A Bridge of Understanding: The Importance of Therapeutic Alliance in Supporting Trans* and Gender Diverse Individuals in Online Therapy

Person smiling in therapy

On the Importance of Therapeutic Alliance: An Introduction

Welcome to this exploration of the therapeutic alliance, a crucial component in psychotherapy that helps facilitate a safe and comfortable environment, particularly for trans* and gender-diverse clients. It’s a powerful tool, a dance of trust and understanding that heavily influences the therapy outcome. This collaboration isn’t just a professional rapport but a bond that evolves through mutual understanding and respect.

Being a transgender individual who has often been a client myself, I have experienced how misunderstanding and disconnect can strain this vital relationship. It hinders progress. It makes it hard to trust the therapist. To counteract this, it’s imperative to discuss regularly and continually monitor the status of the therapeutic alliance during our sessions.

Mental health care often poses barriers, with gatekeeping being a prevalent issue. My top priority is ensuring you feel understood, respected, and valued during therapy. This blog post aims to shed light on the significance of the therapeutic alliance, especially when working with trans* and gender-diverse adults. I’ll present research studies, practical advice, and insights grounded in both personal experiences and professional expertise.

Whether you’re considering psychotherapy with a gender-affirming counsellor or psychotherapist or merely curious about the topic, this exploration will enhance your understanding. The emphasis is on the importance of a robust therapeutic alliance in achieving successful therapy outcomes and how it promotes positive change, empowerment, and improved well-being.

Remember, your journey toward mental health and self-discovery matters. Providing a supportive, affirming, respectful, and understanding environment for trans* and gender-diverse adults is central to the therapeutic process. You’re not alone in this journey; together, we can navigate the path to mental health and self-discovery.

Demystifying the Therapeutic Alliance: Definition and Types

The concept of a therapeutic alliance, sometimes referred to as the “working alliance,” is central to successful psychotherapy. Renowned psychologist Edward Bordin defined an excellent therapeutic relationship as consisting of three essential elements:

  1. An Emotional Bond of Trust, Caring, and Respect: This emotional connection forms the bedrock of the therapeutic relationship. The foundation supports the therapeutic process, creating a safe space where clients can openly discuss their thoughts, feelings, and experiences.
  2. Agreement on the Goals of Therapy: It’s essential for both the therapist and the client to agree on what they want to achieve through therapy. This might involve working through specific issues, developing better-coping strategies, improving relationships, or other personal growth objectives.
  3. Collaboration on the ‘Work’ or Treatment Tasks: Therapy isn’t one-sided. It involves active participation from both the therapist and the client. This “work” might involve discussing and processing emotions, exploring new perspectives, practicing new skills, or completing therapeutic exercises or assignments.

While these elements are foundational, the way they manifest can vary. There are five types of therapeutic alliances that therapists can form with their clients, each with its unique approach:

  1. Directive Alliance: The therapist provides instructions and guidance in this alliance, leading toward therapeutic goals.
  2. Nondirective Alliance: Here, the therapist adopts a more passive role, allowing the client to explore their solutions through self-reflection and discussion.
  3. Facilitative Alliance: This alliance explores the client’s feelings, thoughts, and emotions to promote personal growth.
  4. Supportive Alliance: The therapist provides emotional support and comfort to the client, offering guidance as needed.
  5. Task-Oriented Alliance: This alliance focuses on helping clients attain specific goals or learn new skills through practical activities or assignments provided by the therapist.

Regardless of the type of alliance formed, five key components should underpin every therapeutic relationship:

  1. Mutual Respect: Therapists must always respect their clients and maintain professional boundaries. Conversely, clients should feel respected and supported in their therapeutic journey.
  2. Empathy: Therapists should strive to understand their clients’ experiences from their perspectives. This empathy helps create a nonjudgmental environment where clients feel safe to discuss complex topics.
  3. Genuineness: Therapists should be honest, open, and authentic, avoiding preconceived ideas or stereotypes. This genuineness fosters trust and encourages clients to engage honestly in self-exploration.
  4. Safety: Therapists should foster a safe and secure environment by respecting privacy, maintaining confidentiality, and offering support when needed.
  5. Positive Expectations: Therapists should trust their clients’ ability to make changes and create positive expectations for the therapeutic process.

In summary, a therapeutic alliance is a collaborative, trusting relationship crucial to therapy’s success. It’s the conduit through which understanding, healing, and growth can occur. The alliance can take different forms, but the essential components—respect, empathy, genuineness, safety, and positive expectations—remain constant, guiding principles for every therapeutic encounter.

