Therapists’ perspective on the therapeutic relationship: Examining a tripartite model

The components of a tripartite model of the therapeutic relationship, namely the working alliance, the transference configuration (transference and countertransference), and real relationship, were examined in terms of how they relate to one another and to the outcome of a psychotherapy session, from the therapists’ perspective. Although previous studies have examined these components separately, no study to date has examined the components together in their relation to session outcome. Licensed psychotherapists (n = 249) were recruited from two Divisions of the American Psychological Association. Therapists completed measures for the last session they had with a client. Results revealed that from the therapist’s perspective the real relationship and working alliance related positively to session outcome, and countertransference behavior related negatively to session outcome. The components related to each other mostly as predicted by the tripartite model, and a principal-axis factor analysis revealed the presence of four distinct factors resembling the components theorized to comprise the tripartite model. The components together accounted for 27% of the variance in session outcome and only the real relationship and the working alliance predicted session outcome when all the components were looked at simultaneously in a regression model.     

The working alliance and the transference/countertransference relationship: Their manifestation with racial/ethnic and sexual orientation minority clients and therapists

Theoretical propositions are offered about the interrelations of three key concepts in psychotherapy: specifically, the working alliance, on the one hand, and both transference and countertransference, on the other. The role these concepts play, including the interactions between them, is extended to the areas of race/ethnicity and sexual orientation. We examine working alliance, transference, and countertransference considerations for therapy dyads in which at least one of the participants is a member of a racial/ethnic or sexual orientation minority group. Our hope is that this theoretical examination will generate further research and theory development on working alliance, transference, and countertransference where cultural factors such as race/ethnicity and sexual orientation are implicated in the therapeutic relationship.     

The working alliance and the transference/countertransference relationship: Their manifestation with racial/ethnic and sexual orientation minority clients and therapists

Theoretical propositions are offered about the interrelations of three key concepts in psychotherapy: specifically, the working alliance, on the one hand, and both transference and countertransference, on the other. The role these concepts play, including the interactions between them, is extended to the areas of race/ethnicity and sexual orientation. We examine working alliance, transference, and countertransference considerations for therapy dyads in which at least one of the participants is a member of a racial/ethnic or sexual orientation minority group. Our hope is that this theoretical examination will generate further research and theory development on working alliance, transference, and countertransference where cultural factors such as race/ethnicity and sexual orientation are implicated in the therapeutic relationship.     

The problem of self-disclosure in psychoanalysis

The problem of self-disclosure is explored in relation to currently shifting paradigms of the nature of the analytic relation and analytic interaction. Relational and intersubjective perspectives emphasize the role of self-disclosure as not merely allowable, but as an essential facilitating aspect of the analytic dialogue, in keeping with the role of the analyst as a contributing partner in the process. At the opposite extreme, advocates of classical anonymity stress the importance of neutrality and abstinence. The paper seeks to chart a course between unconstrained self-disclosure and absolute anonymity, both of which foster misalliances. Self-disclosure is seen as at times contributory to the analytic process, and at times deleterious. The decision whether to self-disclose, what to disclose, and when and how, should be guided by the analyst's perspective on neutrality, conceived as a mental stance in which the analyst assesses and decides what, at any given point, seems to contribute to the analytic process and the patient's therapeutic benefit. The major risk in self-disclosure is the tendency to draw the analytic interaction into the real relation between analyst and patient, thus diminishing or distorting the therapeutic alliance, mitigating transference expression, and compromising therapeutic effectiveness.     

On analytic listening

Multiple dimensions of the listening process as implemented in the analytic process are discussed. Listening is not the same as hearing; it is done with the mind rather than just the ears. Listening seeks meaning, specifically the meaning in the mind of the patient. The meaning of words is often obscure, ambiguous, and uncertain, and their deeper implications can only be approached over time through uncovering associative linkages. Listening takes place in multiple perspectives--subjective/objective, active/passive, dynamic/genetic, etc. Listening is also contextually related to dimensions of the analytic relation, including transference, alliance, and real relation. Modalities of listening related to each are explored for both analyst and analysand, and aspects of listening empathically and listening to silence are discussed.     

