Introduction to counseling & building and maintaining alliance

Therapeutic Alliance

• The therapeutic alliance is commonly associated with counseling and psychotherapy but has broader applications in:

  • Counseling
  • Psychotherapy
  • Medical and health settings (e.g., physio, GPs)
  • Coaching (e.g., career, life, executive coaching)
  • School and career counseling
  • Substance use treatment
  • Online therapy and AI-driven tools

• Counseling:

  • Involves support, guidance, and/or assistance to help a client through personal, emotional, and/or psychological resolution.
  • Involves a trained counselor and an individual or group.
  • Promotes well-being, improves coping, and/or empowers change.
  • Examples: stress, anxiety, mood, relationship issues, personal growth, reflection, etc.

• Psychotherapy:

  • A type of counseling that may focus on more deep and long-term mental health issues.
  • Counseling is a more generic term; sometimes refers to a short-term focus on problem-solving, decision-making, personal/career development, and broader meaning.

• Both counseling and psychotherapy deeply depend on a collaborative and trusting relationship between counselor and client.

Definition of Therapeutic Alliance

• A collaborative relationship between therapist and client.
• Includes:
  • Shared goals
  • Agreed-upon tasks
  • An emotional bond (trust, respect, empathy) built upon mutual respect.
• Incongruent with the traditional medical model where the professional "solves" the problem by "prescribing" treatment.

Importance of Therapeutic Alliance

• Helps clients feel safe, supported, and facilitates motivation and effective collaboration.

• Improves client engagement.

• Improves outcomes (not just in psychology).

• Various perspectives on its importance:

  • Some view it as a key predictor of therapeutic outcomes (Kaiser et al., 2021; Miller et al., 2005).
  • Others argue it has less of a central role (e.g., Schwartz et al., 2021).
  • Reviews indicate that around 5-7.5% of the variance in outcome is attributable to the alliance (Hovarth et al., 2011; Martin et al., 2000).

• Regardless, it is generally agreed that a therapeutic alliance is important to some extent.

• Lacking agreed-upon goals, tasks, and rapport would be problematic and potentially unethical.

APA Division 29 Task Force Review

• Concluded that “the alliance relationship . . . makes substantial and consistent contributions to the [helping] outcome, independent of the specific type of [intervention]” (Steering Committee, 2002, p. 441).

• Recommended that helping professionals prioritize creating and cultivating an alliance/relationship.

• Advocated for training programs to provide explicit and competency-based training in effective elements of the professional helping relationship.

• Many approaches to psychotherapy require adherence to specific tasks (e.g., attendance, agenda, homework) and goals (e.g., learning new coping strategies).

• The therapeutic alliance is necessary (though may not be sufficient) by definition.

Building and Maintaining the Alliance

• Focus on HOW you communicate:
  • Establish rapport and trust.
  • Active listening
  • Empathy
  • Use honest and compassionate language (be authentic).
  • Respect (and convey respect) for the client’s autonomy.
  • Clear communication
  • Two-way dialogue (don’t just talk at the client).
  • Respect and understand cultural and personal differences.
  • Drawing upon interpersonal skills.
• Validate client's experience.
• Use collaborative language (e.g., we, our, etc.).
• Socratic dialogue
• Always include clear rationale for any intervention, and check understandings.
• Common pitfall: poorly communicated empathy (needs to be specific, overt, and demonstrate understanding).

Skilled Helper Model

• Egan (1990) provides a counseling model which describes phases of counseling

• Provides a framework for understanding how helping conversations (counseling) generally works.

• Clear/practical, bridges theory and practice, and encourages a goal-oriented approach.

• The Skilled Helper Model relies on basic interpersonal skills, the therapeutic alliance, and progresses to counseling approaches.

• Essential ingredients: quiet and confidential environment, including non-judgmental communication.

• The counselor encourages the client to think deeply about their concerns and develop ways to manage the problem.

• Three stages to move through the “problem” to arrive at a “solution”:

  • Stage I: The problem as it is (explore, identify blind spots, and identify ‘right’ problems).
  • Stage II: Preferred scenario (imagine desired outcomes, goals, and incentives).
  • Stage III: Action programs (develop and implement strategies).

