The chapter begins by providing a brief description of the components thought to be important in the therapeutic relationship and in developing a strong therapeutic or working alliance. Many decades of research have established that a good therapeutic alliance is related to better treatment outcomes for people engaged in psychotherapy. However, there has been relatively little of this research which has focused on individuals with severe mental illnesses such as schizophrenia. A brief review of these studies indicates 'promising' findings with regard to the link between therapeutic alliance and more positive treatment outcomes, but it is argued that a strength-based emphasis in treatment may be particularly important for those with severe mental illnesses. A detailed review is then provided of the research related specifically to the role of therapeutic alliance in vocational rehabilitation contexts. Given the relatively small number of studies focusing on vocational outcomes, this starts with a review of four studies comprising individuals with traumatic brain injury and is followed by a description of the two studies that used participants with mental illness. Again, the data are promising and together suggest a positive relationship between stronger therapeutic alliance and a range of more positive vocational outcomes. This is followed by a description of the main measures used to assess therapeutic alliance and an overview of the key components thought to strengthen the alliance. Finally, the chapter finishes with a section describing how to therapeutically manage difficulties in the alliance. These are described as 'strains and ruptures', and the chapter concludes with strategies for identifying and resolving these fluctuations in the quality and strength of the therapeutic alliance.