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second year psychology essay that received the highest mark in the class (99%) High distinction
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Running Head: THE THERAPEUTIC ALLIANCE
Name hidden
The Therapeutic Alliance: A Comparison of Theories
Introduction to Counselling Psychology
Bond University
THE THERAPEUTIC ALLIANCE 2
Abstract
The Therapeutic Alliance is constructive bond or relationship formed between client
and therapist and is crucial in the counselling process (Cheston, 2000). This essay
examines the therapeutic alliance between 3 separate styles of therapy; Adlerian,
Cognitive Behavioural Therapy and Reality Therapy. As found in the literature these
separate counselling methodologies are vast and varying in some respects such as
difference of importance of Therapeutic alliance, flexibility and rigidness of
techniques, and use of modelling and introspection, yet are very closely bound by the
taking an educative role, notions of faith in abilities, collaborative goal planning, and
consistent positive regard for client (Corey, 2009; Dryden, 2009; Glasser, 1965;
Grencavage & Norcross, 1990; Sperry, 2003). Reaching therapeutic goals in Adlerian
Therapy is reached by a familiar understanding of client goals as well as in Reality
Therapy and Cognitive Therapy, however in REBT is achieved by challenging the
clients faulty life view (Mosak & Maniacci, 1998; Sperry, 2003). It has been found
consistent with finding in the literature that Adlerian therapy provides clients with the
highest degree of therapeutic alliance where as REBT and to some extent Cognitive
and Reality therapies and are shown to be more action-based and directive
methodologies (Cheston, 2000; Corey, 2009; Dryden, 2009; Watts, 2000; Weinrach,
2006).
THE THERAPEUTIC ALLIANCE 3
The Client-Therapeutic Alliance can be outlined as the functional interaction
between client and therapist, which can vary in manner of focus from therapy to
therapy (Horvath & Luborsky, 1993; Luborsky, 1994). Martine, Garske and Davis,
(2000) effectively specified it as “the collaborative and affective bond between
therapist and patient—is an essential element of the therapeutic process” (p 438). It is
the keystone in the counselling process, which is constant across the different
therapeutic approaches in relation to its influence, and is largely predictive of the
therapy outcome (Ahn & Wampold, 2001; Cheston, 2000; Corey, 2009). It has been
suggested by Safran and Muran (1995), that the relationship between client and
counsellor is more salient than actual the methodology that is implemented. However
many counselling approaches will manifest different alliance styles and varying
effectiveness (Asay & Lambert, 1999).
Counselling is an intimate experience that involves a client expressing
intimate life details, thoughts and feelings, with the intention to grow and learn about
himself or herself as a person (Cheston, 2000; Corey, 2009; Horvath & Luborsky,
1993; Johnson & Wright, 2002; Mosak & Maniacci, 1998). The role of the counsellor
can differ from instance to instance, client to client, and theory to theory, but what can
be generally be taken from each approach is the universal goal of helping the client to
realise their own solutions to the issues they may facing (Asay & Lambert, 1999;
Horvath & Luborsky, 1993; Mosak & Maniacci, 1998; Watts, 2000). The underlying
factor that is instrumental in fostering an environment where this possible is the
Client-Therapist Alliance (Ahn & Wampold, 2001; Asay & Lambert, 1999; Cheston,
2000; Corey, 2009). This concept is of primary importance. Literature has shown
consistent support that the therapy outcome is largely dependant upon the therapeutic
relationship as much as the specific treatment method utilized. (Ahn & Wampold,
THE THERAPEUTIC ALLIANCE 4
2001; Asay & Lambert, 1999). If the counsellor does not adopt a suitable approach,
the intimacy and sharing of experience can be detrimentally affected.(Grencavage &
Norcross, 1990; Johnson & Wright, 2002; Prochaska & Norcross, 2001; Ruglass &
Safran, 2005) According to Corey, (2009), the therapeutic alliance has been reported
to be the ‘make or break factor’ of a client deciding to continue or discontinue
treatment with a particular therapist. Skills and theoretical knowledge are a
foundational basis but cannot adequately provide all that is essential in effective
counselling, which remains in the attainment of a strong Client-Therapist relationship
(Ahn & Wampold, 2001; Asay & Lambert, 1999).
The role of a therapist in the last century has taken a dynamitic and adaptive
turn (Cheston, 2000). Therapy has been more widely used as a means of dealing with
the difficult intricacies of life, and as a reaction, therapy has moulded it self to suit the
growing number of diverse clients as well as a variety of client issues (Ruglass &
Safran, 2005). In this faze of adaptation, psychology has yielded a wide variety of
counselling approaches that each address client needs via differing methods and
techniques that facilitate client-therapist relation in diverse styles (Mosak & Maniacci,
1998). The following essay endeavours to outline 3 theoretical approaches, Adlerian,
Cognitive Behavioural Therapy and Reality Therapy and compare the how the
Therapeutic alliance differs between each theory. Each one of the theories; Adlerian,
Cognitive Behavioural Therapy and Reality Therapy, reach client goals along their
own unique pathway (Martin, Garske, & Davis, 2000; Prochaska & Norcross, 2001;
Sperry, 2003).
