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How to Build a Strong Therapeutic Relationship

With Clients
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A solid therapeutic relationship is vital for clients to get the most out of therapy and
remain in treatment (DeAngelis, 2019).

It’s as powerful, if not more so, than the treatment chosen by the therapist (DeAngelis,
2019).

Because we can use the quality of the therapeutic relationship to predict clinical
outcomes, it’s essential to get the alliance right (Ardito & Rabellino, 2011).

This article explores the skills and techniques that therapists need to build a healthy
therapeutic alliance and successful outcome.

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This Article Contains:

• How to Establish a Healthy Therapeutic Alliance

• Components of the Therapeutic Relationship
• 2 Examples of a Supportive Therapeutic Alliance
• 10 Skills of Effective Therapists
• 3 Helpful Techniques for Counselors
• 6 Communication Tips
• Assessing Your Relationship: 2 Questionnaires & Scales
• PositivePsychology.com’s Relevant Resources
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• A Take-Home Message

How to Establish a Healthy Therapeutic Alliance

All therapists require a depth of relating with their clients. In Cognitive-Behavioral

Therapy (CBT), this may be described as a close relationship, while for person-centered
and experiential therapy, it is considered core to the treatment (Knox & Cooper, 2015).

Even though the therapeutic alliance may vary over the course of therapy, its quality
impacts the successful outcome of treatment and, therefore, deserves special attention
(Ardito & Rabellino, 2011).

The degree to which the alliance is correlated with the therapeutic outcome is clear;
its growth is linked to the successful resolution of ruptures, breaches, and repairs
(Ardito & Rabellino, 2011).

There are two clear phases in establishing a healthy therapeutic alliance (Ardito &
Rabellino, 2011):

• First phase:
The alliance develops in the first five sessions of short-term therapy, peaking
around the third. Typically, during this phase, collaboration and mutuality are
fostered, goals are agreed upon, and the client develops confidence in the
therapist and therapeutic process.

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• Second phase:
During this phase, “the therapist begins to challenge the patient’s dysfunctional
thoughts, affects, and behavior patterns, with the intent of changing them”
(Ardito & Rabellino, 2011). Such interventions can lead the client to feel reduced
empathy and a lack of support from the therapist, temporarily weakening or
damaging the relationship.

Early on in therapy, a rupture to the therapeutic relationship can affect commitment to

the process, potentially leading to early termination. As long as it is repaired and
resolved quickly, conflict may be positive and even necessary to a successful outcome
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(Ardito & Rabellino, 2011).

So how do we establish a healthy therapeutic alliance?

The therapist must begin the relationship by considering the therapeutic frame and
boundaries they want to put in place (Knox & Cooper, 2015).

“The therapeutic frame refers to the fixed elements of the therapeutic relationship that
provide the context for the therapeutic work” (Knox & Cooper, 2015, p. 1). The
boundaries define the rules and limits to the relationship from the outset and ensure a
safe, supportive, and contained environment for work to take place.

The setting in which counseling takes place is vital. While it will vary depending on the
context in which the client is seen, points to consider include the following (Knox &
Cooper, 2015):

• Therapy rooms should be calm, quiet, and clear of clutter.

• Chairs should be similar and comfortable.
• Lighting should neither be harsh nor so soft that it appears romantic.
• A comfortable temperature should be maintained.

Ultimately, the location should feel safe and secure, a place where the client can talk
openly without being overheard or interrupted. If the therapy space is located within
the therapist’s home, it is vital to consider the visibility of personal items and their

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potential impact. For example, family pictures may be upsetting if the client discusses
losing a loved one (Knox & Cooper, 2015).

• The timing for the therapeutic work should be agreed upon and set early in the
process. Consider the following questions with the client (modified from Knox &
Cooper, 2015): How many sessions?
If a workplace has arranged the sessions, the organization may decide how many and
how long they continue. Otherwise, it is typical for private clients to agree to review
progress after a set period, perhaps four to six weeks.
• How long should sessions be?
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Typically, sessions last between 50 and 60 minutes. This allows time to dig sufficiently
deeply into issues and prevents the client from becoming exhausted. Consistency can
be helpful.

Clients need to become comfortable and familiar with the process, and knowing the
time remaining in a session can influence the degree to which they open up.

• How often should I meet my clients?