Power of Connection: The Purpose of the Therapeutic Alliance

A solid therapeutic alliance is a cornerstone for successful therapy, fostering a collaborative and trusting environment that encourages client engagement and ultimately leads to improved therapeutic outcomes.

The therapeutic alliance is much more than just a comfortable client-therapist relationship. It plays a critical role in the therapeutic process itself. FFacilitating a secure environment for open communication supports clients as they navigate their internal landscape, explore their emotions and thoughts, confront their struggles, and implement changes in their lives.

Active client participation is vital to therapy’s success, and the therapeutic alliance’s quality significantly influences this. In a safe, understanding, and empathetic atmosphere, clients are more likely to be active contributors to their therapeutic journey, enhancing the effectiveness of therapy.

The alliance also shapes the direction of therapy. With a mutual understanding of therapy goals and tasks, the client and therapist can cooperatively steer the therapeutic process in a way that’s most beneficial for the client.

Moreover, a robust therapeutic alliance positively impacts therapeutic outcomes. For instance, a study by Marcolino & Iacoponi found a significant correlation between higher scores on the Therapeutic Understanding Index (TUI) and improved Beck Depression Inventory (BDI). The TUI measures the strength of the therapeutic alliance, and the BDI evaluates depressive symptoms. This suggests that a solid therapeutic alliance can enhance the effectiveness of therapy for those struggling with depression, illustrating the therapeutic alliance’s profound impact on mental health recovery.

In summary, the therapeutic alliance is not merely a nice-to-have; it’s a must-have. Its significance is evident in every step of the therapeutic journey, from establishing a safe and respectful environment to encouraging active participation and positively influencing therapeutic outcomes. This underscores therapists’ need to cultivate a solid therapeutic alliance with their clients as a fundamental aspect of effective therapy.

Measuring Success: The Impact of Therapeutic Alliance on Psychotherapy Outcomes

Several research studies have delved into the role of the therapeutic alliance in psychotherapy outcomes, consistently highlighting its importance. A notable study by Weck et al. examined the impact of therapeutic alliance and therapist adherence on treatment outcomes. The results of this study were compelling.

According to Weck et al., a solid therapeutic alliance and therapist adherence significantly impacted treatment outcomes. This means that when therapists adhered to their treatment protocol and when there was a robust therapeutic alliance, clients experienced improved results from their therapy.

Interestingly, the study also found that an excellent therapeutic alliance could bolster therapist adherence and competence. This suggests a potential virtuous cycle, where a solid therapeutic alliance promotes greater therapist adherence to treatment protocols, strengthening the therapeutic alliance and further improving therapy outcomes.

These findings underscore the importance of the therapeutic alliance in facilitating successful therapy. They also emphasize the role of therapists in fostering this alliance, as the quality of the therapeutic alliance influences their adherence to treatment protocols and competence.

In assessing the strength and effectiveness of the therapeutic alliance, a popular tool is the Working Alliance Inventory (WAI). The WAI measures the collaborative nature of the alliance, the agreement between therapist and client on therapeutic goals, and the agreement on tasks to be carried out in therapy. By using such tools, therapists can understand the health of the therapeutic alliance and identify areas that may need improvement.

In conclusion, the therapeutic alliance isn’t just beneficial to the psychotherapy process – it’s a critical element that influences the effectiveness of therapy and, ultimately, clients’ mental well-being. This makes cultivating a solid therapeutic alliance an essential skill for all therapists.

Cultivating Bonds: Techniques for Strengthening the Therapeutic Alliance

The quality of the therapeutic alliance can significantly influence the outcome of therapy. Consequently, therapists should invest considerable time and effort into cultivating a solid therapeutic alliance. Here are some strategies therapists can use to strengthen this critical relationship:

Genuine Interest: Therapists can strengthen the therapeutic alliance by showing genuine interest in their client’s experiences. This involves active listening, demonstrating empathy, and investing in understanding the client’s worldview.

Trust and Transparency: Trust forms the backbone of any therapeutic alliance. Therapists can foster trust by maintaining transparency and open communication. This may include clarifying their approach, discussing potential challenges, and answering questions the client might have honestly and openly.

Mutual Goal-Setting: Therapy is most successful when both the therapist and client are on the same page regarding the goals of therapy. The therapist should actively involve the client in defining these goals, thereby creating a sense of collaboration and shared purpose.

Emotional Support and Practical Guidance: The therapist should provide emotional and practical guidance. This could involve validating the client’s feelings, offering coping strategies, or guiding the client through difficult situations.

Client Feedback: A therapist should be open to receiving feedback from clients. Feedback helps therapists understand their client’s perspectives, adjust their approach if necessary, and enhance their therapeutic effectiveness.

