The Therapeutic Alliance

The Therapeutic Alliance

W.W. Meissner
Copyright Date: 1996
Published by: Yale University Press
Pages: 400
https://www.jstor.org/stable/j.ctt32bj01
  • Cite this Item
  • Book Info
    The Therapeutic Alliance
    Book Description:

    One point on which the various helping professions agree is that the crucial factor in the success of therapy is the therapeutic alliance-the collaborative relationship a particular therapist is able to form with a particular patient. W. W. Meissner, a highly regarded teacher and practitioner of psychoanalysis and psychotherapy, examines all the prevailing ideas about the therapeutic alliance in this useful book,which is intended for both clinicians and theoreticians.Dr. Meissner explains that in addition to the more familiar aspects of transference and countertransference, the therapeutic alliance encompasses aspects of the therapeutic relation that make it possible for therapist and patient to work together to accomplish therapeutic goals. Dr. Meissner draws a clear distinction not only between alliance and transference but also between alliance and the real relationship. Aspects of the alliance include arrangements and negotiations governing the therapeutic frame and necessary boundaries, neutrality and abstinence, and also personal qualities and capacities that therapist and patient bring to the analytic situation: empathetic attunement, trust, autonomy, authority, responsibility, freedom, and initiative, among others. To the extent that these qualities become operative in the therapeutic relation, they provide the effective basis for a strong therapeutic alliance, which plays an essential structuring role at every step of the analytic process.

    eISBN: 978-0-300-14630-1
    Subjects: Psychology

Table of Contents

  1. Front Matter
    (pp. i-iv)
  2. Table of Contents
    (pp. v-vi)
  3. Preface
    (pp. vii-x)
  4. Part I. The Nature of the Therapeutic Alliance
    • CHAPTER ONE History and Definition
      (pp. 4-21)

      The “therapeutic alliance” has enjoyed a respectable, if controversial, position among psychoanalytic concepts since it was first articulated.¹ It represents that form of collaboration between analyst and analysand without which the analytic process cannot take place (Olinick 1976). Though its nature and function in the analytic setting continue to be debated, there has been little effort to elaborate the concept itself beyond the level of understanding provided by Zetzel (1956, 1958) and later by Greenson (1965). As Busch (1994) commented: “It is one of those concepts that, while generally accepted as a necessary component of the process, is not fully...

    • CHAPTER TWO Alliance and Transference
      (pp. 22-38)

      The distinction between therapeutic alliance and transference has always been a subject of intense controversy. Analytic opinions cover a broad spectrum from denial of any distinction or the effort to do away with the alliance concept altogether through an array of viewpoints introducing transference components into alliance in various degrees and forms and extending to insistence on the separateness of alliance and transference. The seeds of controversy were sown by Freud’s view of an unobjectionable transference, which made way for the emergence of alliance concepts. Many analysts have since been concerned with the danger that unobjectionable transference, along with its...

    • CHAPTER THREE Alliance and Countertransference
      (pp. 39-58)

      Countertransference, along with therapeutic alliance and transference, is a primary locus of therapeutic action in the analytic process. The term has been used with various connotations, some referring to all the therapist’s responses to the patient (Kernberg 1984; Gunderson 1984), others to specific unconscious transference-like reactions. Early usage implied that countertransference always introduced some distortion or interference into the therapeutic interaction, reflecting unconscious reactions deriving from infantile residues in the therapist’s own personality. Countertransference reactions are generally regarded as forms of transference in the therapist, at times in response to and/or in conjunction with eliciting stimulation of the patient’s transference...

  5. Part II. The Real Relationship
    • CHAPTER FOUR The Analyst as Participant
      (pp. 62-73)

      The operative distinctions in part I were between transference and countertransference, as expressions of intrapsychic dynamic forces entering into and modifying the therapeutic relation, and the therapeutic alliance. In this chapter I shall focus on the place of the real relation in this interaction. Controversy prevails between those who emphasize real or nontransferential factors and others who regard real factors as incidental or irrelevant. A useful cautionary note comes from Hoffman (1994) in response to the question: if spontaneous personal engagement with the patient has potential benefit, why bother with technical directives and ground rules? He answers, “We would then...

    • CHAPTER FIVE Reality, Neutrality, and Resistance
      (pp. 74-91)

      Neutrality has long been honored as an essential component of the analytic situation and process. As Freud (1915a) used the term, it implied avoidance of countertransference (Shapiro 1984), but quickly became linked to the notion of abstinence, meaning withholding of gratifications and preservation of anonymity (Pine 1993). It also came to imply respect for the patient’s individuality (Freud 1912b, 1923b; Schachter 1994). These notions can and should be distinguished (Poland 1984). Neutrality is “one of the defining characteristics of the attitude of the analyst during the treatment. The analyst must be neutral in respect of religion, ethical and social values—...