The dynamics of empirically derived factors in the therapeutic relationship

The therapeutic relationship is the source of major concepts in psychoanalytic clinical theory. Such concepts as resistance, transference, countertransference, and the alliance are fundamental, even though there may be shifts in meaning between theoretical schools and clinical contexts. In the clinical psychoanalytic literature, disagreement exists over the nature of the alliance and its essential components. Empirical studies using reliable patient, therapist, and observer scales to assess the alliance demonstrate a correlation with psychotherapeutic gains. In the study reported here, thirteen patients were followed for 6 to 33 months of psychodynamic psychotherapy, during which time their views of the therapeutic relationship were assessed, and several experiential measures taken, all on a weekly basis. Statistical analyses reveal that the therapeutic relationship, as reflected in the patients' weekly responses to the St. Louis Therapeutic Relationship Rating Scale, has four distinct components: therapeutic alliance, resistance, transference love, and negative transference. On a week-by-week basis, the therapeutic alliance was the strongest predictor of improvement in patient-reported general adjustment, as reflected in such areas as self-esteem, positive affect, social relations, work productivity, satisfaction, and optimism. Time plots of the variables show the typical time course for the components of the therapeutic relationship, as well as for improvement on the experiential variables. Results indicate that the therapeutic alliance, transference, and resistance are central components of the psychotherapeutic relationship, which in turn predict the ongoing life experience of the patient.     

Real relationship,working alliance,transference/countertransference and outcome in time-limited counseling and psychotherapy

Six client/therapist dyads (three therapists each working with two clients) were studied to determine how the real relationship unfolds over the course of time-limited treatment and how this unfolding relates to the development of the client/therapist working alliance, client transference, and therapist countertransference. We also examined how these indices of the relationship fluctuate as a function of treatment outcome. Results indicate that in general for all six dyads, therapists’ and clients’ ratings of the real relationship and working alliance were strong throughout treatment. However, patterns of real relationship and working alliance over the course of treatment varied between dyads categorized as more vs. less successful. Therapists’ countertransference was low, as was client transference, but differences in ratings were evident when the dyads were classified by outcome.     

Transference: current concepts and controversies

In this paper I have presented a brief outline of some of the more important issues regarding transference. To summarize I shall restate ten transference issues heretofore discussed: What should be included in the definition of transference? Should it be defined narrowly or broadly? In what ways can transference be usefully viewed in relation to reality? What merit is there in distinguishing the working alliance from transference? Should self and object transference be differentiated? Should transference neuroses be discriminated from transference reactions on the one hand and from transference psychoses on the other? In addition to sexual and aggressive transferences, should sexualized and aggressivitized transferences, respectively, be distinguished? How may transference be conceived of as a vehicle of cure and yet also as a resistance to cure? What is to be said for the relative merit of the "here and now" versus the "there and then?" What is the role of transference in relation to insight on the one hand and to the therapeutic object on the other? What are some of the basic issues in countertransference?     

The therapeutic and working alliances

Since their introduction, the concepts of the therapeutic alliance and the working alliance have provoked debate regarding the nature and function of these alliances and the applicability and validity of the concepts. Features of these concepts as originally put forth by Zetzel and Greenson, respectively, are delineated, with emphasis on the significant distinctions between them. Their relation to degree of psychopathology is examined, especially with respect to what may be understood as the more "silent" aspects of the therapeutic alliance. Mutual identification, empathy, and role-responsiveness are stressed as constituent features of the therapeutic alliance, with the working alliance seen as possible (theoretically and clinically) only after a therapeutic alliance has to some degree been established. Both alliances are understood as intrinsic structures within the analytic process, and illustrative case material is presented.     

