The Therapeutic Alliance

A Common Factor for Effective Psychotherapy, Pharmacotherapy, and Placebos.

Most school children have heard the riddle: which came first, the chicken or the egg? Of course, most children quickly move past this unsolvable, Zen-like question when asked the other chicken question: why did the chicken cross the road? People tend to like this latter riddle more since answers come more easily to mind. Besides, everyone knows that the chicken crossed the road so it could hop into the frying pan…or escape the frying pan.

The chicken vs. egg challenge is far more than a brainteaser for children. It addresses a very fundamental aspect of our interaction with and our understanding about the world we live in. We believe that the events in our universe are caused by other events. Our assumptions of what causes what is predicated on our observations of two or more events being correlated and our belief that the directionality of those events is easily determined by using common sense. In these situations, common sense can sometimes be effective. For instance, by applying common sense to the chicken and the egg conundrum, we’ll conclude that neither the chicken nor the egg preceded the other. But common sense doesn’t always lead us to the right answer.

Nowhere can common sense-based erroneous conclusions cause greater damage than in health care. To reduce potential harm to patients, physical medicine has moved away from “intuitive” decision-making toward a more empirical model for treatment. Although common sense and gut feelings still play a role in psychotherapy, their undependability as predictors of treatment outcomes has resulted in psychotherapy moving towards a more empirical approach to treatment as well.

This shift has contributed to our making great strides in discovering what’s most effective for bringing about successful outcomes in psychotherapy. These discoveries are leading to a better understanding of the phenomenon. These discoveries ultimately lead to improvements in psychotherapy. More to the point, discovering what works and what doesn’t work is helping therapists increase their efficacy.

For sometime, it’s been recognized that the therapeutic alliance, which accounts for 5% of outcome variance, is a good predictor of outcome. Of course, this tells us nothing about whom or what is responsible for the alliance. For example, does the therapist play a critical role in establishing the alliance? Or, is it the patient or an interaction between the patient and the therapist? And then, there’s the whole chicken and egg question…do strong alliances facilitate successful therapy or does successful therapy build strong alliances?In 2007, Baldwin, Wampold and Imel tested these questions and published their findings in an article titled, Untangling the Alliance-Outcome Correlation: Exploring the Relative Importance of Therapist and Patient Variability in the Alliance. They found two things. First, a strong therapeutic alliance leads to successful outcomes, not vice versa. Second, it is the therapist that plays a key role in the formation of the therapeutic alliance.

Ackerman and Hilensroth have proposed a number of therapist characteristics and techniques that may play a vital role in establishing the therapeutic alliance. For example, warmth, openness, honesty, flexibility, respectfulness and trustworthiness are characteristics commonly found in effective therapists. Being supportive, affirmative, reflective and active are techniques used by these therapists.

Any therapist can develop and hone these characteristics and techniques. By extension, any therapist can enhance their ability to create strong therapeutic alliances and thereby achieve more successful outcomes. The question, though, is how can a therapist know if they are being successful in developing these characteristics and in bringing them into the therapeutic session?

One way is for the therapist to wait to see if he or she is successful. Given the complex nature of therapeutic relationships, this is an approach that fails to put the client’s needs at the center of therapy. To become effective, therapists need feedback and not just occasionally. Only regular feedback will provide the therapist with the necessary insight needed to determine whether they are being effective in forming the therapeutic alliance. Obtaining feedback from the start enables therapists to adjust their interactions with their client so as to become a more effective therapist from the start.

We may never know which came first, the chicken or the egg. But we do know that strong alliances lead to successful outcomes. Just as importantly, we know that MyOutcomes’ Session Rating Scale can assist the therapist in forming and maintaining strong therapeutic alliances.

Upcoming Workshop

Train the Trainers, Florida, February 2015

The Heart and Soul of Change Project is pleased to announce the 2015 annual Training of Trainers Conference. Come to sunny Florida at the best time to escape the cold arctic northland! But reserve your place early.

Training Details

February 2—6, 2015 (27 hours of CEUs or CEs). This intensive training experience is designed to give you all that you need in order to begin training others and implementing the Partners for Change Outcome Management System (PCOMS). It provides the first step in becoming a Project Certified Trainer. The Project Certified Trainer designation reflects completion of the Training of Trainers Conference as well as an exemplary demonstration (via video) of training expertise and a demonstration of conceptual and practical understanding of PCOMS at both an individual practitioner and agency level.

Participants Will Receive

Subscription to Member Site (a $120 value);
Barry’s PowerPoint presentations for the whole week including annotated PowerPoint presentations;
Administration and scoring manual of the ORS/SRS (a $39.95 value);
The Second Edition of the PCOMS Manual which covers the whole gamut from clinical implementation to supervision and agency implementation—Heroic Clients, Heroic Agencies (a $39.95 value); and
Certificate of attendance and 27 hours of Florida CEUs for counselors, social workers, and MFTs and 27 CEs for psychologists provided by the training institute.


December 9th, Webinar

Improving Outcomes One Client at a Time: Feedback-Informed Treatment with Adults Who Have Sexually Abused


It is now well-known that feedback-informed treatment using PCOMS is being successfully integrated into agencies and systems of care around the world. But did you know that these measures are gaining prominence in the world of criminal justice as well?

Join David Prescott, a leading authority on feedback-informed treatment with adults who have sexually abused, and learn:

The current status of treatment for sexual aggression.
Strategies for collecting feedback from clients.
How feedback measures can aid case management decisions as well as improve client outcomes.

Upcoming Workshop

FIT Supervision Training, Chicago, March 2015

After receiving an overwhelmingly positive response to the 2013 and 2014supervision training events, the International Center for Clinical Excellence ispleased to offer this popular event once again in 2015. FIT SupervisionTraining, 2015 will be held from March 16-18, 2015 in Chicago, Illinois, USA.

If you are interested in helping clinicians improve their outcomes and get themost out of client feedback, this three day training event is for you. Through acombination of didactic presentations, skill building exercises and feedback,FIT Supervision Training is designed to prepare participants to provideeffective supervision to clinicians using Feedback-Informed Treatment (FIT). Itis also the first step for those interested in becoming an International Centerfor Clinical Excellence (ICCE) recognized FIT Supervisor.

Participants will learn:

What differentiates FIT supervision from conventional supervision
How to use client feedback to guide clinical supervision practice and help clinicians achieve superior outcomes
What the most common challenges are in FIT supervision and how to overcome them
Strategies to identify and address “at risk” cases in supervision

ICCE Director, Scott Miller, Ph.D, will run the training. A special guest and co-author of the ICCE manual FIT Supervision will also be present.

Participants Will Receive

Set of ICCE FIT manuals valued at $129 USD
Certificate of attendance
Continuing Education units (available for additional fee)
Access to the process for becoming a recognized ICCE FIT Supervisor