(p. 111) Clients’ Perspectives on, Experiences of, and Contributions to the Working Alliance: Implications for Clinicians
Introduction and Overview
This chapter provides a practice-friendly overview of research related to clients’ perspectives on, experiences of, and contributions to the working alliance, with implications for clinical practice. Specifically, this chapter aims to clarify the current state of knowledge about clients’ understandings of the alliance and offer evidence-based suggestions for professionals to develop and maintain a working alliance that is responsive to clients’ subjective understandings. Inevitably, there are no fully consistent findings on any aspect of alliance research. Therefore, presented here are the most likely conclusions and requisite implications of the current body of literature for mental health professionals based on the best available findings.
This chapter focuses on extrapolating from the results of the relatively few studies that allowed clients to present their own perspectives in an open-ended format. In contrast, the majority of alliance research has utilized psychometric measures, which are overwhelmingly premised on researchers’ perspectives. Therefore, the conclusions within this chapter draw largely, but not entirely, on qualitative and mixed-methods research.
Clients frequently bring up variables beyond the parameters of the alliance models and theories most promoted by clinicians and researchers. Such variables include the experience of interventions as an extension of the relationship between the client and the clinician (e.g., Bedi, Davis, & Williams, 2005), the importance of validation and other counseling micro-skills (e.g., Bedi, 2006; MacFarlane, Anderson, & McClintock, 2015), and the impact of early interactions with clinicians and their office environment (e.g., Tryon, Blackwell, & Hammel, 2007). These factors are brought up even when the alliance has been specifically defined for clients in terms of Bordin’s (1979) model and clients (p. 112) are prompted to specifically comment on contributors to developing a bond, a shared understanding of goals, and agreement on tasks (MacFarlane et al., 2015). The frequency with which these findings have been replicated led us to conclude that clients’ experiences of the working alliance are dramatically different from clinicians’ conventional understandings and experiences of the alliance (Bedi, 2006; Bedi & Richards, 2011).
Because clients’ perspectives are underresearched, and many clinicians are unfamiliar with them, this chapter will provide extended attention to outlining clients’ perspectives and experiences of the working alliance prior to providing concrete guidelines for practice. This chapter will use the terms “working alliance,” “therapeutic alliance,” and “alliance” interchangeably to match the mixed terminology of previous research studying this concept. This chapter is organized as follows. First, attention will be given to the importance of clients’ perspective and experiences. Second, an overview will be provided on key research on clients’ perspectives on, experiences of, and contributions to the working alliance. This section is divided into quantitative research and qualitative/mixed-methods research. Third, special attention is devoted to a client experience–focused theory of the alliance and client-identified alliance types. Fourth, the following relatively distinct features of clients’ perspectives and experiences are presented and elaborated on: (a) alliance formation beginning prior to meeting the clinician and early in the first interaction (this includes the importance of the office environment in facilitating alliance formation), (b) the inseparability of clinical techniques and the therapeutic alliance, (c) the lack of collaboration that clients experience in alliance formation, (d) the importance of counseling micro-skills, and (e) the importance of validation in particular. Implications for clinician practice are embedded within each section. Finally, caveats and limitations for clinicians relying on the information synthesized in this chapter are presented.
Importance of Clients’ Perspectives and Experiences
What the client brings to psychological treatment as a person and what the client does while in treatment matter and affect the success of counseling and psychotherapy more so than clinician-related variables such as the theories and techniques they employ (Asay & Lambert, 1999; Wampold, 2001; Wampold & Imel, 2015). In line with this, the latest meta-analysis of the association of the alliance with clinical outcome (Flückiger, Del Re, Wampold, & Horvath, 2018) replicates previous meta-analyses (e.g., Horvath & Bedi, 2002) and indicates that clients’ ratings of the alliance are a better predictor of client outcome than are the ratings of mental health professionals. In other words, how the client experiences the alliance is the better indicator of the success of (p. 113) psychological treatment. Therefore, careful attention to clients’ perspectives and experiences of the therapeutic alliance is warranted.
There is a tendency for clinicians to overestimate the extent to which they grasp clients’ experiences. When clinicians are asked to recall the most significant moment for the client in a session, they only accurately identify what the client believes is most impactful about one-third of the time (Cummings, Martin, Hallbert, & Slemon, 1992; Martin & Stelmaczonek, 1988). Perspective discrepancies extend to the working alliance. In a meta-analytic examination of perspectives on the working alliance, client and clinician ratings of the working alliance were reported to have a correlation of only .36 (Tryon et al., 2007).
These apparent discrepancies cloud the existing body of research on the alliance. While there is ample research that claims to represent clients’ perspectives and experiences of alliance formation and maintenance, most of it is based on the selection of variables theorized by researchers and clinicians. Previous researchers and clinicians have prioritized what they think is important for clients. However, these understandings are not always in line with what clients directly state themselves (i.e., with what they think is important). Using secondary means to try to comprehend clients’ understandings and lived experiences limits our interpretations to those that fall within preexisting clinician and researcher assumptions (Bedi, 2006; Elliot & James, 1989). As a result, we know relatively little about how clients understand and experience the alliance or how the alliance forms relatively independently of the biasing lens of researchers and professionals (Bedi, Davis, & Arvay, 2005; Bedi, Davis, & Williams, 2005).
General Implications for Practice
Clinicians are encouraged to remember that clients’ experiences of the alliance appear to be more important to successful counseling and psychotherapy than are their own (Flückiger et al., 2018). Therefore, clinicians are recommended to devote ample time to fostering the alliance throughout psychological treatment (i.e., not just at the outset), even when the clinician believes a strong alliance exists. In line with this, clinicians should guard against overconfidence in thinking they accurately understand what the client is experiencing (Smith & Agate, 2004) because clients commonly conceal their true feelings and often defer to what the clinician wants or expects (Rennie, 1994).