Stage I: Problem as it is (exploration)

• The professional works with the client to narrate their story, explore past experiences and current assets/strengths.
• Goals:
  • Identify and explore client's concerns & challenges
  • Encourage the client to freely express their thoughts and feelings.
  • Develop a thorough understanding of the client's situation.
• “Can you tell me more about your current situation and what has led you to seeking support?”
• Help the person to tell their stories in such a way that we (and ultimately the person!) will better understand the problem situation
• How to explore the presenting problem
  • e.g., “Thank you for telling me a little about yourself…. So what brings you here today?”
  • Do not offer advice
  • Maintain a neutral curiosity
  • Use open ended questions (as we have covered previously)
  • Gather data/information
  • Draw out client concerns, issues or challenges: “I’d like to hear your story”.
  • Use attending and empathy skills
• Establish open and trusting relationship where the person will feel safe
  • Introduce yourself (using pronouns), the context, the process, and your role
  • Allow person to negotiate their expectations for this relationship
  • Be sensitive to how and what you communicate – convey trust, acceptance, and structure
  • Discuss confidentiality/privacy
  • Normalise their experience
  • Show non-judgement of context/others in that person’s life
• Stage I is also a good time to begin identifying strengths and resources.
  • What has enabled you to cope thus far?
  • Who is there for you when things are difficult?
  • How were you able to achieve that success?
  • What did you do to make that work?
  • Your actions there showed that change is possible. How does that make you feel?
  • What do you feel you need to make this change?
• Comm Skills & Tips in Stage I
  • Listen to person but also maintain self awareness
  • Observe while avoiding undue inference (e.g., labelling)
  • Note non-verbal behaviour – posture, direction, initiative, and eye contact
  • Track i.e., follow person’s agenda
  • Respond to emotional tone to show understanding of person’s emotions
  • Build trust by expressing your warmth, empathy, dedication, respect, acceptance, and genuineness
• Outcome of Stage I
  • Person should trust you and feel safe to disclose information within the facilitative context

Stage II: Preferred Scenario

• The professional assists the client in generating potential goals and exploring various options to achieve those goals.
• Goals:
  • Help the client envision their preferred future.
  • Setting specific and achievable goals.
  • Help client find incentives to help commit to change.
  • Facilitate a shift from problems to possibilities.
• “If we were to work on these concerns and make a positive change, what would your life look like in an ideal scenario?”
• The person has to identify the possibility for what they see as a better future
  • To discover what they want for themselves
  • Commit themselves to what they want to achieve
• Goals should be mutually and collaboratively developed
• Phrase goal-setting positively
• Be realistic
  • “How would you like for things to be different?”
  • “What are you hoping we might be able to do for you?”
  • “How would life be like if the problem was gone? How would things have changed?”
• “What Goals to identify
  • Empathy – learn and adopt person’s ‘language’
  • Convey respect
  • Use facilitative, open questions/probes
  • Be patient and revisit certain topics, if necessary
  • Avoid suggesting solutions
  • Deal with multiple levels of understanding – content, experience, behaviour, feelings, and cognition
  • Start to understand “patterns” in their stories
• Outcome of Stage II
  • Person should: feel better understood, open up more to explore uncomfortable or confronting ideas, better understand how they feel and why, have clear goals.

Stage III: Action Programs

• Based on the best evidence available, clinical expertise, and the client’s preferences, the professional will guide the client in deciding a plan of action and support the client in implementing, committing to, and adjusting the action plan.
• The goals in this stage are to:
  • Assist the client in creating and committing to their chosen action plan
  • Encourage the client to commit to taking specific steps
  • Explore potential obstacles and ways to overcome them
  • Help the client stay accountable and track their progress
• The professional may also encourage the client to test the viability of their options in real life as well as help the client assess the practicality and effectiveness of their chosen options
  • “What has worked in the past?” "What small change might you start with?” "Can we generate some new ways of thinking [or feeling or behaving] about this?” How could you break this down? What reward will you give yourself? What will you do if things don’t go to plan? How can you keep yourself accountable to your commitments?
• “What strategies can you think of to bridge the gap between your current scenario and the preferred scenario you've outlined?”
• It involves generating potential strategies (from best evidence available, person’s values/expectations, and your expertise), considering obstacles and resources, and creating a concrete action plan
  • Encourage the person to see that there are many different ways of achieving goals
  • Help the person organise their ideas into simple, coherent, achievable plans
  • Help build a sense of readiness
• “How, specifically, will you make all of this happen?”
• Working together, develop detailed action plan outlining specific steps, tasks, and milestones required to achieve established goals
• Anticipate potential challenges that may arise during the implementation phase, then develop mitigating strategies
  • We support enhancing commitment and motivation for the chosen plan - reinforcing the person’s self-efficacy
• Remember to identify and mobilise resources necessary for success – includes internal and external resources
• Establish some form of monitoring process to evaluate effectiveness of the action plan - allows for adjustments as needed
• Recognise and celebrate small victories and achievements along the way - this helps to maintain motivation and reinforces the ability to effect change!
• “Empathy Summarising Clarifying Questioning Feedback/challenging
• (Possibly) explore intervention options and take action to address the problem
• People with emotion-based coping preferences may feel better just having shared their experiences while others require problem-focused management approach
• Outcome of Stage III
  • Person should: explore and understand the problem more fully, reflect on their feelings further, consider previously hidden feelings, emotions, attitudes, or behaviours, assess options and alternatives for addressing problem, take action

