The therapeutic alliance (TA) is a term used to describe the collaborative nature of the partnership between client and therapist. The alliance focuses on the preferences and goals of the client and outlines methods to achieve these goals. It is based on listening to the client without judgement and without giving unwarranted advice. A strong alliance between counsellor and client is one of the most important factors when looking towards treatment progress. Research has shown that ‘client ratings of the client-counsellor relationship are the most consistent predictor of client improvement. If the client does not believe that you can help them change their behaviour, they will be unlikely to overcome their resistance to treatment’ – ‘Therapeutic Alliance’ Independent Study.
There exist different theoretical principles on how to best achieve this relationship. The Rogerian approach is one such principle. This was developed by Carl Rogers in the 1940’s and 1950’s and is known as person- centred therapy. The goal of PCT is to provide clients with an opportunity to develop a sense of self and find their true potential. In this technique therapists create a comfortable, non-judgemental environment by demonstrating congruence, empathy and unconditional positive regard towards their clients while using a non-directive approach. Rogers stated that there are six necessary and sufficient conditions required for therapeutic change –
1 Therapist-Client Psychological Contact: a relationship between client and therapist must exist, and it must be a relationship in which each person’s perception of the other is important.
2 Client in-congruence, or Vulnerability: that in-congruence exists between the client’s experience and awareness. Furthermore, the client is vulnerable or anxious which motivates them to stay in the relationship.
3 Therapist Congruence, or Genuineness: the therapist is congruent within the therapeutic relationship. The therapist is deeply involved him or herself- they are not acting- and they can draw on their own experiences to facilitate the relationship.
4 Therapist Unconditional Positive Regard(UPR): the therapist accepts the client unconditionally, without judgement, disapproval or approval. This facilitates increased self-regard in the client, as they begin to become aware of experiences in which their view of self worth was distorted by others.
5 Therapist Empathic understanding: the therapist experiences an empathic understanding of the client’s internal frame of reference. Accurate empathy on the part of the therapist helps the client believe the therapist’s unconditional love for them.
6 Client Perception: that the client perceives, to at least a minimal degree, the therapists unconditional positive regard and empathic understanding. – Rogers, C ‘ A Theory of Therapy, Personality and Interpersonal Relationships as Developed in the Client-centred Framework’.
Rogers believed that the most important factor in successful therapy is the therapist’s attitude. He believed that a therapist who displayed the three attitudes of congruence, unconditional positive regard and empathy would allow the client to express their feeling freely without feeling judged.
The therapeutic alliance is also a key feature of Cognitive Behavioral Therapy. A CBT therapist will bring congruence, empathy, active listening and UPR to the client. The alliance in CBT is further developed through the highly collaborative nature of the relationship. It is as though the client and therapist are working as a team. This is demonstrated even in the position of chairs with the client and therapist sitting at times side by side working with a tool, as opposed to in front of each other. CBT is educative and clients are encouraged to develop skills and tools to manage their issues so they can, in effect, become their own therapist. The collaborative element of the CBT therapeutic alliance is demonstrated throughout each session. The client will be invited to bring issues to the agenda. At the beginning of treatment the client will be invited to express goals for therapy. The process of working on setting goals and how to achieve them has been seen as a significant factor in developing an effective therapeutic alliance. There is a popular definition of this is by ES Bordin, he defined the alliance as consisting of three related components:
1 client and therapist agreement on goals of treatment
2 client and therapist agreement on how to achieve the goals (Task agreement)
3 the development of a personal bond between the therapist and the client – Bordin ES: The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research and Practice 1979.
The TA is maintained and developed using this collaborative way of working throughout treatment. This will be displayed in discussing problems and teaching skills for problem solving, the setting of homework and inviting the client’s feedback t the end of each session.
Some of the principles of Neuro-Linguistic Programmming (NLP) work to enhance the TA. NLP is described as the study of human excellence and demonstrates how to communicate effectively and influence others. It was developed in the 1970’s by a group of psychologists who were studying successful people in order to analyse human behaviour. The group included Richard Bandler (psychologist), John Grindler (linguist) and Gregory Bateson (anthropologist). They were looking at styles of brain patterns and how words and actions are linked together to form certain programmes or sequences of behaviour. NLP is seen a skill which will improve the effectiveness and impact of communication.
