By Alexandra Kelly, Ph.D.
Dec. 17, 2018

U.S. Air Force photo by Tech. Sgt. James Hodgman

Much of our talk about evidence-based practice focuses on specific interventions and protocols that have been found to be efficacious in treating a given mental health disorder or behavioral concern (e.g., behavioral activation, systematic desensitization, challenging unhelpful cognitions). But beyond the "active ingredients" of these standardized treatments, there are certain factors that are shared among all forms of effective talk therapy.

Psychotherapy researchers call these treatment components "common factors." Common factors include a strong working relationship between the patient and therapist, a patient's expectation that treatment will be helpful, the therapist's demonstration of empathy for the patient, and (when appropriate) adaptations to make evidence-based treatments (EBTs) more culturally relevant to the patient.

Working alliance, or therapeutic alliance, is one of the most thoroughly researched common factors. The construct of working alliance in therapy comprises three elements:

• The bond between the therapist and patient encompassing trust, attachment, and genuineness
• Agreement on the goals of therapy
• Agreement on the tasks of therapy

Meta-analytic studies have found that a strong working alliance is associated with positive therapy outcomes(link is external) – particularly when the alliance is rated highly by the patient – whereas a weak therapeutic alliance is associated with treatment dropout. A positive therapeutic alliance is also associated with greater satisfaction with care, and may make the working relationship more resilient.

In the context of delivering EBTs in a military treatment setting, attending to the working alliance may help to bolster outcomes and retention. Below are some implications to keep in mind as you're approaching your clinical work with service members.

The Relationship

Ideally, our interactions with patients are characterized by trust, interpersonal authenticity, and a sense of mutual liking. Therapists generally work to facilitate this connection with patients by conveying empathy and positive regard, as well as a sense of confidence and expertness. Of course, patients and therapists may experience the relationship differently; feedback from tools like the Working Alliance Inventory(link is external) can be helpful in assessing and responding to patients' perceptions of the therapeutic relationship.

Establishing trust and rapport can be particularly challenging in a military treatment setting, where concerns about career impact and differences in rank between therapist and patient can present barriers to patient disclosure. Service members whose military occupations place a heavy emphasis on optimal functioning may be particularly reluctant to speak openly with a provider about their concerns at the outset of the working relationship. It is important for therapists to have patience with the trust building process in their initial sessions, and not to take skepticism or challenges personally.

Of course, no provider is a perfect match with every single patient. Therapists' techniques and personal attributes, as well as patient characteristics and attachment styles(link is external), all have an impact on the quality of the working alliance. With so many contributing variables – and in a treatment setting where patients have limited say in assignment to providers – mismatches are bound to occur. If a trusting alliance simply isn't materializing despite your best efforts, it may be worth exploring a change of therapist.

Goals & Tasks

In a military setting, reduction in symptoms and improvement in occupational functioning are obvious treatment goals. Still, it is essential to ask patients what they are hoping to get out of therapy; you might hear that a service member wants to increase their self-awareness, develop healthier habits, or strengthen their interpersonal relationships. Touching on and tracking progress toward all of a patient's goals over the course of treatment can strengthen the working alliance by demonstrating that you care about the full range of outcomes.

It is just as important to agree on the tasks of therapy: what you and the patient will do to accomplish these goals. For many presenting concerns, there are multiple treatments that are supported by clinical trial research. In these cases, it is advisable to present all of the options and to allow the service member to choose the treatment that he or she resonates with most strongly. A recent study of prolonged exposure therapy versus sertraline for posttraumatic stress disorder (PTSD) demonstrated the power of patient buy-in by including patient preference in its design: participants who received their preferred treatment were more likely to report reduction in symptoms and lose their PTSD diagnosis, and less likely to drop out of treatment, than those who were randomized into their non-preferred treatment modality.

After choosing an EBT, it's important to establish agreement on tasks by confirming that the service member understands – and is on board with – the rationale behind the treatment and the aims of each intervention. EBTs often involve daily homework in addition to weekly therapy sessions; it's easy to understand how a patient who is skeptical about a treatment's mechanism of change or the value of out-of-session assignments might be less than adherent. Explaining why you're doing what you're doing in treatment, and giving patients a chance to ask questions and even push back, can help to troubleshoot adherence challenges, make patients feel more included in their care, and build the working alliance.

Dr. Kelly is a contracted psychological health subject matter expert at the Psychological Health Center of Excellence. She has a masters' degree in counseling and psychological services and a doctorate in counseling psychology. She specializes in trauma, vocational psychology, and multicultural counseling.