https://doi.org/10.56992/a.v1i34.420

ARTÍCULOS

 

The Influence of Therapeutic
Alliance in Psychotherapy

 

Influencia de la alianza terapéutica
en la psicoterapia

 

 

Delly María Loro Ortega^*
* Estudiante Doctoral en Psicología Clínica, The Chicago
School of Professional Psychology.
Correo: delly.loro@gmail.com
Fecha de recepción: 10 de diciembre de 2022     Fecha de aprobación: 24 de mayo de 2023

 

 

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Abstract

Psychotherapy is a treatment for mental illnesses that helps the person to reduce symptoms, improves daily functioning and overall well-being. The therapeutic alliance is an essential com-ponent of psychotherapy, it influences the clients' adherence and treatment efficiency. There are many elements that influence the development of the therapeutic alliance like the therapist characteristics and training. The therapist must establish rapport with the client and set with them realistic goals and recognize their improvement and accomplishments. Therapists with hi-gher social skills are perceived as more efficient, the capacity to empathize, genuineness with the client and understandment of client's concerns helped in the development of the therapeutic alliance and benefitted the therapy outcome. Training is key in the development of these skills, especially for therapists with low social abilities. Therapist should make sure to leave assumptions aside, avoid suppositions about beliefs and customs based on what is "known" about a specific group, consider cultural and religious beliefs, they should also be aware of possible bias they may have towards that specific group. Psychotherapists should try to understand the problem from the client's point of view, given that if they feel misunderstood, this could be a barrier for the therapeutic alliance. Mental health specialists are responsible for creating a safe space and a cooperative relationship, so the client feels comfortable expressing their issues, set goals and for the effectiveness of therapy.

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Resumen

La psicoterapia es un tratamiento para las enfermedades mentales que ayuda a las personas a reducir los síntomas, mejora el funcionamiento diario y la sensación de bienestar general. La alianza terapéutica es un componente esencial de la psicoterapia, influye en la adherencia de los clientes y en la eficiencia del tratamiento. Existen muchos elementos que influyen en el desarrollo de la alianza terapéutica, como las características y la formación del terapeuta. El terapeuta debe establecer una relación con el cliente y elegir con ellos objetivos realistas, reconocer su mejoría y logros. Los terapeutas con habilidades sociales más altas son percibidos como más eficientes, la capacidad de empatizar, la autenticidad con el cliente y la comprensión de los problemas del cliente ayudan en el desarrollo de la alianza terapéutica y benefician el resultado de la terapia. El entrenamiento es clave en el desarrollo de estas habilidades, especialmente para terapeutas con bajas habilidades sociales. El terapeuta debe asegurarse de dejar de lado las suposiciones, evitar asumir sobre creencias y costumbres basadas en lo que se "sabe" de un grupo específico, considerar las creencias culturales y religiosas, también debe ser consciente de los posibles sesgos que ellos mismos puedan tener acerca de ese grupo específico. Los terapeutas deben tratar de entender el problema desde el punto de vista de los clientes, ya que, si ellos se sienten incomprendidos, esto podría ser una barrera para la alianza terapéutica. Los especialistas en salud mental son responsables de crear un espacio seguro y una relación cooperativa, para que el cliente se sienta cómodo expresando sus problemas, establezca metas y para la efectividad de la terapia.

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Introduction

Psychotherapy is a way of treatment that uses diverse techniques which are based on theoretical expertise with the goal of helping the client. This method of treatment has been around for about a hundred years (Adam & Agnieszka, 2020). Overall, Psychotherapy is a way to treat psychologi-cal illnesses and related symptoms or difficulties, the therapist assists users towards reaching or recovering normal functioning (Mahrer, 2009).

Psychology schools train future psychologists in numerous types of therapies whose develop-ment could change over time based on the constant research that is in the field. Research has shown that psychotherapy is successful, and leads to enhanced outcomes, including an increase in daily functioning, a reduction of symptoms, and an improvement in clients' well-being and life quality (Adam & Agnieszka, 2020).

