The concept of the therapeutic alliance.

Journal of the American Psychoanalytic Association http://apa.sagepub.com/

The Concept of the Therapeutic Alliance W. W. Meissner, S.J. J Am Psychoanal Assoc 1992 40: 1059 DOI: 10.1177/000306519204000405 The online version of this article can be found at: http://apa.sagepub.com/content/40/4/1059

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T H E CONCEPT OF T H E THERAPEUTIC ALLIANCE 11'. 1V.

hlEIsSNEK,

S.J., h1.D.

Certaiii coiiceptual aspects of the therakeittic alliaiice are coiisidered. Altlioiigli tliera/ieiitic allinlice, traiisfereiice, aiid the real relation are iiiteriningletl aiid iiitertmined in the actiinlitj of the analytic rela ti0 iuli ip, t h e j rein a iii dist iiigiiisli a ble a ii d open t o (!iffereii t ia t iiig aiialysis. The distiiictiom between the tlierapetttic alliaiice aiid traiisference, aiid betzoeeii alliaiice aiid the real relation, are explored aiid their differeiices clarified, iiicliidiiig the dijfereiice betweeii therapeutic misalliaiices arid traiufereiices. Some of the coiniioiieiit diiiieiuioiu of the theinkeiitic alliaiice are explored, iiicliidiiig eiiipatlij, the therakeiitic fr-ninework, respomibilitj, niitlioritj, freedoin, trust, atitoiioiuj, initiative, aiid ethical considerntioiu iiicliidiiig values aiid coiifidentialitj. Further exploratioii of these mid other cliinensioirs of the tlierapeutic allinrice is called for, es/ieciallj the exteiuioii of these diiiieiuioirs to their practical cliiiical applica t ioii .

a respectable position among psychoanalytic concepts since its introduction by Zetzel(1956) and its further elaboration by Greenson (1965). While its nature and function in the analytic setting has been and continues to be debated, there has been little effort directed to a more elaborated formulation of the concept itself. For the most part, the concept remains at much the same level of understanding as that provided by Zetzel and Greenson. I am assuming that the therapeutic alliance is a central aspect of psychoanalytic therapy. My purpose is to try to explore in greater depth particular facets of the notion of the therapeutic alliance with the hope of bringing added significance to its therapeutic implementation. I am concerned in the present essay only with conceptual development of the meaning, and not with the technical and therapeutic role of the alliance in clinical

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Training and Supervising Analyst, Boston Psychoanalytic Institute; University Professor of Psychoanalysis, Boston College. Accepted for publication August 2, 1991.

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praxis. Obviously the meaning we attach to the alliance must bear its technical fruit, but that subject lies beyond the scope of this paper.

Nature of the Therafetitic Alliance Definition There is considerable confusion over the use of the term “therapeutic alliance”; some analysts use it almost as the equivalent of transference (Gutheil and Havens, 1979) or even reject the terminology as merely expressing an aspect of transference phenomena (Brenner, 1980; Gill, 1979, 1982; Modell, 1986). Brenner (1980), for example, rejects any distinction between alliance and transference. There were difficulties with the original formulations of both Zetzel and Greenson. An early approximation to the notion of the alliance was offered in Freud’s (1912) “unobjectionable aspect of the positive transference.” He regarded this aspect of the transference as essential for success of the treatment and as based in the patient’s attachment to the analyst and the treatment process. The next important step was Sterba’s (1934) distinction of the part of the patient’s ego that is attuned to reality and can enter an alliance with the analyst, and that opposes the powerful forces of instinct and repression. The split in the ego between participant and observant functions leads to an identification with the analyst and supports the efforts of the ego to reflect on the analytic material and gain effective insight. This approach brought into sharp relief the opposition between the alliance and the transference, and stressed the role of autonomow ego functions in facilitating the a 11’lance. When Zetzel (1956) took up the idea, the interpenetration of aspects of transference with the alliance provided the framework for her thinking. T h e transference situation took on a broader meaning that seemed to include the whole analytic relationship (Langs, 1976). T h e therapeutic split resulted in the


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alliance between the analyst and the patient’s adaptive ego and advanced the distinction between therapeutic alliance and transference neurosis, which Zetzel regarded as the neurotic part of the transference. T h e alliance called on more mature and autonomous ego functions to preserve the real object relationship with the analyst in the face of the transference distortions that were the core of the transference neurosis. A further distinction between alliance and unobjectionable or nonneurotic transference was left unclear. I n her view the alliance was a necessary condition for the analysis and interpretation of unconscious derivatives. T h e preservation and sustaining of the alliance was required for the overcoming of resistances and for the development and resolution of the analytic regression. T h e capacity for alliance required relatively mature ego functions and capacity for object relations, and a n underplaying or disregard of unconscious fantasy and transferential derivatives that might impair o r undermine the alliance. T h e analyst’s part in promoting the alliance was related to his greater activity and presentation of himself as a more real participant in the analytic interaction. And on the part of the patient the emphasis fell on the capacity for trust as a developmental achievement from very early infantile levels. When Greenson (1965) offered his version of the “working alliance,” he viewed it as a rational alliance between the patient’s reasonable ego and the analyst’s analyzing ego. T h e difference from Zetzel’s formulation was not great, and seemed to elide if not override any distinction between the alliance and the real relation between patient and therapist. Greenson’s implementation of the working alliance led him to a number of deviations in technique-surface interventions, explanations, discussions of real problems without any effort to search out unconscious determinants, deviations from neutrality-generally leaning toward more direct and manipulative interventions rather than more purely analytic understanding (Langs, 1976). This aspect of the technical application of the alliance by both Zetzel and Greenson gave rise to concerns regarding the clinical utility of


