Enhancing the Therapeutic Alliance with Clients

1. ENHANCING THE
THERAPEUTIC ALLIANCE
WITH CLIENTS
Jeffrey T. Guterman, Ph.D.
Thursday, February 18, 2016
Copyright © 2016 Jeffrey T. Guterman
PowerPoint presentation available at http://JeffreyGuterman.com

2. Enhancing the Therapeutic Alliance with Clients 2
Contents
About the Presenter ................................................................................................................. 3
Session Description ................................................................................................................. 3
Session Objectives .................................................................................................................. 3
Common Change Factors ........................................................................................................ 4
Principles of Strength-Based Approaches to Therapy............................................................. 4
Problem and Exception ........................................................................................................... 5
Theory of Change ................................................................................................................... 5
Stages of Strength-Based Counseling ..................................................................................... 5
Mapping the Influences of the Problem .................................................................................. 5
Identifying Exceptions ............................................................................................................ 6
Questions for Amplifying Exceptions .................................................................................... 6
Decision Tree for Solution-Focused Tasks ............................................................................. 7
Scaling Form ........................................................................................................................... 8
References and Suggested Readings ....................................................................................... 9
Suggested Internet Resources ................................................................................................. 9

3. Enhancing the Therapeutic Alliance with Clients 3
About the Presenter
Jeffrey T. Guterman, Ph.D. is a mental health counselor in Fort Lauderdale, Florida. He is
author of over 125 publications. The first edition of his book Mastering the Art of Solution-
Focused Counseling was published by the American Counseling Association (ACA) in 2006,
it was translated in Korean in 2007, and an updated and expanded second edition was
published by ACA in 2013. He has also presented numerous workshops on solution-focused
counseling.
Contact Information
Email: jguterman@gmail.com
Phone: 305-725.4583
Web: http://JeffreyGuterman.com
Twitter: http://twitter.com/JeffreyGuterman
Jeffrey T. Guterman, Ph.D. is available to provide training and workshops for your
organization on various topics. Program topics and formats will be tailored to meet the
unique needs of your organization.
Education Session Description
Many clients have negative treatment experiences, including recidivism, referrals to multiple
counselors and agencies, and being mandated into treatment. Given these treatment issues, it
is common for clients to exhibit resistance in counseling. Research has shown that resistance
can be reduced by enhancing the therapeutic alliance. Collaborative and strength-based
techniques aimed at reducing resistance and enhancing the therapeutic alliance to facilitate
positive change are identified and reviewed. Case examples illustrate the application of
techniques aimed at enhancing the therapeutic alliance.
Education Session Objectives
1. Participants will identify and review factors that contribute to client resistance.
2. Participants will identify and review principles corresponding to collaborative,
strength-based approaches to counseling.
3. Participants will identify and review techniques aimed at reducing resistance and
enhancing the therapeutic alliance to facilitate positive change for clients.

4. Enhancing the Therapeutic Alliance with Clients 4
Common Change Factors
Lambert (1992) identified four common change factors that contribute most to improvement
in counseling and psychotherapy. According to Lambert, each of these common change
factors accounts for the following percentages of improvement that occur in counseling and
psychotherapy:
1. Client factors (or self-help): 40%
2. Therapeutic alliance factors: 30%
3. Expectancy factors: 15%
4. Model factors: 15%
The finding that client factors accounts for the most improvement in therapy (40%) affirms
the theory of change of collaborative, strength-based models of therapy (cf. Guterman, 2013).
The primary function of strength-based counseling is to help clients tap into their problem-
solving resources and potentials. Although a wide variety of techniques are used (which
accounts for 15% improvement based on the research), strength-based therapy is to be
considered a process model because it attributes change mainly to what clients do to solve
problems rather than to the model. In effect, its focus on client factors is the model. The
second reason that research on common change factors supports strength-based therapy is
because these approaches emphasize the important role of the therapeutic alliance. The
finding that therapeutic alliance factors account for 30% of improvement supports the unique
emphasis that strength-based counseling places on developing a collaborative relationship
between the client and counselor.
Principles of Strength-Based Approaches to Therapy
1. Viewing the client’s behaviors as their unique way of cooperating and educating
therapists as to the most fitting way to help them change.
2. Learning and incorporating the client’s worldview during therapy to enhance cooperation
and reduce resistance.
3. An emphasis on identifying and amplifying the client’s resources, strengths, and skills
rather eliminating deficits, problems, and psychopathology.
4. Eliciting and respecting the client’s previous negative treatment experiences, and
working with them to avoid ineffective approaches in the current therapy.
5. Identifying and incorporating positive supports into the therapy process, including people
who already recognize and encourage the client’s strengths and potentials.