In addition, clinicians should be mindful of confirmation bias when they believe they understand how the client is experiencing the alliance and what the client thinks is the best way to develop and maintain it (Lilienfeld, Ritschel, Lynn, Cautin, & Latzman, 2014; Wright-McDougal & Toriello, 2013). To guard against confirmation bias, clinicians should seek out counterevidence to their clinical (p. 114) hypotheses for how to best develop/maintain an alliance with the client and remain open to testing out different interpersonal stances/strategies and evaluating the results (Lazarus, 1993). Moreover, clinicians are advised to regularly seek out feedback from the client about the strength of the working alliance, either verbally in session or formally through structured testing such as the Session Rating Scale (Duncan et al., 2003). Clients often appreciate the opportunity to disclose their difficulties with the treatment and the clinician when those experiences are acknowledged and validated (Miller, Duncan, Sorrell, & Brown, 2005), and therefore this strategy is also encouraged.
A Primer of Research on Clients’ Perspectives on, Experiences of, and Contributions to the Alliance
The differences between clients’ and clinicians’ perspectives go well beyond mere differences in terminology whereby clinicians use psychological jargon and clients use lay terms. Instead, their entire conceptualizations of the alliance construct diverge in notable ways, such as perceiving different components of the alliance, valuing different variables for its formation, and subscribing to different theories for how it operates and creates positive outcomes.
Summary of Quantitative Research
Clients consistently rate the quality of the alliance higher than do their clinicians, especially those experiencing early success (Tryon et al., 2007). This can be problematic because research shows that when client and clinician ratings were inconsistent, even if one party rated psychotherapy highly, clinical outcomes were hindered (Zilcha-Mano et al., 2016). This difference may be partially due to clinicians having more experience with the working alliance and thus being able to draw on a larger set of experiences (Zilcha-Mano et al., 2016). This difference may also partially be due to clients relying on early outcomes as a sign of the alliance, whereas clinicians more commonly consider the alliance and outcome to be conceptually distinct (Zilcha-Mano et al., 2016).
Indeed, quantitative research frequently indicates that clients’ views on the working alliance are more closely tied to the perceived benefit of the treatment (i.e., feeling helped)—that is, the separation of alliance and outcome is much less distinct in the minds of clients than clinicians (Hatcher, Barends, Hansell, & Gutfreund, 1995). In other words, psychological treatment may need to be experienced as somewhat helpful for the client before the client will rate the working alliance as strong. In addition, clinicians are also prone to overestimate (p. 115) the strength of clients’ ratings about the helpfulness of the clinician and the treatment (e.g., Hartmann, Joos, Orlinsky, & Zeeck, 2015). Given the close association clients make between the perceived benefit of treatment and what clinicians refer to as the alliance, this would logically translate into a misunderstanding of the strength of the alliance from the clients’ perspectives.
In this manner, many clients’ experiences and perspectives closely fit Luborsky’s (1976) model of the alliance. In Luborsky’s two-type sequential model, type I alliance refers to a warm, supportive relationship that the client experiences as helpful, and a type II alliance refers to client investment in the process and shared responsibility for outcome. Somewhat further distancing themselves from Bordin’s (1979) conceptualization, clients often make less conscious differentiations between the goals of psychological treatment and the tasks that are designed to meet these goals (Hatcher & Barends, 1996, 2006). Frequently observed high correlations between the goals and task subscales of the client version of the Working Alliance Inventory also challenge the separation of these two (out of three) pillars of Bordin’s model (Hatcher & Barends, 1996, 2006) for describing how clients experience the working alliance.
Moreover, factor analyses of measures of the alliance, purportedly tapping into clients’ experiences, identify underlying dimensions that are discrepant with popular alliance theories, such as confident collaboration, idealized relationship, and help received (Hatcher & Barends, 1996, 2006). This discrepancy has led some to conclude that, when it comes to the alliance, clients experience much more than and in a different manner than clinicians (Hatcher & Barends, 1996, 2006). In connecting this to Bordin’s theory, Hatcher and Barends (1996) state that clients develop a bond based on effective therapeutic work and confidence in the collaboration. However, they point to the need for substantial revising of existing alliance measures to better capture clients’ perspectives.
Implications for Practice
Clinicians should recognize that they are likely misunderstanding the strength of the alliance that the client is experiencing, and this could partly be because they are overestimating the degree of helpfulness that the client is experiencing. Therefore, clinicians should continually and directly seek explicit client feedback to compare against their own observations, even when treatment appears to be going smoothly (Kivlighan, Marmaroth, & Hilsenroth, 2014). The research can be taken to suggest that clinicians need to spend more time trying to accurately evaluate the strength of the alliance, in collaboration with the client, and try to come to an honest, mutually agreeable understanding, especially in early interactions when initial expectations are being developed and tested (Zilcha-Mano et al., 2016). For example, a clinician could say something like, “everyone is different and what works for one individual can be quite different from what (p. 116) works for another; because we’ve only just started to get to know each other, I’m just wondering what’s going well in our working relationship and what I could be doing differently?” Alternately, a clinician could utilize brief process-oriented measures, such as the Session Rating Scale (Duncan et al., 2003), and discuss them with the client at the next session.
Resolving disagreements about and clarifying expectations for the eventual process of psychological treatment is further recommended because successfully doing so may further strengthen the alliance (Zilcha-Mano et al., 2016). In many cases, clients should be directly asked about what they expect from psychological treatment at the present time, and a frank discussion should be had about what the professional can and cannot reasonably offer. Clients cannot always answer these questions or may be unwilling to do so early in the process. As such, it also seems important to explore the answers to questions indirectly by speaking to clients’ current expectations: “Have you ever seen a counselor and psychologist before, and what was that experience like?” “What did you like and not like as much about your last counselor?” “What do you know about what happens in a counseling session?” “What do you think about how therapy is portrayed on television and movies?” And, “do you know anyone else who has gone to counseling and what was that like for them?” In some situations, clients’ expectations may be unrealistic, be based on misunderstandings of what psychological treatment is and how it works, or be beyond the training and capabilities of the particular clinician. But having open and direct conversations about these discrepancies, if handled with honesty, respect, and humility, can sometimes help to create a great sense of collaboration (Crits-Christoph, Gibbons, & Hearon, 2006).