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the idea (Brenner, 1980; Curtis, 1979). T h e relation between the working alliance and the real relation was not very clearly maintained. Greenson argued that the real relation was predominant in the opening and closing phases of the analysis, while the working alliance filled in the middle-emerging toward the end of the introductory phase and receding as the terminal phase approached. Part of the difficulty in these formulations-ne that to my mind has contributed to subsequent confusions and difficulties in conceptualizing the therapeutic alliance--was that a clear line was not drawn between alliance factors and transference on the one hand, and between alliance and the real relation on the other. Part of the problem is that conceptual clarity often yields ground to actual concurrence and intermingling of these aspects of the therapeutic relationship. T h e therapeutic relationship actually involves three discriminable components that can be adequately distinguished, but that occur simultaneously and concurrently within the therapeutic relationship. T h e three components are the therapeutic alliance, the transference, and the real relationship. T h a t they overlap and intersect in complex patterns and are in continual interaction and mutual modification poses a problem for preserving their distinctive and separate intelligibility. I am proposing that the effort to keep them at least conceptually separate serves the purposes of further understanding better than the prevailing approaches that tend to blur the edges of distinction and bring with them a trail of confusion. For example, Greenacre’s (1968) use of the term “transference” to embrace the total relationship between analyst and patient overrides any distinction between alliance and transference. T h e alliance becomes synonymous with the positive transference rooted in the early mother-infant bond. This tends to shift the emphasis toivard basic trust as the essential element in the alliance and to the maternal and need-fulfilling functions of the analyst-reminiscent of Zetzel’s emphasis on trust. T h e alliance, then, becomes just another form of transference based


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on early, primitive, and infantile contributions from the earliest developmental strata. A like emphasis can be found in Stone’s (1961) appeal to transference to the mother of separation. There is a similar drift in Stein’s (198 1) more recent discussion of the so-called unobjectionable transference and its connection with the transference neurosis. There are differences of opinion regarding the use of the terms “therapeutic alliance” and “working alliance.” Some use the terms synonymously; others distinguish them. Curtis (1979) recommended against their interchangeable usage, even dropping the term “working alliance.” Dickes (1975) saw the therapeutic alliance as the more developed and evolved pattern of relationship, including all the elements that would favor the patient’s participation and the effectiveness of the collaborative therapeutic effort. This would include such elements as the patient’s positive motivation for treatment, aspects of the positive transference, and the capacity for rational interaction between patient and therapist-similar to the rational alliance described by Gutheil and Havens (1979). T h e working alliance would then be regarded as more limited in scope, involving a basic capacity for patient and therapist to work together, and expressing the extent to which the more mature part of the patient’s ego can involve itself in the therapeutic process. T h e working alliance seems to represent the more rational core of the therapeutic alliance (Dickes, 1975).’ Although there is a great deal more to be said about the basic nature of the therapeutic alliance, we can take the description of the rational alliance provided by Gutlieil and Havens, following the work of Sterba (1934), Zetzel (1970), Greenson ‘The terni “working” in tliis view connotes a limitation in the therapeutic relationship to those factors that make it possible for patient arid therapist to work together-the necessary and sufficient conditions for tlie tlierapeutic work to continue and progress-suggestirig that tlie concept o f the alliance is limited or constrained to sotlie degree. i\’liile this usage is acceptable, the distinction need not be pressed excessively. I sliall LISC tlie term “ivorking” to express a liniitetl or sufficient alliance, but “therapeutic” when the fuller connotations of the alliance are in question.


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(1965), and Sandler (Sandler et al., 1973), as o u r starting point. T h e therapeutic alliance involves “the therapeutic split in the ego which allows the analyst to work with the healthier elements in the patient against resistance and pathology” (Gutheil and Havens, 1979, p. 479).

Alliance us. Transference Although traditional discussions of the therapeutic alliance have included a transferential component in the alliance itself, I would argue that they are essentially distinguishable and that our efforts to further explore both entities is better served by maintaining their conceptual distinction rather than obscuring it. T h e transference and the alliance have essentially different roots and express themselves in differentiated ways in the analytic process. I n certain respects the distinction seems murky, if not uncertain. If we consider basic trust, as Erikson (1963) defined it, as a component of the patient’s capacity for alliance, it is often difficult to keep aspects of early infantile positive transferential determinants distinct from basic trust itself (Stein, 1981). For the most part, they go together and are mutually influential and supportive. But primitive positive transference carries other connotations that are not part of basic trust-wishes for dependency, merger, symbiotic reunion, even idealization, for example, that are not germane to basic trust and are in many ways antithetical to it. T h e distinction is easier to grasp around issues of autonomy. T h e patient’s capacity for autonomous relationship with the therapist may be mingled with and influenced by a variety of transference dispositions, whether positive or negative, but clearly the autonomy itself is a present and concurrent quality of the object relation and cannot be regarded as synonymous with any of the related transference dynamics. T h e r e also are more pragmatic connotations that come into play in the analytic relationship and can have implications for therapeutic processing and response. T h e alliance comes into


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play as an active factor in the therapeutic relationship from the very first moment of contact between patient and therapist-ven if the initial exchange takes place over the telephone. T h e alliance not only comes into play, but it is being generated and shaped at every moment of the therapeutic interaction by both patient and therapist. Transference factors may or may not come into play from the beginning. For some patients, portions of transference material become active quite early in the process; for others, the emergence of transference is more gradual and often delayed, coming to the fore only as the analytic process deepens and regressive pulls take increasing hold. T h e differences can even have diagnostic implications (hleissner, 1984a). One implication of this distinction that has relevance to analytic praxis is that alliance factors are immediately involved in the vicissitudes of the ongoing analytic relationship itself, while transference aspects are derived from some other nonanalytic frameworks and enter into the analytic relationship from the outside. Transference elements may facilitate or inhibit the therapeutic relationship; they are always contrary to and undermining of the therapeutic alliance, whether they are positive or negative in content. Negative transference elements undermine the essential collaborative nature of the alliance, and for the most part this distortion of the alliance is easily recognized. Positive transference elements have the potential for providing a more subtle and often confusing picture insofar as they can provide motivational elements that reinforce or sustain the therapeutic relationship in some fashion. They do so, however, at cost to the therapeutic alliance. Elements of positive libidinal regard or attachment, dependency, aspects of idealization, and other aspects of a positive transferential attitude may at times and in certain conditions contribute to the therapeutic process, but they always erode and undermine the alliance. If there is a therapeutic gain to be extracted from the influence of such factors, the gain is more often short-term and is purchased at the longer-term cost of the distorting or undermining of the


