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Mental Health: The Therapeutic Alliance and How Psychotherapy Heals

Updated on March 5, 2017
AudreyHowitt profile image

Audrey is a poet, classical singer and voice teacher, recovering attorney and licensed psychotherapist.

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In recent years, studies have shown that when looking at effectiveness of counseling or psychotherapy measured in terms of the number of clients improved, the results are remarkably similar across studies—approximately 22% make significant changes, 43% make moderate changes , and 27% make some improvement. [i] So how and why is counseling effective? What makes it effective and why does it work.

Culturally, psychotherapy can be divided into two major camps: the treatment camp and the relationship camp. The question boils down to whether one believes that treatment heals or whether one believes that relationships heal. [ii] This both informs and grows from a therapist's theoretical orientation.

Client Centered Approaches

New studies show that certain treatment methodologies work better for certain presenting problems. Called “evidence based practice,” this approach, rather than a strict adherence to modalities dictated by theoretical orientation, is rapidly becoming commonplace in psychotherapy. It can be likened to a problem solving model. The therapist uses whatever seems to work best for the client.

In addition, certain qualities of the therapist appear to be important to positive client outcomes: empathic stance, the ability of the therapist to provide a strong therapeutic alliance, and the therapist’s ability to adhere to theoretic stance regardless of the approach used in the work done with the client. [iii] A therapist must hold the client in positive regard for the therapeutic bond to develop.

In addition to the above factors, a new corrective experience by the client is important. A client must have a positive emotional experience that allows emotional trust and growth to occur as a result of the client’s work with the therapist. In essence, the client relives or experiences the difficulty or painful experience with the therapist. By providing a different emotional response, the client experiences the problem differently. When this experience is positive, the client is able to cope with the difficulty in a new and more positive manner.

The Importance of a Strong Therapeutic Alliance

A strong therapeutic alliance is key to a positive relationship between client and therapist. This relationship can be defined as the feelings and attitudes that the therapist and client have toward one another and the way in which they are expressed. [iv] In a 2006 study, it was shown that for clients with a strong therapeutic alliance, adherence to a treatment manual was found to be irrelevant toward the issue of outcome. But for clients with a weaker therapeutic alliance, a moderate level of adherence by the therapist to theoretical treatment modalities provided the best outcome. [v]

In reality, what a therapist does, what techniques or interventions are used, is inextricably linked with how a therapist behaves with a client. In an era of managed care, limited treatment and limited coverage for treatment, codified treatment modalities, and the like, it is easy to dismiss the role of the therapist, and yet, studies show that the therapist and the level and type of relationship between the therapist and the client are critical to positive therapeutic outcomes, regardless of the treatment modalities implemented.

Elements of a Strong Therapeutic Alliance

Therapeutic alliance includes the idea of “fit.” It is important that a client feel comfortable with the therapist. From the therapist’s perspective, a therapist strives to enhance treatment effectiveness by tailoring it to the individual. [vi] In essence, each therapeutic relationship is unique and each client receives a different therapeutic experience. The goal is for an empathic therapist to achieve a collaborative relationship with an active client based on that client’s needs. This allows the client to experience their needs being met in an empathic relationship, which in turn allows, the client to take responsibility for effectuating change and healing within a safe environment. Ultimately, it is the client who provides the lion’s share of success in a therapeutic environment. The therapist provides a container for the relationship that heals.


[i] Edward S. Neukrug, Counseling Theory and Practice (Brooks/Cole Press: Belmont, CA 2011) 2, 3

[ii] John C. Norcross, Psychotherapy Relationships That Work: Evidence Based Responsiveness (Oxford University Press: 2002) 3-4.

[iii] Neukrug Counseling Theory and Practice , 3.

[iv] Norcross, Psychotherapy Relationships That Work , 4.

[v] Id.

[vi] Id., 10.

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    • HattieMattieMae profile image

      HattieMattieMae 5 years ago from Limburg, Netherlands

      What is interesting is sometimes a spiritual teacher, life coach, or maybe healer, actually can have better chances of helping a person, I think because they don't label a client as mentally ill. I think it some how gives people purpose and direction without saying they are sick, or need a doctor, and depending where your at, psychology and spiritual psychology can make all the difference in helping a person. More the mind,body,spirit wellness scenario. It is interesting, but have to agree, it depends on the client, therapist, and what works for the client, as well as the diagnosis. I think sometimes though with all my training, that the training never really reached in the part where you are usually treating broken hearts, which take time to heal. Pills are not always the answer, and fortunately most psychologists will have you talk, but never do teach life skills or coping skills. It's nice to pay someone to sit for an hour, but if you have 10 sessions a year and never learn anything, and never beyond the surface, what can you really do to help people. Sure you can listen all you want to a client, but if you have nothing to teach them to survive and apply to their lives, they will keep coming back and never learn to problem solve. If you teach a man how to fish, he'll never have to come back.

