Provider Perspectives on Developing the Therapeutic Alliance

Background:  A body of research has documented the importance of the therapeutic alliance across helping professionals, settings, and modalities. Yet, little is known about the challenges experienced by community mental health providers in developing the alliance. This study utilized focus groups with community mental health providers to increase understanding about the barriers they experience in developing the alliance as well as strategies they use to develop and enhance the relationship.

Methods: Six focus groups (n=41) with mental health providers employed by community mental health centers were conducted. Ninety percent (n=37) had a master’s degree and 10% (n=4) held a doctorate, in psychology, counseling, or social work. Participants averaged 11.6 years (SD=8.2) of experience. Their mean age was 40.5 (SD=10.7), ranging from 26 to 59.

            The interview guide consisted of questions related to indicators of a strong relationship, challenges to developing the relationship, and strategies used to enhance the relationship. Focus groups were audio-taped and the tapes were transcribed. Each of the researchers independently read the transcripts and themes and patterns were identified for each group and compared across groups.

Results: Indicators of a strong relationship included that the clients kept appointments, but more important was how clients responded to the provider. Client feedback, obtained informally, was used to assess the quality of the relationship. A primary theme was the relationship as a process, beginning even prior to the first contact and continuing until and even beyond termination.  Primary challenges were client beliefs about seeking help and their environmental constraints (for example, lack of transportation to appointments), as well as provider time constraints and high work load.  Agency policies and structure (for example, location with other health providers; policies around missed appointments and discharge; training for receptionists in interacting with clients), also emerged as a theme for either challenging or enhancing the development of the relationship. Participants noted how social policies in relation to insurance, etc. can trickle down to impact their relationship with clients. Strategies used to enhance the relationship included provider persistence, probing for the client’s past experiences with professional helpers, and educating clients about what to expect in the helping process. Actual quotes will be used in the poster session to illustrate the primary themes.

Implications: The helping relationship is impacted by factors at multiple levels. It is fairly easy to understand how client and provider characteristics can affect the relationship, but agency and social polices also have the potential to impact behaviors and attitudes of providers and clients and hence the development of the relationship. Agencies can assess how their policies influence the helping relationship and ultimately client outcomes. Although the responsibility for developing the relationship is often placed on the helper, the realities of practice often present challenges in doing so. Future research on the relationship should incorporate factors at larger system levels in addition to client and helper characteristics.