In addition, clinicians should be mindful that, although they are typically taught that clinical outcome is a wholly distinct concept from the working alliance, this is not typically the case in the minds of clients. Clients appear to base their perceptions of the quality of the overall working alliance on the perceived helpfulness of the therapeutic work. Although this is somewhat of an oversimplification, we can expect clients who are experiencing early benefits from psychological treatment to feel closer to and bond better with the clinician, to be more willing to agree with clinician-suggested therapeutic tasks, and to collaborate or compromise more willingly on therapeutic goals. If the client believes that the clinician will be or has been helpful, positive relational consequences will result, including for the alliance (Puschner, Wolf, & Kraft, 2008). In support of this notion of the effectiveness of counseling and psychotherapy being tied to the quality of the alliance (Luborsky, 1976; Zilcha-Mano et al. 2016), there is a small body of literature that demonstrates that early clinical outcomes subsequently contribute to higher ratings of the working alliance (Crits-Christoph et al., 2006; Crits-Christoph, Gibbons, Hamilton, Ring-Kurtz, & Gallop, 2011) rather than just the other way around. In addition to directly asking the client about (p. 117) how effective treatment is and collaboratively assessing progress toward client-stated goals, standardized measures of outcome can be useful (e.g., the Outcome Questionnaire-45; Lambert, Gregersen, & Burlingame, 2004), including when they are discussed in session with the client and the client is given the opportunity to agree, disagree, and ask questions.
A similar conflation occurs in the minds of clients for goals and tasks. Clients may not experience or appreciate the distinction in session as much as clinicians do. Clinicians should be cognizant that, despite whatever concept of the alliance they are using to structure their understanding (e.g., Bordin’s goals, tasks, bond), the client is likely not using this same framework and may in fact be drawing on a different understanding of the alliance. Therefore, clinicians should generally refrain from inflexibly promoting their own particular view of the working alliance onto the client. Instead, clinicians should treat their conceptualization of the alliance as a hypothesis with each client, seeking both confirmatory and disconfirmatory evidence as well as being aware about alternative conceptualizations of the alliance and considering them in the same manner. Evidence can be gleaned directly from what clients say about the working alliance (noting that they may refer to it as a “working relationship”; Bedi, Davis, & Williams, 2005), either when asked directly or when talking spontaneously about it.
Summary of Qualitative and Mixed-Methods Research
A Client Theory of Alliance
Only one major theory of the alliance has been proposed that has been solidly grounded in clients’ unimpeded reported lived experiences. A Positive Emotion-Exploration/Negative Emotion-Lack of Exploration Spiral Theory has been proposed to explain the nature of the alliance from clients’ perspectives and its connection to therapeutic outcome (Bedi, Cook, & Domene, 2012; Fitzpatrick, Janzen, Chamodraka, & Park, 2006; Fitzpatrick, Janzen, Chamodraka, Gamberg, & Blake, 2009).
According to this theory, in order to develop and grow the alliance, the process begins with the client ascribing favorable meaning to a particular clinician behavior or verbalization and experiencing positive affect. A positive client understanding and experience can be the result of, for example, the clinician asking an intriguing question, offering a new way to look at an issue, providing useful psycho-education or psychological skills training, permitting the client unfettered verbal or emotional expression, making an appreciated self-disclosure, complimenting the client, or reassuring the client (Fitzpatrick et al., 2006). For example, the clinician could say something like, “Have you ever looked at it this way . . . ?,” or “there’s a lot of people who’ve gone through this and made it (p. 118) through,” “I can tell how hard of a worker you are,” or “it was really hard for me when I went through something similar.” In return, the client may think something constructive and affirmative such as “my therapist can help me” or “I’m important” (Fitzpatrick et al., 2006, p. 491) and experience positive affect. As a result of this positive affect, the client then responds with increased openness to deeper exploration through both self-disclosure (i.e., productive openness) and making use of input from the clinician (i.e., receptive openness). For example, the client may then say: “for the first time this session, I was talking about something really hard to hear and even to talk about” or “I was very open. I wasn’t knocking things down” (Fitzpatrick et al., 2006, p. 491). Being open can result in further positive feelings and inspire further openness, which then can lead to further positive feelings and so on. In other words, it is theorized that client openness to exploration, combined with positive emotional responses to the clinician’s actions, results in the initial development of the working alliance and its subsequent strengthening. It can be further postulated that through this client openness, progress is made in counseling and psychotherapy, and therefore the alliance should be associated with clinical outcome.
According to this theory, alliance development and strengthening is premised on client openness and positive emotions. Connecting this theory with Bordin’s (1979) model, positive feelings on the part of the client contribute to bonding with the clinician, which then subsequently leads to greater openness and exploration, which results in shared goals and agreement on tasks to achieve those goals (Fitzpatrick et al., 2009).
In contrast, a negative downward spiral can also account for diminished alliances and alliance ruptures (Bedi et al., 2012; Fitzpatrick et al., 2006). In this case, the client interprets and then reacts to something that the clinician said or did with negative feelings that impede additional exploration and openness. For example, in response to a clinician being highly directive, stating something factually incorrect, or looking distracted, the client may react by not telling the professional what the client was really thinking or minimize the severity of the problem (Bedi et al., 2012). This, in turn, predictably prompts additional negative affect in the client, which leads to further reduced exploration and openness, which creates more negative affect, following a decreasing spiral and reducing the quality of the working alliance.
In Richards and Bedi (2015), decrements in the alliance with male clients were the most associated with rigidly adhering to a therapeutic approach that was “not the right fit” (p. 170). In other words, these approaches were incongruent with the client’s understanding of what was helpful, important, appropriate, or related. As evidence, clients in their study said things such as (a) “the counselor and I did ‘weird’ exercises to address my issues that I thought were a waste of time” and (b) “the counselor suggested that her way—her philosophies (p. 119) and method of healing—were the only way that would work” (Richards & Bedi, 2015; p. 176). Based on research by Coutinho, Ribeiro, Hill, and Safran (2011), it was concluded that there are a wide variety of precipitants of alliance ruptures from clients’ perspectives. The examples they found in their study included the professional doing or saying things that the client did not like, such as providing unsolicited advice, talking about a painful topic with the client before the client was ready; or failing to do something the client wanted, such as not remembering something the client previously said. About 19–37% of clients experience significant ruptures in the alliance with their professional (Eames & Roth, 2000; Muran, Safran, Samstag, & Winston, 2005), about 30% of which remained unresolved in the client’s opinion (Coutinho et al., 2011). Often, clients do not directly inform their clinicians about this weakening of the alliance (Rhodes, Hill, Thompson, & Elliot, 1994). Although, as noted earlier, the specific content of alliance ruptures can be quite variable across clients, it appears that the impact on clients’ experiences is fairly consistent. As a result of an experienced rupture, clients typically feel sad, helpless, abandoned, criticized, or confused. For example, in response to an alliance-rupturing event, clients have said (a) “I felt very angry when the therapist suggested I do different activities because the therapist knew all the problems I had at home. So, it was like telling a paraplegic to walk”; and (b) “when the therapist suggested to do something different, I got confused. It was very hard to see things in a way I never saw before. It seemed I was losing my identity” (Coutinho et al., 2011, p. 534).
