BACKGROUND

The therapist alliance was first described by the Frued in 1912 in which he
outlined the concepts of transference and counter transference, which are the
unconscious feelings or emotions that a patient feels towards their therapist and
vice versa. Further research by Rogers1951 was the first to highlight the empathy
as a core characteristics of this therapeutic alliance and Anderson (1962)
conceptualized both empathy and rapport as qualities within the therapeutic bond.
Hougaard (1994) consolidated previous data into a conceptual structure composed
two branches, the personal relationship area and collaborative area. The personal
relationship area focuses on the socio-emotional aspect of the therapist-patient
relationship are consist of more task related aspects, such as goal setting and
treatment planning. It was Martin, Garske and Davies (2000) concretely described
the therapeutic alliance as the collaborative and effective bond between therapist
and patient as an element of therapeutic process.

INTRODUCTION
Therapeutic alliance is also referred to as working alliance is a description of the
interaction between the psychotherapist and their clients. In other words it can be
defined as the relationship between the therapist and the clients.it is the means by
which the therapist and a client hope to engage with each other and effect
beneficial change in the client.
Therapeutic Alliance is considered an important aspect of therapeutic process and
have an impact on treatment outcomes by establishing a therapeutic alliance, the
therapist then seek to provide patients-centered care, in which the therapist is seen
as a facilitator for the patient to achieve their goals instead of in authority figure.
The previous research has highly lighted the importance of providing patient-
centered care not only in psychotherapy but in other medical professions as well.
This is accomplished by encouraging the patient to become more active in their
treatment to engage them in more collaborative, active approach to recovery. By
establishing a strong therapeutic alliance and encouraging patient participation,
therapists can also seek to address psychosocial aspects of pain, which are often
over-looked in traditional unidirectional patient therapist interactions. This is
especially important as recent research support that the physical treatment alone
cannot fully account for the improvement of the patient outcomes.
CONDITIONS FOR THERAPEUTIC CHANGE
In the humanistic approach, Carl Rogers identified a number of necessary and
sufficient condition that are required for the therapeutic change to take place.
These includes core conditions which include
1 .Congruence
2. Unconditional positive regard
3. Empathy
Rogers (1957; 1959) stated that there are six necessary and sufficient conditions
required for therapeutic charge;
1. Therapist- client psychological contact
Here a relationship between client and therapist must exist and it must be a
relationship in which person’s perception of the other is important.
2. Clients incongruence:
Here state that incongruence have to exist between the clients experience and
awareness
3. Therapist congruence or genuineness:
The therapist have to be congruent within the therapeutic relationship. The
therapist is deeply involved, they are not acting and they can draw on their own
experiences (self-disclosure) to facilitate the relationship.
4. Therapist Unconditional Positive Regard:
The therapist accept the client unconditionally, without judgment disapproval or
approval. This facilitates increased self-regard in the client as they can begin to
become aware of experiences in which their view of self-worth was distorted or
denied.
5. Therapist empathic understanding:
The therapist experience an empathic understanding of the client’s internal frame
of reference, accurate empathy on the part of the therapist helps the client believe
the therapist helps the client believe the therapists unconditional regard for them.
6. Client perception:
Here entails that the client perceives to at least a minimal degree the therapist
unconditional positive regard and empathic understanding.

Components of the Therapeutic Alliance

Boding describes the three components that contributed to a strong therapeutic
alliance which includes:
1. Agreement on goals (collaborative goal setting)
2. Agreement on interventions (shared decision)
3. Effective bond between patient and therapist (therapeutic relationship)

Collaborative Goal Setting

Goal setting serves a fundamental role in guiding rehabilitation so that a
specific outcome can be reached. The agreement of goals between the patient
and the therapist increases adherence to those goals which in turn lead to
improve outcomes, it improve patient satisfaction as well as motivation. All
these factors positively influence the therapeutic alliance.

Shared Decision Making

Shared decision help to strengthen therapeutic alliance. It is a process of
providing the patient with information and support through the decision
making process.

The Therapeutic Relationship

The Therapeutic relationship refers to the professional bond between the
therapists and the client. It is the key component of a strong therapeutic
alliance.
The following components contribute to the development of a strong
therapeutic relationship.

Communication skill which include:

1. Active Listening
2. Empathy
3. Friendliness
4. Encouragement
5. Confidence
 Practical skills which include:
1. Clients education that is simple and clear
2. Therapist expertise and training
Patient-centered care
1. Individual treatments
2. Taking patients opinions and preferences into consideration

Organizational and Environmental factors

1. Giving Patients enough time for thorough assessment and management.
2. Flexibility with Patients Appointment and Care

Operationalization and Measurement

Several scales have been developed to assess the patient – professional
relationship in therapy, including the working Alliance Inventory (WAI), the
Barret-Lennard Relationship Inventory and the California psychotherapy Alliance
Scales (CALPAS). The Scale to Assess Relationships (STAR) was specifically
developed to measure the therapeutic relationship in community psychiatry or
within care in the community settings.

REFERENCES
1. Babtunde F, Mac Dermid J, M acltyre N. characteristics of therapeutic
alliance in musculoskeletal physiotherapy and occupational therapy practice:
a scoping review of the literature BMC health serv Res.2017; 17(1):375.
2. Freud S. The Dynamics of transference. The standard Edition of the
complete psychological works of Sigmund Freud 1912; 11(1911-1913); 97-
108.
3. Rogars C. client centered therapy, 1st ed. Boston: Houghton Mifflin
4. Hougaard E. the therapeutic alliance – a conceptual analysis Scandavian
journal of Psychology. 1994, 35 (1):67-85.
5. Martin D. Garske J Davis M. relation of therapeutic alliance with outcome
and other variables. A Meta –analytic review. Journal of consulting and
Clinical Psychology 2000;68(3)438-450
6. Gelso C.J and Hayes, J.A. (1998). The psychotherapy relationship: theory,
Research and Practice