While sessions are often weekly, some client treatments may require more frequent
meetings. Factors to consider include costs, context, therapeutic approach,
approaching the end of therapy, and the need for ongoing support.
• External contact
Communication outside of sessions is often best kept to a minimum. The therapist may
limit contact to administrative matters, such as rescheduling or canceling
appointments. However, there may be exceptions, so it is vital to convey a warm,
caring attitude and agree early in therapy.

Social media can bring other issues and challenges, and it is advisable to keep
therapeutic relationships separate from social ones (Knox & Cooper, 2015).

Putting in place the practices above and ensuring that the following softer components
are addressed can lead to a healthier and more productive therapeutic alliance.

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Components of the Therapeutic Relationship

There are several crucial factors and components to building and maintaining a
therapeutic relationship. While not exhaustive, the following sections introduce key
features of therapy that require focus and, often, ongoing attention.

• While the idea of confidentiality may seem straightforward, it can be complicated. At

the beginning of the therapeutic journey, it is vital to explain to clients that the
relationship is confidential. The only circumstances where the counselor may break it
are when the client or someone else discussed is at risk of serious harm or death (Knox
& Cooper, 2015).
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• Therapists have come to recognize, especially over recent decades, that successful
treatment relies on mutuality and collaboration. Forming an equal partnership between
clients and therapists involves a commitment to a two-way relationship, “working
together to define and actualize therapy goals, including the direction the therapy is
taking” (DeAngelis, 2019).
• Client feedback lets the therapist know what works well and what does not. Allowing
the client to provide input into the therapeutic process and relationship supports
client agency and ensures both are working together in the same direction (Knox &
Cooper, 2015).

Then, of course, feedback must be put into action, with therapists improving their
skills, managing their mistakes, and trying new or alternative interventions (DeAngelis,
2019).

• When therapeutic relations break down, ruptures must be repaired. They typically
occur when the client withdraws or is confrontational, including verbal and nonverbal
expressions of frustration or anger (DeAngelis, 2019).

Such distancing behavior may result from a lack of trust or the client feeling judged or
misunderstood. If the therapist senses the start of a breakdown or a strain in the
relationship, they must not let it grow but clarify any issues and repair mistakes (Knox
& Cooper, 2015).

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• “Empathic listening is often said to be at the heart of a facilitative relationship” and a
vital predictor of therapeutic success (Knox & Cooper, 2015, p. 40). The client must be
given the therapist’s full attention and listened to with empathy.

Empathic listening requires that the counselor experience the client’s feelings as
though they were their own; such active listening is more intense than typically found
in our daily lives.

• Research suggests that warmth and caring in therapy are critical factors in a solid
therapeutic relationship. The client must feel that their lives and problems are essential
to the therapist and that they care. Sometimes this is as simple as seeing a natural,
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unprompted human response to what they say (Knox & Cooper, 2015).

A strong, authentic therapeutic relationship can facilitate a positive and deep

connection between the therapist and client that will benefit the treatment and
outcome (Knox & Cooper, 2015).

2 Examples of a Supportive Therapeutic Alliance

A supportive therapeutic alliance is crucial to client perseverance and a positive

treatment outcome (Ardito & Rabellino, 2011).

The following two examples taken from case reports provide examples of the results of
healthy therapeutic relationships between the client and therapist.

Psychodynamic therapy

Having been married for 29 years, ‘Wendy’

was shocked to be told by her husband that
he wanted a divorce (Tamplin, 2014). Unable
to cope with constant crying and feelings of
extreme anxiousness, Wendy sought help.

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Wendy attended 18 therapy appointments over 8 months to help her cope.

From the outset, her therapist, ‘C,’ encouraged Wendy to express her feelings as much
and as often as possible regarding the sudden and drastic life changes. Wendy found
support in the empathy and understanding that her relationship with C fostered
(Tamplin, 2014).

C asked Wendy to think of the things she had wanted but had previously sacrificed for
the sake of her marriage. With the support of their alliance, Wendy ultimately found
the courage to move forward and live her life as though her husband wasn’t returning.
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Obsessive-Compulsive Disorder
‘Darcy’ and her psychologist, ‘Marian,’ had a
particularly strong therapeutic alliance that got
them through 12 years of treating Darcy for
obsessive-compulsive disorder (Australian
Institute of Professional Counsellors, 2013).

Following decades of compulsive behavior that included elaborate prayer routines to

keep everyone safe, Darcy had sought treatment.

