Theraputic Alliance Essay

Running Head: THE THERAPEUTIC ALLIANCE

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The Therapeutic Alliance: A Comparison of Theories

Introduction to Counselling Psychology

Bond University

THE THERAPEUTIC ALLIANCE 2

Abstract

The Therapeutic Alliance is constructive bond or relationship formed between client

and therapist and is crucial in the counselling process (Cheston, 2000). This essay

examines the therapeutic alliance between 3 separate styles of therapy; Adlerian,

Cognitive Behavioural Therapy and Reality Therapy. As found in the literature these

separate counselling methodologies are vast and varying in some respects such as

difference of importance of Therapeutic alliance, flexibility and rigidness of

techniques, and use of modelling and introspection, yet are very closely bound by the

taking an educative role, notions of faith in abilities, collaborative goal planning, and

consistent positive regard for client (Corey, 2009; Dryden, 2009; Glasser, 1965;

Grencavage & Norcross, 1990; Sperry, 2003). Reaching therapeutic goals in Adlerian

Therapy is reached by a familiar understanding of client goals as well as in Reality

Therapy and Cognitive Therapy, however in REBT is achieved by challenging the

clients faulty life view (Mosak & Maniacci, 1998; Sperry, 2003). It has been found

consistent with finding in the literature that Adlerian therapy provides clients with the

highest degree of therapeutic alliance where as REBT and to some extent Cognitive

and Reality therapies and are shown to be more action-based and directive

methodologies (Cheston, 2000; Corey, 2009; Dryden, 2009; Watts, 2000; Weinrach,

2006).


The Client-Therapeutic Alliance can be outlined as the functional interaction

between client and therapist, which can vary in manner of focus from therapy to

therapy (Horvath & Luborsky, 1993; Luborsky, 1994). Martine, Garske and Davis,

(2000) effectively specified it as “the collaborative and affective bond between

therapist and patient—is an essential element of the therapeutic process” (p 438). It is

the keystone in the counselling process, which is constant across the different

therapeutic approaches in relation to its influence, and is largely predictive of the

therapy outcome (Ahn & Wampold, 2001; Cheston, 2000; Corey, 2009). It has been

suggested by Safran and Muran (1995), that the relationship between client and

counsellor is more salient than actual the methodology that is implemented. However

many counselling approaches will manifest different alliance styles and varying

effectiveness (Asay & Lambert, 1999).

Counselling is an intimate experience that involves a client expressing

intimate life details, thoughts and feelings, with the intention to grow and learn about

himself or herself as a person (Cheston, 2000; Corey, 2009; Horvath & Luborsky,

1993; Johnson & Wright, 2002; Mosak & Maniacci, 1998). The role of the counsellor

can differ from instance to instance, client to client, and theory to theory, but what can

be generally be taken from each approach is the universal goal of helping the client to

realise their own solutions to the issues they may facing (Asay & Lambert, 1999;

Horvath & Luborsky, 1993; Mosak & Maniacci, 1998; Watts, 2000). The underlying

factor that is instrumental in fostering an environment where this possible is the

Client-Therapist Alliance (Ahn & Wampold, 2001; Asay & Lambert, 1999; Cheston,

2000; Corey, 2009). This concept is of primary importance. Literature has shown

consistent support that the therapy outcome is largely dependant upon the therapeutic

relationship as much as the specific treatment method utilized. (Ahn & Wampold,


2001; Asay & Lambert, 1999). If the counsellor does not adopt a suitable approach,

the intimacy and sharing of experience can be detrimentally affected.(Grencavage &

Norcross, 1990; Johnson & Wright, 2002; Prochaska & Norcross, 2001; Ruglass &

Safran, 2005) According to Corey, (2009), the therapeutic alliance has been reported

to be the ‘make or break factor’ of a client deciding to continue or discontinue

treatment with a particular therapist. Skills and theoretical knowledge are a

foundational basis but cannot adequately provide all that is essential in effective

counselling, which remains in the attainment of a strong Client-Therapist relationship

(Ahn & Wampold, 2001; Asay & Lambert, 1999).

The role of a therapist in the last century has taken a dynamitic and adaptive

turn (Cheston, 2000). Therapy has been more widely used as a means of dealing with

the difficult intricacies of life, and as a reaction, therapy has moulded it self to suit the

growing number of diverse clients as well as a variety of client issues (Ruglass &

Safran, 2005). In this faze of adaptation, psychology has yielded a wide variety of

counselling approaches that each address client needs via differing methods and

techniques that facilitate client-therapist relation in diverse styles (Mosak & Maniacci,

1998). The following essay endeavours to outline 3 theoretical approaches, Adlerian,

Cognitive Behavioural Therapy and Reality Therapy and compare the how the

Therapeutic alliance differs between each theory. Each one of the theories; Adlerian,

Cognitive Behavioural Therapy and Reality Therapy, reach client goals along their

own unique pathway (Martin, Garske, & Davis, 2000; Prochaska & Norcross, 2001;

Sperry, 2003).