Implications for Practice
Clinicians should stay alert to and respond to ongoing clients’ negative affect in session (explicit or implied), noting that it is likely indicative of a weakened alliance or full-blown alliance rupture. Sometimes paying careful attention to momentary client facial responses can cue the clinician that a hindering event has occurred (Barros, Altimir, & Perez, 2016). Given that clients often keep this information secret (Coutinho et al., 2011), it is recommended that clinicians persist in their exploration of negative affect in session and engage the client in an explicit and active discussion about the working alliance and ways to improve it. This can be accomplished in various ways. For example, a clinician could use immediacy and share the clinician’s awareness of the client’s potentially problematic nonverbal behavior, such as avoiding eye contact, crossed arms, turning away from the clinician, and rolling eyes. A clinician could also directly ask the client to discuss negative emotions in the moment if the clinician believes that a rupture has occurred or if the client expresses negativity (Safran & Muran, 2000). The clinician can then respond in an empathetic manner rather than with defensiveness (Safran & Muran, 2000). Something that a clinician could specifically say is, “I noticed that your responses to me are much less detailed after I asked (p. 120) if you had told your partner about your changing values, and I’m curious what shifted after my questions.”
Research shows that clinicians rarely do anything different when the client experiences a rupture and instead often continue as if nothing had happened (Coutinho et al., 2011). In some cases, they are unaware of the rupture, but many times they are aware but continue in the same manner because they do not know what to do (Coutinho et al., 2011). Instead, clients typically want the clinician to change strategies and do something different, particularly as many ruptures are repetitions of previous ruptures (Coutinho et al., 2011). Clients in the Coutinho et al. (2011) study also reported wishing for more guidance from the clinician about what to do to resolve the rupture, wanting the clinician to express interest in the client as a person, and wanting more empathy for their heightened emotional states, even when they were confrontational toward the clinician. Therefore, it is also recommended that clinicians bring up and openly discuss ruptures in the alliance and explicitly offer suggestions on resolving them, all the while remembering to express care and concern about the person and empathize with any negative feelings and/or reactions toward the clinician (Coutinho et al., 2011; Safran, Muran, & Eubanks-Carter, 2011). A clinician might say something such as, “Now that you’ve mentioned it, I can totally understand your frustration at me not noticing the small but very important changes you’ve made this week. I should have noticed and mentioned them but I was too focused on trying to push you to go further. Can we take a few minutes to discuss what is the best balance of challenge and support/acknowledgment that will help you get the most of our work together? Helping me figure this out will help us work together more effectively and prevent me from making the same mistake over and over again.”
Client Alliance Types
From clients’ perspectives, the alliance can be conceptualized according to two different typologies. It can either be conceived of across the personal–professional dimension (Mohr & Woodhouse, 2000, 2001) or as one of three distinct kinds: nurturant, insight-oriented, or collaborative (Bachelor, 1995).
A personal alliance is one characterized by warmth, a deep emotional connection, a nonthreatening working relationship, and mutual self-disclosure (Mohr & Woodhouse, 2000, 2001). For example, clients have said “something that turned me on to my current therapist is how down-to-earth, caring, respectful and honest he is with me. He has no problem telling me why my day was bad or why he is pissed off. . . . I honestly can say that when you can call your therapist one of your best friends, it is critical” (Mohr & Woodhouse, 2001, p. 16). In contrast, a professional alliance is characterized by stronger personal boundaries, (p. 121) impartiality, explicit collaboration, and a working relationship where the clinician challenges the client and facilitates deeper exploration and insight. For example, clients have said, “I am not quite comfortable with the ‘I am your friend, I feel your pain’ approach. . . . I pay you. . . . While I understand the need of genuine concern in therapy, it is not always helpful. I’d like a therapist to be two steps ahead of me” (p. 16). Most clients’ expectations likely fall somewhere in between these two extremes. Extant research suggests that most clients prefer elements in line with a personal alliance (Bedi & Duff, 2009).
Alternatively, alliances can be understood as either primarily nurturant, insight-oriented, or collaborative (Bachelor, 1995). A nurturant alliance centers on warmth, friendliness, active listening, patience, and strong empathic understanding—similar to the classic person-centered approach (Rogers, 1961). In a nurturant alliance, the client might say “she’s truly a friend for me. . . . I feel her to be attentive, sensitive, available, listening. . . . I trust her entirely” (Bachelor, 1995, p. 336). An insight-oriented alliance centers on the exploratory nature of the therapeutic work, with the clinician focused on explicit guidance, keeping the client on track, and both facilitating greater client self-expression and helping the client achieve greater self-understanding than clients can on their own. In an insight-oriented alliance, the client could say, “she makes me talk a lot and I feel intensely all the emotions that she makes me experience. . . . I am surprised by what she is able to make me say, because often these are things which I had forgotten or not suspected as being a problem” (p. 336). A collaborative alliance centers on equality, two-way active involvement, and mutuality. In a collaborative alliance, the client can say “she told me that it wouldn’t be her who would find my problems but us together” and “the exchange . . . consists of mutual verbal exploration of the situation, of exchanging, and mutual evaluation of solutions” (p. 336). It is unclear what most clients expect. Bachelor’s (1995) study found the highest prevalence rate for a nurturant alliance (46%), while the two studies contained within Bedi and Duff (2009) found insight-oriented (52%) and collaborative (54%) to be most prevalent, respectively, with nurturant the least common in both samples. When asked directly, it appears that clients prefer the triadic typology of Bachelor’s over Mohr and Woodhouse’s dyadic typology in conceptualizing the alliance (Bedi & Duff, 2009).