Reflective practice

• A process of reviewing an event or experience to draw your awareness to your own knowledge
• Allows a person to make new meaning of an experience by: analysing and critiquing the situation that occurred, questioning our own assumptions and understanding evaluating the same situation from a number of perspectives
• Content reflection: reflecting on the nature of an issue or client presenting concern or situation
• Process reflection: focus on the efficacy of practice through interpreting data from feedback. For example, psychotherapists would examine the process of therapy with a client re how useful the approach was
• Premise reflection, AKA critical reflection, practitioners reflect on their underlying beliefs and assumptions and challenge the validity of these presuppositions formed from prior learning (Mezirow, 2000) This could include an exploration of self and one’s own cultural identity because constructions of “normality” are culturally, socially and historically situated and impacts on how we perceive the world and interact with others
• Reflective Writing
  • Most reflective pieces of writing require some structure (e.g., for the purposes of your assessment, you will find the marking guide and rubric very helpful in this respect)
  • It is a highly personal process so when used in an academic sense, you can write in first person language For example. “I have experienced… ”
  • There are several models of reflection, which can sometimes be overwhelming if you have not been provided with a clear structure. So….
  • For your Written Reflection Assessment, you must select and use one of the following reflective models: Gibb’s reflective model (1988), Rolfe et al. ’s Model of Reflection (2001), Johns’ Model for Structured Reflection (2006)
• Part of being an effective helping professional involves understanding and incorporating reflection into daily activities to continually improve your professional practice and skills
• Reflection is all about making sense of things and experiences that happen in our lives and learning how to grow from them
• “Reflective Thinking” is the thoughtful consideration of an event or experience and any different perspective or knowledge as a result
• “Reflective Writing” is a form of evidence of reflective thinking
• This then only becomes “Reflective Practice” when the new perspective or knowledge is applied to practice
• The “reflective practitioner” is one who seeks to continually commit to the progressive development of their practice by utilising their reflective insights to both constructing and reconstructing their knowledge
• Schön (1983) described two forms of reflection: Reflection-in-action: quick thinking while you’re engaged in an activity, Reflection-on-action: when you consider the activity afterward
• Reflection is a journey: thinking, writing, practice

Gibb's Reflective Model (1988)

• Strength: Basic, good starting point, five distinctive stages. Makes you aware of all the stages you go through when experiencing an event
• Weakness: superficial reflection unless reflector initiates critical thinking/analysis/assumptions. This requires posing self-directed probing questions not implied by the model

Rolfe's Model of Reflection (2001)

• Strength: allows for increasingly deeper reflection at each level. The levels are descriptive, theoretical and action-orientated. Working through the same questions at different levels can be used to develop from novice to expert
• Weakness: May be too complicated for a beginner who is new to reflection

Johns' Model for StructuredReflection (2006)

• Strengths: Organisational model, examines situations in context of the environment. Provides prompt questions that are easy to follow, can be used in any order (although they follow a natural progression). Can be used by individuals or groups. Based on Carper’s (1978) four types of knowing - empirical, personal, ethical and aesthetic - Johns adds a fifth one i.e., reflexivity- to create his model

• Weaknesses: The prompt questions aren’t rigidly structured which could be confusing for someone inexperienced to know which ones could be omitted and which are salient for their particular reflection. The number of questions means it could be time consuming

• Bassott (2016) connects reflective thinking and writing to reflective practice by: provides a space for deep thinking because, in real time, there is pressure to make decisions quickly, helps the professional to avoid repeated errors and build professional confidence. prevents stagnation as practice ensures that helping professionals do not become complacent and can adjust to changing communities and clients. This encourages a more considered approach to promoting equality and social justice

• Reflective thinking and writing also sparkins creativity through questioning the status quo and being prepared to consider looking through a different lens to find solutions provides an aid for debriefing as reflection can help define issues to discuss at supervision fosters professional wellness by highlighting self -awareness, which leads to actions in self - care for the helping professional

• Relevance to your career

  • Our personal and professional relationships are founded on effective communication (including reflection) to a significant extent
  • In health and wellbeing practice, this can have a profound impact on the perceived (and very real) quality of healthcare received, which can impact outcomes for treatment and care
  • Regardless of your chosen profession, demonstrating effective verbal and non-verbal communication (and good self-reflection) is an important selection criterion for any job application