I’m officially done with the first year of grad school 🥳! The spring semester seemed to fly by, but it has provided some of the most valuable growth in my knowledge and approach as an aspiring “helping professional.” One of the most striking learnings that I am still appreciating is related to the Therapeutic Alliance. The Therapeutic Alliance is basically the working relationship between the therapist and the client. In a moment I’ll explain its significance.
There is understandable skepticism around whether therapy actually works, in part because there is such a broad range of what constitutes therapy, and because outcomes seem difficult to measure. Addressing what constitutes therapy, you may be familiar with different types such as Cognitive Behavioral Therapy (CBT), Dialectic Behavior Therapy (DBT), Psychodynamic Therapy, Eye Movement Desensitization and Reprocessing (EMDR), Somatic Therapy, Family Systems Therapy (FST), Gestalt Therapy, or Person-Centered Therapy (PCT). The list goes on!
An interesting thing about research on therapy effectiveness is that despite the many differences across types, researchers have been able to identify what are called common factors, which are the aspects of therapy that all types share in common. The common factors for all therapy types or “modalities” are: The Therapeutic Alliance, Extratherapeutic Change, Expectancy (placebo effects), and Techniques.
The Therapeutic Alliance is the relationship between therapist and client. If the client feels well supported by the therapist, that by itself is effective at helping them achieve desirable outcomes, such as symptom reduction, better relationships, and enhanced quality of life. This is pretty remarkable to me, and I’ll come back to this later.
Extratherapeutic Change is what clients bring to therapy, including strengths and resources, motivation to solve the presenting problem, and even luck. Oftentimes the process of therapy is about helping the client activate strengths and resources they already have, but find difficult to access due to fear of negative consequences or stuck feelings. Even luck can have a meaningful effect, such as the circumstances changing (e.g. weather, job market, windfalls, problems resolving on their own) without any direct intervention.
Expectancy is the placebo effect, meaning if the client believes that therapy will help them, then that by itself has an effect on the outcome. Also if they don’t believe it will help them (nocebo), then that will have an effect.
Finally, there is the specific type of therapy and skill of the therapist applying it, which does have a modest effect on the outcome too.
What is interesting about these common factors is that research has shown how much each factor contributes to improved outcomes as determined by the client’s assessment over time, and objective measures such as symptom reduction. This pie chart summarizes the effects:
Source: Assay, T. P., & Lambert, M. J. (1999). The empirical case for the common factors in therapy: Quantitative findings. In M. A. Hubble, B. L. Duncan, & S. D. Miller (Eds.), The heart and soul of change: What works in therapy (pp. 33–56). American Psychological Association.
What do you notice about the proportions on the chart? Hopefully you notice that Extratherapeutic Change has the largest effect (40%), and that the Therapeutic Relationship has the second largest effect (30%). In summary, when the relationship between the therapist and the client supports the client realizing strengths and motivation within themselves, they get better. Whether the client believes in therapy will have some effect (15%), as will the specific techniques that align with the client’s needs (15%). But overall it’s the emotional bond that translates into improved self-efficacy and self-belief, which motivates clients to keep doing the things they learn in therapy.
With exercise and health habits, which are often our focus when we coach clients at Zen, this aligns well with cardio and weightlifting being certain “techniques” we provide education about, but are actually less important towards their growth than whether they like the way we communicate with and support them, and that the process of training enables them to realize they are strong, capable, and able to see themselves sustaining the habits long-term.
What is the “right or wrong” way to eat, do cardio, stretch, or lift weights? What are my ideal macros, or which supplements should I take? These are the things we see lots of coaches and media content focusing on. It suggests that technique is the most important thing. From my perspective and education thus far, this focus is misguided. Instead, a better question might be: how can I best support you in your pursuit of a healthy lifestyle? This centers the client as capable of being aware of their needs and asking for the kind of support that helps them take the next step as powerful agents of change in their own lives. This is also why many skilled therapists, sometimes to the frustration of their clients, do not often give advice directly. Telling people exactly what to do seems like a great shortcut to gains, but instead it disrupts the process of activating strengths, reinforces hierarchy in relationships with the coach or therapist being the expert with exclusive knowledge, and the client depending on them for understanding themselves, blunting their development of self-trust and self-understanding.
One more surprising learning that connects to all of this is the 85+ years running Harvard Study of Adult Development (TedTalk summary) – one of the longest-running studies of human life ever conducted. It began in 1938, has followed participants (and later, many of their families) for more than 85 years, and is still going today.
Researchers tracked health, careers, marriages, habits, psychological well-being, and aging across entire lifespans. The core finding is that the strongest predictor of happiness, health, and longevity was not wealth, genetics, cholesterol levels, or social class — it was the quality of close relationships.
People with strong, warm social connections were happier and physically healthier. Not discipline, biohacking, or individual success. Relationships. Relationship satisfaction in midlife predicted health in old age better than many traditional medical markers. Chronic isolation correlated with earlier decline in physical health and brain function. Conversely, emotionally secure relationships appeared to buffer stress responses in the body. And this connection to the Therapeutic Alliance and your goals, whatever they may be, is what I will leave you with. What if relationship is the outcome you seek?
Mauricio