    • CHAPTER SIX Reality and the Analytic Situation: Personal Factors
      (pp. 92-106)

      In previous chapters, my focus was on exploration of the role of reality in the analytic relationship, specifically factors intrinsic to the relation and personalities of the participants. The interplay of such factors with transference, countertransference, and therapeutic alliance is impressive, but these personal and interpersonal elements of the analytic relation do not exhaust reality-based influences on the course and intricacies of the analytic process.¹ A multiplicity of real events and influences come to bear on the analytic process, often with decisive impact, affecting both transference and therapeutic alliance and operating quite independently of personal factors stemming from either participant....

    • CHAPTER SEVEN Reality and the Analytic Situation: Gender-Related and Accidental Factors
      (pp. 107-124)

      The sex of both analyst and patient is part of the reality attending the analytic situation and plays a decisive role in the dynamics of the process (Bibring 1936; Greenacre 1959; Ticho 1972). The sex of both participants is immediately evident—“an actuality that punctures the illusion of anonymity from the first moment” (Appelbaum and Diamond 1993, p. 146)—and may influence the choice of analyst (Goz 1973; Person 1983; Thompson 1938b). Transference, as we have seen, tends to amalgamate with aspects of the reality of the analyst, and age and sex (also race) are among the few real components...

  6. Part III. Aspects of the Therapeutic Alliance
    • CHAPTER EIGHT Developmental Aspects
      (pp. 128-139)

      Early attempts to articulate the therapeutic alliance tended to view it restrictively as reflecting accomplishments from quite early developmental strata. The emphasis in Zetzel’s (1956, 1965, 1966) rendition, for example, fell on residues of caretaker vicissitudes from earliest child-mother interactions centering around issues of trust—much along the lines of Erikson’s (1963) discussion of trust. In this view, the basic capacity for alliance was laid down at a pregenital level at the point at which the capacity for object relationship and object constancy began (Zetzel 1958; Fleming 1975). Greenacre (1956) also located the primitive basis of alliance in characteristics of...

    • CHAPTER NINE The Therapeutic Framework
      (pp. 140-153)

      The concept of the therapeutic frame or framework has many connotations. Spruiell (1983) observed: “The situation that develops between an ordinary analyst and an ordinary patient is indeed a social situation, but a most peculiar one. In this social situation a number of usual rules governing two-party relationships are specifically abrogated—in particular, the to-and-fro dance of organized, eye-to-eye dialogue, the ubiquitous censorship of thoughts which might disrupt rational communication and interaction, and amenities of a (usually amiable) hypocritical nature. The analytic situation has a frame, if one thinks of a frame as referring tounchanging basic elements or principles...

    • CHAPTER TEN Empathy and Alliance
      (pp. 154-173)

      The interactional perspective in psychoanalysis has gained increasing acceptance as being integral to therapeutic and theoretical consensus. The problem on both levels centers on difficulties in bringing disparate perspectives together in a coherent form that allows intrapsychic and interactional frameworks to be utilized in mutually reinforcing ways in clinical analytic work. Until Kohut (1959, 1971, 1977, 1984) elevated it to the centerpiece of his clinical approach, empathy held a respected place in clinical analysis that was more assumed than articulated. Significant exceptions were the contributions of Sullivan (1956) and Fromm-Reichman (1950), who emphasized the critical role of empathy in the...

    • CHAPTER ELEVEN Personal Qualities in the Alliance
      (pp. 174-187)

      The alliance concept, as developed here, includes not merely structural aspects of the analytic situation, but also personal qualities of the participants as they experience the vicissitudes of the analytic process. These qualities are in the first place characteristic features of the individual personalities of both analyst and patient, and, second, they reflect their mutual interaction. I have commented on the developmental underpinning of some of these qualities (trust, autonomy, and so on) in chapter 8, but in this chapter my focus is on their evolution and interaction in the course of the analytic or therapeutic process. As these aspects...

    • CHAPTER TWELVE Personal Factors: Authority, Freedom, and Responsibility
      (pp. 188-199)

      The personal factors discussed in this chapter also have their respective ontogenies, but they have been paid little direct attention in the developmental literature and remain more or less implicit in analyses of growth to psychological maturity. Nonetheless they are essential components of therapeutic alliance. As was the case for personal factors considered in the previous chapter, these elements also undergo development within the analytic process, extending from the beginning of analysis to its termination and beyond.

      The issue of authority is inherent in the therapeutic relationship. Analyst and patient play different roles in the analytic drama. From the beginning...