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therapeutic alliance. These contribute to the forms of distortion of the therapeutic alliance that Langs (1975a, 1975b, 1976) describes as “misalliances.” It should be clear that the transference in these situations is not synonymous with therapeutic misalliance. Transference distortions may give rise to such misalliances, but they are conceptually different. An example may help to clarify the point. Early in a series of evaluative sessions in which a patient and therapist were working toward a decision to undertake a course of therapy, the patient, a young woman in her late twenties who had had difficulties with an earlier eating disorder, and had recently experienced the abrupt and unexplained termination of a therapeutic relationship that had lasted over six years, described her mother as an alcoholic and her father as an overeater. She complained tearfully that her mother would drink and become unavailable to her and that her father would eat and become similarly unavailable. FVith some trepidation and hesitation a ‘few minutes later in the discussion, she commented that the therapist seemed to be overweight and that made her afraid he would not listen to her and would not be able to hear her pain. This material could easily be heard in transference terms, namely, a negative father transference triggered by the similarity between the father’s corpulence and the therapist’s. If one were to consider the transference only, one would regard this reductively as transference material and would deal with it in those terms. I would suggest, however, that the situation is more complex. What was also being expressed was the patient’s concern that the therapist would be unable to hear her internal distress, that h e would be unavailable to her and be unable to stay with her during the experiencing of that pain, and that he would be incapable of responding empathically and understandingly. T h e patient was clearly suffering from an unresolved mourning for the former therapist and was struggling with issues of trust on the brink of entering another such relationship. I would regard these as basically alliance issues, arising


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within the present interaction as an aspect of the immediate situation to which both patient and therapist are contributing. T h e transference elements are operative here, but the concerns go beyond transference since they are pertinent and alive within the immediate context of the patient’s involvement with the therapist, regardless of transference derivatives. T h a t the concerns should arise and be expressed in terms of a transference metaphor is by no means irrelevant and may in the long run be of central importance in the resolution of the issues involved, but at this early juncture in the therapeutic relationship it is secondary. T h e patient’s immediate concerns regarding the therapist’s availability, empathy, and capacity take priority and must be addressed as issues with their own inherent validity. Even if transference interpretation would prove to have greater therapeutic utility, it is more usefully introduced through priniary attention to alliance issues. Failure to address the alliance difficulties may run the risk that such a maneuver can communicate to the patient or be perceived by the patient as a reflection of the therapist’s insecurity, anxiety, uncertainty, or other unwillingness o r inability to respond to the patient’s pressing need of the moment.* T h e relation and interaction between alliance and transference are complex and can follow various patterns. From one point of view, there is a kind of negative proportionality that operates between them-if the alliance becomes dominant in the clinical interaction, the transference tends to recede and plays a less prominent role. It was on this basis that many of the negative reactions to the work of Zetzel and Greenson was based. If the analyst paid too much attention to the alliance, the transference and its development in the analytic process would be hampered and interfered with (Brenner, 1980; Curtis, 1979). Efforts to support the therapeutic alliance could, it 2The issues liere are technical rather than conceptual-reasons why Brenner (1980) objects to the alliance concept. I am using the clinical example only in the interest of clarifying the distinction and not of addressing the technical question.


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was feared, reinforce the analyst’s countertransference, particularly needs to deny unconscious fantasies and transference material; analyst and patient would run the risk of collusively avoiding unconscious conflicts and fantasies. If there is such a reciprocal connection between them, this is not the only pattern of activation that can prevail. It can also be the case that the establishment and consolidation of a secure and firm alliance becomes a necessary condition for the more regressive emergence of more powerful, meaningful, and even dangerous transference dimensions. In such cases the alliance offers a safe context within which intense, powerful, and frightening transference derivatives can be allowed access to consciousness and analytic processing.

Alliance vs. R ea 1 Rela tio?zship ‘Much of the discussion of the therapeutic alliance has suffered from efforts to distinguish it from transference. Aspects of the therapeutic relationship include transference and nontransference, but little effort was directed to drawing a line between alliance and the real relation, both of which are nontransferential. T h e failure to maintain the distinction between alliance and reality has led to some problematic misunderstandings. Here again, the fact that these factors intermingle and interact in the actuality of the therapeutic relation tends to obscure the distinctions between them and the different ways in which they contribute to the overall relation. Reality pervades the analytic relationship. There are realities of time, place, and circumstance. T h e realities of the locqtion of the analyst’s office, the physical surroundings, the furniture and decorations in the room, the geographic location itself, and even how the analyst dresses, affect the analytic relation and influence how the patient experiences the person of the analyst. T h e surrounding circumstances set the conditions for


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the analytic effort-the patient’s financial situation, j o b demands, arrangements for payment of the fee, whether the patient has insurance o r not and what kind, what kinds of pressures are pushing the patient into treatment-all reality factors extrinsic to the analysis, but exercising significant influence on the analytic relation and how it becomes established and maintained. T h e most important reality is the person of the analyst. Every analyst has his own constellation of personal characteristics, mannerisms, style of behavior and speech,,habits of dress, sexlgender (Lester, 1990), way of going about the task of managing the therapeutic situation, attitudes toward the patient as another human being, prejudices, moral and political views, and personal beliefs and values. All these are relevant aspects of his existence and personality as a functioning human being. They are realities that play into and condition the therapeutic relationship. They are entirely exclusive of matters of transference and countertransference. In terms of the analytic process, none of this is lost on the patient who is comprehendingly observant and sensitive to the least details of the analyst’s person. T h e same realities are operative from the side of the therapist’s view of the patient. As he enters the consulting room, the patient carries with him certain determinate real qualities and characteristics that stamp him as this human individual. They are similar qualities to those possessed by the therapist, butcarrying the stamp of his own individuality. Central to this configuration of reality elements are the aspects of the patient’s personality and behavioral style. T h e patient may have certain mannerisms o r forms of behavior that elicit a reaction from the analyst. A female patient may be beautiful, attractive, and may behave in a sexually seductive manner-aspects of her usual style of behavior and mode of interaction with men. These are real aspects of the patient’s person that cannot be reduced to transferential components. They may elicit a response from the therapist, especially if he is male, that may even be affective in


