The Therapeutic Alliance: A Benefit or a Liability?

When talking about self-help or internet-based approaches to psychological therapy or self-management, people routinely point out a problem with such therapist-absent approaches: The demonstrated value of the therapeutic alliance.

The alliance is a general term for the complex relationship between therapist and client, composed of mutual understanding, empathy, an agreement on the goals and methods of change, and so on. Studies routinely show that the quality of the alliance is a stronger predictor of therapeutic change than is the modality of psychotherapy being delivered.

If this is the case, then self-care focused strategies have a real problem. How can there be a genuine alliance if there is no real relationship with the clinician? We might sense that the author of a self-help book or the teacher in an online course is a nice person, but clearly they have no real relationship with the user.

If the potent factor in therapy is the relationship, and we have a therapy with no relationship, how could the therapy be effective? In nutritional terms, it would be missing the crucial vitamin.

Arguments like this presume that the effect of the alliance is, in a sense, additive. Sure, there may be some useful information in a less personal modality like a self-help guide, but the relationship adds something important.

Could the relevance of the relationship be subtractive, instead?

In order to find a relation between alliance quality and outcome, there has to be variability in the alliance. Some therapist-client pairs have to have a better alliance, others a worse one.

We have been presuming that the good alliance adds something extra to whatever is delivered in therapy. What if this is not true? What if, instead, a bad relationship subtracts from the impact of what is delivered? In other words, what if the alliance looks important not because a good alliance is so great, but because a bad one fouls things up so badly?

If the alliance is only subtractive (which I suspect is unlikely), then it would actually be better to have a form of therapy with no alliance at all. A self-help book, a therapy guide, an online lecture-format course, all of which have no off-putting relationship factors, would be the ideal form of therapy.

I raise the issue because of the profound effects clients sometimes report from purely receptive therapy efforts – like reading self-help books. Even my own: I often get notes of appreciation from readers of The Assertiveness Workbook, saying how much it has helped them in their lives. It would be nice to take these accolades as evidence of my abilities as a therapist. “Look how much they benefitted just from reading something I wrote – imagine what they’d get from actually meeting with me.”

It’s a nice thought, but glosses over the obvious anxiety. Perhaps I expressed myself clearly in the book but would be less concise, less organized, and less effective in person. As well, readers of the book can imagine me as any kind of teacher they like. In person they might discover that they don’t like my way of speaking, the shape of my nose, or my obnoxious habit of interrupting. Perhaps I am literally a better therapist on paper than I am in person.

I suspect this is often true. How often have we met our therapeutic gurus and been disappointed with their narcissism, or imprecision, or sloppy technique? Reading their words we can see and understand their points, reflect on how the ideas relate to our own lives, and calmly decide how to put changes into effect. Faced with a sneezing, ill-dressed, imperfect individual, the waters are sometimes only muddied.

And gurus or not, we have all seen individuals dispense undeniably good advice in such a ham-handed manner that no one in their right mind would accept it. Forget my name, act as though you don’t care, shout me down, and then tell me to exercise, be nice to myself, eat my vegetables, and make enjoyable activity a priority in my life. I’ll do the opposite just to spite you.

I imagine that in actuality the effect runs both ways. A good therapist can add to their content with a warm, inspiring nature, and a bad one can subtract from otherwise good material by alienating the client. But we only hear about the former, leading many to assume – almost certainly wrongly – that the alliance is crucial for people to get anything out of a psychological intervention. The evidence on therapist-absent approaches suggests otherwise.

Online Course

Can you perform therapy on yourself? Well, in a word, no. Psychotherapy is inherently an interaction between client and clinician. But you can use many self-care strategies on your own.

Our clinic has developed a cognitive behavioral guide to self-care for depression. Though not a substitute for professional face-to-face care, UnDoing Depression may be a useful adjunct to your efforts.  The preview is below. For 50% off the regular fee of $140 USD, use coupon code “changeways70” when you visit our host site, here.

We also have courses for professionals and for the public entitled What Is Depression, What Causes Depression, Diagnosing Depression, Cognitive Behavioral Group Treatment of Depression, How to Buy Happiness, and Breathing Made Easy. For the full list with previews and substantial discounts, visit us at the Courses page of the Changeways Clinic website.