    • CHAPTER THIRTEEN Ethical Dimensions: Confidentiality
      (pp. 200-208)

      Ethical considerations enter into all phases and aspects of therapeutic alliance, and for both the patient and the analyst. Freud’s (1915a) emphasis on moral standards and his commitment to truthfulness cast analysis in an ethical mode—a form of ethical therapeutics (Rieff 1959).¹ When Freud (1940) proposed the “analytic pact,” he meant it to include an ethical code: “With the neurotics, then, we make our pact: complete candour on one side and strict discretion on the other” (p. 174). Even the fundamental rule serves as an ethical imperative, analogous to freedom of thought or freedom of speech (Breggin 1971), its...

    • CHAPTER FOURTEEN Ethical Dimensions: Values
      (pp. 209-222)

      Values hold a central place in personality organization and functioning and directly influence behavior and experience. In addition, value distortions and conflicts come to play a significant part in many cases of neurotic and character pathology. Gedo (1979) has even proposed “that the personality as a whole is most fruitfully understood as a hierarchy of potentials for actions, i.e., of both organismic and subjective goals, as modified by a system of values” (pp. 11–12). In this sense, the value system becomes an intrinsic part of the individual’s identity as an adult. In addition, the value system integrates a series...

  7. Part IV. The Therapeutic Alliance in the Analytic Process
    • CHAPTER FIFTEEN Establishing the Therapeutic Alliance
      (pp. 226-244)

      Therapeutic alliance, far from being a static or unitary phenomenon, has a development within any analysis that can be traced through the analytic progression. Our major concern in the process approach to therapeutic alliance is to delineate some of the dimensions of this progression. But, first, if therapeutic alliance has a developmental progression, what is the starting point of the therapeutic alliance?

      Another way of phrasing this is to ask: What are the minimal conditions that allow for setting up and putting into play basic constituents of the analytic situation? (This inquiry is not about structural requisites for therapeutic alliance,...

    • CHAPTER SIXTEEN Therapeutic Management of Alliance Deviations
      (pp. 245-256)

      For the general run of neurotic patients, the alliance poses no particular technical difficulties, but one can never ignore or take the alliance aspect of analysis for granted. When therapists make such presumptions, alliance difficulties and complications are most likely to come into play. At a minimum, the therapist needs to ascertain whether and to what extent he and the patient are operating within a common ground of assumptions and acceptance of the requirements of the analytic frame. If patient and analyst are operating on the basis of different sets of rules and expectations, difficulties within the alliance would not...

    • CHAPTER SEVENTEEN Interpretation
      (pp. 257-271)

      Interpretation is the primary and basic technical tool in psychoanalytically oriented psychotherapy and psychoanalysis and the essential process in developing insight and gradual resolution of underlying neurotic conflicts. While interpretation is always central to the therapeutic process, in different contexts various aspects of the interpretive process tend to play a differential and at times weightier role. While content remains important, with more primitive patients the mood and manner of interpretation may be even more significant than with healthier neurotic patients. It may be useful, therefore, to consider the nature of psychoanalytic interpretation as well as the therapist’s function as interpreter....

    • CHAPTER EIGHTEEN Internalization
      (pp. 272-287)

      A central aspect of the therapeutic process is the role of internalizations during therapeutic involvement (Meissner 1981, 1991; Schafer 1968). Mechanisms and processes of internalization are elicited throughout the analytic process and vary in quality and type, depending on aspects of the analytic relation. Those caught up in the vicissitudes of transference and countertransference tend to reflect the inherent dynamics of conflict, drive, and defense. Those reflective of a well-developed therapeutic alliance tend to be more secondary process, integrative, and constructive, expressing higher-order and more evolved and differentiated integrations of ego-superego functions and adaptive potentialities. The former type of transferentially...

    • CHAPTER NINETEEN Termination
      (pp. 288-296)

      The question of termination work centering on therapeutic alliance has been little discussed in the literature. Zetzel (1956, 1958) suggested that therapeutic alliance had to be worked through and resolved in the termination phase, but she never made clear how this was to be done, and the suggestion was contaminated by her view of therapeutic alliance as incorporating transference elements. She may well have had the resolution of transference components involved in residual dependence and attachment in mind. In her view, resolution of dependence and issues of separation were essential to facilitate movement toward autonomy, but this also implied acceptance...

  8. APPENDIX: General Guidelines Related to the Maintenance of Boundaries in the Practice of Psychotherapy by Physicians (Adult Patients)
    (pp. 297-302)
  9. Notes
    (pp. 303-326)
  10. References
    (pp. 327-376)
  11. Index
    (pp. 377-385)