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Name hidden The Therapeutic Alliance: A Comparison of Theories Introduction to Counselling Psychology Bond University

THE THERAPEUTIC ALLIANCE 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 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 patientis 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 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 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 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 clients 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 ones 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 clients 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 jointly together in a warm genuine and appreciative environment as coinvestigators(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 Elliss Rational Emotive Behavioural Therapy (REBT) and Becks 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 clients 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 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 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 Elliss 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 Glassers 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

THE THERAPEUTIC ALLIANCE Adlerian perspective, clients 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 counsellors 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, 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 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 clients 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 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).


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