In Adlerian therapy, as called by Adler as Individual Psychology, the focus

lies on all dimensions of a person aimed towards the achieving of a specific life goal

in a collaborative and egalitarian relationship between client and therapists (Sweeney,


1998; Watts, 2000; Watts & Pietrzak, 2000). Adlerian Therapy proposes that the

client therapeutic alliance is the first requirement in the beginnings of the therapeutic

process as opposed to initially identifying the actual issue at hand (Corey, 2009).

Clients are not viewed as pathologically unwell but as lacking support and faith in

their ability to bypass unsuccessful ways (Sperry, 2003). Encouragement is

considered to be a crucial aspect of human development, which is a key theme in the

Adlerian approach to the therapeutic relationship (Corey, 2009; Grencavage &

Norcross, 1990; Horvath & Luborsky, 1993; Johnson & Wright, 2002). This is

developed by demonstrating a genuine concern for clients by showing empathy,

actively listening, providing support, understanding and respect, building confidence

in clients, tactfully and positively negating negative or unrealistic beliefs and shifting

focus from discouraging thoughts (Mosak & Maniacci, 1998; Sweeney, 1998; Watts

& Pietrzak, 2000) and directing thinking “towards effort and progress and helping

clients see the humour in life” (Watts & Pietrzak, 2000, p443).

Client and therapist work together collaboratively in a mutually agreed upon

goal that is established often by the formulation of a plan that outlines what the client

wants and the means in which they intent to attain that want, followed by possible

obstacles and faulty behaviours that may inhibit their attainments of goals

successfully (Prochaska & Norcross, 2001; Sperry, 2003; Sweeney, 1998). It is only

in the circumstance that the client and therapist goals are aliened that effective therapy

will occur. If the client is able to gauge that therapist has grasped a firm and thorough

understanding of his or her needs then the client is likely to be more directive in

establishing goals with the therapist (Watts & Pietrzak, 2000). This approach

positions clients as the decision-makers who are responsible for his or her own change

and requires concerning listening from the therapist (Cheston, 2000).


Specific techniques are not rigidly adhered to but rather changed and adapted

to suit the individual needs of the client (Watts, 2000; Watts & Pietrzak, 2000).

Counsellors of the Adlerian persuasion strive to promote social interest through

modelling this to clients in their own behaviour (Mosak & Maniacci, 1998; Watts &

Pietrzak, 2000). The development of a genuine, trusting and nonjudjemental

environment are essential skills for the exploration of the clients compitencies(Watts,

2000). The Adlerian therapist is one who enables client to overcome feelings of

inferiority and is able to address dysfunctional motivations in order for the client to

function within society successfully (Corey, 2009). Helping the client to understand

that optimum wellbeing is achieved when these issues are resolved can be reached by

adapting the client’s problematic life story and alleviating it with a more favourable

one (Mosak & Maniacci, 1998). This is what Alder classically called the

reorganisation of a life schema of how one viewed one’s self and the world. What is

the underlying theme within Adlerian Psychology is that this schematic adjustment is

only possible with formation of a firm therapist relationship (Sperry, 2003; Sweeney,

1998; Watts, 2000). Overall, the role of the therapist in an Adlerian perspective can be

summed as a supportive collaborative educator that maintained mutuality in status

that fosters a friendly disposition (Sperry, 2003).

Cognitive behavioural therapy (CBT) also draws upon a collaborative and

instructional style that educates clients to address client’s unhelpful cognitions, which

are directive of unwanted or unhelpful behaviour (Cheston, 2000; Corey, 2009;

Martin, Garske, & Davis, 2000; Sperry, 2003). CBT, quite similar to the Adlerian

approach, also addresses client maladaptive schemas or perception of self and life in

attempt attain of betterment (Sperry, 2003). Beck (1989) proposed client-therapist

relationship themes similar to that of Adler, in that the client and therapist acted


jointly together in a warm genuine and appreciative environment as “co-

investigators”(p.301). As we compare and analyse the therapeutic alliance within the

discipline of CBT, it is necessary to inspect the relative theories. For this reason the

therapeutic alliance will be examined within the two separate constructs of Albert

Ellis’s Rational Emotive Behavioural Therapy (REBT) and Beck’s Cognitive Therapy

(CT).