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tone, but has nothing to do with countertransference. He is simply responding to the reality of a n attractive woman. Similarly, from both sides of the analytic relation, objective qualities of the participants come into play continually to shape the quality and course of the interaction between them. T h e analyst may be authoritarian and directive in his style of intervention and interpretation. His approach to the analytic situation and interaction may be simply an expression of his habitual manner of interacting, o r it may in some degree be dictated by defensive needs and even derived from underlying unresolved conflicts, and still not necessarily constitute an expression of countertransference. It may simply be a facet of his personal style and his habitual mannerisms in approaching and dealing with this particular patient. IVhile the distinction between these real aspects of the therapeutic interaction and elements of transference is easily drawn, the related distinction between such real factors and - the therapeutic alliance is more difficult. T h e alliance concerns itself with specific negotiations and forms of interaction between therapist and patient that are required for effective and meaningful therapeutic interaction. T h e element of basic trust, for example, is not part of the real relation, but entails a quality of the interaction within the object relation that must be engendered by specific behaviors that aim at the establishing and sustaining of such trust. T h e capacity for trust may be a part of the reality of the patient’s personality structure and functioning. But this capacity must be realized in the ongoing interaction between analyst and patient, and in this sense becomes a contributing element in the therapeutic alliance. Similarly, a patient may have a real capacity for autonomous functioning, but that capacity must be implemented and allowed to emerge as a functional aspect of the analytic relationship and interaction in order to be regarded as a factor in the therapeutic alliance. hloreover, the alliance is specific to the therapeutic situation and relationship, while the reality of the patient’s personality structure pervades his whole life experience and relationships.



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Early attempts to articulate the therapeutic alliance tended to view it restrictively as reflecting developmental accomplishments from quite early developmental strata. The emphasis in Zetzel’s (1956) rendition, for example, fell on the residues of the caretaker vicissitudes from the earliest child-mother interaction that centered on issues of trust-much along the lines of discussion of trust laid down by Erikson (1963). This approach fell into a too ready dichotomy between preoedipal and oedipal developmental levels in which transference dynamics tended to be viewed in oedipal terms and alliance factors in preoedipal terms. We would now tend to view transference as reflecting conflictual issues at all levels of development, preoedipal, oedipal, and postoedipal. T h e same is true of the therapeutic alliance which also reflects developmental achievements drawn from all levels of developmental experience. There is a developmental aspect of the interchange between therapist and patient that involves mutual cuing and reciprocal relatedness that reaches back to the earliest strata of mother-infant interaction for its foundations. To the extent that positive dimensions of earlier developmental experiences can be recaptured, the potential for constructive alliance building is reinforced. To the extent that such factors are lacking o r that negative and destructive aspects of the mother-child interaction are tapped into, the potential for meaningful therapeutic alliance is compromised and the basis is reinforced for disruption of the alliance or for a therapeutic misalliance. hlore is involved on this level than merely specifiable aspects of the contemporary interchange. T h e question arises as to how to articulate these developmental contributions. I have not been able to improve on the epigenetic schema by Erikson (1959, 1963). At each level of developmental attainment, from the rudimentary level of basic trust, through the development of autonomy, initiative, the achievement of identity, industry, and even generativity, we


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have a resolution of developmental crises that constructs a basic capacity and source of strength within the evolving structure of the self. These constructive resolutions draw the developmental course of the individual away from unresolved conflicts and pathological compromises toward a greater capacity for more mature, adaptive, and effective ego functioning. These are the capacities in the analytic relation that the therapeutic alliance builds on and toward which its therapeutic efforts are directed. T h e therapeutic alliance both builds on basic trust and builds it. It both builds on the patient’s capacity for autonomy and reinforces it. A point that should be emphasized is that these qualities and capacities for adaptive personality functioning have their own inherent history in the course of the analytic process. They evolve in somewhat epigenetic fashion during the course of the analytic work. Trust may thus play a more telling role in the opening phase of the analysis than autonomy. T h e patient must -be able to allow o r tolerate a certain degree of dependence in order for the analytic process to take hold. T h e evolution of trust within the analysis may involve increasing degrees of dependence, even of a fairly primitive kind, as the analytic regression takes hold. But that dependence will have to be worked through and gradually resolved in order to make way for a trusting relationship that allows room for the emergence and facilitation of basic autonomy within the therapeutic relationship. As autonomy begins to grow, there is more room for the patient to take responsibility for the progression of the analytic work and to assume more initiative and industry in directing the course of the analytic inquiry and even the interpretive process. My intention here is simply to indicate that the alliance rides on multiple levels of developmental determinants, that these determinants follow their own pattern of epigenetic articulation within the analytic process, and that the study and therapeutic enhancement of these issues and the putative resolution of the developmental crises as they arise in the analysis are crucial matters of technique and the theory of therapy.


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While a certain consensus regarding definition is possible, difficulties remain in the manner in which the therapeutic alliance is operationalized. Elements that contribute to establishing the therapeutic alliance include contractual arrangements between patient and therapist regarding the logistics of the therapy (scheduling, fees, payment confidentiality, etc.), some agreement as to how the parties will work together and for what purposes, and an understanding and acceptance on both parts of their respective roles and responsibilities. Consequently, the therapeutic alliance embraces many aspects of the relationship between the patient and the therapist that do not fall within the scope of transference, nor are they pertinent to the real relationship between the two, even though the development and shaping of the therapeutic alliance is intimately related to aspects of both transference and reality. Moreover,.the therapeutic alliance is not something that is inherent only in the patient; rather, it involves a process of interaction to which both patient and therapist contribute. Consequently, the therapist’s attitudes, the way in which he regards, responds to, and deals with the patient are important contributing elements to both establishing and maintaining the therapeutic alliance. T h e therapist’s respect, consideration, courtesy, tactfulness, and empathy are important contributing factors. Further, the therapist must adopt a firm, consistent, and unchanging position v i s - h i s the patient that holds the patient consistently responsible for participation in the therapeutic process. This kind of emphasis within the therapeutic interaction is entirely consistent with the technical approach recommended by Gray (1990) when he comments, “Obviously I am trying to implement and maintain a principle of drawing more and more of the patient’s ego into conscious participation in the analytic process’’ (p. 1087). T h e analyst maintains an expectation of the patient’s meaningful involvement in the therapeutic process and an implicit persuasion that the patient accept ’


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and observe his responsibilities both within and outside of the therapy. I’arallel to this is a consistent, secure, firm, and unwavering posture of the therapist that conveys (in behavior rather than words) that he will fulfill his role and meet his responsibilities in the therapy in a consistent, mature, and constructive manner. These issues seem almost to transcend the realm of technique, insofar as they express and reflect qualities of the therapist’s own personality and values as they enter into the tlierapeutic process and engage with the needs of the patient. Thus, the therapeutic alliance has profound implications for the outcome of the therapy, since it is a central component of the arena within which patient and therapist engage in the work of the therapy, and provides a matrix within which important interpersonal experiences and crucial identifications, which may modify the patient’s patliogenic inner structurc, can take place (hleissner, 1981). I shall discuss the components of the tlierapeutic alliance under the following headings: empathy, the therapeutic framework, responsibility, authority, freedom, trust, autonomy, initiative and ethical considerations. T h e .list makes no pretense at completeness, nor is my discussion intended to exhaust the potential implications of any of these components. My purpose is to suggest some of the core elements of the therapeutic alliance in the hope that some brief consideration might open the way to further and more probing exploration of their place in the analytic armamcntarium.