Marian felt and displayed enormous compassion for Darcy. She began by working with
her to achieve emotional stability before starting a long-term process of changing her
thinking habits. Over the years, Darcy discontinued all medication and ultimately
married a “wonderful” man with whom she had a daughter. “Marian felt blessed to have
had Darcy as a client” (Australian Institute of Professional Counsellors, 2013).

10 Skills of Effective Therapists

International research about what makes a great therapist explored what such
professionals were doing, thinking, and feeling when they were at their most effective
(Novotney, 2013).

Results suggest that effective therapists have sophisticated interpersonal skills,

including (Novotney, 2013):

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• Verbal fluency
• Warmth
• Acceptance
• Empathy

And they are highly capable of:

• Identifying how a person is feeling

• Forming strong therapeutic alliances with a range of patients
• Helping clients accept treatment and engaging in positive work with them
• Being highly tuned to patient progress
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• Taking the actions needed to address issues that impede progress

• Choosing the right treatments for specific client problems

3 Helpful Techniques for Counselors

There are several techniques that counselors can adopt to improve the therapeutic
relationship.

Create a therapeutic bond

Creating a bond requires building warmth and trust within the relationship. The client
should feel heard, supported, and able to connect deeply with the therapist when
needed (Knox & Cooper, 2015).

While the counselor cannot always change whether the client sees them as the right
person to work with, there are some techniques that can help them foster client trust
(modified from Knox & Cooper, 2015):

1. Create an atmosphere that is friendly, warm, and welcoming.

2. Remain sensitive to why the client has sought help.
3. Maintain consistency in the approach.
4. Maintaining reliability is vital to gaining and maintaining trust.
5. Form boundaries and maintain confidentiality.
6. Do not judge.

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There is no single recipe that works for all clients, but an ongoing awareness of client
needs will improve trust conditions.

Ask for feedback

Sometimes the best way to find out what is working and what needs to change is to
ask. At the end of each session, consider asking your client the following questions
(modified from Knox & Cooper, 2015).

What did you find helpful today?

What worked well for you today?
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What did not work so well today?

Was anything in this session particularly unhelpful or annoying?
What would you like to see more or less of in future sessions?

Prepare for empathy

Empathy is one of the most important aspects of being a good therapist and developing
successful alliances.

Some techniques can help you prepare for empathic listening, including (modified from
Knox & Cooper, 2015):

1. Practice putting aside judgments in your everyday conversations with friends, families,
and strangers.
2. Explore issues that make you uncomfortable. As your understanding grows, consider
whether your feelings and opinions have changed.
3. Be ready to say ‘no’ if you feel unable to work with a particular client.
4. Discuss with a colleague or supervisor any feelings you need to sideline to be
successful with a client.

6 Communication Tips

When the therapeutic alliance appears to fail, it is worthwhile considering your

approach to communication (Knox & Cooper, 2015).

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1. Reflect on your skills and ability to relate in depth.
2. Consider how you personally disconnect (or appear to) from others or actively prevent
connection with others.
3. Does your theoretical approach impact how you relate to the client?
4. When you have experienced deep connections with clients in the past, what were you
doing to facilitate the experience? What qualities were you using or displaying?
5. Having reflected on your abilities to relate in depth, consider what you could do to
develop these skills further.
6. How might you relate in depth to someone with communication difficulties? How
might you adapt your style?
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A Take-Home Message

Research confirms the importance of the link between healthy therapeutic

relationships and positive treatment outcomes. The quality of the alliance appears even
more crucial than the type of intervention or therapeutic model employed (Ardito &
Rabellino, 2011).

Indeed, “a good relationship is essential to helping the client connect with, remain in,
and get the most from therapy” (DeAngelis, 2019).

Setting up a calm and safe environment and ensuring empathy, confidentiality,

warmth, and caring help build and maintain a healthy relationship between the client
and therapist. Furthermore, through adequate preparation, feedback, and reflection,
mistakes can be managed and a rupture to the therapeutic process overcome.

Therefore, it remains vital that soft skills that build the therapeutic relationship receive
the attention needed and are tailored according to clients’ needs. As therapists and
counselors, we must continue to seek training, supervision, and feedback to identify
further growth and development opportunities.Why not use this article and awareness
of your strengths and weaknesses to reflect upon how you can develop your skills? Use
the learnings to put in place robust and healthy relationships with your clients and
increase the potential for a successful treatment outcome.

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