    • AudreyHowitt profile image
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      Audrey Howitt 5 years ago from California

      Thank you Hattie. I find the medical model to not be very helpful--it tends to focus on labels and a diagnosis is not all that helpful sometimes. Depression is so very different from person to person. It is when we see what depression is like for that person that we can help them find finds to not only survive, but to accept and even to thrive--

    • WD Curry 111 profile image

      WD Curry 111 5 years ago from Space Coast

      This takes me back. I worked at Devereux for ten years. I was not a therapist. I was the resident artist and a vocational instructor. I started an apprentice program, and we had a working art related shop and business. Therapists were often amazed at my results. My methods were to find something they liked to do and assign them to it. I didn't get involved with deep therapeutic issues, there were people for that. Most of my students would cooperate with their program to be able to participate more with my effort. Many times, problems would diminish from keeping busy and accomplishment. Of course the biggest problem my students had was low self-esteem. I learned a sure fire approach to any behavior problem.

      Love never fails.

    • AudreyHowitt profile image
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      Audrey Howitt 5 years ago from California

      You are so right WD! Love never fails. Therapists are born that way. Training helps, but it can't replace the ability to connect. You were doing the good work of therapy without talking about the deep seated issues--thank you for the read and comments!

    • WD Curry 111 profile image

      WD Curry 111 5 years ago from Space Coast

      Sure. I did my share, but there was deeper work to do. We had a multi-disciplinary team . . . the Psychiatrist, the therapist, the case worker, the nurse, the teacher, yours truly, the supervisor of the line staff, and the dietitian (often cured ADHD).

      I can't help but wish we could all have a multi-disciplinary approach to our lives. We are so dysfunctional as a society.

    • AudreyHowitt profile image
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      Audrey Howitt 5 years ago from California

      Our society doesn't seem to value people very much--we value money and status more than an individual's experience and I think people feel disenfranchised often--it makes me so sad.

    • WD Curry 111 profile image

      WD Curry 111 5 years ago from Space Coast

      Our society also has souls like you. There is much hope!

    • HattieMattieMae profile image

      HattieMattieMae 5 years ago from Limburg, Netherlands

      Well that is the thing if you listen to Carolyn myss on you tube she explains the spiritual healing aspect of stuff. Medical model I am not always sure about to much.

    • AudreyHowitt profile image
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      Audrey Howitt 5 years ago from California

      Thank you--WD and Hattie---I do know that when I have sat with clients, the connectedness provides the platform for healing to occur--and that connectedness if what I think we all strive for in our daily lives.

    • authorfriendly profile image

      authorfriendly 5 years ago from Charleston, SC

      How a therapist behaves is far more important than what he believes works or how he has been trained. Most therapies work, if the therapist is genuine and a decent person.

    • AudreyHowitt profile image
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      Audrey Howitt 5 years ago from California

      Thank you so much for the read and comments authorfriendly! I couldn't agree with you more!

    • molometer profile image

      molometer 5 years ago

      Very useful and informative hub on the issue of treatment modalities.

      I remember reading somewhere many years ago, that in some cases 'eventually you find the therapist that works for you'

      This indicates the central role of the therapist.As you pointed out strict adherence to one methodology is no longer the norm.

      This can only be a good thing.

      Excellent and clear advice on current trends. Voted up.

    • AudreyHowitt profile image
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      Audrey Howitt 5 years ago from California

      Thank you Molometer--I do think there is more flexibility in treatment modalities among therapists these days--therapy is dictated as much, if not more, by what works for the client--and that is a good thing!

    • Frank Atanacio profile image

      Frank Atanacio 5 years ago from Shelton

      A very useful Hub.. Psychotherapy heals.. I guess it does.. up and useful

    • AudreyHowitt profile image
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      Audrey Howitt 5 years ago from California

      Thank you Frank! I am a believer in the relationship as the healer. Positive relationships--love-- can heal a great many wounds.

    • Vinaya Ghimire profile image

      Vinaya Ghimire 5 years ago from Nepal

      I'm interested in psychology which means I'm also interested in psychotherapy. Thanks for sharing this informative article.