Empa thy Empathy is the sine qua ?ion of analytic work. T h e nature of empathy and its role in the psychoanalytic process have been thoroughly discussed by various authors (Beres, 1968; Beres and Arlow, 1974; Buie, 1981; Greenson, 1960; Kohut, 1959, 1971, 1977; Olden, 1958; Shapiro, 1974; Lichtenberg et al., 1984). It provides one of the major channels of information by which the analyst is enabled to continuously assess the ongoing


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status of the therapeutic alliance. It is also a major component of the patient’s capacity to read and respond to the analyst’s working ego and therapeutic intent rather than in terms of transference distortions and projections. T h e emphatic point is that empathy is a two-way street and that mutual empathic attunement is essential for maintenance of the therapeutic alliance. This is especially the case when some form of therapeutic misalliance is in question. T h e sense of being understood, which is so central to the experience of the therapeutic alliance, reflects the presence of a good working alliance and is based on good empathic resonances on the part of both participants.

Tlierapeiitic Franieworli This aspect of the therapeutic alliance includes those elements described in terms of the “therapeutic contract.” Shapiro (1989) objects to the idea of the contract on the ground that the patient’s ego is not sufficiently disengaged from neurotic needs to undertake the required self-observation. He writes, “This assumption is also contained in the attractive-sounding but problematical concept of ‘therapeutic alliance,’ at least in one of its meanings. T h e supposed ‘contemplative ego’ or ‘observing ego’ of the patient that is critical to such a n ‘alliance’ is just such an introspective agency. But the fact that the patient’s articulation of his subjective experience serves and is not detached from the dynamics of the neurotic personality precludes reliance on such a ‘contemplative ego’ or any ‘alliance’ that, in turn, depends on it” (pp. 72-73). T h e framework, however, is more a statement of the necessary conditions for therapeutic engagement than a demand imposed on the patient. It also includes more than is suggested by a merely contractual model. T h e framework refers to those conditions that are required on the part of both therapist and patient in order that good and effective therapeutic work can be conducted. T h e elements include scheduling . (the place and time for analytic appointments), fees and the method of their payment (including the


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management of any insurance payments), arrangements for missed appointments or vacations, and questions regarding confidentiality (Uchill, 1978; Meissner, 1979, 1986). Other elements of the framework have to d o with the stability of time and place and the maintenance of the conditions for the analytic setting. Part of the framework, therefore, is the consistency of the place of meeting, adherence to the specifics of scheduling, maintaining the integrity of the therapeutic hour (meaning no interruptions, no telephone calls) as far as is reasonably possible. All these are matters for discussion, negotiation, and agreement.

Responsibility Responsibility is an essential component from both sides of the therapeutic alliance. From the patient’s side, the therapeutic alliance requires that he take responsibility for his part in the process. T h e negotiated terms of the framework include his taking responsibility for coming to the determined hours, coming on time, paying the fee in a regular and responsible manner. In addition, he assumes responsibility for producing the material that the analytic process can work on-particularly through free association, but also in terms of his openness about thoughts, feelings, fantasies, and other mental processes that come to the level of conscious attention during the sessions. T h e patient’s responsibility also includes taking some degree of active participation in the process of trying to understand and put in perspective the material that comes into focus in the course of the analytic work. This aspect of the therapeutic alliance calls into play capacities of the patient to engage with the analyst in the collaborative work of the analysis-the work ego of the patient, in a sense (Gray, 1990). Clearly, the transferencedictated assumption that the analyst bears the responsibility for maintaining the analytic effort-a not uncommon persuasion-is contrary to the therapeutic alliance.



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From the analyst’s side, the assumption of his analytic responsibilities plays a central part in his function as analyst and in his participation in the analytic process. His responsibilities include being there, being on time, attending to the maintenance of the analytic framework, preserving the regularity and integrity of the analytic situation-with particular regard for maintaining the conditions for confidentiality, listening with careful attention to the patient’s productions, trying consistently and persistently to understand, conveying what seem to be useful understandings to the patient when appropriate, dealing with the patient in terms that are appropriate, respectful, ethical, and professional, avoiding countertransference traps and technical errors to the best of his ability, and consistently using his skills and knowledge in the best interest of the patient. T h e list is hardly complete, but my purpose is to indicate that the patient and the analyst both have significant responsibilities that bear on the analytic process in crucial and meaningful ways. Without verging on the question of technical implications, I wish to make the point that much of the analytic effort is frequently devoted to facilitating the patient’s capacity to engage more effectively in his appropriate responsibilities in the analytic work and in monitoring and sustaining the analyst’s own fulfillment of his responsibilities in the process-both in terms of living up to these responsibilities in the analytic work and in not exceeding them in the interest of maintaining the integrity of the therapeutic alliance.

A ti thority T h e issue of authority is inherent in the therapeutic relationship. Analyst and patient occupy different positions, play different roles in the analytic drama. From the beginning of their mutual involvement, the analyst wears the mantel of authority based on his professional role and expertise; as he enters the analytic situation, the patient dons the mantel of the one needing and seeking expert help, assistance, support, and caring.


