P. (2010). The therapeutic alliance: An evidence-based guide to practice. The Guilford Press.
Norcross, J. C. (2010). The therapeutic relationship. In B. L. Duncan, S. D. Miller, B. E. Wampold, & M. A. Hubble (Eds.), The heart and soul of change: Delivering what works in therapy (2nd ed., pp. 113-141). American Psychological Association.
Raue, P. J., & Goldfried, M. R. (1994). The therapeutic alliance in cognitive-behavior therapy. In A. O. Horvath & L. S. Greenberg (Eds.), The working alliance: Theory, research, and practice (pp. 131-152). John Wiley & Sons.
Rubel, J. A., Hilpert, P., Wolfer, C., Held, J., Vîslă, A., & Flückiger, C. (2019). The working alliance in manualized CBT for generalized anxiety disorder: Does it lead to change and does the effect vary depending on manual implementation flexibility? Journal of Consulting and Clinical Psychology, 87(11), 989-1002. https://doi.org/10.1037/ccp0000433