In Adlerian therapy, as called by Adler as Individual Psychology, the focus
lies on all dimensions of a person aimed towards the achieving of a specific life goal
in a collaborative and egalitarian relationship between client and therapists (Sweeney,
THE THERAPEUTIC ALLIANCE 5
1998; Watts, 2000; Watts & Pietrzak, 2000). Adlerian Therapy proposes that the
client therapeutic alliance is the first requirement in the beginnings of the therapeutic
process as opposed to initially identifying the actual issue at hand (Corey, 2009).
Clients are not viewed as pathologically unwell but as lacking support and faith in
their ability to bypass unsuccessful ways (Sperry, 2003). Encouragement is
considered to be a crucial aspect of human development, which is a key theme in the
Adlerian approach to the therapeutic relationship (Corey, 2009; Grencavage &
Norcross, 1990; Horvath & Luborsky, 1993; Johnson & Wright, 2002). This is
developed by demonstrating a genuine concern for clients by showing empathy,
actively listening, providing support, understanding and respect, building confidence
in clients, tactfully and positively negating negative or unrealistic beliefs and shifting
focus from discouraging thoughts (Mosak & Maniacci, 1998; Sweeney, 1998; Watts
& Pietrzak, 2000) and directing thinking “towards effort and progress and helping
clients see the humour in life” (Watts & Pietrzak, 2000, p443).
Client and therapist work together collaboratively in a mutually agreed upon
goal that is established often by the formulation of a plan that outlines what the client
wants and the means in which they intent to attain that want, followed by possible
obstacles and faulty behaviours that may inhibit their attainments of goals
successfully (Prochaska & Norcross, 2001; Sperry, 2003; Sweeney, 1998). It is only
in the circumstance that the client and therapist goals are aliened that effective therapy
will occur. If the client is able to gauge that therapist has grasped a firm and thorough
understanding of his or her needs then the client is likely to be more directive in
establishing goals with the therapist (Watts & Pietrzak, 2000). This approach
positions clients as the decision-makers who are responsible for his or her own change
and requires concerning listening from the therapist (Cheston, 2000).
THE THERAPEUTIC ALLIANCE 6
Specific techniques are not rigidly adhered to but rather changed and adapted
to suit the individual needs of the client (Watts, 2000; Watts & Pietrzak, 2000).
Counsellors of the Adlerian persuasion strive to promote social interest through
modelling this to clients in their own behaviour (Mosak & Maniacci, 1998; Watts &
Pietrzak, 2000). The development of a genuine, trusting and nonjudjemental
environment are essential skills for the exploration of the clients compitencies(Watts,
2000). The Adlerian therapist is one who enables client to overcome feelings of
inferiority and is able to address dysfunctional motivations in order for the client to
function within society successfully (Corey, 2009). Helping the client to understand
that optimum wellbeing is achieved when these issues are resolved can be reached by
adapting the client’s problematic life story and alleviating it with a more favourable
one (Mosak & Maniacci, 1998). This is what Alder classically called the
reorganisation of a life schema of how one viewed one’s self and the world. What is
the underlying theme within Adlerian Psychology is that this schematic adjustment is
only possible with formation of a firm therapist relationship (Sperry, 2003; Sweeney,
1998; Watts, 2000). Overall, the role of the therapist in an Adlerian perspective can be
summed as a supportive collaborative educator that maintained mutuality in status
that fosters a friendly disposition (Sperry, 2003).
Cognitive behavioural therapy (CBT) also draws upon a collaborative and
instructional style that educates clients to address client’s unhelpful cognitions, which
are directive of unwanted or unhelpful behaviour (Cheston, 2000; Corey, 2009;
Martin, Garske, & Davis, 2000; Sperry, 2003). CBT, quite similar to the Adlerian
approach, also addresses client maladaptive schemas or perception of self and life in
attempt attain of betterment (Sperry, 2003). Beck (1989) proposed client-therapist
relationship themes similar to that of Adler, in that the client and therapist acted
THE THERAPEUTIC ALLIANCE 7
jointly together in a warm genuine and appreciative environment as “co-
investigators”(p.301). As we compare and analyse the therapeutic alliance within the
discipline of CBT, it is necessary to inspect the relative theories. For this reason the
therapeutic alliance will be examined within the two separate constructs of Albert
Ellis’s Rational Emotive Behavioural Therapy (REBT) and Beck’s Cognitive Therapy
(CT).