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T h e physicianly model plays a part here, complete with overtones of paternalism and authoritarianism. In some part, this configuration is built into the analytic relationship and cannot be expunged. In some degree, the dynamics of this aspect of the therapeutic relation reflect transference issues that may have a particular cast in individual terms, but that play some part in all analyses. However one conceives authority-I personally prefer to see it in terms of an authority relation that obtains between analyst and patient as an essential part of the therapeutic relationship-the balance of the elements that constitute the authority relation are never static, and are constantly shifting and evolving during the course of the analytic work. In a sense, one of the objectives of the analytic process is to shift the balance and quality of the authority relation as the therapeutic effort progresses. In these terms, the analyst becomes less the “authority” in the relation, and more an egalitarian participant in the process of discovery and understanding. As the analysis moves forward, his professional understanding gives way to increasing uncertainty and an increasing encounter with the unknown in which both he and the patient become collaborating investigators. T h e patient moves from a position of looking to the analyst for guidance or interpretive input to one of taking greater activity and responsibility for uncovering, sorting out, and integrating his own psychic experience and analytic productions. T h e respective roles of analyst and patient shift so that they gradually come to occupy a middle ground in which both contribute, share, and collaboratively process analytic material, and so gain deepening understanding and resolution of neurotic difficulties. T h e upshot of this process is that the patient moves from a position of reliance on the authority of the analyst to one of claiming his own degree of authoritative standing. This applies not only within the analytic context, but has further reverberations more generally. Part of the process involves the internalization of authority as a result of identification with the analyst.


1079 .. * In any case, the patient comes to claim as his own a degree of personal authority he has previously lacked or conflictually undermined. The emergence and maturation of such a sense of authority is a fundamental acquisition of the self-an important developmental achievement in and through the analytic process. T H E T H E R A P E U T I C ALLIANCE

Freedom is a concept that has had an uncertain place in analytic thinking. Its conceptualization in psychoanalytic terms has only gradually been clarified and articulated as an aspect of autonomous psychic functioning (Waelder, 1936; Knight, 1946; Lewy, 1961; Holt, 1965; FVeisman, 1965; Hartinann, 1966; hleissner, 1984b; IVallace, 1985). Nonetheless, freedom is an essential ingredient in the patient’s participation in the analytic process as well as a core component of the therapeutic alliance. Unless the patient freely chooses to enter the analytic process and willingly engages in it, there is no possibility of a sound therapeutic alliance. T h e same is true from the side of the analyst, but as therapists we are more ready to recognize that our participation in the process as professional healers is of o u r own choosing and determination. iVe do not treat the patient unless we decide to do so; any coercion would have to be regarded as countertherapeutic. Even when the patient undertakes the analytic effort of his own choice, we have little difficulty in recognizing the neurotic constraints that limit and contaminate his basic human freedom. Part of the work of the analytic process is to help the patient come to recognize these limitations 011 his basic freedom, to come to understand the reasons for them, and to find a way to free himself from their power. Even the constraints imposed by the patient’s transference impose limits on his capacity to enter into the analytic relationship and to utilize it to his best advantage. T h e analytic work entails a gradual process of resolving these constraints and helping the patient to gain


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not only increased freedom from external constraints, but more particularly internal freedom from the defenses, anxieties, and inhibitions that impinge on his capacity for a more fulfilling and meaningful human existence. T h e sector in which this development toward increasing freedom takes place is the therapeutic alliance. IVe have long recognized that patients gain greater freedom in the course of analytic work in relation to the resolution of neurotic inhibitions and repetitions. But the view from the side of neurotic defenses and transferences is negative-the gain in freedom is seen as the result of removing obstacles to it. T h e view from the therapeutic alliance, however, asserts the positive component of that process-that it is in the experience and working through of the therapeutic alliance that the growth to greater freedom is facilitated and fostered.

Trust has been recognized from the first as a central ingredient in a meaningful therapeutic alliance-Zetzel (1958) designated it as one of the primary building blocks. hIany patients come to analysis with an at least implicit sense of trust in the analyst and in the analytic process. Many, however, d o not. For many patients the issues of trust lie close to the core of their psychopathology, and they experience considerable difficulties in engaging themselves in the analytic relationship. For patients to whom trust comes easily, part of the analytic work is to enable them to find a more balanced position that avoids the difficulties of naivete and willing compliance, or unwillingness to question, evaluate, o r criticize the analyst’s contributions. Excessively infantile trust tends to avoid certain key responsibilities that are part of the patient’s functioning in the analytic context. In contrast, patients for whom trust comes with difficulty must be helped to unearth and resolve at least some of the sources of their mistrust in order to facilitate the analytic work. In such cases, the establishing and maintaining of a sense of trust


1081 .. r becomes an objective of the analytic process requiring at times considerable effort. I would argue, then, that even though trust takes its origins from basic levels of early infantile mother-child experience, the trust that is essential to the therapeutic alliance is not simply that. I n my view, basic infantile trust is another form of transf e r e n c e - o r at least not easily discriminable from unobjectionable positive transference (Stein, 198l)-certainly not the kind of trust optimal for the therapeutic alliance. Infantile trust may serve as a starting point or building block for a more mature form of trust that can be meaningfully integrated with increasing autonomy and responsibility. Trust itself, in this view, has a developmental perspective that allows for increasing circumspection, independence, and judgment. IVe can add to this that, if the work of the analysis rides on a certain degree of trust in the analyst on the part of the patient in the early stages, the ultimate trust toward which the process aims lies more in the patient’s capacity to trust in himself, to gain a sense of his own trustworthiness in taking control of his own desires, wishes, hopes, and purposes. T H E THEI1APEUTIC ALLIANCE

Autonomy Autonomy is not the same as independence. Autonomy occupies a balanced middle ground between excessive independence on one side and excessive dependence on the other. Thus, there is no contradiction between autonomy and independence nor between autonomy and dependence. In clinical terms, the phenomenon of a hyperadequate or hyperindependent facade covering an underlying fragile and threatened selfautonomy is familiar enough. By the same token, we accept the goal of a combined maturity of dependence and relative intrapsychic autonomy as a worthy therapeutic objective for many of our patients. Autonomy, as is the case with other dimensions of the alliance, is both a goal of the analytic process


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and a requirement for its working. Whether considered in reference to the autonomy of specific ego functions (Beres, 1971) o r of the self (Rleissner, 1986) autonomy may be fragile and questionable as the patient undertakes analysis, with the result that he may tend to be excessively dependent, suggestible, anxious to please and gain acceptance and recognition from the analyst. To the extent that autonomy is lacking, the bases for the analytic process,.at least as it begins to take hold, lie more in the sectors of trust and dependency. These factors, along with a n at least minimal acceptance of the analyst’s authority, are the rudiments of the therapeutic alliance that allow the process to begin. As the analysis progresses, however, the status of autonomy changes so that, by increasing degrees, the patient can come to claim a more authentically autonomous stance within the analytic relationship. This is one of the indices that allow the analyst to gage the progression in the analytic work. If movement toward greater and more reliable autonomy does not take place over time, this would suggest that something is not right in the analytic process. The emphasis here is on authentic autonomy and not on hyperindependence, which is a form of misalliance and can serve as a major resistance.