REBT is an active-directive therapy that focuses on the ‘doing’ of therapy and

is often set out in an agenda format session (Cheston, 2000; Corey, 2009; Dryden,

2009). Like the Adlerian therapeutic approach, attention is drawn to empathy and

ensuring a secure environment for the client, so that he or she may feel comfortable to

disclose information (Dryden, 2009). REBT focuses on the present condition of the

client, their current emotional being and their state of thinking that may be leading to

dysfunctional behaviour and gives little emphasis on past experiences or background

information such as relationships with family members (Neenan, 2001). This style of

therapy takes upon the notion that an extensive relationship that is too indulgent is not

conducive to eliciting effective change in a client’s behaviour, and may harbour

emotional reliance upon the therapist (Corey, 2009; Neenan, 2001; Weinrach, 2006).

However, Ellis encouraged REBT therapists to offer unconditional acceptance of

clients regardless of imperfections and to facilitate clients to do so for themselves and

for others, which can be inferred to cast similarity with the Adlerian approach (Ahn &

Wampold, 2001; Cheston, 2000; Corey, 2009; Glasser, 1965; Neenan, 2001; Watts &

Pietrzak, 2000; Weinrach, 2006). In this aspect REBT helps client to recognise

behaviour that may hinder them and address it in a logical approach (Dryden, 2009).

REBT assumes that imperfections are common to all humans and can be

addressed through a repertoire of techniques, such as behaviour modification (Corey,


2009; Dryden, 2009). The role of an REBT counsellor is to challenge to clients

defeated way of thinking which may involve debate and dispute to enable clients to

realise a more rational way to overcome false beliefs (Neenan, 2001; Weinrach,

2006). According to Dryden, (2009) this type of alliance is seen to be a ‘working’

alliance that creates a sense of teamwork within the relationship between client and

therapist. Due to the highly involved nature of REBT clients completing assignments,

the maintaining of an intense emotionally facilitative relationship is not seen as a

requirement, however as we saw in Adlerian therapy, this is the fist requirement and

the foundation of the therapeutic process of achieving goals (Kinney, 200; Martin,

Garske, & Davis, 2000). A commonality that Adlerian Therapy and REBT share is

that therapist of both of the disciplines emphasise faith in the abilities of the client to

change them selves (Grencavage & Norcross, 1990). Likewise both of the approaches

facilitate and egalitarian relationship between client and therapist (Sweeney, 1998).

As opposed to Adlerian Therapy, techniques of REBT are more adhered to keenly as

it is seen as the techniques and active participation of the client are able to aid the

client in amending behaviour – rather than the bond between client and therapist

(Corey, 2009; Dryden, 2009; Weinrach, 2006).

CT similarly like REBT offers the client a platform that is educational based

and utilizes homework with the client (Corey, 2009). Again, like REBT it is an

action-directive based discipline that is collaborative, present and problem

focused(Kinney, 200). Clients issue are assumed to arise from faulty thinking and

flawed interpretations of the their world (Grencavage & Norcross, 1990). Akin to

Adlerian and REBT, CT seeks to restructure the schema of an individuals thought

process with better functioning thoughts (Beck & Weishaar, 1989). CT is not as

confrontational as REBT, and follows Socratic questioning with the aim of client self-


realisation and reflection rather than a direct challenge of maladaptive thought,

similarly to the Adlerian approach, which encourages clients to gently arrive at

conclusion (Beck & Weishaar, 1989; Cheston, 2000; Corey, 2009; Grencavage &

Norcross, 1990). Directly opposing the assumption of REBT, CT holds the

therapeutic alliance as an important and required aspect of the counselling process to

building a warm and understanding relationship that enables a therapist to utilize

skills (Beck & Weishaar, 1989; Neenan, 2001).

Both REBT and CT emphasise the therapist as an educator who administers

homework and allows the client to take upon the responsibility of change both within

sessions and independently outside of therapy (Corey, 2009). However in CT,

homework tasks are more caringly negotiated and mutually agreed upon and easily

adjusted to suit the client rather than appointed or instructed to complete (Beck &

Weishaar, 1989; Sperry, 2003). A fundamental concept of CT is that the

reorganisation of behaviour to enable better functioning is achieved through various

behavioural strategies and a client-therapist understanding, enabling the realising of a

clients’ self-statements, and adjusting maladaptive thinking to that which is conducive

to better behavioural habits (Sperry, 2003). Parallel to Ellis’s educational teamwork

relationship, Beck proposes a partnership like relationship that guides the client to

understand how their thoughts and feelings affect their behaviour, but discourages the

spoon-feeding of answers to the client, but rather enables self-initiative (Cheston,

2000; Corey, 2009; Grencavage & Norcross, 1990).