Is possible to select the best way of managing a particular case, by understanding the essential psychotherapeutic fields. However, the key to successful therapy is a correct diagnosis of the issue, which requires time (Pawlak & Kacprzyk-Straszak, 2020). There are several predictors for successful outcomes and effective treatment factors, including strong therapeutic alliance, therapist countertransference, and therapist technique (Smith-Hanses & Probert, 2014). As we can see, many subjects are able to influence the outcome of the therapy, nevertheless, the topic on which this article is going to focus is the therapeutic alliance.

 

Therapeutic Alliance

The therapeutic alliance is a cooperative relationship between the client and the therapist, which is reinforced by consensus on therapeutic objectives and therapeutic assignments, and a positive connection between the client and therapist (Strappini et al., 2022). In order to have treatment efficiency, adherence to the treatment is key. Being the therapeutic alliance essential to this ad-herence in some cases, it was found to explain more of the result than the treatment itself (Van Herwaarden et al., 2022).

There is a debate if whether the client or the therapist are the ones that contribute more to deve-loping a strong therapeutic alliance. Clients with good attachment histories and great advanced social skills could form better alliances leading to a superior prognosis; in this case, the outcome of the therapeutic alliance is the result of the client's characteristics and not something that the therapist dies in treatment. However, others argued that this is due to the therapist, and characteristics offered by him/her during treatment. Numerous recent studies suggested have used mixed effect models and found confirmation that the therapist's contributions are more critical than the clients, therefore it seems that the value of this alliance considers more the therapist's contributions, therefore the therapist's job is essential to achieve favorable results (Del Re, Flückiger, Horvath, Symonds & Wampold, 2012).

Due to COVID-19 therapies were forced to merge into online settings, even though the situa-tion is better, a lot of clients are selecting this modality. The therapeutic alliance in online inter-ventions persist limited since there are not many studies done in this specific setting, however Eichenberg, Aranyi, Rach & Winter (2022), carefully investigated the therapeutic relationship and got to the conclusion that e-therapy appears to be equal to in-person therapy in the develo-pment of therapeutic alliance, nevertheless working alliance was lower, but the reduction of the symptoms was equivalent. Concluding that the modification of the scenery had no consequence on the perceived worth of the therapeutic alliance. There was global progress in the therapeutic alliance over time, meaning that it was not affected by the alteration of settings. Yet, clients and therapists did have different scores of the therapeutic alliance, clients' scores for the quality of the relationship were higher than the therapists.

In order to build the therapeutic relationship, the therapist must support the client's goals of treatment, offering a realistic hopeful attitude toward the achievement of the goal, and recogni-zing improvement in the accomplishment of these goals. Therapists are encouraged to establish rapport with their clients, and show support, by highlighting their capability to find answers, and strengths, but also cooperate as a team towards a mutual goal and tasks of treatment (Or Front, McCarthy, Zilcha-Mano & Hilsenroth, 2020).

A crucial aspect of the therapeutic alliance construct includes the connection that the therapist and the client establish, along with an agreement on therapeutic goals (Del Re et al., 2012). Iden-tifying the client's main concern and understanding it from the client's perspective enhances the bond between the therapist and client (Or Front et al., 2020).

 

Psychological Diagnose

To have a psychological diagnosis, in hospital settings patients are given at least one questionnai-re so they can answer on their own. However, one-third of the patients refuse to fill them or argue that they don't understand it. For those patients having a clinical interview with a psychologist was crucial to determine whether they had a mental health condition or not. Furthermore, patients that received therapeutic care had higher compliance to fill the tests (Bonachi et al., 2010).

Consequently, the detection of a mental condition was determined by the clinical interview, ma-king it available to patients that refused to fill the tests, they detected mental disorders in se-veral of these patients, and depending on the level of impairment some of them were selected to obtain mental care. Meaning that a clinical interview is not only important for psychological diagnosis but it is also beneficial because it helps choose which clients need to receive treatment (Bonachi et al., 2010).

In the elderly population patients that were assessed with semi-structured questionnaires, allowed the mental health practitioners to recognize alterations, detect more diagnoses than with the DSM-5, and increase the prediction of psychological and social performance. An assess-ment should always be multidimensional, considering health status and social factors and not just checking the symptoms in the DSM (Mansueto, Romanazzo & Cosci, 2022).

