Working Alliance Skills for Healthcare Professionals

In this chapter, the authors provide a brief overview of the history of the working alliance and a brief summary of the primary empirical findings on the topic to date. They also provide a rationale for the current book, including the need to better advance training in working alliance skills in graduate programs and, relatedly, the need for examples of in-session interventions that can help beginning as well as advanced clinicians establish stronger working alliances with their clients. A brief description is given of the chapters making up the book, along with an overall summary of the importance of educating students in the skills needed to form and maintain the working alliance with clients.

A Therapist’s Guide to Repairing Ruptures in the Working Alliance

The authors discuss the phenomena of “misattunements,” or ruptures, in the working alliance. They present a set of skills and tools that aim to help therapists recognize and identify when ruptures occur, and they introduce a model for managing these moments. Albeit difficult, ruptures in the working alliance are common, and research shows that a therapist’s ability to recognize and attend to these ruptures has a positive relationship with client improvement at the end of therapy. Strategies that have been successful in rupture repair (the therapist’s attempts to address the rupture and restore the alliance with the client) include the therapist’s exploration of the client’s experience of the rupture and the acknowledgment of the client’s perspective. Finally, they present real-world, clinical examples of their rupture repair model, which consists of strategies that can help therapists negotiate difficult therapeutic moments by employing the technique of mindfulness and demonstrating genuineness and authenticity in the therapist–client relationship.

Setting Goals and Tasks in the Working Alliance

The author reviews skills for setting and developing attainable therapy goals and methods to achieve goal consensus. These goals should be determined in collaboration with the patients, should be in the patients’ best interest, and should address the patients’ problems. Once the therapist–patient dyad has established the goals of therapy, the therapist and client will need to collaborate on establishing the treatment tasks that will help patients achieve their goals. Finally, progress toward goals should be assessed and termination should be discussed from a goal perspective. Moreover, therapists should discuss plans for the future with their patients, including an invitation to return to treatment if the need were to arise, as well as possible referrals for additional help if necessary. The author presents clinical examples of how to develop goals and tasks in therapy.

The Bond of the Working Alliance

The authors describe the “working bond” aspect of Bordin’s conceptualization of the working alliance. Within the working alliance, the bond refers to an emotional attachment formed and maintained between client/patient and therapist. This bond reflects the feelings and attitudes that client/patient and therapist have toward each other and enables the therapeutic work through a sense of collaboration and trust. First, the authors discuss the defining features of the bond. Then they identify various skills and facilitative attitudes that can foster the bond, such as empathy, unconditional positive regard, and genuineness. Finally, they discuss how the working bond and possible ruptures will manifest at various stages in the treatment, from building the initial bond to working through termination.

Multicultural Considerations in the Working Alliance

The author addresses the importance of the working alliance from a multicultural perspective. In order to best serve the needs of racial/ethnic minority clients, it is critical to acknowledge and consider their differential social and cultural realities, as well as the therapists’ own sociocultural contexts. Therapists may need to be intentional in their attempt to connect with racial/ethnic minority clients by developing appreciation and respect for cultural diversity. The appreciation and respect for cultural diversity that is developed from therapist’s self-work can then facilitate an open, accepting, honest, and empathic working relationship with racial/ethnic minority clients. The author of this chapter provides clinical examples and specific therapeutic skills that can foster the working alliance with racial/ethnic minority clients.

Consensus and Collaboration in the Working Alliance

In this chapter, the authors address the concepts of consensus and collaboration, which are two related constructs that underlie the working alliance. The authors discuss how to establish consensus and collaboration with patients, as well as how consensus and collaboration evolve from the beginning of treatment to termination. Additionally, they provide clinical examples of how to achieve consensus and collaboration within the working alliance and discuss three interrelated markers of client behavior that signal that there is consensus and collaboration in the therapist–client dyad—collaborative motivation, framework consensus, and collaborative action. The goal of this chapter is to provide therapists with the tools to foster a “confident collaborative relationship.”

Integration and Discussion

In this chapter the author discusses the most salient content from each of the previous eight chapters with the goal of highlighting themes and of integrating ideas for the reader. A working alliance must be cultivated and maintained, at times even repaired. Simply putting together a well-meaning therapist and a motivated client does not guarantee that a working alliance will develop between the two. While the working alliance is a collaborative effort and product, it is the therapist’s primary job to foster its development, along with the contributions and collaboration of the client. Finding a shared focus and purpose to the work is at the heart of what constitutes the working alliance, and this is exactly what the therapist must set to accomplish from the earliest moments in treatment. The author organizes the themes along the lines of the therapist, the client, and therapist–client interactions. The author discusses implications for future thinking with respect to training and clinical practice from the perspective of the working alliance.

Therapeutic Interpersonal Skills for Facilitating the Working Alliance

The authors focus on the interpersonal skills that can be cultivated to promote a productive working alliance between therapist and client/patient. Specifically, they identify pan-theoretical, pragmatic methods of improving therapist interpersonal skills with the goal of establishing and maintaining working alliances. The authors review the eight facilitative interpersonal skills (FIS) and discuss the role of therapist responsiveness—the ability to detect and modify in-session processes based on subtle, interpersonal shifts in the client’s expression and communication. Therapist responsiveness and the use of FIS is of particular importance during challenging, emotionally charged incidents during therapy, known as “critical relational markers.” Finally, they discuss how therapists can foster these relational capacities through deliberate practice. Clinical examples are utilized to facilitate understanding of the application of these skills.

Facilitating Supervisee Competence in Developing and Maintaining Working Alliances

The quality of the therapist-client working alliance predicts both a client’s persistence in treatment and the outcomes he or she achieves. More effective therapists are better able to establish strong alliances across a range of clients, and this is true regardless of the model from which they work. It is important, therefore, that training programs ensure that their graduates are able to develop and manage alliances with their clients. Supervisors are key to accomplishing this training goal. This chapter focuses on the supervisor–supervisee relationship and its effect on the supervisee–client working alliance. As detailed by the authors, the working relationship between a supervisor and a supervisee is paramount in the supervisee’s professional development. The supervisor–supervisee relationship provides the contextual framework from which supervisees begin to form working alliances with their own clients. The authors highlight areas of supervisory focus that can improve the supervisee–client working alliance by focusing on specific attitudinal and skill-related issues that affect working alliance-related competence.

Clients’ Perspectives on, Experiences of, and Contributions to the Working Alliance

This chapter focuses on the “other side” (argued here as the more important side) of the working alliance—that is, clients’ perspectives, experiences, and contributions. The authors provide a practice-friendly review of the research on clients’ understandings of the alliance and offer suggestions and techniques that professionals can use to develop and maintain a working alliance that is responsive to clients’ subjective understandings. Moreover, they remind clinicians that the client’s experience of the working alliance is more predictive of successful counseling and psychotherapy than clinician’s own experience of the working alliance. Therefore, clinicians should dedicate significant effort on the development of a working alliance that fosters openness and positive emotions. Particular emphasis should be placed on the early interactions in and prior to psychological treatment, the relational experience of interventions, and the value of micro-skills (i.e., validation) when developing and maintaining a working alliance.