How do we begin psychotherapy effectively? In short, we invite the patient to share her story and we convey interest and compassion in a manner that fosters the patient’s trust in our capacity to be of help. We do this by starting an inquiry in which the patient feels listened to, understood, and provided with helpful questions and ideas that she had not thought of before. In doing so, we engage in a collaborative process of exploration in which patient and therapist are both committed to seeing change for the better in the patient’s quality of life. Such an alliance between therapist and patient is highly infl uential in determining the effectiveness, progress, and outcome of a treatment (Castonguay, Constantino, & Holtforth, 2006; Pachankis & Goldfried, 2007; Safran & Muran, 2006; Safran, Muran, & Eubanks-Carter, 2011). The therapeutic alliance has long been regarded as a common principle of change in psychotherapy (Pachankis & Goldfried, 2007) and is the therapeutic process variable that has received the most consistent empirical support across the major therapeutic approaches (Horvath, Del Re, Flückiger, & Symonds, 2011). This chapter focuses on establishing an alliance with the patient that serves as the bedrock foundation of treatment. While all major approaches to psychotherapy recognize the importance of a strong therapeutic alliance, we will highlight key factors specifi cally relevant to brief dynamic psychotherapy.