Implications for Practice
Based on the preceding information, it is recommended that clinicians develop a highly malleable and flexible interpersonal stance. In a sense, they may need to become, relationally, “an authentic chameleon” (Lazarus, 1993, p. 404) in order to tailor their relational stance to provide the working relationship of choice for the particular client at hand (Norcross & Beutler, 1997). For example, some clients may wish to hear about the clinician’s personal life and maintain more (p. 122) of an alliance that represents some aspects of a close friendship, while others consider this harmful to the alliance (Mohr & Woodhouse, 2000). Clinicians should, early in treatment, attempt an assessment of the client’s preferred relational stance based on the preceding dimensions or categories. Because no formal, well-accepted psychometric measure exists (to our knowledge) that assesses client relational preferences, this will likely have to be done through less standardized means. One manner is to ask about the client’s relationship with a previous clinician (“So how did you get along with your previous counsellor and what worked and didn’t work?). Another is to identify significant relational patterns in the client’s life and relate them to psychological treatment (e.g., “I have noticed that you really respect your friends who tell it to you like it is; that is, they don’t hold back telling you the truth, and I am guessing that this approach will be helpful for me to take on.”). Of course, this can also be done through a combination of (a) asking clients directly (e.g., “Is it better that I spend more time listening and trying hard to understand what you’re going through or would you rather I just jump in with any insights that I think I might have?”) and (b) appraising early interactions with clients for their reactions (e.g., does the client respond more or go deeper after a clinician self-disclosure versus when confronted about an inconsistency between their words and actions?). The clinician should keep in mind that these are tendencies, and clients may resemble more than one type and change their preference over time (Bachelor, 1995). Clinicians should therefore remain watchful and continually reassess the expectations of the client.
Distinct Features of Clients’ Perspectives and Experiences
As noted earlier, professionals’ understandings of the alliance can diverge substantially from clients’ understandings. Some key ways that clients’ perspectives and lived experiences are at odds with those of professionals and deviate from the conclusions of most alliance researchers revolve around pretreatment and initial interactions, the office environment, the techniques–alliance interface, collaboration, clinician micro-skills, and the prominence of validation over other micro-skills.
Initial and Early Interactions and the Environmental Context
Before attending treatment, many clients have initial reservations (MacFarlane et al., 2015). These preconceptions are developed in a variety of ways, including through popular media representations (MacFarlane et al., 2015), and can (p. 123) support or impair the initial development of the alliance. Even before meeting their clinicians, clients have been found to extrapolate their impressions from their initial interactions with front office staff, which can make it easier or more difficult for the clinician to subsequently develop an alliance with the client (Bedi, 2006; Bedi, Davis, & Williams, 2005). In addition, clients also seem to create quick impressions based on their initial and early interactions with the clinician by things as seemingly innocuous as clinician attire, clinician grooming, the manner by which the clinician greets the client (e.g., warmly, by name), appropriately firm handshakes, and whether or not the clinician recognizes the client in the waiting room (Bedi, 2006; Bedi, Davis, & Arvay, 2005; Bedi, Davis, & Williams, 2005). For example, clients have said, (a) “my counselor always seemed happy to see me, greeting me with warmth” (Simpson & Bedi, 2012, p. 361) and (b) “the psychotherapist recognized me (remembered my name, made eye contact with me while I was in the waiting room)” (Bedi & Richards, 2011, p. 384).
Furthermore, at the outset of the first session, clients typically scan the office environment and make judgments about the clinician based on factors such as the tidiness of the clinician’s desk, the nature of books on shelves, the lighting and colors of the office, and the comfort of chairs (Bedi, 2006; Bedi, Davis, & Arvay, 2005; Bedi, Davis, & Williams, 2005). For example, clients have said, (a) “you want to see it as a professional place and not dirty and grungy. You want to see that the person cares about the office. The office helps make you feel comfortable” and (b) “I was surprised at the importance I’d put on setting. . . . For my own experience, in looking back, I see how it had a profound influence on my feeling safe to continue with my counselor” (Bedi, 2006, p. 32). These initial experiences then reportedly also predispose clients toward developing working alliances with professionals in an easier or more difficult manner (Bedi, 2006; Bedi, Davis, & Arvay, 2005; Bedi, Davis, & Williams, 2005; Simpson & Bedi, 2012). So, in the minds of clients, alliance formation actually begins before the professional first meets the client. Fortunately, there is slowly growing recognition from clinicians about the importance of the office environment and other contextual factors in impacting clients (e.g., Benton & Overtree, 2012; Borenstein, 2006; Devlin et al., 2009; Devlin & Nasar, 2012; Miya & Hanyu, 2006; Nasar & Devlin, 2011).
Implications for Practice
Clinicians should inform their office staff how vital of a role they play in client success. The better the impression and experience the client has with the front staff and the physical reception area, the easier it will be for the client and clinician to quickly develop a solid working alliance. Therefore, clinicians should appropriately thank the support staff and, if possible, work with support staff and (p. 124) administrators to ensure that the initial impression of the physical space is likely to be inclusive and welcoming.
In addition, the clinician should be mindful of the apparent importance of first impressions created at the outset of psychological treatment and at the start of every session. Research implicates the importance of devoting time early in treatment to understanding and working through initial misgivings that clients may have about psychological treatment. It is therefore recommended that clinicians, each session but especially the first one, show recognition of the client if there was previous contact, warmly greet the client by name, and groom and dress well. Furthermore, clinicians should take extra effort to structure their office to create the type of impression that they wish to portray as well as maximize the comfort of clients. Clients do not usually offer this type of information willingly, even when prompted (Blanchard & Farber, 2016). Clinicians will likely need to initiate the discussion, take initial client responses with “a grain of salt” (because clients may not initially be forthright), engage in assessment based on something other than clients’ direct responses, and revisit the topic as needed. One thing a clinician could say would be, “I sometimes worry about the first impression that I can create on the days that I am so busy that I don’t have time to tidy up my desk.” Another thing is, “It’s pretty common for individuals to develop quick impressions of their counselors. Now that we’ve been working together for a while, I am curious to know your thoughts and feelings about our work together so far?”