5. Enhancing the Therapeutic Alliance with Clients 5
Problem and Exception
 Problem: Subjective and intersubjective complaint
 Exception: “Times when the complaint/problem does not happen even though the
client has reason to expect it happen” (de Shazer, 1991, p. 83).
Theory of Change
Theory of Change: When the problem is the rule, then exceptions tend to remain hidden
or decrease. When exceptions are identified and amplified, the problem tends to decrease.
Exceptions can be amplified by encouraging clients to do more of the behaviors that have
led them to solve the problem in the past, or to observe times when they are dealing better
with the problem, or ascribe significant meaning to the exceptions.
Stages of Strength-Based Counseling
 Coconstructing problems and goals
 Identifying and amplifying exceptions
 Coconstructing tasks
 Evaluating the effectiveness of tasks
 Reevaluating problems and goals
Mapping the Influences of the Problem
Mapping the influences of the problem is a line of questioning aimed at helping a client
understand how the problem has influenced his or her life (cf. White & Epston, 1990). If
the problem is depression, then the therapist might ask the client, “How has the
depression affected school?” “How has the depression affected your relationships with
family members?” or “How has the depression affected your health?” In cases when

6. Enhancing the Therapeutic Alliance with Clients 6
clients are very problem-focused, mapping the influences of the problem is a way to
speak to their need to talk about the problem and address its influences. This technique
also serves to increase opportunities for identifying exceptions. For example, when
mapping the influences for the problem of anger, the therapist might ask how the problem
has affected various aspects of the client’s life. After various influences of the problem
have been identified, the therapist can go back to these influences and inquire about
exceptions.
Mapping the influences of the problem is also aimed at externalizing the problem (White
& Epston). The principle of externalization is aimed at helping clients view themselves as
separate from their problems. In effect, clients are encouraged to see that they are not the
problem; the problem is the problem (White, 2004; White & Epston). Toward this end,
clients are frequently encouraged to put a name to the problem (White & Epston). For
example, a client might name the problem of anger as “The angry monster.” Naming the
problem can be a first important step in the process of externalizing the problem. Such an
approach creates a linguistic separation between the client and the problem.
Identifying Exceptions
 Presuppositional questions: Ask, “When has there been a time when _____ (the
problem) has not happened?” or “When has _____ (the goal) happened?” rather than,
“Has there been a time?
 Identifying small exceptions
 Identifying potential exceptions
o The miracle question:
Suppose that one night there is a miracle and while you are sleeping the
problem . . . is solved: How would you know? What would be different?
(de Shazer, 1988, p. 5)
Questions for Amplifying Exceptions
 How did you make it happen?
 How is that different from how you have dealt with the problem in the past?
 How did it make your day go differently?
 Who else noticed?
 What did you tell yourself to make it happen?
 What does this say about you and your ability to deal with the problem?
 What are the possibilities?