A Respectful and Safe Environment: Therapists must create a respectful, safe, and non-judgmental environment. Clients should feel comfortable discussing complex topics without fear of judgment or criticism. This is especially important for transgender clients, who may have faced stigma or discrimination in other aspects of their lives.

By implementing these strategies, therapists can build a solid therapeutic alliance that promotes meaningful change and health outcomes. But, remember, the therapeutic alliance is not a static entity – it evolves throughout therapy. Therefore, continuous efforts are required to maintain and strengthen this vital therapeutic relationship.

Building a Strong Therapeutic Alliance with Transgender and Gender-Diverse Individuals

Transgender and gender-diverse individuals often face unique challenges regarding mental health support. Therefore, therapists must understand and address these needs to build a therapeutic alliance that fosters safety, respect, and empathy. Such an alliance enhances the therapeutic experience and can empower these individuals, leading to better mental health outcomes and overall well-being.

Understanding the Unique Challenges

Transgender and gender-diverse individuals may encounter numerous obstacles when seeking mental health care. These can range from outright discrimination and stigma to more subtle forms of marginalization, like a lack of understanding or connection to their experiences. Moreover, as pointed out by Aaron Brockie in his study from Eastern Illinois University, therapists often serve as gatekeepers to medical treatments and surgeries that transgender clients may need to alleviate dysphoria. Unfortunately, this dynamic can lead to therapists being perceived as obstacles rather than sources of help and support.

The Role of Therapist Practices

Brockie’s study also delved into how therapist practices and the therapeutic relationship impact transgender clients’ perceptions of their therapists. It highlighted the importance of therapists’ affirming practices in shaping positive perceptions. Affirming practices include, among other things, using the client’s correct pronouns, validating their gender identity, and displaying knowledge and sensitivity about issues unique to transgender individuals. These practices convey respect for the client’s identity and foster a sense of safety and acceptance in the therapeutic relationship.

The Power of a Strong Therapeutic Alliance

Brockie’s research revealed that the working alliance (the agreement between therapist and client on therapy goals and tasks) and the actual relationship (the personal relationship between the therapist and client) significantly predict transgender clients’ feelings about their therapists. This finding underlines the profound impact of a robust therapeutic alliance in fostering a positive therapeutic experience.

Therapists can leverage the power of this alliance by demonstrating empathy, authenticity, and unconditional positive regard towards transgender and gender-diverse clients. These qualities strengthen the therapeutic alliance, reaffirm the client’s sense of self, and empower them to engage actively in the therapeutic process.

Towards Better Mental Health Outcomes

The therapeutic alliance influences transgender clients’ perceptions of their therapists. Therefore, a solid therapeutic alliance based on trust, mutual respect, and understanding can significantly improve therapy outcomes for transgender and gender-diverse clients.

By prioritizing the therapeutic alliance, mental health professionals can provide effective, affirming care that addresses the unique needs of transgender and gender-diverse individuals, ultimately leading to better mental health outcomes and increased well-being for this marginalized population. Remember, in a world that often fails to validate their identities, the therapeutic space can be a powerful beacon of acceptance and understanding for transgender and gender-diverse individuals.

Embracing Digital Connections: Establishing an Online Therapeutic Alliance

As the digital age continues to expand the ways we communicate and connect, so does it expand the possibilities for therapeutic interactions. As a result, online therapy has surged as a viable alternative to traditional face-to-face therapy, offering accessibility and flexibility that can often not be achieved in traditional settings. However, building and maintaining a therapeutic alliance online comes with unique challenges and opportunities.

Role of Technology in Therapeutic Alliance

Online therapy uses several forms of technology to foster the therapeutic alliance. Video calls, instant messaging, and emails can all be used to establish and maintain the bond between client and therapist. Each has its strengths and can be utilized according to the preferences and needs of the client.

For instance, video calls can replicate the experience of face-to-face therapy to some degree, allowing for real-time interaction and non-verbal cues. In addition, instant messaging provides immediacy and can feel less formal or intimidating to some clients. At the same time, email allows for thoughtful, in-depth communication without the pressure of real-time response.

Building a Strong Online Therapeutic Alliance

Even in an online environment, the core elements of building a therapeutic alliance remain the same – empathy, respect, and understanding. However, therapists must pay special attention to certain aspects of online communication to foster a strong alliance. This can include communicating clearly and thoroughly, demonstrating empathy and understanding through words, and ensuring a stable and secure technological setup to avoid disruptions during therapy sessions.