Iizifiative Initiative is another dimension of the alliance that develops during the analytic process in more o r less epigenetic fashion. T h e patient who comes seeking help and self-understanding exercises a degree of initiative in so doing, but his initiative may be contaminated by infantile derivatives. But initiative changes its shading as the analysis progresses. As the process evolves, the patient assumes increasing initiative-bringing in material for the analytic process to work on, gradually assuming greater responsibility for associating and processing the material, even for interpretation. T r u e initiative facilitates the work of the analysis and does so in collaboration with the analyst-without


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undermining or subverting the contributory initiatives of the analyst. Otherwise, initiative can become a deviation that expresses a misalliance and serves as a resistance to the process-as, for example, when the patient assumes or insists on his own initiative to the exclusion of any initiatives from the analyst. Such deviant initiative can subvert and negate the analyst’s efforts to interpret. Likewise, the failure of initiative or the lack of progressive development in initiative during the course of the analysis can serve as a signal of an underlying misalliance and related transference difficulties.

Ethics Ethical considerations enter into all phases and aspects of the therapeutic alliance, both from the side of the patient and from that of the analyst. Any ethical deviations are contrary to the alliance and will inevitably undermine and distort it. All arrangements, negotiations, and interactions between analyst and patient must be conducted openly, honestly, without concealment or deception. From the side of the patient, this requires openness, honesty, no effort to deceive or mislead the analyst, and fairness in dealing with the analyst, particularly in meeting responsibilities related to the therapeutic framework. From the side of the analyst, it implies observance of more than the socalled ethical codes of professional conduct to which he may be bound; the analyst is held to a higher standard. Within this context, the issue of values takes on special relevance. T h e analyst brings to the analytic encounter values that are in part personal and in part professional. These values are governing norms that determine in some degree the character of his analytic work with the patient. There is no way he can avoid or escape from the influence these values exercise within the analytic process and the extent to which they come to shape the analytic work and influence the patient. While a good therapeutic alliance dictates a position of value neutrality


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(with the possible exception of Hartmann’s (1960) “health values,” these values assert themselves simply by virtue of the fact that the analyst is engaged in the analytic process with his total personality-including his superego and ego ideal. T h e good analyst’s participation in the process may involve value elements he cannot’be expected to exclude, nor would it be in the interest of the analytic work and the benefit to the patient to do so. By the same token, ethical values are embedded in the very structure of the psychoanalytic process-e.g., values of understanding, authenticity, the centrality of self-knowledge-that cannot be expunged without destroying the very nature of the process (Meissner, 1983). Granted these value dimensions of the analytic situation, the intent of the analyst and the process is not to impose values on the patient, but rather to accept and work with the patient’s own values, whether they be personal or cultural, and to help him examine and assess them so as to integrate them in a less neurotic and conflictual life adaptation. T h e therapeutic alliance aims at attaining this objective and preserving the context within which such exploration and evaluation can take place meaningfully and objectively.

Concltuion While many formulations regarding the therapeutic alliance focus only on the aspects of rational cooperation and collaboration with the analyst on the part of the patient, I have tried to show that the concept of the therapeutic alliance is considerably more complex and touches on basic dimensions of the analytic situation and process. I suggest that the therapeutic alliance is a legitimate and significant aspect of the therapeutic relationship, and that it consists of a highly complex and rich constellation of factors vital to the beneficial outcome of any therapeutic process, analytic or not. The above analysis is intended to accomplish no more than to assert this richness and Centrality to analytic work. If that point has been established, it follows that



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more careful and in-depth reflection on the therapeutic alliance is called for. I hope that these considerations may contribute to the future direction of such inquiry. I would argue that the alliance plays as important and determinative a role in the therapeutic outcome as does transference. Obviously, all of the above considerations have their appropriate and important practical implications and consequences. To extend the discussion into that vast territory would carry well beyond the limits of this paper, but I would urge that such an endeavor would carry the promise of abundant fruit for the further understanding and development of psychoanalytic praxis and technique. REFERENCES BERES,D. (1968). The role of empathy in psychotherapy and psychoanalysis. J . HilLside Hosp., 17:362-369. (1971). Ego autonomy and ego pathology. Psjclioanal. Study Child, 26:3-24. ARLOW, J. A. (1974). Fantasy and identification in empathy. Psyhoanal. Q.,43:26-50. C. (1 980). IVorking alliance, therapeutic alliance, and transference. BRENNER, In Ps)choana&ic Explorations of Technique: Discourse on flie Theory of Therapy, ed. H. P. Blum. Neiv York: Int. Univ. Press, pp. 137-157. BUIE,D. H. (1981). Empathy: its nature and 1imitations.J. h e r . Psjcfioanal. Assn., 29:281-307. CUR-ns, H. C. (1979). The concept of therapeutic alliance: implications for the “widening scope.” J. Amer. Pyhoatzal. Assti., 27 (Suppl.): 159-192. DICKES, R. (1975). Technical considerations of the therapeutic and working alliances. Int. J. Psjchoanal. Psychofher., 4: 1-24. ERIKSON, E. H. (1959). Identify and the Life Cjcle. Psyhol. Issues, hlonogr. 1. New York: lnt. Univ. Press. (1963). Childfiood and Society. Neiv York: Norton. FREUD,S. (1912). T h e dynamics of transference. S. E., 12. GILL,hi. hi. (1979). T h e analysis of the transference. J. Aaier. Psjclioanal. Assn., 27 (Suppl.):263-288. (1982). Atialyis of Transference, Vol. I : Theory and Technique. Psjcliol. Issues, hlonogr. 53. Neiv York: Int. Univ. Press. GIOVACCHINI, P. L. (1979). Treafmenf of Primitive Mental States. Neiv York: Aronson. GRAY,P. (1990). The nature of therapeutic action in psychoana1ysis.j. h e r . Psjchoanal. Assti., 38: 1083-1097. GREENACRE, P. (1968). T h e psychoanalytic process, transference, and acting out. In Emotional Growth, Vol. 2. New York: Int. Univ. Press, pp. 762-775.