 

Therapist characteristics

There are important therapeutic characteristics within therapy sessions. Therapist empathy, emotional expression, understanding, warmth, and bonding must be observable during the the-rapy session, furthermore remaining involved with clients throughout challenging interpersonal moments, being responsive regarding this situation and having verbal fluency, having the ability to help clients find a new meaning of the problematic issue in the therapy session, enhances the therapeutic alliance (Anderson, Stone, Angus & Weibel, 2022).

Therapists with higher interpersonal skills, practice some interactions during the session, which allows them to create a different understanding of the feelings, thoughts, and problems the client was having. On the other hand, commonly influential therapists, support clients to rethink their stories, and find another meaning to them, by pointing out possible opportunities and prospects (Anderson et al., 2022).

Therapists that are perceived as more efficient are the ones that have higher social skills, this could be a result of their personal experiences and quality of intimate relationships. Lower basic relational skills, such as the capacity to empathize, genuineness with clients, communicating and understanding clients' concerns, and engaging in a work alliance, were beneficial in therapy.

Therapists that had less confidence in their capacities predicted inferior outcomes, particularly in brief treatments. Therapist awareness of skillfulness predicted earlier symptoms decrease. Mo-reover, better results were anticipated by the therapist that use coping strategies like consulting with colleagues when there was a doubt, self-reflection, or problem-solving with the client (Hei-nonen & Nissen-Lie, 2019).

The capacity to integrate emotion, decreased client's complaints, while the capability of ma-naging emotions reduced client's interpersonal problems, finally, the therapeutic ability of understanding the emotion, predicted a significant reduction in therapeutic complaints related to interpersonal problems. Mindfulness of the therapist is also a skill that must be considered, un-derstood as the capability of bringing one's attention to the current moment without judgment and complete acceptance. Therapists that had this skill predict a reduction of client's interpersonal problems (Heinonen & Nissen-Lie, 2019).

Clients and therapists could become emotionally aroused during the session, reaching the highest level and then going back to the initial emotional state. The comprehensive way in which the therapist helps the client release their emotions is equivalent to the construction of a safe space for them. Research has established that the capacity to deal with physical pain is higher in the presence of someone else. An explanation of this in psychotherapy is that the client is capable of regulating in a better way when they are conscious that the therapist understands their feelings and is supporting them. Therapy gives the client a place where they could speak about their emotional distress, potentially dragging the therapist to an emotive state, being empathy a key to success, this involves the therapist's awareness of the emotions the client is expressing and showing understanding of the situation (Soma et al., 2019).

Therapists with low social abilities and without previous training have sessions that lack focus on the client's emotions and experiential processes (Anderson et al., 2022). Nevertheless, these qualities are modifiable and trainable (Heinonen & Nissen-Lie, 2019).

 

Training

Supervisors and training programs could learn to cultivate these qualities. Just being aware of which are the beneficial characteristics a therapist should have, could help therapists monitor themselves in offering the abilities that are known to improve outcomes via deliberate and reflec-tive practice (Heinonen & Nissen-Lie, 2019).

Training is essential for the sake of improvement on the necessary interpersonal skills needed to bond with the client. After supervision and training, students were able to improve their skills in numerous areas of their interview. Like receptive listening and receptiveness to clients' fee-lings and needs, understanding verbal and non-verbal cues, exhibiting an understanding of the client's situation, sensitivity, empathy, and avoidance of negative judgment (Hannah, Lim & Ayers, 2009). The way students structure their interview is enhanced significantly by introducing themselves and the reason for the consultation, gathering the explanation of current issues and related biopsychosocial problems, medical history, cost of the session, use of closed and open questioning styles, and the skill of summarizing the session properly. Students were also aware of the increase in their interview competence (Hannah et al., 2009).

Working with a diverse population people tend to follow stereotypes, making suppositions about someone's beliefs or costumes based on what globally is known about a specific group. Clients feeling misunderstood is a big barrier that ultimately will affect therapeutic alliance. Research on South Asian Women, has found that after going to therapy, most of the women had the feeling of "not belonging". One of the issues was that religion and culture were not considered in therapy, being this an essential part of a person's identity, moreover there were some occasions in which culture was pathologized (Yamin-Quereshi & Ledwith, 2021).

Fear of stigmatization or discrimination could increase in several persons from a diverse commu-nity. For example, undocumented immigrants have restricted access to health services, being this subject distressing for them, compared with the U.S. population, they have fewer medical visits and hospitalization rates, dependent on the use of emergency locations, most of the ones that had contact with mental health providers felt misunderstood (Garcini et al., 2022). This is a big issue to consider, some of them could be at high risk, and because of all these misconceptions not willing to lookfor help.

