The “It” Factor: Strategies for Developing the Therapeutic Alliance

As clinicians, we have seen firsthand the successful outcomes that voice therapy can produce. However, despite being so close to the processes involved in voice therapy, speech-language pathologists may not always be clear as to how their methods work. Research shows that we get similar outcomes from voice therapy regardless of the type of intervention, number of sessions, duration of sessions, or service delivery model (e.g., face to face vs. teletherapy) used.1

It is helpful to think of voice therapy like baking: The different aspects of therapy—intervention type, session number and duration, and service delivery models—are the ingredients. To get the desired output, we must apply those ingredients to a specific recipe. However, not all recipes yield the same result.

Just as the same set of ingredients can either create a chocolate cake or a batch of brownies depending on the recipe you follow, patients may produce different outcomes due to the “recipe” the clinician used, even if using the same “ingredients.” This tells us that what we are doing in voice therapy (the ingredients) may be less significant than how we are doing it (the recipe).

Thinking back on your own clinical experience, you may recall a time when you’ve asked a colleague to work with a patient with whom you are not making progress, only to have the patient find success with that clinician while using the same treatment strategies! If the ingredients of the therapy haven’t changed, it must mean that something is different in the recipe.

We can call this difference the “It” Factor of voice therapy.

What Is the “It” Factor?

The “It” Factor can be thought of as the components that help us build the therapeutic alliance with our patients. The therapeutic alliance (also referred to as the working alliance or therapeutic relationship) is the interaction between the SLP and the patient that develops an effective bond in which the patient and clinician come together in a joint commitment towards an established end goal. The “It” Factor is comprised of relevancy, trust, communication, and partnership.


For voice therapy to be effective, it must be personally relevant to the patient. Relevancy can be accomplished through the use of meta-therapy. Meta-therapy is defined as “the clinical dialogue via which direct and indirect voice treatments are introduced and discussed and which help build a useful conceptual framework for voice therapy.”2 By combining the principles of meta-therapy with targeted language, we can guide patients toward realizations as to how the various interventions we introduce are relevant to them.

One specific tool is the use of analogies. Analogies can make new ideas clear to a patient by drawing a comparison between two things in a way that allows for greater understanding of, or even personal attachment to, the newly presented concept. They can also create opportunities for meaningful dialogue between the clinician and patient that are only accessed through the exploration of that analogy.

In our MedBridge course, we highlight many clinical narratives, analogies, and spiels of clinical dialogue, crowdsourced from some of the best and brightest voice clinicians around the country that you can use in sessions with your patients. Likewise, if you as a clinician have analogies or spiels that you have found helpful in creating a “lightbulb” moment for your patients, write them down and use them again, because that is a huge part of the It Factor!


Establishing trust is essential to the development of a successful therapeutic alliance. You can build trust in your therapeutic alliance in the following ways:

  • Show a desire to understand your patient’s perception of their current situation, barriers to rehabilitation, and goals for the future.
  • Communicate a vested interest in seeing your patients recover and ensure ongoing support to them as they work toward their goals.
  • Tailor your therapy plan so it is individualized to your patient’s specific needs. This will not only ensure your patient feels their unique needs are being considered, but also will deliver the best outcomes.


Verbal and nonverbal behavior come into place when building the therapeutic alliance. Active listening, pertinent questioning, and displays of sensitivity allow the clinician to build a stronger relationship with their patient. Clinicians can also make use of their facial expressions, physical stance, tone of voice, eye contact, and pace of speaking to create the foundation for meaningful communication.

As clinicians, we can get very busy. However, each patient deserves the opportunity to tell their story and to feel that you are present with them when they do so. The space we allow each patient to convey their experience to us, and the language we use in response can make a difference in their level of comfort. Our MedBridge course highlights specific therapy language that you can use to build trust with your patients. 


Paying attention to the way your patient communicates and wants to be communicated with can be particularly helpful in establishing a sense of partnership between SLPs and patients with whom we may not be an immediate “good fit.” This level of attention and flexibility allows us to morph our approach on a patient-by-patient basis to meet each one where they are at.

In the development of the therapeutic alliance, we need to remember that patients are our partners (and vice versa). Each comes with individual needs and desires, both emotional and cognitive, that should drive our care. As a part of this patient-clinician match, we can help patients confront their resistance to change, build self-efficacy, and come to the decision that changing has more benefits than not changing.

Finding Your Voice

SLPs learn the pedagogy and techniques of voice therapy interventions in our Master’s of Speech Language Pathology programs. It is the how of voice therapy that is rarely taught the same way.

Discover strategies for building the therapeutic alliance, hear about its effectiveness from a patient perspective, and hear from two SLPs—one a novice clinician and the other a well-known veteran in the field—on how they were able to find their voices as clinicians and build a therapeutic alliance with their patients in our course “The It Factor: Strategies for Developing the Therapeutic Alliance.”

  1. Weidner, K., & Lowman, J. (2020). Telepractice for adult speech-language pathology services: A systematic review. Perspectives of the ASHA Special Interest Groups, 5(1), 326–338.
  2. Helou, L. B., Gartner-Schmidt, J. L., Hapner, E. R., Schneider, S. L., & Van Stan, J. H. (2021). Mapping meta-therapy in voice interventions onto the rehabilitation treatment specification system. Seminars in Speech and Language42(1), 5–18.