At the beginning stages of the TA it is essential that a rapport is established. Rapport is defined as ‘the establishment of trust at the unconscious level’ or, ‘a relationship of harmony and accord’. In NLP it is argued that we can all create rapport by consciously refining the natural rapport skills we use everyday. One way of building rapport is the matching and mirroring technique created by Milton Erickson in the early 1970’s. It is linked to body language, where the therapist would endeavour to match the body language of the client. It is useful to consider at this point the theory that human beings express themselves in many more ways than what we say, ‘communication is so much more than the words we say. These form only a small part of our expressiveness as human beings. Research shows that in a presentation before a group of people, 55% of the impact is determined by your body language – posture, gestures and eye contact – 38% by your tone of voice, and only 7% by the content of your presentation’- Introducing Neuro-Linguistic Programming, O’Connor & Seymour, Thorsons. Using the mirroring and matching technique involves being in a similar body posture to the other person and using similar gestures, styles of behaviour, and tone and speed of voice. This is likened to a dance where partners respond and mirror each others movements with movements of their own with their body language being complementary. The therapist then would match the client’s body language in a sensitive way, using techniques such as matching the client’s whole or half body and/or head and shoulders poses. Gestures and facial expressions can also be matched. The therapist will pay attention to the tone, tempo and volume of the client’s voice, and the rhythm of their speech. I have experienced mirroring and matching when throughout the session I was suddenly aware at several points that the client and I were seated in the same position. I was not consciously trying to make this happen and can see it as an indication of an established rapport. Another way of building rapport is that the therapist will adjust their breathing to be in sync with the client’s. When a rapport is established using mirroring and matching it can be maintained and deepened by the process of pacing and leading. This is a useful way to help the client feel at ease. An example of this is to consider working with a client who is feeling very low. The therapist would match and mirror posture and use a gentle tone to their voice which matches how the client feels. Then the therapist would gradually change their posture so that it is more positive and perhaps slightly quicken the pace of their voice. If a good rapport and TA has been established, the client will unconsciously follow the therapist’s lead and adopt a more positive attitude.
Once a sound TA has been established it can be further enhanced by the therapist and client communicating as effectively as possible. In NLP it said that communication starts with our senses and that we use our eyes, nose, ears, mouth and skin as our contact with the world and how we perceive it. The way we do this to store information in out minds through our senses are known as representational systems. We can develop our senses to have a richer awareness in each of them. This is known as sensory awareness. In NLP the senses are thought of as,
Visual – what you see, pictures, colours, etc, – when we are looking at the outside world and what we see when we are mentally visualising an experience
Auditory – what you hear, sounds, voices – external or internal
Kinaesthetic- the feeling sense, including tactile sensations like touch, temperature and moisture, this also looks at internal kinaesthetic such as remembered sensations and emotions
Olfactory – what you smell
Gustatory – tastes and responses to it
We use all our senses externally all the time, although we will pay more attention to particular sense depending on what we are doing. However, when we think we will favour one or maybe two representational systems regardless of what we are thinking about. Many people can make clear mental images and think mainly in pictures while others will find this difficult. This will then have an impact on how they communicate, what words and images they use to describe thoughts and experiences.
I feel the next important element of NLP which enhances the TA is the Meta Model, or making sense of words and gaining a fuller understanding of what people say. There are two levels of language –
Surface structure – everything we say, either to ourselves or to other people
Deep structure – the underlying meaning of what we say – containing information neither expressed nor consciously known about.
The meta model gives a framework to find out the layers of meaning below the spoken words. The therapist will use the meta model to have a deeper communication and understanding of the client and to clean up any ambiguity. They will use questions that will challenge the deletions, distortions and generalisations of the client’s language. This is done by the therapist paying attention and challenging the following –
Unspecified nouns – e.g. ‘I have been hurt’, would be challenged by, ‘who hurt you?’
Unspecified verbs – e.g. ‘she helped me’, would be challenged by, ‘how did she help you’
Comparisons – these are clarified by asking, ‘compared with what?’
Judgements – e.g. ‘I am stupid’, would be challenged by,’ who told you you are stupid?’
I feel another useful NLP technique which further enhances the TA is the theory around ‘perceptual positions’. This involves an awareness of the different positions from which we look at out experiences. There are three of these perceptual positions. In the 1st position we are looking at a situation from our own point of view. In the 2nd position we step back and look at the situation from someone else’s point of view, this is essentially displaying the skill of empathy. In the 3rd position we can look at the situation from an outside point of view, as an independent observer. Ideally we will able, consciously or unconsciously, to be flexible and move between the three positions. Living your life in one particular position would bring difficulties, ‘someone stuck in the first position will be an egotistical monster, someone habitually in second will be unduly influenced by other people’s views. Someone habitually in third will be a detached observer of life.’ – Introducing Neuro-Linguistic Programming, O’Connor & Seymour, Thorsons
I believe I could draw on many of the NLP skills I have described in order to further my own practice as a therapist. I have been able to establish rapport and a sound TA with many clients. I do this by being aware of my body language and tone of voice, sometimes adapting the kind of words I use. Being aware of the surface and deep levels of client’s communication means that I will look for the deletions and distortions in what they are saying and know how to challenge them. I have experience at this stage of my training with CBT techniques and feel that I could incorporate NLP as a way of both developing a therapeutic alliance and also the tools I would use with clients. I am working with a client currently who experiences high anxiety in social situations. After using thought records and the 5 factor model, it has become apparent that she has difficulty expressing her thoughts and is much more able to describe feelings and sensations. We have worked on mindfulness exercises which she works well with as she is becoming more in tune to what she is experiencing through her senses. I feel the technique of anchoring would be beneficial to this client. This would involve inviting her to think of something which brings positive state of mind for, be it a visual image, a memory or perhaps a piece of music. I would then invite her to close her eyes and use visualisation to be back in this memory. She would then access an ‘anchor’ which could be touching her thumb and little finger together one hand. When she then thinks of a forthcoming situation which will bring anxiety she would then ‘touch’ the anchor and experience it with the positive ‘imagined’ experience. I have some experience of trying this technique and can see that with a lot of practice it could be very powerful.