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_. r GKEENSOS,R. R. (1960). Empathy and its vicissitudes. I t i f . J . Psyhoatial., 4 1 :4 18-424. (1965). The working alliance and the transference neurosis. I n Explorations iiz Psylroaiialpis. Ntxv York: Int. Univ. Press, 1978, pp. 199-224. GUTIIEIL, T. G. & HAVENS,L. L. (1979). The tlicrapeutic alliance: contemporary meanings and confusions. 1111.Rev. Psyhoaiial., 6:467481. H A R T ~ I A N E. N , (1966). The psychophysiology of free will: an example of vertical research. In Psjclioaiiafyis-A Geiieral Psjcliolog)., ed. R. hi. Loewenstein, L. hl. Schiir, 8: A. J. Solnit. New York: lnt. Univ. Press, pp. 521-536. H A K T ~ I A NH. N , (1960). PsyAoaiin&s and Moral Values. New York: Int. Univ. Press. HOLT, R. R. (1965). Ego autonomy re-evaluated. I t i f . J. Psylzoaiial., 46: 15 1-167. KNIGHT,R. P. (1946). Dctcriiiiiiisni, “freedom” and psychotherapy. I n PsjcltoanabficPsjcliiafvaiid P’s).c/iology.New York: Int. Univ. Press. pp. 365-38 1. KOIIUT, H . (1939). Introspection, empathy, aiid psychoanalysis: a n esaniination of the relationship between mode of observation and t1ieory.J. Aiiier. Psjclroaiinl. Assir., 7A59-483. (1971). Tlie Aiinljsis of the Self. New York: lnt. Uiiiv. Press. , (1977). Tlie Resforalion of fhe Self. New York: Int. Univ. Press. LANGS,R. (19754. Therapeutic misalliances. 1111.J. Psylioaiinl. Psyliotlier., 4377-109. (1975b). The therapeutic relationsliip and deviations in tecliniquc. 1111. J . Psyhoaiial. Psyhofher., 4: 106141. (1 976). The Tliempeiitic IiiIernclion, 2 vols. New York: Aronson. LESTER.E. P. (1990). Gender and identity issues in the analytic process. Iiil. J . Psjclioaiml.. 7 I :435444. LEW. E. (1961). Responsibility. free will, a n d ego psycliology. 1111. J. PSJclioaiial., 42:260-270. LICHTENREKG, J. D., B O R N S T E I hl. ~ , 8; SILVER. D.. Etls. (1984). Eiii,batIrj, 2 vols. Hillsdale, N.J.: Analytic Press. ~ I E I S S S E R , 11’. 11’. (1979). Threats of confidentiality. Psylrinf. AiiiiaLr, 954-71. (198 1). fiiteriinlizafioiiiii Psylioniinbsis. I’syliol. Issues, hlonogr. 50. New York: Int. Univ. Press. (1983). Values in the psychoanalytic situation. Psylioaiial. f i i g . , 3~577-598. (1984a). The Borderliiie Specfritm:Differeiitinl Diagiiosis aiid Deuelopiiieiital Issues. New York: Aroiison. (1984b). Psjchoaim+s arid Religious Expen’eiicc. New Haven, Cqtin.: Yale Univ. Press. (1986). Cali psychoanalysis find its self? J . Aiiier. I-?cyclioaiial. Assir., 34:379400. h l o w L L , A. H. (1986).Tlic niissing elements in Koliut’s cure. Psyhoaiial. I i i q . . 6~367-385. OLINN, C. (19%). Notes on tlie development of empathy. Psyhoaiial. Sfrtdj Cliild, 8: 1 1 1-126. SANDLEK, J., DAKE,C. 8: HOLDER,A. (1973). The Pafieiif a r i d [lie r i i i a f y f : Tlie Basis of /lie Psyhoaiiabtic Process. New York: Int. Univ. I’ress. S~IAPIRO D., (1989). Psyliofhera,bj of hTEtirotic Chamcfer. New York: Basic Books.


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T. (1974).T h e development and distortions of empathy. Psjclioatial. Q., 43:4-25. STEIN,hi. H. (1981). The unobjectionable part of the transfercr1ce.J. A m r . P~jcAoatid.Assti., 29:869-892. STERBA, R. (1934). T h e fate of the cgo in psyclioanalytic therapy. 1111. J. Psjchoatial., 15:1 17-126. STONE. L. (19G1). The Psjchoannljfic Sifuafion.New York: Int. Univ. Press. UcIm.L, A. B. (1978). Deviation froiii confidentiality and tlie tlierapcutic holding environment. I t i t . J. Psjchoarinl. Psjcliother., 7:20&2 19. WAELDER,K. (1936). The probleni of freedom in psychoanalysis and the problem of reality-testing. lnf.J. Psjrlioatial., 17:89-108. \VALLACE, E. R. (1989). H i s f o r i o p p l i jatid Criirtntioii in Psjclioaiinljsis. Hillsdale, N.J.:Analytic Press. \VEISMAX, A. D. (1965). The Existletifial Core of Psjclioaiinlyk. Boston: Little, Brown. ZErLEL, E. K. (1936). T h e concept of transference. 111 The cnpzcifj for Emufioiial Grorc*fIi.New York: Int. Univ. Press, pp. 168-181. (1958). Tlierapeutic alliance in the analysis of hysteria. 111 The Capacifj for Emofiotinl Grourtli. New York: Int. Univ. Press, pp. 182-196. (1970). The Capocilj f o r Eviofioirnl Grozrfli. New York: lnt. Univ. Press. StiAPmo,

120 hfounl Aiilitni Sfreef Cnaibridge, AlA 02138


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Trauma group therapy: the role of attachment and therapeutic alliance.

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Therapeutic alliance in the personal therapy of graduate clinicians: relationship to the alliance and outcomes of their patients.

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Metabolic reprogramming: the emerging concept and associated therapeutic strategies.

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Therapist Effects and the Impact of Early Therapeutic Alliance on Symptomatic Outcome in Chronic Fatigue Syndrome.

Object representation quality, therapeutic alliance, and psychotherapy process.

Mutual attention and joint gaze as developmental forerunners of the therapeutic alliance.

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Erratum: Therapeutic Alliance between the Caregivers of Critical Illness Survivors and Intensive Care Unit Clinicians.

Therapeutic Alliance between the Caregivers of Critical Illness Survivors and Intensive Care Unit Clinicians.