Introduction

Most evaluations of counselling interventions focus on the type of counselling and on the techniques and activities used by the counsellor (e.g. psychoeducation, meditation and mindfulness or art therapy). However, these may be missing the most important part of the story when it comes to client outcomes. Decades of research draw attention to a group of factors common to all counselling interventions that have greater influence over client outcomes than the counselling type (Dobud & Harper, 2018; Fife et al., 2014; Hess, 2019). These common factors in counselling relate to the relationship between counsellor and client, regardless of the specific counselling type or intervention (Wampold & Imel, 2015). 

This short article focuses on the quality of what is called the ‘therapeutic alliance’ between counsellor and client. This resource also provides some strategies for counsellors to consider for strengthening the relationships they have with the people they work with, including children, young people and adults. This resource will be useful for frontline workers and program managers in child and family services, especially those providing counselling services.

What do we know about counselling and positive outcomes for clients?

The common factors associated with positive outcomes for clients who have attended counselling can be grouped into counsellor, client and relationship factors.

Counsellor factors:

• therapeutic reasons for delivering the service (Dobud & Harper, 2018)
• the counsellor’s confidence that the type of counselling being delivered is effective (Fife et al., 2014)
• unconditional positive regard for the client (Hess, 2019) – that is, supporting and accepting the client without conditions
• congruence – that is, how much the counsellor’s behaviours and other forms of communication match the expectations that they have set with the client about the intervention and the nature of the work they will do together (Frankel et al., 2016; Hess, 2019).

Client factors:

• unique life factors (e.g. current level of distress, cultural background) (Dobud & Harper, 2018; Hess, 2019)
• motivation (Fife et al., 2014)
• willingness to change (Hess, 2019)
• placebo, hope and expectancy (e.g. when clients believe that the counselling is likely to help, they are more likely to actively engage in the service, and so more likely to experience improved outcomes) (Dobud & Harper, 2018; Fife et al., 2014; Hess, 2019).

Relationship factors:

• the relationship/alliance between the counsellor and client (Dobud & Harper, 2018; Fife et al., 2014; Hess, 2019) – here, the client’s rating of the alliance is more important than the counsellor’s (Wampold & Imel, 2015)
• setting goals together (Hess, 2019).

Therapeutic alliance between counsellor and client

Since the late 1970s, researchers have struggled to understand exactly what makes different kinds of counselling interventions effective. For example, we know that art-based interventions are effective in promoting resilience. But there is also evidence that replacing art with music or sport or nature-based counselling may be equally effective. Researchers have found that knowing the client’s attitude to the therapeutic alliance with the counsellor is a better predictor of positive outcomes than knowing what techniques and activities are done in the specific type of counselling. That is, clients who are more positive about the relationship they have with the counsellor have better counselling outcomes.

Clients have a better attitude towards the therapeutic alliance with the counsellor when:

• there is a shared sense of trust and empathy between the client and counsellor (i.e. ‘relational bond’)
• there are higher levels of agreement about the goals and purpose of the counselling intervention
• there are higher levels of agreement about how to achieve those goals.

Client outcomes are consistently predicted by the counsellor’s ability to build strong therapeutic alliances with clients from a wide range of backgrounds and experiences (Del Re et al., 2021). The counsellor developing the skills and ability to form a therapeutic alliance with the client is more predictive of highly effective counselling than the type of counselling provided or the counsellor’s qualifications, gender, caseload or age (Chow et al., 2015). This relationship, in turn, improves client engagement and reduces the likelihood of client dropout. For this reason, when counselling seems like it isn’t working as expected, such as not improving wellbeing, counsellors and program providers could encourage discussions between counsellors and clients about the quality of the client’s engagement. 

Although counsellor demographic factors (e.g. their age, ethnicity, gender, etc.) on their own are not predictive of effective counselling, counselling services should still respond and adapt to the cultural factors present in each therapeutic relationship. This is because evidence-based practice is ‘the integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences’ (American Psychiatric Association, Presidential Task Force on Evidence-Based Practice, 2006, p 273).

Implications for practice

Counsellors can reflect on the following evidence-informed strategies for building a strong therapeutic alliance with clients (Bohart & Tallman, 2010):

• Although some clients may be stuck in a challenging and difficult position, approach your work with the belief that all clients are resilient and capable of overcoming their difficulties.
• If a client appears uninterested or disengaged from the service, avoid thinking the client is resistant, in denial, unmotivated or not ready, this includes how you write case notes and in discussions with other counsellors and managers. Resistance only exists in the context of a relationship and is not a quality or descriptor of the client. Instead, ask clients what motivates them – for example, ‘What are your best hopes for coming here today?’ 
• Focus on the client’s perception of the problem, lived experience and view of therapeutic alliance and intervention.
• Provide space for clients to come up with their own solutions and avoid leading clients into solutions crafted by you.
• Remain open to client feedback, whether positive or negative, and use the feedback to tailor the intervention and improve the therapeutic alliance.

