Some years ago, a young woman I’d been treating — let’s call her D — arrived for her fifth or sixth therapy appointment and announced that she wouldn’t be coming back. “This will be my last session,” she said, politely but definitively. I asked her why she wanted to terminate therapy, and she answered, “Because I don’t feel a connection.” D told me that she just hadn’t been able to form, in her mind, the kind of close relationship with me that she had needed to have with her therapist.
The odd thing was, I knew exactly what she meant.
There are times, as a therapist, when you meet a new patient and, right off the bat, you feel as if you understand them. You care about their problems right away, and your brain immediately fills with theories and interpretations. You strongly believe you can help the person. But of course, not every patient is like this. Most of the time, when a new patient arrives, a therapist has to work a little bit to see things their way. It might take two sessions, or even three — and let’s put a pin in that number for now — but as you go on listening, you make a real effort to reach out to the patient with empathy. You try hard to feel what they feel, to see through their eyes. That’s when something in the patient’s presenting concerns resonates with you, and you’re able to initiate a strong working relationship. With patience, empathy, and warmth, a good therapist works to develop sincere connections to all of his or her patients. This genuine, honest relationship is often referred to as the therapeutic alliance.
And the alliance is, without a doubt, the most important aspect of any psychotherapy. Most studies of psychotherapy outcome concur, suggesting that a strong alliance is the number one predictor of therapeutic success -- even more important than the psychologist’s theoretical orientation. The best way to understand the significance of the therapeutic alliance is to ask yourself how you feel when you’re in treatment. Do you believe your therapist has your best interests at heart? Do you feel understood at a deep, personal level? Can you be honest with your therapist in a real way, without feeling judged or ashamed? Without such an alliance, no one would speak openly to the stranger in the therapist’s chair. No patient would feel safe enough to explore painful emotions in a direct, here-and-now way, and no course of psychotherapy would thrive.
Which brings me back to Patient D. Although she was a kind, pleasant person, whose problems were well suited to psychotherapy (and not to mention, a reasonably good fit for my skills and my practice), she was absolutely right about the lack of connection between us. I had noticed it as well — I’d struggled for a few sessions to find empathy for her, to build a common understanding about her family problems, and even to connect on the level of a shared sense of humor. Nothing had worked well. So despite my efforts, and my frustration at my difficulty in connecting to her personally, I agreed with her that something was amiss.
But did Patient D have to end therapy for that reason? Maybe not. Although studies of the developing therapeutic alliance indicate that it reaches its peak during the third session of therapy, if you’re not feeling connected to your therapist after three sessions, dropping out isn’t your only course of action. You might be able to take matters into your own hands — to do your own part to help the alliance form. The best course of action is to be open about your feelings regarding the therapy. Tell your therapist what you’re feeling, even if it makes you feel vulnerable. Talk about what has helped you feel connected, and what hasn’t. Be as clear as you can about when you’ve felt the alliance strengthen, and even when you’ve felt misunderstood.
Most psychologists will be perfectly comfortable with this kind of immediate, in-vivo emotional expression; the therapeutic relationship is unique in this way. In therapy, getting your feelings out in the open might give the alliance a much-needed boost. And even if it doesn’t, you’ll know that you tried everything and didn’t end the treatment prematurely. As in all important human relationships, speaking honestly to your therapist about difficult things is an essential part of developing a real affinity, a genuine connection, and a strong alliance.
Ackerman, S. & Hilsenroth, M. (2003) A review of therapist characteristics and techniques positively impacting the therapeutic alliance. Clinical Psychology Review, 23, 1-33.
Safran, J.D., Muran, J.C., and Proskurov, B. (2009) Alliance, negotiation, and rupture resolution, in Handbook of Evidence Based Psychodynamic Psychotherapy (eds R. Levy and S.J. Ablon), Humana Press, New York, pp. 201-5.
Ardito, R. B., & Rabellino, D. (2011). Therapeutic Alliance and Outcome of Psychotherapy: Historical Excursus, Measurements, and Prospects for Research. Frontiers in Psychology, 2, 270. Retrieved from URL.