7. Enhancing the Therapeutic Alliance with Clients 7
Decision-Tree for Solution-Focused Tasks
Task # 1
The client is told and asked, “Between now and the next time, I would like you to observe, so
that you can tell me next time, about those times when you are able to make it (the goal)
happen.”
Rationale: This task is given if the client is able to construct a problem and goal, and
identify and amplify exceptions.
Task # 2
The client is told and asked, “Between now and the next time, I would like you to pay
attention to and make note of what you do when you are able to effectively cope with or deal
with the problem.”
Rationale: This task is given if the client is able to construct a problem and goal and
identify exceptions, but is unable to amplify exceptions.
Task #3
The client is told and asked, “Between now and the next time, I would like you to observe, so
that you can tell me next time, what happens in your life (relationship, family, work
situation) that you want to continue to have happen.”
Rationale: This task is given if the client is able to construct a problem and goal, and
potential exceptions, but is unable to identify exceptions.
Task 4
The client is told and asked, “Try to avoid making any drastic changes. If anything, think
about what you will be doing differently when things are improved.”
Rationale: This task is given if the client is able to construct a problem, but is unable to
construct a goal.
Task 5
The client is told and asked, “The situation is very volatile. Between now and the next time,
attempt to think about why the situation is not worse.”
Rationale: This task is given if the client is in severe crisis.

8. Enhancing the Therapeutic Alliance with Clients 8
Scaling Form
Name ________________________Age (Years):____ Sex: M / F
Session # ____ Date: ________________________
Who is filling out this form? Please check one: Self_______ Other_______
If other, what is your relationship to this person? ____________________________
Please rate your progress on the problem and goal for each day on a scale from 0 to 10
with “10” being the least and “0” or “1” being the best. Also, describe what you did to
make the progress in relation to the problem and goal.
Date Rating Describe what you did

9. Enhancing the Therapeutic Alliance with Clients 9
References and Suggested Readings
de Shazer, S. (1982). Patterns of brief family therapy. New York: Norton.
de Shazer, S. (1984). The death of resistance. Family Process, 23, 11-17.
de Shazer, S. (1985). Keys to solution in brief therapy. New York: Norton.
de Shazer, S. (1988). Clues: Investigating solutions in brief therapy. New York: Norton.
de Shazer, S. (1991). Putting difference to work. New York: Norton.
de Shazer, S. (1994). Words were originally magic. New York: Norton.
de Shazer, S. (1997). Commentary: Radical acceptance. Families, Systems, & Health, 15,
375-378.
de Shazer, S., Berg, I. K., Lipchik, E., Nunnally, E., Molnar E., Gingerich, K., & Weiner-
Davis, M. (1986). Brief therapy: Focused solution development. Family Process, 25,
207-222.
Duncan. B.L., Miller, S.D., & Sparks, J.A. (2004). The heroic client: A revolutionary way to
improve effectiveness through client-directed, outcome-informed therapy. San
Francisco: Jossey-Bass.
Guterman, J.T. (1996). Doing mental health counseling: A social constructionist re-vision.
Journal of Mental Health Counseling, 18, 228-252.
Guterman, J.T. (2013). Mastering the art of solution-focused counseling (2nd
ed.).
Alexandria, VA: American Counseling Association.
Lambert, M.J. (1992). Implications of outcome research for psychotherapy. In J.C. Norcross
M.R. Goldfried (Eds.), Handbook of psychotherapy integration (pp. 94-129). New
York: Basic Books.
Martin, C.V., Guterman, J. T., & & Shatz, K. (2012). Solution-focused counseling for eating
disorders. VISTAS, 1-11.
White, M. (2004). Narrative practice and exotic lives: Resurrecting diversity in everyday life.
Adelaide, South Australia: Dulwich Centre Publications.
White. M., & Epston, D. (1990). Narrative means to therapeutic ends. New York: Norton.
Suggested Internet Resources
Jeffrey T. Guterman, Ph.D.
PowerPoint for this session is available at http://JeffreyGuterman.com
Twitter: http://twitter.com/JeffreyGuterman
Facebook: http://facebook.com/solutionbook
International Center for Clinical Excellence (ICCE)
http://www.centerforclinicalexcellence.com
Scott D. Miller, Ph.D.
http://www.scottdmiller.com
Institute for Solution-Focused Therapy
http://www.solutionfocused.net
Solution-Focused Brief Therapy Association (SFBTA)
http://www.sfbta.org