REBT is an active-directive therapy that focuses on the ‘doing’ of therapy and
is often set out in an agenda format session (Cheston, 2000; Corey, 2009; Dryden,
2009). Like the Adlerian therapeutic approach, attention is drawn to empathy and
ensuring a secure environment for the client, so that he or she may feel comfortable to
disclose information (Dryden, 2009). REBT focuses on the present condition of the
client, their current emotional being and their state of thinking that may be leading to
dysfunctional behaviour and gives little emphasis on past experiences or background
information such as relationships with family members (Neenan, 2001). This style of
therapy takes upon the notion that an extensive relationship that is too indulgent is not
conducive to eliciting effective change in a client’s behaviour, and may harbour
emotional reliance upon the therapist (Corey, 2009; Neenan, 2001; Weinrach, 2006).
However, Ellis encouraged REBT therapists to offer unconditional acceptance of
clients regardless of imperfections and to facilitate clients to do so for themselves and
for others, which can be inferred to cast similarity with the Adlerian approach (Ahn &
Wampold, 2001; Cheston, 2000; Corey, 2009; Glasser, 1965; Neenan, 2001; Watts &
Pietrzak, 2000; Weinrach, 2006). In this aspect REBT helps client to recognise
behaviour that may hinder them and address it in a logical approach (Dryden, 2009).
REBT assumes that imperfections are common to all humans and can be
addressed through a repertoire of techniques, such as behaviour modification (Corey,
THE THERAPEUTIC ALLIANCE 8
2009; Dryden, 2009). The role of an REBT counsellor is to challenge to clients
defeated way of thinking which may involve debate and dispute to enable clients to
realise a more rational way to overcome false beliefs (Neenan, 2001; Weinrach,
2006). According to Dryden, (2009) this type of alliance is seen to be a ‘working’
alliance that creates a sense of teamwork within the relationship between client and
therapist. Due to the highly involved nature of REBT clients completing assignments,
the maintaining of an intense emotionally facilitative relationship is not seen as a
requirement, however as we saw in Adlerian therapy, this is the fist requirement and
the foundation of the therapeutic process of achieving goals (Kinney, 200; Martin,
Garske, & Davis, 2000). A commonality that Adlerian Therapy and REBT share is
that therapist of both of the disciplines emphasise faith in the abilities of the client to
change them selves (Grencavage & Norcross, 1990). Likewise both of the approaches
facilitate and egalitarian relationship between client and therapist (Sweeney, 1998).
As opposed to Adlerian Therapy, techniques of REBT are more adhered to keenly as
it is seen as the techniques and active participation of the client are able to aid the
client in amending behaviour – rather than the bond between client and therapist
(Corey, 2009; Dryden, 2009; Weinrach, 2006).
CT similarly like REBT offers the client a platform that is educational based
and utilizes homework with the client (Corey, 2009). Again, like REBT it is an
action-directive based discipline that is collaborative, present and problem
focused(Kinney, 200). Clients issue are assumed to arise from faulty thinking and
flawed interpretations of the their world (Grencavage & Norcross, 1990). Akin to
Adlerian and REBT, CT seeks to restructure the schema of an individuals thought
process with better functioning thoughts (Beck & Weishaar, 1989). CT is not as
confrontational as REBT, and follows Socratic questioning with the aim of client self-
THE THERAPEUTIC ALLIANCE 9
realisation and reflection rather than a direct challenge of maladaptive thought,
similarly to the Adlerian approach, which encourages clients to gently arrive at
conclusion (Beck & Weishaar, 1989; Cheston, 2000; Corey, 2009; Grencavage &
Norcross, 1990). Directly opposing the assumption of REBT, CT holds the
therapeutic alliance as an important and required aspect of the counselling process to
building a warm and understanding relationship that enables a therapist to utilize
skills (Beck & Weishaar, 1989; Neenan, 2001).
Both REBT and CT emphasise the therapist as an educator who administers
homework and allows the client to take upon the responsibility of change both within
sessions and independently outside of therapy (Corey, 2009). However in CT,
homework tasks are more caringly negotiated and mutually agreed upon and easily
adjusted to suit the client rather than appointed or instructed to complete (Beck &
Weishaar, 1989; Sperry, 2003). A fundamental concept of CT is that the
reorganisation of behaviour to enable better functioning is achieved through various
behavioural strategies and a client-therapist understanding, enabling the realising of a
clients’ self-statements, and adjusting maladaptive thinking to that which is conducive
to better behavioural habits (Sperry, 2003). Parallel to Ellis’s educational teamwork
relationship, Beck proposes a partnership like relationship that guides the client to
understand how their thoughts and feelings affect their behaviour, but discourages the
spoon-feeding of answers to the client, but rather enables self-initiative (Cheston,
2000; Corey, 2009; Grencavage & Norcross, 1990).
