What are the ingredients that make up good psychotherapy? This is a longstanding question that the field has wrestled with and there are many possible angles and facets to consider and there is not much in the way of shared consensus among the experts. However, I do believe that one can use one of the longest standing conceptions, that of Bourdin’s “therapeutic” or working alliance to get a good handle on the major issues.
When many folks think of the therapeutic alliance, they think in terms of the quality of the therapy relationship. That is a part of the alliance, but it is only a part. In fact, there are three distinct elements that constitute the therapeutic alliance, as originally conceived of by Bordin (1980) and then explored in various programs of psychotherapy research.
The first element of the alliance is what I call the relationship quality, often referred to as the “bond”. For me, relationship quality can be divided into three domains. First, how the client sees the therapist. This refers to the extent to which the client trusts the therapist, feels safe, and thinks the therapist is both competent and has the best interests of the client in mind. Second, how the therapist feels toward the client. Does the therapist see the humanity of the other and feel, naturally, that intuitive positive regard and sense that there is hope for their growth and potential?
Finally, there is what I call the participatory dance in the actual therapy encounters. Do the two participants (if we are discussing individual therapy) flow well in relationship to each other? Is there a sense of empathy, implicit intersubjective harmony, and the felt sense of mirroring? And, if there is a period where things are out of step or there is a rupture, is there enough skill and relational “money in the bank” so that the issues can be honestly addressed and repaired. Ideally, all of this will be set up on a dialectic of authentic support and challenge that allows the client to have the courage and wherewithal to face one’s demons and grow toward more adaptive ways of being.
The second element refers to the shared conceptualization of the problem that leads to an understanding of the work. This is often called the “goals”, but for me it is more than that. It is the deepening of awareness of both parties of the current situation the client is in and who they are, what they value, what traumas have impacted them, why they are stuck or what they deeply feel. In other words, it is a formulation of the situation, the person, and the valued outcomes, which I represent with the adaptive living equation.
The third element of the alliance refers to the work itself of the therapy in terms of developing different ways of being and becoming. This is often referred to as the “tasks”. For me, this can be divided into the tasks of acceptance (which fosters a healthier way of being with ones’ self, feelings, past or present) and active change, which is about fostering needed skills in becoming, or growth toward more valued states of being, or more optimal functioning in some domain. This domain also involves the tracking of outcomes, such that there is an understanding of the kind of progress that therapy is expected to be making and making changes in approach or conceptualization or in the therapy itself if such changes are not being realized over time.
In the doctoral program I teach, we have a three-part course that is modeled off this structure. The first, Processes of Psychotherapy, focuses on the process elements of the relationship (here is the primary text). The second, Integrative Psychotherapy Across the Lifespan, focuses on how to build effective, comprehensive conceptualizations that frame the goals of the work. The third, Advanced Diagnosis and Treatment Planning, focuses more on moving to tasks that foster adaptive change in the areas the client has identifiable challenges.
Psychotherapy is an incredibly complex endeavor and I am suspicious of approaches that try to reduce it to a one size fits all way of thinking. However, there is definitely a shared structure that has a history and cuts across the continuum of approaches. Thinking in terms of psychotherapy as a process that fosters a healthy, healing relationship, a shared understanding of the person, situation, problem and goals, and engagement on processes of acceptance and active change that enable adaptive growth seems to represent a core that the field largely agrees frames what it is about.
Gregg Henriques, Ph.D.