Research on Online Therapeutic Alliance

Studies have suggested that it is indeed possible to establish a stable and positive therapeutic alliance in an online environment. For example, a study by Cook and Doyle (2002) found that online therapy consumers reported higher scores on the Working Alliance Inventory, specifically in the goal subscale and the composite score, compared to traditional face-to-face therapy clients.

A further study by Knaevelsrud and Maercker (2006) also found high alliance scores in online therapy for traumatized patients. However, the relationship between the quality of the therapeutic alliance and treatment outcome was found to be lower to modest compared to traditional therapy. This suggests that while a solid therapeutic relationship can be established online, its predictive relevance for treatment outcomes might differ from face-to-face therapy.


In conclusion, a robust therapeutic alliance can indeed be established in an online therapy environment. The flexibility and accessibility of online therapy can offer significant benefits to many clients. However, therapists need to be mindful of the unique challenges of online communication and use technology effectively to build and maintain a strong therapeutic alliance. While the therapeutic alliance’s impact on treatment outcomes may differ online, its importance in creating a supportive, collaborative, practical therapeutic experience remains undeniable.

The Critical Role of the Therapeutic Alliance in Gender-Affirming Therapy

Therapeutic alliance, a concept that dates back to the works of Edward Bordin, plays a critical role in successful therapeutic outcomes. It is an emotional bond of trust, respect, and collaboration between a therapist and a client, facilitating a fruitful exploration of the client’s concerns. This alliance is built upon critical principles such as mutual respect, empathy, genuineness, safety, and positive expectations.

Various studies have underscored the importance of a solid therapeutic alliance. For example, Marcolino & Iacoponi’s research highlighted a significant correlation between higher Therapeutic Understanding Index (TUI) scores and improved outcomes on the Beck Depression Inventory (BDI). Similarly, Weck et al. found that a solid therapeutic alliance promotes therapist adherence and competence, improving treatment results.

This alliance is crucial for all but takes on an even greater significance for marginalized populations such as transgender and gender-diverse individuals. They face unique challenges that require therapists to show greater sensitivity, understanding, and affirmation. For example, Aaron Brockie’s study shows that therapist practices and the therapeutic relationship significantly impact how transgender clients perceive their therapists.

With the rise of online therapy, the therapeutic alliance has expanded to digital platforms. Research indicates that a robust therapeutic alliance can be established online, even though its predictive relevance for treatment outcomes might vary slightly compared to face-to-face therapy.

If you’re considering therapy, seek a therapist who can provide a supportive, respectful, and understanding environment. The strength of the therapeutic alliance directly influences the outcomes of therapy. For trans* and gender-diverse individuals, finding a therapist who affirms your identity and experiences is vital.

Here at ClayreSessoms.com, we understand the nuances of therapy for trans* and gender-diverse adults. We strive to provide a safe, affirming, and understanding space where a solid therapeutic alliance can be fostered. We aim to facilitate meaningful change and health outcomes through a collaborative and respectful therapeutic relationship, whether online or face-to-face.


Brockie, A. (2021). The Impact of the Therapeutic Relationship on Transgender Clients’ Perceptions of Their Therapist. Eastern Illinois University. Retrieved from The Keep, Eastern Illinois University’s institutional repository.

Cook, J., & Doyle, C. (2002). Working Alliance in Online Therapy as Compared to Face-to-Face Therapy: Preliminary Results. Cyberpsychology & Behavior: The Impact of the Internet, Multimedia and Virtual Reality on Behavior and Society, 5(2), 193-203. https://doi.org/10.1089/109493102753770480

Marcolino, J., & Iacoponi, E. (2003). The early impact of therapeutic alliance in brief psychodynamic psychotherapy. Revista Brasileira de Psiquiatria, 25(3), 155-161. https://doi.org/10.1590/S1516-44462003000300007

Weck, F., Grikscheit, F., Jakob, M., Höfling, V., & Stangier, U. (2015). Treatment failure in cognitive-behavioural therapy: Therapeutic alliance as a precondition for an adherent and competent implementation of techniques. The British Journal of Clinical Psychology, 54(1), 91-108. https://doi.org/10.1111/bjc.12049

Disclaimer: This blog shares general information only, not professional advice or recommendations. Consult healthcare providers for personal guidance. Decisions based on content are the reader's responsibility. Thank you.

Clayre runs a group practice of three queer and trans therapists, including youth therapist Audrey Wolfe, RCC, LGBT therapist Camber Giberson, RCC, CCC, and gender-affirming therapist Clayre Sessoms, RP, RCT, RCC, CCC, ATR-P. Work with us: book a session.