Techniques Versus Working Alliance
Clients’ understandings of the alliance seem to challenge the frequently used distinction among therapists between techniques and therapeutic alliance (Mohr & Woodhouse, 2001). Psychotherapy strategies and interventions are central to clients’ accounts of alliance formation (Bedi, 2006; Bedi, Davis, & Arvay, 2005; Bedi, Davis, & Williams, 2005; Bedi & Richards, 2011; Fitzpatrick et al., 2006, 2009; Simpson & Bedi, 2012) and reduced alliance quality (Bedi et al., 2012; Richards & Bedi, 2015). For example, Bedi, Davis, and Williams (2005) found that clients frequently note specific clinical techniques as responsible for alliance formation. In this study, most examples of client-identified alliance formation related to clinician technical activity. Additionally, most clients also reported technical activity as key to their alliance formation. Similarly, Bedi, Davis, and Arvay (2005) found that general counseling skills was both the largest category of client-identified alliance formation variables as well as the most prevalent one across clients in their sample, being noted (p. 125) by every single one of the clients in their study. In research by Bedi (2006), clinician technical activity revolving around teaching the client skills, assigning clinical homework, and psycho-education was the second highest rated category of client-identified alliance formation factors, only behind the category of “validation.”
In Fitzpatrick et al.’s (2006, 2009) research, clinician technical interventions that promoted alliance development were ones that helped clients think or act in a new way, encouraged clients to take space, demonstrated interest, provided emotional support, communicated understanding, demonstrated nonjudgmental attitudes, shared something meaningful (such as compliments, reassurance, positive feedback, tools, or assignments), or met clients’ unexpressed needs. Bedi and Richards (2011) found that when a male client experienced practical help from the clinician, this correlated largely with Working Alliance Inventory – Short Form revised total scores (r = .41). Other evidence consistent with the claim that techniques can facilitate the alliance include (a) Luborsky’s (1976) findings that psychodynamic interpretations, if suitable, resulted in improved alliances while unsuitable ones had the opposite effect and (b) Kivlighan’s (1990) finding that technical activity accounted for 32% of the variation in clients’ ratings of the working alliance.
Whereas a clinician implements a particular clinical technique with the intention of impacting outcomes positively (i.e., helping the client get better), in the minds of clients, these interventions have significant relational implications that can override the outcome-focused intention of the professional (Bedi, Davis, & Arvay, 2005; Bedi, Davis & Williams, 2005). The clinician may not be offering a particular intervention with the goal of fostering the working alliance with the client, but that is what often occurs from the client’s perspective. Therefore, to clients, clinical techniques serve the additional function of alliance-formation strategies when delivered in a manner that makes the client feel cared for, respected, and hopeful (Fitzpatrick et al., 2006, 2009).
Implications for Practice
Clinical interventions are often understood by clients as having relational consequences for the formation, strengthening, and maintenance of the alliance beyond their direct impact on outcome. So, in the minds of clients, techniques cannot be divorced from the context of the working alliance and neither should they be for clinicians. When deciding on an intervention, clinicians should be aware that the client is likely looking at the suggestion and implementation of the intervention through a relational lens. The process and outcome of the intervention will likely provide feedback to the client about the nature and quality of the working alliance between the client and clinician.
(p. 126) Collaboration
Collaboration is well-regarded in predominant alliance theories as one of the foundational components of the alliance (Bordin, 1979; Hatcher & Barends, 1996). In contrast, the most replicated finding across research on clients’ perspectives on and experiences of the alliance is that clients do not characteristically reaffirm the collaborative nature of alliance formation and maintenance. Instead, clients highlight clinical contributions as the engine of alliance formation and place the primary responsibility for alliance formation on clinicians (Bachelor, 1995; Bedi, 2006; Bedi & Duff, 2014; Bedi & Richards, 2011; Bedi, Davis, & Arvay 2005; Bedi, Davis, & Williams, 2005; Bedi et al., 2012; Duff & Bedi, 2010; Fitzpatrick et al., 2006, 2009; MacFarlane et al., 2015; Mohr & Woodhouse, 2001; Simpson & Bedi, 2012). Clinicians should not necessarily expect clients to be initially thinking about therapeutic collaboration as clients often enter treatment in great psychological distress, feeling incompetent in resolving their problems, and “unable to handle much responsibility” (Bedi, 2006, p. 32).
Implications for Practice
Despite collaboration not being a core phenomenological experience of clients, clients do not have to identify or experience what they are doing in alliance formation and maintenance as collaborative for it to actually be collaboration in some objective manner (Hatcher & Barends, 2006). In other words, clients often do not readily identify what they are doing as collaboration or notice their own contributions to the alliance. A small amount of research indicates that, as sessions progress, later in psychological treatment, clients tend to take on more agency in maintaining the alliance (e.g., Fitzpatrick et al., 2009) and that men might be more collaborative early in treatment (Bedi & Richards, 2011). Nevertheless, clients can sometimes recognize greater collaborative self-involvement in the alliance with direct probing (Fitzpatrick et al., 2009). In counseling and psychotherapy, understanding how client participation can help or hinder the development and maintenance of the alliance could be quite therapeutic for clients in and of itself, as well as improve the working alliance directly (Fitzpatrick et al., 2006).
Therefore, it is recommended that clinicians focus clients’ attention on the collaborative nature of the alliance and perhaps educate them on the need for mutual responsibility and effort in creating a successful working relationship—in a sense, demystifying the process (MacFarlane et al., 2015). For example, a clinician can say something such as, “A relationship takes two people to work—and this includes the working relationship between me and you. We really need (p. 127) to work together to be most effective. I will always try what has been successful for most people I have worked with but everyone is different—and what has worked for someone else may not necessarily work for you. So we really need to put both of our heads together and combine our wisdom and experience.” This idea is completely in line with the larger principle underlying role induction techniques, which have been shown to improve client engagement and prevent clients’ unilateral termination (Swift & Greenberg, 2015). Role induction can be accomplished simply by giving the client a handout on what counseling or psychotherapy is and what to expect or by spending 5 minutes telling the client what the clinician expects and what the client should expect of the clinician (and then processing it and coming to a mutual understanding).
