By Dr Melody Smith, Clinical Psychologist
When aspiring clinical psychologists think about developing clinical skills, it is easy to focus on assessment, formulation, intervention models or research knowledge. Yet the therapeutic alliance sits underneath much of this work. It can influence whether a service user feels able to speak openly, whether assessment information becomes meaningful and whether a formulation feels genuinely collaborative. Research has repeatedly linked stronger therapeutic alliances with better psychotherapy outcomes. But the most useful lesson is not simply that relationships matter. It is understanding what we are actually doing when we build one — and what happens when that relationship becomes strained.
A therapeutic alliance is more than being warm, approachable or “good with people”. Bordin’s influential model described it through agreement on goals, agreement on therapeutic tasks and the development of a relational bond. Rogers’ earlier work also emphasised empathy, genuineness and acceptance. Together, these ideas remind us that psychological work is relational as well as technical.
Why therapeutic alliance matters in clinical psychology
For an aspiring psychologist, therapeutic alliance can sound like something that matters once you are “doing therapy”. In reality, the principles begin much earlier. Consider an assessment. You might have excellent questions and a clear structure, but if the person feels judged, rushed or misunderstood, the information you gather may be limited. A formulation may be psychologically sophisticated, but if it leaves someone feeling talked about rather than worked with, its clinical value may be reduced.
This is why alliance is better understood as part of psychological thinking rather than an optional interpersonal extra. A major meta-analysis of 295 independent studies involving more than 30,000 people found a consistent positive association between alliance and psychotherapy outcome across therapeutic approaches and client characteristics (Flückiger et al., 2018). That does not mean alliance alone causes improvement. It does mean the working relationship deserves serious clinical attention.
Empathy is part of this picture, but empathy is more active than simply being kind. A meta-analysis of 82 samples involving more than 6,000 clients found therapist empathy was positively associated with outcome (Elliott et al., 2018). In practice, this might mean checking whether you have understood correctly, slowing down when somebody appears uncertain or being willing to revise your own understanding. Good relational practice is about remaining curious and responsive.
What happens when the relationship goes wrong?
Strong alliances are not relationships without difficulty. Misunderstandings, disagreement, withdrawal or tension can occur. These moments are often described as alliance ruptures. Evidence suggests that successful rupture resolution is associated with better outcomes, although this does not mean every rupture can be repaired in the same way (Eubanks et al., 2018).
This has useful implications for reflective practice. Rather than asking only, “Did I communicate that well?”, you might ask, “How did that land with the person?”, “What assumptions was I making?” or “Were we still working towards the same goal?” These questions move reflection away from simply judging your performance and towards clinical curiosity.
Culture, power and the alliance
Therapeutic relationships never happen outside a social context. Psychologists and service users may differ across culture, race, class, gender, disability, age, language, faith, sexuality and professional status. Cultural humility offers a useful framework here. It emphasises openness, respect and awareness of the limits of our own perspective, rather than assuming we can become fully knowledgeable about somebody else’s culture.
A 2025 systematic review and meta-analysis found a strong positive association between therapist cultural humility and alliance quality, alongside a smaller positive association with psychotherapy outcomes (Orlowski et al., 2025). This fits with a broader clinical psychology emphasis on empathic, respectful and collaborative relationships. Clinical psychology texts similarly emphasise the importance of an empathic, positive, respectful and collaborative alliance when working with service users (Carr & McNulty, 2016).
For aspiring clinical psychologists, relationship-building therefore also means thinking about power. Professional knowledge matters, but so does the service user’s expertise in their own life. Collaboration involves taking both seriously.
A skill you build through reflection
You do not need to be a qualified psychologist to begin developing your understanding of therapeutic alliance. You can reflect on it in support work, research roles, Assistant Psychologist posts, groups, multidisciplinary meetings and everyday professional conversations. Notice what helps people feel heard, when collaboration becomes difficult, how you respond to feedback and whose perspective is being prioritised.
Building therapeutic alliances is not about finding the perfect phrase or becoming endlessly agreeable. It is about developing purposeful, collaborative and respectful relationships while remaining able to think when those relationships become complicated. That is a skill worth practising long before a DClinPsy interview, because it sits at the heart of the psychologist you are becoming.
References
Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice, 16(3), 252–260.
Carr, A., & McNulty, M. (Eds.). (2016). The handbook of adult clinical psychology: An evidence-based practice approach (2nd ed.). Routledge.
Elliott, R., Bohart, A. C., Watson, J. C., & Murphy, D. (2018). Therapist empathy and client outcome: An updated meta-analysis. Psychotherapy, 55(4), 399–410.
Eubanks, C. F., Muran, J. C., & Safran, J. D. (2018). Alliance rupture repair: A meta-analysis. Psychotherapy, 55(4), 508–519.
Flückiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O. (2018). The alliance in adult psychotherapy: A meta-analytic synthesis. Psychotherapy, 55(4), 316–340.
Orlowski, E. W., Moeyaert, M., Monley, C., & Redden, C. (2025). The effects of cultural humility on therapeutic alliance and psychotherapy outcomes: A systematic review and meta-analysis. Counselling and Psychotherapy Research, 25, e12835.
Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21(2), 95–103.
Disclaimer
This blog is intended for educational and reflective purposes only and does not constitute psychological, medical or legal advice. The views discussed are designed to encourage thoughtful reflection and professional development among aspiring clinical psychologists. Readers are encouraged to engage critically, utilise ACPsych Hub resources via Aspiring Clinical Psych, seek supervision where appropriate, and refer to current professional guidance and evidence-based practice standards.
