Strategies to Build a Working Alliance
As recently as 2004, there was limited empirical evidence for specific actions that therapists could use to improve alliance (Kendall & Ollen- dick, 2004). Recent studies and theory have converged, however, to suggest several strategies to build a therapeutic alliance. We attend to the available evidence and offer a range of strategies for determining and adapting the therapeutic relationship with youth (see summary in Figure 15.2). First, a therapeutic relationship requires an empathic therapist. The therapist is an ally to the child or adolescent client (Diamond, Liddle, Hogue, & Dakof, 1999; Shirk, Karver, & Brown, 2011). A next step to build alliance is to help the child set goals for therapy (Creed & Kendall, 2005). The child’s agreement on therapy goals reflects a willingness to engage in treatment and modify behaviors, both of which contribute to the therapeutic relationship and to success.
FIGURE 15.2. A framework to determine and build alliance with youth in CBT.
Although collaboration has been defined differently across therapeutic orientations, collaboration in CBT is defined as “active shared work,” as described in more detail in Chapter 4 of this text. A collaborative therapist defines goals using a team approach, and the collaborative style has been supported by research (Creed & Kendall, 2005; Podell et al., 2013). The child and therapist team can also include parents, with developmental considerations taken into account. Parents can be consultants (provide information about their child), collaborators (assist in the provision of the intervention), or co-clients (receive the treatment concurrently), and decisions about such roles are guided by recognition of the youth’s level of development. For younger children, parents may be more active, whereas the degree of parental involvement may be reduced for adolescent clients.
DiGiuseppe et al. (1996) suggest that agreement on the goals and tasks of therapy is a part of therapeutic alliance that does not receive sufficient attention and that a combination of social problem-solving skills training, motivational interviewing, and strategies for overcoming resistance are necessary. To shape a negative evaluation of the target behavior, the first two strategies employ selective verbal reinforcement and Socratic questioning (a dialogue in which the therapist first attempts to evoke the client’s perceptions of the accuracy and usefulness of his or her thoughts and then tries to entertain alternate thinking through questioning—see Chapter 5; Calero-Elvira et al., 2013).
Guided discovery and collaborative empiricism help to build a positive therapeutic alliance with child and adolescent clients. Collaborative empiricism involves the therapist and client working together as a team to organize evidence and data to help explore the client’s beliefs as objective hypotheses to be tested out through behavioral experiments using the scientific method. In guided discovery, the therapist helps the client learn to analyze and eventually modify false thinking or beliefs. Flexible use of guided discovery and collaborative empiricism fosters a strong therapeutic alliance between therapist and client (Friedberg, Crosby, Friedberg, Rutter, & Knight, 1999; Friedberg & Gorman, 2007).
Even though the child may be the identified client in individual therapy, it is also important to monitor and be aware of the therapeutic relationship with the parent(s). Given the importance of agreed-upon goals, the therapist should identify conflicting interests and priorities with both the child and the parent(s) (Clark, 2013), as would be done in the course of family therapy. Furthermore, to maximize treatment compliance and effectiveness, the family’s cultural values merit consideration (Harmon, Hawkins, Lambert, Slade, & Whipple, 2005). The parent needs to concur regarding his or her role in treatment. With a manualized approach, it is particularly important to be aware of the family’s treatment goals. As described earlier, therapist flexibility is an important ingredient in fostering alliance (e.g., Chu & Kendall, 2009). If the child or parent’s treatment goals are not consistent with a certain portion of the manual, the therapist should be prepared to adapt the manual appropriately.
In contrast to the strategies that build the therapeutic relationship, other approaches may be detrimental (Karver et al., 2008; Shirk & Karver, 2006). Some of the more obvious behaviors that may have a negative impact on alliance include lacking empathy and failing to maintain collaboration; acting inappropriately confrontationally with the client; and being negative or pessimistic about the client’s ability to change. Treatment inflexibility (e.g., strict adherence to a therapy manual) is also problematic (Chu & Kendall, 2009). Similarly, being too formal with clients, especially children, can make it difficult for the client to view the therapist as an ally (Creed & Kendall, 2005). Other problematic strategies may be less apparent. For example, “pushing the child to talk” about difficult or anxiety-provoking experiences is associated with lower child-rated alliance (Creed & Kendall, 2005). Also, although discussions of anxiety- provoking situations take place in therapy, they are not for the initial session. Finally, the therapist may need to “nudge” a child, or encourage or motivate the child in a productive fashion.
While many of the alliance-building behaviors described are consistent with good clinical skill, there is also a need to strike a delicate balance between challenging the client and building an alliance. Although the therapist encourages the client to engage in difficult and new behaviors (e.g., exposures), this effort is conducted in such a way that the client remains aware that the therapist is on his or her side. A therapeutic relationship that provides a supportive experience is likely to maximize engagement and treatment response (McLeod & Weisz, 2005).