Forming the alliance may be deceptively simple and centered on counseling micro-skills (Bedi, 2006; Bedi, Davis, & Arvay, 2005; Bedi, Davis & Williams, 2005; MacFarlane et al., 2015). However, these micro-skills may be so ubiquitous that professionals may fail to fully appreciate their potentially powerful impact on the alliance. Clients frequently note the pivotal importance of nonverbal and paraverbal skills, such as the SOLER physical attending skills (face the client Squarely, Open posture, Leaning in slightly, Eye contact, and Relaxed posture), head nodding, paraverbal prompts (e.g. “uh-huh,” “mm-hmmm,” “yes,” “okay”), smiling, and shared laughter (e.g., Bedi, Davis, & Arvay, 2005). Clients also frequently acknowledge as integral the pivotal importance of nonjudgmental, active listening verbal skills, especially for initial alliance formation: identifying and reflecting feelings/empathic reflections, paraphrases/content reflections, summaries, validation, normalization, and complimenting the client/pointing out client strengths (Bachelor, 1995; Bedi, 2006; Bedi et al., 2012; Bedi, Davis. & Arvay, 2005; Bedi, Davis, & Williams, 2005; Bedi & Duff, 2009, 2014; Bedi & Richards, 2011; Duff & Bedi, 2010; Fitzpatrick et al., 2006, 2009; MacFarlane et al., 2015; Mohr & Woodhouse, 2001; Richards & Bedi, 2015; Simpson & Bedi, 2012). Such research findings even hold up when the alliance was overtly defined for clients in line with Bordin’s (1979) definition. Clients still listed these micro-skills as essential for the bond, goals, and tasks components of the alliance (MacFarlane et al., 2015).
To further highlight the importance of counseling micro-skills, presented here is a collection of sample quotations from clients concerning what they identified as important for alliance formation and maintenance as related to the above-mentioned micro-skills:
1. “The therapist made eye contact while listening to me” (Bedi, Davis, & Williams, 2005, p. 318).
2. “The way my counsellor sat, moved etc. indicated that he was comfortable and he was not somehow personally threatened, closed-off, or upset” (Simpson & Bedi, 2012, p. 357).
3. “The therapist remembered and repeated back things that I had said in previous sessions” (Bedi, Davis, & Williams, 2005, p. 318).
4. “The therapist recognized my feelings and put a name to them when I couldn’t” (Bedi, Davis, & Williams, 2005, p. 318).
5. “The therapist normalized my feelings saying ‘this happens to couples’ and ‘that happened to me, too’ ” (Bedi, Davis, & Williams, 2005, p. 319).
6. “The psychotherapist identified and reflected back my feelings” (Bedi & Richards, 2011, p. 384).
7. “The counselor did not judge me and made me feel like everything I was dealing with was normal” (Simpson & Bedi, 2012, p. 357).
8. “My counselor took my perceptions and beliefs at face value without putting his meaning on my experience. My counsellor worked with me, not the counselor’s story of me” (Simpson & Bedi, 2012, p. 361).
9. “My counselor always seemed happy to see me, greeting me with warmth and a solid hug. She commented on my strengths as an individual and expressed heartfelt happiness when things in my life were going well” (Simpson & Bedi, 2012, p. 361).
10. “I felt it was very easy talking to my therapist because he gave a sense that he was understanding my feelings” (MacFarlane et al., 2015, p. 367).
11. “I brought forward this issue . . . and we covered that first and then she let me sort of explain, she was very unobtrusive and she let me get it all off my chest” (Fitzpatrick et al., 2006, p. 491).
12. “We talked about something and she related it to something in my life that I had already told her and it was . . . a connection that I had never made” (Fitzpatrick et al., 2009, p. 568).
Although it is not without its limitations, the micro-skills approach has become the dominant paradigm for counselor training (McLennan, 1994; Ridley, Kelly, & Mollen, 2011). There is an abundance of research that shows the effectiveness of counseling micro-skills (e.g., Kim & Kim, 2013), including in randomized control trials of facilitative interpersonal skills (e.g., Anderson et al., 2016). Notably, even entire training textbooks have been grounded in the micro-skills approach (e.g., Daniels & Ivey, 2007). Fortunately, such skills are highly trainable (Levitt, 2002; Kuntze, van der Molen, & Born, 2009).
In Bedi and Richards (2011), clinician nonverbal behaviors correlated .33 to .46 with the total Working Alliance Inventory – Short Form, revised (WAI-Sr) (p. 129) and its subscales of goals, tasks, and bond, with the highest correlation with the tasks subscale. Duff and Bedi (2010) found moderate to high correlations between clinician eye contact, greeting the client with a smile, referring to details discussed in previous sessions, clinician responding honestly, clinician sitting still without fidgeting, and clinician facing the client and alliance as measured by the WAI-Sr. Duff and Bedi’s (2010) study further demonstrated that what clients believe to influence alliance development is supported by quantitative research.
Implications for Practice
Although one can easily be seduced by advanced theoretical conceptualizations of the client and of the alliance, as well as by the plethora of clinical techniques available, clients’ reports frequently make note of basic counseling micro-skills as essential for developing and maintaining the working alliance. Therefore, it is recommended that clinicians make frequent use of the micro-skills noted here—not only at the outset of psychological treatment to develop the alliance but throughout it to maintain the alliance, especially after ruptures occur.
Of all the counseling micro-skills, validation appears to play the most prominent role as reported by clients. Researchers studying clients’ perspectives have defined validation as communicating to the client that their experiences are not abnormal and that they are legitimate or defensible (Bedi, Davis, & Williams, 2005). Duff and Bedi (2010) stated that validation was grounded in the clinician’s positive regard and liking of the client (Rogers, 1961). In their own words, by validation, clients mean that a clinician “[said] that my reaction was understandable and reasonable, that it was okay to feel this way,” “normalized my experience,” “made encouraging comments,” “made positive comments about me,” and “agreed with what I said” (Bedi, 2006, p. 31). Validation can also be accomplished by appropriate clinician self-disclosure, as noted by the client who stated that validation occurred when the counselor said, “That happened to me, too” (Bedi, Davis, & Williams, 2005, p. 319).