Similar to CT, William Glasser’s Reality Therapy (RT) proposes a relationship

in which the therapist takes upon the role of a mentor in yet another educative setting

in which the client is guided by the therapist to evaluate their choices (Cheston, 2000;

Corey, 2009; Wubbolding et. al, 2004). Likened to the Adlerian perspective, clients


are not viewed as psychologically unwell – but seen as not able to meet their needs

and be happy (Glasser, 1965). An empathetic and understanding relationship is of

primary importance in RT, however it is not considered to be a mending factor of

behaviour, and that further proactive steps are needed to change behaviour (Corey,

2009; Glasser, 1965). A counsellor in an RT setting should be one who is accepting,

respectful, and have keen listening skills. The idea of demonstrating faith, as in

Adlerian and REBT approaches is key in this theory also (Cheston, 2000; Corey,

2009; Dryden, 2009). According to Wubbolding et. al. (2004) modelling this faith

enables the belief of their capabilities to become their own self-belief. These skills are

close to that found in Adlerian therapy, though RT assumed a firmer stance with

clients and accepts no excuses (Glasser, 1965).

Clients are seen as responsible completely for choosing the way they deal with

the emotions they experience. Choice theory assumes that all behaviour is resulting

from choice in some aspect, and that all actions are aimed at fulfilling a basic need

(Glasser, 1965). RT counsellor’s role is to better assist in choices to allow for a client

to better achieve these needs. What is a major dysfunction in behaviour according to

RT is that individuals are not connected adequately to the world and therefore need

assistance in enabling these connections, thus meeting the need to be connected

(Corey, 2009; Glasser, 1965). A fundamental aspect in this approach is to set

appropriate goals, much like in Adlerian style therapy that helps attain fulfilment of

an individuals needs, such as love or belonging (Glasser, 1965; Grencavage &

Norcross, 1990; Horvath & Luborsky, 1993; Sweeney, 1998;Wubbolding et.al, 2004).

Reality Therapists are encouraged to make a connection with the client so that

they may be able to assist the client in fulfilling their own goals (Corey, 2009;

Glasser, 1965). If this connection is not established then the therapist is not able to


teach the client how these goals can be reached. In this process self-evaluation is

taught to give clients and introspective view on how they can better effectively meet

their own needs (Wubbolding et. al., 2004). RT In this sense is considerably similar to

CT and Adlerian in that it encourages self-reflection in order to reach a client’s own

proposed solution (Sperry, 2003). REBT differs in this respect, as self-evaluation is

not as prominent as in the other disciplines (Dryden, 2009; Glasser, 1965).

Adlerian Therapy, CBT theories and Reality Therapy are varying and vast in

many aspects of practice and techniques, but interestingly, though these theories each

claim to offer to assist a client in their own unique way, it seems that there are more

commonalities than one would assume, which lay in the very essence of the

therapeutic process – the therapeutic alliance (Ahn & Wampold, 2001; Asay &

Lambert, 1999; Sperry, 2003). Though this author anticipated to be reporting a myriad

of differing methods and approaches to building a client relationship, it seems that

there are many common underlying factors in which these disciplines mutually share.

Concepts of egalitarianism, mutual respect, a collaboration of ideas, faith in abilities,

encouragement, self-reflection, teamwork, partnerships and an educative rather than

curing-mindset, resinate within all of these therapy approaches – which is just

mentioning some of the more prominent aspects (Beck & Weishaar, 1989; Cheston,

2000; Corey, 2009; Dryden, 2009; Glasser, 1965; Grencavage & Norcross, 1990;

Horvath & Luborsky, 1993; Johnson & Wright, 2002; Kinney, 200; Mosak &

Maniacci, 1998). What these findings turn a new focus to is the question: is it the

technique and theory of the therapy the causing factor of effectives of therapy or is the

salience and quality of the therapeutic alliance? As claimed by Safran and Muran

(1995) it is the therapeutic alliance that is the predictor of successful therapy, and not

the actual technique implemented (Luborsky, 1994). Nevertheless, theorist such as


Alder, Ellis, Beck and Glasser have all uniquely and invaluably contributed a different

colour to the diverse and intertwined picture of therapy – with each demonstrating

how one can gain in deepening the relationship between client and therapist. As we

can see, it is this foundation that successful therapy can be achieved (Asay &

Lambert, 1999; Cheston, 2000; Grencavage & Norcross, 1990; Mosak & Maniacci,

1998).


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Theraputic Alliance Essay