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Therapeutic alliances and effective care

Mental health issues can be difficult topics to broach. Even after decades of normalizing people reaching out for help, many people are hesitant to take the step of speaking with a professional. This reluctance can be dramatically affected by the professionals they see and the relationships they build with them. Patient-provider relationships, also known as therapeutic alliances, are a critical component of successful mental healthcare. In this article, we’ll explore the essential elements involved in establishing trust between providers, with a particular focus on mental health counselors, and their patients/clients. From foundational communication skills to nuanced techniques, let’s take a closer look.

What is a therapeutic alliance?

A therapeutic alliance, sometimes known as a ‘working alliance’, refers to the relationship between mental healthcare providers and patients. It is a critical part of the therapeutic process and can have a big impact on successful treatment efforts. The ideal therapeutic alliance is both trusting and filled with rapport so that the patient feels as comfortable as possible. Comfort allows patients to express themselves and their struggles more honestly than they might to strangers.

There are a few key characteristics of therapeutic alliances, including:

  • Trust
  • Collaboration
  • Empathy and understanding
  • Respect
  • Boundaries
  • Communication
  • Positivity

Trust is probably the most important element of a strong therapeutic alliance. It allows patients to feel safe and supported during treatment and makes them more likely to share their feelings, experiences and fears with their provider. Through this trusting relationship, providers can collaborate with their patients or clients to build their coping skills and identify areas for improvement. These issues and concerns are addressed with empathy and understanding by the professional, with an emphasis on encouragement and motivation.

Professionals also work to establish boundaries in their therapeutic alliances so that their patients understand the professional relationship. This is done with respect, ensuring that everyone involved feels heard while also ensuring that provider-patient interactions do not reflect any judgment on the side of the provider. Clear communication and positivity round out the most important characteristics of therapeutic alliances.

Why do therapeutic alliances matter?

Therapeutic alliances are important because they facilitate honest communication between patients and providers and lead to better patient outcomes. A 2020 study, for example, found that better relationships between patients and providers led directly to better patient outcomes. This includes both the quality of care that patients receive as well as their ability to effectively self-manage chronic conditions. 

Some of the most critical reasons therapeutic alliances matter include:

  • Increased trust and openness
  • Improved patient motivation and engagement
  • More effective collaboration
  • Patient empowerment
  • Better patient outcomes
  • Enhanced emotional support

Overall, patients with strong therapeutic alliances have consistently demonstrated better outcomes. This indicates that the provider-patient relationship matters a great deal and that patients who have good interactions with their providers receive better care than those who don’t have such good interactions.

How are therapeutic alliances established?

In mental health care, professionals are required to build close professional relationships with their clients that are ‘person-centered’. They revolve around building patient experiences tailored to individual needs. Establishing this kind of relationship requires time, dedication, and expertise. We’ll go over some of the skills and techniques used in building strong therapeutic alliances a bit later in the article. For now, let’s look at some of the broader steps providers can take when interacting with their patients and establishing or maintaining therapeutic alliances. 

There are two main phases in the relationship-building process known as ‘phase one’ and ‘phase two’. Phase one consists of five initial sessions of therapy. Over the course of these sessions, mutuality and collaboration are fostered between the patient and the provider. At the same time, obtainable and measurable goals are set. It is during this initial phase that patients begin to build trust and confidence in their providers and the treatments they provide and offer.

Phase two begins when providers first start to challenge the dysfunctional thoughts and behavior patterns their patients are demonstrating and the way they are affected. Initial rapport is crucial to this phase of the relationship as patients must trust that their providers are on ‘their side’ and are constantly working to help them improve. This phase can often lead to short-term damage to the therapeutic alliance. Providers who managed to foster a strong relationship during phase one are more likely to repair this damage and emerge with even stronger, more trusting, interactions over time.

 Relationship-building requires energy and dedication, of course, which is why the right skills and techniques are crucial. Let’s take a closer look at these skills and techniques, and explore how mental health providers utilize them in their therapeutic alliances.

Skills and techniques for building therapeutic alliances

Those interested in pursuing mental health counseling careers should start by considering the core skills, techniques and qualifications that are needed in this profession. The most effective practitioners have a solid academic foundation upon which they build their expertise, obtained by qualification from reputable institutions, such as a Master’s in Clinical Mental Health Counseling from the American International College. This program facilitates flexible and accessible study, designed to equip students with the relevant communication skills and techniques needed for a successful career.

Before they build strong therapeutic relationships with their patients/clients, mental health professionals must master several skills and understand a few techniques. In this section, we’ll explore some of the most important of each of them.