Although validation of clients’ experiences is already highly regarded in the psychological treatment literature (Linehan, 1997), in the minds of clients, it seems to be one of the most important variables for alliance formation. Some research shows that it can actually be more potent than empathic verbal reflections, particularly in increasing client self-esteem and elevating low client mood (Kim & Kim, 2013). In Bedi, Davis, and Williams (2005), validation was one of the more prevalent categories of client-identified alliance formation factors. In Bedi (2006), validation was the highest rated category of client-identified alliance (p. 130) formation factors. In Duff and Bedi (2010), validation, defined as making encouraging comments, making positive comments about the client, and greeting the client with a smile, accounted for 62% of the variance in client-rated working alliance scores (WAI-Sr). Also in this study, client-experienced validation correlated .69 with the WAI-Sr. In Bedi and Duff (2014), validation was among the highest rated and most prevalent client-identified alliance formation variables. Validation was also frequently noted as resulting in positive client feelings, which spiraled into increased openness and exploration necessary for alliance formation in the research of Fitzpatrick and colleagues (2006, 2009). The evidence is clear. In the minds of clients, validation is core to developing and maintaining the alliance.
Implications for Practice
It is recommended that clinicians frequently communicate to clients, when possible and appropriate, that they and their thoughts, feelings, and behaviors are acceptable to the clinician, valid, and worthwhile in order to maximize the alliance. Although this construct corresponds greatly with the Rogerian strategy of unconditional positive regard (Rogers, 1961), it is often reported by clients as feeling validated. As a result of this validation, clients should be willing to say things like, “the therapist congratulated me for the things I was doing and had done to help myself” (Bedi, Davis, & Williams, 2005, p. 318) and “the counsellor did not judge me and made me feel like everything I was dealing with was normal” (Simpson & Bedi, 2012, p. 357).
Caveats and Limitations
Similar to any intervention or clinical strategy, clinicians are cautioned to apply the interventions and strategies outlined in this chapter with careful consideration of contextual factors such as unique client characteristics, client preferences, client past experiences, attunement with the client in the moment, timing, clinician skill level, and clinician expertise. For a potentially silly example but one whose underlying principles can be generalized well: the fact that eye contact was noted across research studies as a key clinician behavior that clients strongly believe helped develop and maintain the alliance does not mean that clinicians can just stare incessantly at every client throughout the entire session. There will be times when eye contact should be maintained for longer periods and times when full eye contact should not be made. Timing and appropriateness to the situation are necessary for eye contact to facilitate the development of the alliance.
In addition, there are some notable limitations of the pool of research that this chapter draws on. First, clients’ self-report data can be limited by social, (p. 131) cognitive, and memory biases and restrictions (Hyman & Loftus, 1998; Nisbett & Wilson, 1977; Villejoubert, 2005). This includes the notion that there will be variables that impact the working alliance that are beyond the awareness of clients (such as the impact of one’s history of positive or negative interpersonal relationships and one’s attachment style) (Sharpless, Muran, & Barber, 2010).
Second, despite the massive accumulation of research evidence pertaining to the working alliance, virtually all of it is based on research designs (e.g., correlational, regression, qualitative) that do not justify making cause-and-effect claims. However, there is a growing pool of research and reported clinical experience consistent with claims of causality made in this chapter (e.g., Duff & Bedi, 2010).
Third, most theorizing and research is based on treating alliance and clinical technique as distinct components of treatment. In contrast, Hatcher and Barends (2006) propose that alliance and technique are inseparable—that the alliance is actualized when techniques engage clients in collaborative and purposeful work. So, rather than viewing alliance as a component of the overall therapeutic relationship or as distinct from techniques, Hatcher and Barends (2006) describe the two constructs as necessarily intertwined and requiring each other. According to them, the alliance is what occurs when clinicians’ interventions and strategies engage the client toward shared goals and agreed-upon tasks. In other words, the alliance is a result of multiple components of psychological treatment acting together, rather than an isolated component. Techniques that can enhance or embody collaborative purposeful work reflect a sound working alliance (Hatcher & Barends, 2006). Considering alliance and technique as intertwined, while diverging from how the alliance is predominantly understood, actually best embodies the growing body of research on clients’ experiences of the working alliance. Adopting this perspective, however, is inconsistent with how the alliance is usually researched.
Fourth, what is offered in this chapter is what clients believe contributes to developing or maintaining the working alliance with their mental health professionals. Extrapolation of these findings to the actual process of alliance formation, which involves interaction between two individuals, should be done cautiously and with consideration for the fact that clients’ experiences of the alliance may diverge substantially from clinicians’ experiences or personal observations. Clients’ subjective experience of establishing a working alliance cannot be equated with, and is therefore not synonymous with the actual interactive process of alliance formation (Duff & Bedi, 2014). In other words, what the client thinks is this one single person’s interpretation and understanding of how the alliance is formed and maintained with them, but the alliance is a relationship and requires another person (the clinician) who may see, understand, and experience things differently. Nonetheless, the results within this body of (p. 132) research are suggestive of causal processes to be further investigated in future research.
Clients’ experiences of the alliance are more predictive of therapeutic outcomes than are clinicians’ experiences (Flückiger et al., 2018). Growing research on clients’ perspectives on, experiences of, and contributions to the working alliance (much of which is qualitative or mixed-methods) seems to counter the dominant understandings of the working alliance, which are based on quantitative research and psychometric measures that are grounded in viewpoints of clinicians (Bedi, 2006). Research privileging the voices of clients has concluded the importance of early interactions in and prior to psychological treatment (Tryon et al., 2007), the relational experience of interventions (Bedi, Davis, & Arvay, 2005; Bedi, Davis, & Williams, 2005), and the value of micro-skills (MacFarlane et al., 2015) such as validation (Bedi 2006; Bedi, Davis, & Williams, 2005), and has taken a critical look at the lived experience of client collaboration when it comes to developing and maintaining a working alliance (Bedi, 2006). Each of these principles has key practice implications as outlined in this chapter. However, more research is needed on the client perspective for professionals to have a better understanding of how to develop and maintain the working alliance with clients.
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