Therapeutic Alliance

The Basic Idea

Let’s say you’ve been struggling with anxiety for a while, and after doing some research, you found a therapist who you think could be a good fit. 

After having a few sessions with her, you’ve started to build mutual trust with one another. She trusts that you will arrive at your sessions and work on the agreed-upon skills, and you trust that she has your best interest at heart. 

This type of partnership, founded on mutual trust, is referred to as a therapeutic alliance: a positive, collaborative partnership between a patient and their therapist. This relationship is made up of mutually agreed-upon goals and tasks, and is an essential component of therapy.

The theory of therapeutic alliance can be traced back to later versions of Sigmund Freud’s theory of transference from over a century ago. He argued that a supportive attitude from the therapist would prompt the patient to associate them with images of those who usually treat the patient with affection.1 While the field of psychology has made significant strides in the last century, Freud set the foundation for future understanding of therapeutic alliances. 

Theory, meet practice

TDL is an applied research consultancy. In our work, we leverage the insights of diverse fields—from psychology and economics to machine learning and behavioral data science—to sculpt targeted solutions to nuanced problems.

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Contemporary Context

While telehealth has had somewhat of a slow uptake since its inception in the 1990s,2–4 the pandemic dramatically shifted how patients receive care, making telehealth (alternatively called “telemental health”) much more appealing. 

There are a few options available, including synchronous engagement (e.g. live interaction between a patient and therapist) and asynchronous engagement (e.g. emails for online messaging between a patient and therapist).5

Telemental health treatments facilitate outcomes that are comparable to in-person treatments,6 however there are a few considerations for both patients and practitioners to keep in mind. First, if patients experience technical difficulties, they may feel that their alliance has become strained.7

Telehealth would also not be a best fit for patients with more intense needs, such as addicts or those experiencing thoughts of suicide. In this context, the therapeutic alliance could be negatively affected because a patient may not feel fully supported by their therapist, and the therapist may not be able to fully understand the needs of the patient.

Finally, with self-guided telemental health treatments, the lack of a therapeutic relationship may negatively affect outcomes and is best when supplemented with some clinician interaction.7

A conceptual model of a therapeutic alliance, as proposed by Hougaard, 1994.

The Behavioral Science

Part of why a strong therapeutic alliance is so integral to therapy is its demonstration of trust between both parties. A patient shares personal details of their lives, and the therapist trusts that they’re being honest and willing to do the work to improve. 

Think about it: if neither party had trust in the other, therapy sessions would be tense stalemates that accomplished little. Trust allows for vulnerability, and as eloquently stated by Brené Brown, there is power in vulnerability.8 While a therapeutic alliance may tackle more delicate information than other types of alliances, trust and vulnerability are as pivotal in this relationship as any.

Case Study

For low-income pregnant women and new mothers, the US Government created the Women, Infants, and Children (WIC) program, providing supplemental food, healthcare referrals, and dietary information.

The non-profit IDEO approached our team to locate potential bottlenecks or barriers to engagement with the WIC program. 

After conducting an extensive literature review of potential behavioral barriers in healthcare, we developed a nutritional toolkit that leveraged the COM-B model that would lead to increased therapeutic alliance between nutritionists and clients. Our toolkit has been integrated into IDEO’s nutritionist curriculum that is geared towards WIC nutritionists.

You can read more about the case study here.


1. Freud, S. (1913). On the beginning of treatment: Further recommendations on the technique of psychoanalysis. The Standard Edition of the Complete Psychological Works of Sigmund Freud, 122–144.

2. Austen, S., & McGrath, M. (2006). Attitudes to the use of videoconferencing in general and specialist psychiatric services. Journal of Telemedicine and Telecare, 12, 146–150.

3. Calkins, H. (2021, January 1). Online therapy is here to stay. American Psychological Association.

4. Perle, J. G., Langsam, L. C., Randel, A., Lutchman, S., Levine, A. B., Odland, A. P., Nierenberg, B., & Marker, C. D. (2013). Attitudes Toward Psychological Telehealth: Current and Future Clinical Psychologists’ Opinions of Internet-Based Interventions. Journal of Clinical Psychology, 69(1), 100–113.

5. Lopez, A., Schwenk, S., Schneck, C. D., Griffin, R. J., & Mishkind, M. C. (2019). Technology-Based Mental Health Treatment and the Impact on the Therapeutic Alliance. Current Psychiatry Reports, 21(8), 76.

6. Andrews, G., Basu, A., Cuijpers, P., Craske, M. G., McEvoy, P., English, C. L., & Newby, J. M. (2018). Computer therapy for the anxiety and depression disorders is effective, acceptable and practical health care: An updated meta-analysis. Journal of Anxiety Disorders, 55, 70–78.

7. Richards, P., Simpson, S., Bastiampillai, T., Pietrabissa, G., & Castelnuovo, G. (2016). The impact of technology on therapeutic alliance and engagement in psychotherapy: The therapist’s perspective. Clinical Psychologist, 22(2), 171–181.

8. Brown, B. (n.d.). Brené Brown: The power of vulnerability | TED Talk. Retrieved November 16, 2022, from

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