    • AudreyHowitt profile image
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      Audrey Howitt 5 years ago from California

      Thank you Vinaya!

    • Ruchira profile image

      Ruchira 5 years ago from United States

      Humans being Social Animals...Psycotherapy is a very good means of helping them solve their problems.

      In this rat race, people want instant results thus, most depend on drugs.

      Loved your hub...voted up and interesting & useful

    • AudreyHowitt profile image
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      Audrey Howitt 5 years ago from California

      There is something so very powerful in the deeper relationships that people have--healing and wonderfully loving--thank you for reading Ruchira!

    • Sandyspider profile image

      Sandy Mertens 5 years ago from Wisconsin, USA

      Very useful hub. Therapy is the best way.

    • AudreyHowitt profile image
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      Audrey Howitt 5 years ago from California

      Thank you sandyspider!!! How are you??

    • profile image

      iamaudraleigh 5 years ago

      Audrey, I can relate to finding the therapeutic alliance. It has been difficult over the years to do so. I am working with a good psychotherapist and trust her. I cannot say it is always easy though.

      Thank you for writing this...well done.

    • AudreyHowitt profile image
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      Audrey Howitt 5 years ago from California

      Actually, I think therapy is a difficult and brave endeavor--I have been on both ends of it, and feel that the fit with the therapist is critical--best to you and hang in there

    • Michael Salas profile image

      Michael Salas 5 years ago from Dallas, Texas

      This is an interesting Hub with a lot of good information. As a therapist I respect what you wrote here, and the good dialogue you have created in the comments below. Thank you!

    • AudreyHowitt profile image
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      Audrey Howitt 5 years ago from California

      Thank you Michael!

    • gsidley profile image

      Dr. Gary L. Sidley 4 years ago from Lancashire, England

      I think that rigid adherence to a theoretical model is on the wane, and not before time. It is the quality of the relationships people have which strongly influences their mental health, whether these relationships be with therapists, psychiatric nurses, peers, family members or doctors.

      Although it is happening at snail's pace, the recognition of the importance of relationships is seeping into the secondary mental health ("severe mental illness") domain in the form of recovery approaches.

      Useful hub - voted up.

    • poshcoffeeco profile image

      Steve Mitchell 4 years ago from Cambridgeshire

      Audrey, I was quite surprised at the figures of clients getting benefit from counselling. It just shows how it really does pay to talk problems through. Interesting stats.

    • AudreyHowitt profile image
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      Audrey Howitt 4 years ago from California

      I so agree with you gsidley! Thank you for reading this and happy holidays to you!

    • Vellur profile image

      Nithya Venkat 4 years ago from Dubai

      Very interesting, am glad people are seeking for help. Very vital help that will improve their lives and make them happy instead of just giving up. Thanks for sharing and voted up.

    • AudreyHowitt profile image
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      Audrey Howitt 4 years ago from California

      The stats are interesting I thnk--thank you so much for reading this poshcoffeeco!

    • AudreyHowitt profile image
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      Audrey Howitt 4 years ago from California

      Thank you Vellur!!

    • Cyndi10 profile image

      Cynthia B Turner 4 years ago from Georgia

      It appears from what you have written, that therapy is becoming a lot more intuitive and in tune with the patient rather than adhering to a particular mode of therapy. I would think that would be very effective in many cases because the patient then comes first and the treatment model becomes secondary. The therapist will really work with the patient rather than "work on" the patient. Very interesting article to start my morning. I'm retweeting and sharing.

    • AudreyHowitt profile image
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      Audrey Howitt 4 years ago from California

      Hi Cyndi! I think you are right--it is so much better for the client!

    • mary615 profile image

      Mary Hyatt 4 years ago from Florida

      This is a subject that I've always wanted to know more about. In reading your article, I feel I have learned about psychotherapy. I think more people now a days depend too much on pills to solve their mental problems.

      I enjoyed and voted this UP, etc

    • AudreyHowitt profile image
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      Audrey Howitt 4 years ago from California

      Thank you Mary!! I am so glad that you enjoyed this! There is nothing that can replace a healing relationship--

    • tillsontitan profile image

      Mary Craig 3 years ago from New York

      Trust and a relationship that works can foster healing better than most people think. You've proven the pont.

      Voted up and interesting.

    • AudreyHowitt profile image
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      Audrey Howitt 3 years ago from California

      Thank you Mary!!

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