The LGBT community was highly stigmatized since it was considered a mental disorder in DSM-I, even after being removed, many people got used to hiding because of the panic of being pathologized. The fear of being stigmatized is a barrier to trust therapists (Bochicchio, Reeder, Ivanoff, Pope & Stefancic, 2022). However, nowadays different models of therapy are emerging for diverse populations, one of them is the LGBT affirmative practice, which stimulates resilience and positive self-regard, also addressing the impact that discrimination has on clients. It is critical for success to set aside identity expectations, group counselors must use affirmative practice skills by creating a welcoming space, and requesting for pronoun information, which helps build the therapeutic alliance, promoting participant’s validation, also focusing on the client's strengths authenticates their experience (Craig et al., 2022).

For members representing diverse racial backgrounds, the amount of persons that pursue psy-chological well-being descends notably. African Americans are one of the most affected ones since the microaggressions and persistent discrimination. Mental health specialists are accounta-ble for creating a safe environment and cooperative relationships so the clients feel comfortable speaking about their past experiences, treatment leads to addressing common discriminations, and racism, additionally counselors should review possibly oppressive, prejudiced conducts they display towards their clients (Fripp & Adams, 2022).

Stigma surrounding mental health is a powerful obstacle for clients to seek for help. Some traditional cultural beliefs may affect the possibility of even considering it as an option sometimes. Is vital that the therapist considers this when treating clients, the understanding of these stigmas could provide a better understanding of the person's background, and establish that culture could have a direct impact on the way someone perceives mental health. Some cultures think that only weak people need mental health assistance. There are also negative attitudes about speaking of mental health, based on the fear of public opinions as well as a misconception about mental health diagnoses. Moreover, the distrust in mental health services and consider religion as a more efficient way of coping than psychotherapy, since most practitioners are from different cultures and don't understand their backgrounds (McSpadden, 2022).

Language is key for the therapeutic alliance, if the clients feel that they are in a safe space and have the opportunity to explain their culture, values, and personal preferences, the health pro-vider doesn't have to guess, he/she will have even better information since it is provided by the client. Approaching clients with cultural humility helps them learn who clients are as people and not as stereotypes (Solorzano, 2021). All mental health practitioners, disregarding their background, are challenged to acknowledge their biased thoughts, especially white counselors, are motivated to meticulously observe how their actions could encourage microaggressive actions or prejudice since their role in society comes from a privileged identity. Mental health practitioners are encouraged to conduct therapy in a framework of a multicultural paradigm, aligning their personal values, and beliefs, towards it. To battle unsuccessful psychotherapy practices, experts in the therapeutic area should have in mind cultural diversity and social justice as a context to regulate multicultural ability. To develop multicultural competence, the therapist must be aware of their thoughts and how they could affect therapy, should be able to establish rapport with clients, and appropriately conduct psychological interventions. Counselors must understand their beliefs and assumptions, and recognize the way their position could influence their language or how they express themselves, recognize what makes them the person they are, realizing that, is a great opportunity to understand how vulnerable clients are affected by rules, principles, and governments (Fripp & Adams, 2022).

 

Conclusion

This literature review supports the importance of the therapeutic alliance through theoretical articles and fieldwork. It has an essential role in therapy, being essential for the client's outcome, therapist empathy, understanding, and emotional expression are some of the characteristics that can influence this alliance. The mental health practitioner has an important role to create this bond, leaving aside assumptions, avoiding generalization regarding a cultural background, and using neutral language is essential. If the client doesn't feel in a safe space, it's going to be more difficult to create that bond. To diagnose accurately it is better to use semi-structured interviews leaning on DSM diagnostic criteria for a superior understanding of the situation, instead of just giving the patients questionnaires. During the session, the client's and the therapist's emotions will change depending on the topic being discussed, it is fundamental that the counselor reflects empathy in this stage. The therapist must not impose goals on the client, but they need to understand the client's issue and have a common goal considering the client's perspective. We could have the most efficient therapy but if we lack therapeutic alliance with the client, the results are not going to be accomplished.

 

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