Similar to CT, William Glasser’s Reality Therapy (RT) proposes a relationship
in which the therapist takes upon the role of a mentor in yet another educative setting
in which the client is guided by the therapist to evaluate their choices (Cheston, 2000;
Corey, 2009; Wubbolding et. al, 2004). Likened to the Adlerian perspective, clients
THE THERAPEUTIC ALLIANCE 10
are not viewed as psychologically unwell – but seen as not able to meet their needs
and be happy (Glasser, 1965). An empathetic and understanding relationship is of
primary importance in RT, however it is not considered to be a mending factor of
behaviour, and that further proactive steps are needed to change behaviour (Corey,
2009; Glasser, 1965). A counsellor in an RT setting should be one who is accepting,
respectful, and have keen listening skills. The idea of demonstrating faith, as in
Adlerian and REBT approaches is key in this theory also (Cheston, 2000; Corey,
2009; Dryden, 2009). According to Wubbolding et. al. (2004) modelling this faith
enables the belief of their capabilities to become their own self-belief. These skills are
close to that found in Adlerian therapy, though RT assumed a firmer stance with
clients and accepts no excuses (Glasser, 1965).
Clients are seen as responsible completely for choosing the way they deal with
the emotions they experience. Choice theory assumes that all behaviour is resulting
from choice in some aspect, and that all actions are aimed at fulfilling a basic need
(Glasser, 1965). RT counsellor’s role is to better assist in choices to allow for a client
to better achieve these needs. What is a major dysfunction in behaviour according to
RT is that individuals are not connected adequately to the world and therefore need
assistance in enabling these connections, thus meeting the need to be connected
(Corey, 2009; Glasser, 1965). A fundamental aspect in this approach is to set
appropriate goals, much like in Adlerian style therapy that helps attain fulfilment of
an individuals needs, such as love or belonging (Glasser, 1965; Grencavage &
Norcross, 1990; Horvath & Luborsky, 1993; Sweeney, 1998;Wubbolding et.al, 2004).
Reality Therapists are encouraged to make a connection with the client so that
they may be able to assist the client in fulfilling their own goals (Corey, 2009;
Glasser, 1965). If this connection is not established then the therapist is not able to
THE THERAPEUTIC ALLIANCE 11
teach the client how these goals can be reached. In this process self-evaluation is
taught to give clients and introspective view on how they can better effectively meet
their own needs (Wubbolding et. al., 2004). RT In this sense is considerably similar to
CT and Adlerian in that it encourages self-reflection in order to reach a client’s own
proposed solution (Sperry, 2003). REBT differs in this respect, as self-evaluation is
not as prominent as in the other disciplines (Dryden, 2009; Glasser, 1965).
Adlerian Therapy, CBT theories and Reality Therapy are varying and vast in
many aspects of practice and techniques, but interestingly, though these theories each
claim to offer to assist a client in their own unique way, it seems that there are more
commonalities than one would assume, which lay in the very essence of the
therapeutic process – the therapeutic alliance (Ahn & Wampold, 2001; Asay &
Lambert, 1999; Sperry, 2003). Though this author anticipated to be reporting a myriad
of differing methods and approaches to building a client relationship, it seems that
there are many common underlying factors in which these disciplines mutually share.
Concepts of egalitarianism, mutual respect, a collaboration of ideas, faith in abilities,
encouragement, self-reflection, teamwork, partnerships and an educative rather than
curing-mindset, resinate within all of these therapy approaches – which is just
mentioning some of the more prominent aspects (Beck & Weishaar, 1989; Cheston,
2000; Corey, 2009; Dryden, 2009; Glasser, 1965; Grencavage & Norcross, 1990;
Horvath & Luborsky, 1993; Johnson & Wright, 2002; Kinney, 200; Mosak &
Maniacci, 1998). What these findings turn a new focus to is the question: is it the
technique and theory of the therapy the causing factor of effectives of therapy or is the
salience and quality of the therapeutic alliance? As claimed by Safran and Muran
(1995) it is the therapeutic alliance that is the predictor of successful therapy, and not
the actual technique implemented (Luborsky, 1994). Nevertheless, theorist such as
THE THERAPEUTIC ALLIANCE 12
Alder, Ellis, Beck and Glasser have all uniquely and invaluably contributed a different
colour to the diverse and intertwined picture of therapy – with each demonstrating
how one can gain in deepening the relationship between client and therapist. As we
can see, it is this foundation that successful therapy can be achieved (Asay &
Lambert, 1999; Cheston, 2000; Grencavage & Norcross, 1990; Mosak & Maniacci,
1998).
THE THERAPEUTIC ALLIANCE 13
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