On Therapeutic Alliance

Sometimes a discussion between colleagues can have an unexpected effect on the way you see things. As an adjunct instructor teaching adolescent psychology at Kean College in Union, New Jersey, I met Jose Perez, who was my office mate.  Jose was in his last year at Rutgers University in the doctoral program of psychology.  Upon inquiring about that program, which I subsequently entered, one comment Jose made still stands out in my mind:  Behavior Therapy does not make Arnold Lazarus’s patients well, Arnold Lazarus makes them well.

Jose’s point is quite critical in understanding the process of therapy and its efficacy.  His reference to behavior therapy was simply to illustrate the point that even though Arnold Lazarus may be considered a behavior therapist, its methodology was not what cured the patients of Arnold Lazarus.  In truth, I am not sure whether the late Dr. Lazarus would disagree with this idea inasmuch as he recently had published a book (1971) titled:  Behavior Therapy and Beyond.  In that book he discussed a mélange of therapeutic techniques, and how he employed them as a therapist.  These techniques went well beyond what people typically attribute to those clinicians who practice behavioral therapy.

On the contrary, I recall Lazarus stating it is not theories that cure patients, but rather the selective use of therapeutic techniques geared toward their specific problems.  In an article he later wrote, he underscored the importance of selecting out the appropriate techniques for an individual, and he labeled this procedure technical eclectism.  He believed that the more therapeutic techniques a therapist understood, and knew when and how to employ, the greater success that therapist would have in treating patients. 

I gained a greater awareness of technical eclectism when I had the opportunity to observe Arnold Lazarus do therapy, with a seminar patient, in a class he taught.  After the therapy session was over and the patient left the room, the class discussed what had happened in the session with Dr. Lazarus.  I must say I was extremely impressed with the improvised techniques that Lazarus was able to come up with, but also, I was struck by the fact that what he was doing bore little resemblance to behavior therapy.

While completing my doctorate in psychology, I had the good fortune of studying under Albert Ellis, the late renowned psychologist. Dr. Ellis had a direct confrontational style in treating his patients.  But, nevertheless, he made it clear to his patients that he had an unconditional acceptance or unconditional positive regard for his clients.  So, even when he was confronting them in his typically abrasive manner, Ellis’s patients knew that what he was doing was meant to be beneficial and not harmful to them.  Similarly, the results of the methods practiced by shamans and other faith healers have to do with the interaction of the individual with that particular healer.  If the individual has a strong belief and faith in the curer, this sets the tone for a favorable outcome.  Because there is no active ingredient, such as medicine involved in the treatment, scientists have referred to the causal agent as the placebo effect.  The placebo effect can be attributed to the positive expectation the subject or patient may have vis-à-vis the treatment the he/she is undergoing.

As a matter of fact, not to detract from the capabilities of past, eminent therapists such as Virginia Satir, Arnold Lazarus and Albert Ellis, I have no doubt that patients seeking out their services were well aware of their reputations.  Prior to their first meeting with any well-known and well-regarded name in the area of psychotherapy, I am sure they had great respect and with that, a positive expectation that they would get better.  This belief of the patient creates a positive therapeutic alliance that contributes to a treatment outcome that is beneficial. 

Most therapists do not carry the prestige and fame possessed by the celebrated names of their profession.  I have honed my own therapeutic skills with a combination of course work and reading in conjunction with the experience of having seen many patients that present with different problems.  To quote Albert Einstein: “Learning is an experience. Everything else is just information.” Here, I would add as a therapist goes through the different stages of life (e.g. career path, marriage, mentor), a therapist can more easily relate to more patients, a stance that would facilitate therapeutic bonding.

In summary, the therapeutic alliance is a sine qua non between patient and treating doctor.  No matter how intelligent or competent you are, if the patient does not like you or does not have a good opinion of you, your efforts to help that person will go in vain.  A client will more likely let you enter into his life if you have established good rapport with that individual.  That gets you in the door.  From there, you will need to apply whatever techniques you deem appropriate to counter the client’s issues in the therapeutic process.  I agree with Dr. Lazarus that the more therapeutic techniques you have mastered in combination with your experience, the greater likelihood of success you will have in dealing with the myriad of problems your patients may be facing. Although I specialize in cognitive behavioral therapy, the key to my success has been to tailor my techniques to the specific needs of my clients.