Guide to the Therapeutic Alliance assessment

It is agreed by clinicians and researchers alike that one of the best predictors of outcome in psychotherapy is the therapeutic alliance. Meaning, that if therapeutic alliance is strong, the probability that the client will also see their therapy as a success, increases. Therefore, it makes sense that by understanding this relationship, therapists can be better equipped to create effective treatment plans, foster a stronger and positive therapeutic alliance, and ultimately improve therapeutic success. But as a clinician, how can you get a better understanding of what is happening with the therapeutic alliance?

The Working Alliance Inventory (WAI-BR)– available to you in your list of assessments, allows you to monitor whether the therapist and the client are in fact “working together” at the time the assessment is completed. The 16 questions help both you and the client explore key aspects of the therapeutic alliance including the bond and the goals of therapy.

As many therapists know, the bond, specifically a positive connectiveness early in the therapeutic relationship, has been shown to be connected to behaviours such as being consistent in sessions, using non-verbal gestures (e.g. eye contact and body language), and using verbal behaviours including active listening skills. Some studies also highlight that the use and demonstration of behaviours such as empathy, positive regards and congruence builds a stronger alliance. Which non-verbal and verbal techniques do you use in your sessions regularly with clients to help form a strong therapeutic alliance?

Research also points out that the ability of a therapist to instill confidence and trust within the first few sessions is essential to therapeutic success. Verbal and non-verbal cues are not enough in maintaining a strong alliance alone. Being responsive in sessions, collaborative on tasks and goals, and open minded allows the client to feel that as a therapist, you are open to working together, more connected and having a stronger alliance.

To have a better understanding of what is happening with the therapeutic alliance, you may want to become familiar the questions in the WAI- BR. After review, consider the following:
As you plan your first 2-3 sessions, do you have time allotted to discuss and establish a mutual understanding of goals?
Do you know what is important to the client versus what you might consider clinically important? How do you reconcile this with the client and come to an agreement?
Are the tasks discussed are understood by the client? Many times, clients may leave an office nodding yes to a beautifully laid out plan including goals and associated tasks, but deep down, they are feeling overwhelmed and hesitant to let the therapist know that they really feel uncomfortable or everything is going to fast.
Consider assigning this questionnaire within the first 2-3 sessions to help gather an initial baseline of the client’s feelings particularly about their goals and the bond they feel with you. If there are items or questions where the client scored neutral, disagree and/or strongly disagree, consider taking some time at the beginning of the next session to discuss how you can make the client feel better and what that might look like. Think about the very concepts of using empathy, positive regard and congruence to help build your alliance.
Maintenance of a positive therapeutic alliance is also important in accomplishing tasks and goals. If the goals change during therapy, how do you discuss this with your client, is the client on board? If not, why?

To learn more about the Therapeutic Alliance assessment check out this article.