Of all the skills necessary for excellent communication and relationship-building, the following six are among the most critical:

  • Verbal fluency
  • Warmth
  • Acceptance
  • Empathy
  • Genuineness
  • Flexibility

From being able to recall the right words at the ideal moment to providing patients with a warm environment to help them heal, mental health professionals should have these six skills.

Verbal fluency

Verbal fluency is the ability to remember words on the fly. Someone with high verbal fluency can speak fluidly without pausing to consider word choice. Word retrieval requires control over a variety of cognitive processes including selective attention, mental set shifting, selective inhibition, self-monitoring and internal response generation, among others. 

You can improve your verbal fluency by focusing on activities that actively engage your brain. Doodling, drawing and taking notes, for example, require more of your attention than scrolling through social media. Cutting down on the latter, especially, can help improve the cognitive processes related to verbal fluency. 


According to the Association for Psychological Science, “warmth” is a collection of behaviors that project to patients that they are welcomed. Things like nodding, smiling and actively attempting to understand what patients are saying are all elements of exuding warmth. In the article described above, researchers studied people with negative beliefs about therapy as they began their therapy journey. They found that warmth was independently influential when predicting patient satisfaction.


Often paired with ‘non-judgment’, acceptance is a skill that allows providers to interact with their patients without outwardly judging them. Providers with high levels of acceptance project the sense that, no matter what patients say, they won’t judge them and will help them fix negative behaviors and thoughts. This, unsurprisingly, leads to patients who are more willing to share the dark and intense moments of their lives and, in turn, receive effective treatment to heal.


Empathy is a skill that helps providers provide compassionate care. Professionals with a good grasp of empathy can understand their patients’ situations, feelings and perspectives. They can also communicate their understanding and act on their understanding in a therapeutic way. The higher the level of empathy providers display, the more comfortable patients are during sessions and treatments. 


Genuineness is the ability to give nonverbal and verbal cues that match your words. Mental health counselors, for example, with a good grasp of this skill understand not only how to empathize with their patients, but also how to project that empathy and follow expressed empathy with actions. You can also think of this as transparency. Providers who are transparent with their patients about their intentions and their beliefs build more trusting relationships with patients than those who are not transparent.


Flexibility is crucial to mental healthcare in a few different ways. First, on a practical level, flexibility in scheduling and treatment techniques can have a big impact on patient motivation. If they are unable to schedule a convenient time for counseling, for example, patients might be much less likely to continue visiting their provider. Providers who make that process easy, however, give patients the opportunity to schedule their care around their daily lives. 

Flexibility is also important in the actual treatment process. Most providers work with patients from varying backgrounds with varying concerns. They must be able to transition from one technique and perspective to another as necessary as they move from patient to patient. This helps them respond genuinely to their patients’ needs. All of this, in turn, leads to better therapeutic alliances and more effective care.


In addition to the skills described above, mental health providers use many different techniques and approaches to help build strong provider-patient relationships. We’ll focus on cultural competence/sensitivity and empowerment/collaboration techniques in this article, but you should know that there are plenty of additional options if you’re interested in learning more.

Cultural competence

It is difficult to discuss mental healthcare without taking culture into account. The community you grew up in and/or currently reside in can have a huge impact on your willingness to seek out help for your mental health concerns. Some communities are much more willing to consider mental health concerns ‘valid’ health conditions to treat than others, and patients within those communities are more likely to have a positive and motivated approach to their mental health needs. Patients from cultures which are less accepting might have a harder time coming to terms with their needs as well as maintaining motivation for ongoing treatment.

Care providers must demonstrate cultural competency while practicing. This includes recognizing the background of their patient; the cultural challenges that might be standing in their way and making treatment difficult; and the likelihood of their patient agreeing to continue treatment. By keeping these considerations at the forefront of their minds, professionals are able to craft communication and treatment techniques that might motivate their patients to continue treatment.

Empowerment and collaboration

People with mental health concerns are often overwhelmed by the time they seek out professional help. They might be exhausted and unsure where their treatment will lead them, and their motivation might be quite low. Effective care providers give patients the skills they need to achieve their goals. These include enhancing awareness, responsible choices, discovery, and self-determination. This approach seeks to help patients acquire the tools they need to be proactive with their mental health for the rest of their lives.

Part of empowering patients is collaboration. The best care providers can work closely with their patients to establish measurable goals and realistic changes to foster long-term change. Strong therapeutic alliances make this process much easier and facilitate open communication.

The potential long-term impact of strong therapeutic alliances

Fostering communication and building solid therapeutic alliances is imperative to long-term mental health treatment. With the right approach, professionals can provide patients with personalized and transparent care that encourages their involvement and enhances their chances of success. 

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