This is only a brief set of strategies. We have linked to further reading and related resources below.

Further reading and related resources

• Therapeutic alliance
  This Psychology Today resource provides further insights about building the therapeutic alliance through authenticity, attentiveness and positivity.
• Is resistance dead? Or have the rumors been exaggerated?
  This article in the Psychotherapy Networker provides reflections and tips for increasing client engagement and working to build a strong therapeutic alliance.
• Common Factors and the Uncommon Heroism of Youth
  This article from Psychotherapy in Australia provides some common factors to consider when working with young people, including the importance of making space for the client to have their own voice in counselling.
• Defining and delivering effective counselling and psychotherapy
  This CFCA policy and practice paper addresses the similarities and differences between the terms counselling and psychotherapy, explores counselling's essentially voluntary nature and examines the practice and research divide between individual, couples and family focused work.

Conclusion

Counsellors and program coordinators can have greater influence over the effectiveness of counselling interventions by focusing on the counsellor’s ability to build strong therapeutic alliances with clients across from a wide range of backgrounds and experiences. This can be more important than whether the counsellor has clinical experience or which type of counselling they do. Strong therapeutic alliances are based on a shared sense of trust and empathy between the client and counsellor and higher levels of agreement about the goals, purpose and methods of the counselling intervention.

Acknowledgements

Dr Jasmine B. MacDonald is Senior Research Officer in the Child Family Community Australia (CFCA) team at the Australian Institute of Family Studies. Dr Will Dobud is Lecturer in Social Work at Charles Sturt University. This resource was improved through revisions based on feedback provided by Dr Stewart Muir.

This resource used material from an upcoming CFCA policy and practice paper, Building resilience in children and young people: Good practice in community-based group counselling to be published later this year.

References

American Psychiatric Association, Presidential Task Force on Evidence-Based Practice. (2006). Evidence-based practice in psychology. American Psychologist, 61(4), 271–285. doi:10.1037/0003-066X.61.4.271

Bohart, A. C., & Tallman, K. (2010). Clients: The neglected common factor in psychotherapy. In The heart and soul of change: Delivering what works in therapy (2nd ed., pp. 83–111). Washington, DC: American Psychological Association.

Chow, D. L., Miller, S. D., Seidel, J. A., Kane, R. T., Thornton, J. A., & Andrews, W. P. (2015). The role of deliberate practice in the development of highly effective psychotherapists. Psychotherapy, 52(3), 337–345. doi:10.1037/pst0000015

Del Re, A. C., Flückiger, C., Horvath, A. O., & Wampold, B. E. (2021). Examining therapist effects in the alliance-outcome relationship: A multilevel meta-analysis. Journal of Consulting and Clinical Psychology, 89(5), 371–378. doi:10.1037/ccp0000637

Dobud, W. W., & Harper, N. J. (2018). Of Dodo birds and common factors: A scoping review of direct comparison trials in adventure therapy. Complementary Therapies in Clinical Practice, 31, 16–24. doi:10.1016/j.ctcp.2018.01.005

Fife, S. T., Whiting, J. B., Bradford, K., & Davis, S. (2014). The therapeutic pyramid: A common factors synthesis of techniques, alliance, and way of being. Journal of Marital and Family Therapy, 40(1), 20–33. doi:10.1111/jmft.12041

Frankel, M., Johnson, M. M., & Polak, R. (2016). Congruence: The social contract between a client and therapist. Person-Centered & Experiential Psychotherapies, 15(2), 156–174. doi:10.1080/14779757.2016.1182061

Hess, N. (2019). A neuroscientific perspective on the therapeutic alliance and how talking changes the brain: Supporting a common factors model of psychotherapy. Psychotherapy and Counselling Journal of Australia, 7(2). doi.org/10.59158/001c.71106

Vos, J., Chryssafidou, E., van Rijn, B., & Stiles, W. B. (2022). Outcomes of beginning trainee therapists in an outpatient community clinic. Counselling and Psychotherapy Research, 22(2), 471–479. doi.org/10.1002/capr.12466

Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work (2nd ed.). New York: Routledge/Taylor & Francis Group.