I feel that another way for the TA to be enhanced is for the client and therapist to work together to achieve progress for the client. By feeling this growth I feel it would deepen trust from the client. This is where CBT and NLP would work well together. In NLP we would be looking at outcomes which would involve my asking the client to express exactly what she wants, what that will feel and look like and what resources she has to achieve this. In NLP this is framed as precise and positive, ‘think of what you want rather than what you do not want’, also specific, ‘who, where, when, what and how? I would draw on the CBT goal setting tools alongside this concept of outcomes. This would be done in the initial assessment when exploring the client’s goals for therapy. Both NLP and CBT see the importance of specific, achievable and realistic goals with a time frame in mind. The client will be invited to have an awareness of what is changing in their lives and what is not, and then to ‘ have the flexibility to keep changing what you do until you get what you want’. This would work alongside problem solving techniques in CBT. I feel the NLP techniques would be beneficial when approaching psycho education. Helping a client explore the concept of perceptual positions, perhaps the 3rd position in particular would help them to look objectively at their behaviour and begin to evaluate it.
I can see a place for NLP techniques in developing a sound therapeutic alliance. I feel that anything I can use to more fully understand what a client is trying to communicate is very beneficial. A lot of the NLP literature appears to be written with the business industry in mind and therefore how to use the techniques as a way to influence others to further your own interests. When a therapist is using the techniques I believe it is their responsibility to use them to help build a rapport and TA with the client, to enhance communication and as psycho education so the client can develop new ways of looking at their world and their place in it.
I believe a sound therapeutic alliance will enable any boundary issues or ethical difficulties to be addressed easier. I had been working with a client when during a session she disclosed that she had concerns over the welfare of her daughter who was living in another city with her ex-partner. She had been making visits to her ex-partners home to see him and her child. During one of the sessions she explained that at her last visit she had noticed her child looking unkempt and other signs of potential neglect. I was aware at this point that under the Child Protection Act I am duty bound to report any instances of neglect or abuse of a child. Although I strive to be transparent with clients, I made the decision not to highlight specific legislation during the session, but to gently say that I would need to seek advice from my supervisor on the situation. My client became emotional and asked me not to do this. I had to then remind her of the limits to confidentiality that we discussed in our first session. She said she understood this, although was still emotional and anxious. I invited her talk about her fears and anxieties which were about her ex-partner’s reaction to any investigation. At the end of the session the client was no longer emotional, but was still unhappy about the situation. I explored what support she would have until the next session and she assured me she had the support of friends. I really struggled with this issue. Afterwards I looked into the child protection ACT and also codes of practice and although I knew I was right to raise the issue, I struggled with the feeling that I had indirectly caused distress in a client. The client was a referral through my placement which is were I work as a social care worker, this meant that I was able to have supervision the day after the session. I talked through the issues with my supervisor who confirmed I had made the right decision to bring this to her. We also discussed the feelings which had risen in me in terms of responsibility for the client’s anxiety. During this I was able to reflect and see that although I had acted professionally it is always difficult to see a client emotional as a result of these ethical issues. My supervisor informed me that she would look into the situation and speak to social services. The result was that social services decided to investigate but would be able to secure the anonymity of my client. At the next session I made my client fully aware of the situation. She was happy about the anonymity and also said that she had reflected on the previous session and fully understood that I had to act on what she had disclosed. She was also able to see that my concerns were about the welfare of her child. We were able to move on from this issue and have further productive sessions. I believe it was the sound therapeutic alliance formed in earlier sessions which enabled us to move on and continue working together. I felt confident and trusted myself to be transparent with my client, and my client felt she was able to trust that I was acting in her best interests. This has been a source of deep learning for me and as a result I will always ensure clients fully understand the limits to confidentiality.