It’s time to ask your mental health vendors about therapeutic alliance

Mental health crisis continues to afflict the U.S.

Since the pandemic, several of our surveys have found employers have increased focus on employee mental health issues. In our 2024 Wellbeing Diagnostic Survey, which surveyed almost 700 employers in the U.S. and Canada, 77% of respondents noted that the key business issue influencing organizations’ wellbeing strategy was the growing mental health crisis. This aligns with our 2024 Best Practices in Healthcare Survey, where 82% of the more than 400 U.S. organizations acted on or planned to act on mental health to improve member health. Even with the pandemic officially ending in May 2023, both responses remain the top business and clinical areas noted by employers in each survey.

To help the 37% of employees self-reporting symptoms of anxiety or depression, of which 21% haven’t been treated, employers have been improving their mental health and behavioral health programs, such as employee assistance programs, point-solutions for stress and resiliency and improving parity between mental health/substance use disorder and medical/surgical benefits, among others. To improve mental health programs, we need to make it easier for mental health professionals to reach employees. They can provide therapy in-person, online or by phone.

Outcome measure for mental health programming isn’t optional

The costs of adding such clinical expertise to support employees with mental health conditions can be expensive. Many leading-edge organizations that have responded to the current mental health crisis with clinical support have developed quantifiable financial and nonfinancial metrics measuring the positive impact of mental health programs. In the mental health space, these metrics often cover such things as absenteeism, presenteeism, patient satisfaction and clinical improvements in anxiety and depression using the General Anxiety Disorder-7 scale and Patient Health Questionnaire-9.

However, one of the key outcome measures missing from these scoring dashboards is the measuring of therapeutic alliance, or the positive, collaborative, working relationship between client and therapist. Therapeutic alliance is one of the most frequently studied topics within modern clinical psychology. Researchers and practitioners see it as one of the most important aspects of the therapeutic process.^{[1], [2], [3]} Despite this importance, little discussion occurs between benefit managers and mental health vendors on therapeutic alliance.

What’s the therapeutic alliance?

Scholars may disagree on how the therapeutic alliance is conceptualized. But most theoretical definitions of therapeutic alliance have three common themes:

1. The collaborative or give-in take in the relationship
2. The emotional connection between client and therapist
3. The client’s and therapist’s ability to agree on treatment goals and tasks

To agree on treatment goals and tasks, several characteristics must be present between provider and client that promote collaboration and emotional bonding.^{[1], [2], [3]}

• Therapist characteristics: Therapists trained in client-centered therapy believe the therapist should relate authentically with the client, while offering acceptance and empathy for the client’s perspective.
• Client motivation and commitment: The therapeutic alliance reflects the client’s motivation and capacity to perform psychotherapy work.
• Patient trust in the therapist: If the client thinks the therapist is competent and loyal, this’ll give the therapist the power to bring about changes in the client.
• Behavioral synchrony: Client and therapist’s bodies interact with each other in space and time. The client and therapist’s body language, such as vocal pitch, head movement and physiological processes, can become synchronized during psychotherapy, playing a key role in establishing rapport and perspective-taking.
• Emotional synchrony: The client and therapist are invested in their roles, feel like they understand each other and act in a caring way.

What are the implications for vendors, employees and employees?

As organizations keep improving their mental health programs as part of a continuous quality improvement program, several key positive implications should be kept in mind when discussing therapeutic alliance with your vendors.

• Measuring therapeutic alliance: We’re starting to see some vendors measuring therapeutic alliance in the mental health space. Organizations should be asking their vendors if they are measuring therapeutic alliance with their providers? If so, ask what specific measures they are they using? Is therapeutic alliance something they report back to you as part of their metrics?
• Treatment outcomes: Current research suggest that the quality of the client-therapist alliance is a reliable predictor of positive clinical outcome independent of psychotherapy approach and that the average effect of the therapeutic alliance is larger than the effects of other treatment variables such as therapist adherence to treatment manual or therapist competence.
• Improved client and therapist satisfaction: Improved client motivation and satisfaction benefit both the client and therapist. Findings show that clients with weaker therapeutic alliance are more likely to drop out of psychotherapy. Psychiatric patients miss appointments more often than patients in other medical specialties. Improving the client-therapist relationship can improve dropout rates, increasing vendor utilization and therapist satisfaction.
• Training for clinicians: Mental health clinical directors and supervisors should train clinicians on how to communicate better with clients. Using a three-prong approach can improve the client-therapist therapeutic alliance.
  1. Patient-centered: Clinicians should ask about the client’s hopes and concerns about treatment. Clinicians should also convey to the client that they strive to ensure that the client is getting their needs met and that barriers to the alliance will be openly addressed.
  2. Setting clear goals when building a treatment plan: Clinicians should stress that they and the client will formulate a treatment plan together. Clinicians should also review the therapy process regularly, on what’s working and what isn’t working, making changes as appropriate.
  3. Client satisfaction: Clinicians should regularly check in with the client about how they feel about the therapy process, their relationship and the treatment plan. They should also talk about any problems that can be fixed.

As the therapeutic alliance has a major effect on positive clinical outcomes, employers should begin the discussion with their vendors on how the concept of therapeutic alliance can be implemented with their solutions. Many vendors struggle with the utilization of their programs and services. Measuring therapeutic alliance can give vendors and their providers potential insights into this less than stellar utilization. It can also give providers information about their dropouts. This gives them a chance to fix any problems between themselves and their clients, which can lead to stronger relationships and better results.

Footnotes

1. Ardito RB. and Rabellino. Therapeutic Alliance and Outcome of Psychotherapy: Historical Excursus, Measurements, and Prospects for Research. Frontiers in Psychology, 2011. 2:270. Return to article undo
2. Koole SL and Tschacher W. Synchrony in Psychotherapy: A Review and an Integrative Framework for the Therapeutic Alliance. Frontiers Psychology, 2016. 7:862. Return to article undo
3. Munder, T., Wilmers, F., Leonhart, R., Linster, H.W., and Barth J. Working Alliance Inventory- Short Revised (WAI-SR): Psychometric Properties in Outpatients and Inpatients. Clinical Psychology and Psychotherapy, 2010, 17:231-239. Return to article undo

Author

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Rob Jarvis, LCSW

Associate Director, Health, Equity & Wellbeing

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