Therapeutic Alliance,Interpersonal Relations,and Trauma Symptoms: Examining a Mediation Model of Women With Childhood Abuse Histories

The current study explored the dimensions of the early therapeutic alliance (tasks, goals, bonds, and other-therapist [people important to clients who support their involvement in therapy]) as mediators between clients’ interpersonal relations problems and outcome measures of trauma symptoms (dissociation and total trauma symptoms). Seventy-six female participants who were receiving treatment for posttraumatic stress due to child abuse (CA), were recruited from a university training clinic. The bond and other subscales mediated the association between interpersonal relations problems and dissociation. The element of client trust associated with the alliance bond, as well as clients’ sense that people who are important to them support their involvement in therapy, should be focal in treating CA survivors. Clinical implications revolve around developing, maintaining, and repairing the therapeutic relationship, especially the bond, within the context of dissociation, as well as exploring clients’ views of important others and its impact on their therapy.     

Use of transference interpretations in dynamically oriented individual psychotherapy for patients with personality disorders

The use of transference interpretations in the individual treatment of patients with personality disorders is a controversial issue. Both expressive approaches that stress the importance of transference interpretations and supportive approaches that avoid interpretation of the transference have been advocated by dynamically oriented therapists. Literature is reviewed regarding recommendations for individual psychotherapy and the different views on interpretation of the transference. Available research that has attempted to illuminate the impact of these interventions is also summarized. Although the findings are limited by a number of methodological shortcomings, three implications have emerged. First, a strong therapeutic alliance is imperative for successful exploration of the transference. Second, transference-focused work should be balanced with supportive interventions. Third, the patient's quality of object relations and his or her ability to work within the transference should be considered. However, without further research to guide clinical decision making, clinicians will be left with a confusing array of recommendations and only their intuition.     

The many faces of self-harm

This paper explores why open dialogue on the subject of erotic transference and countertransference is so difficult and attempts to offer an understanding of these phenomena which might enable counsellors to work more confidently with it. It also briefly examines the author's own research on therapists' thoughts and experiences of erotic transference, seeking to differentiate between inappropriate sexual contact between clients and therapists and the experience of erotic transference in the context of therapy as a reworking of the Oedipal relationship. Case examples illustrating the experience of countertransference within the therapeutic situation and how its presence can act as a help or a hindrance are offered. The paper concludes by examining the need to reflect on the erotic transference in therapeutic work and proposes its usefulness as a therapeutic tool. Suggestions about how the erotic transference can be managed to therapeutic effect are also explored.     

Childhood Sexual Abuse

Abstract

Childhood sexual abuse is a problem that leads to serious psychological disturbances evidenced through the symptoms of post-traumatic stress disorder (PTSD). This article discusses the treatment of sexual abuse survivors within a psychoanalytic framework. Different theoretical perspectives including classical Freudian, ego-psychological, object-relational and self-psychological are presented. Several relational treatment models, including feminist psychodynamic approaches, are offered. Themes include the importance of developing a strong therapeutic alliance and analyzing transference responses.     

The therapeutic alliance–A conceptual analysis

The role and function of the therapeutic alliance in psychotherapy has increasingly been the focus of clinicians' and researchers' interests over the last decade. Alliance concepts have, however, been criticized for lack of conceptual clarity. The paper presents a generic model as a heuristic means for clarifying the conceptual meaning of the therapeutic alliance. The model distinguishes between the personal relationship aspect, and the collaborative, task-related aspect of the alliance, with therapist, patient, and common contributions to each of these aspects. The model is compared to other alliance conceptualizations, and its implications for alliance theory and research are discussed. A content analysis of four widely used alliance scales in relation to the model shows the scales to represent conceptually different, yet overlapping constructs. It is argued that the componential nature of the therapeutic alliance will render difficult any interpretation of findings regarding the relationship between alliance and outcome in traditional process-outcome research. More complex research strategies guided by theory are called for, if the therapeutic alliance should remain a vital field of research.     

Quality of object relations as a moderator of the relationship between pattern of alliance and outcome in short-term individual psychotherapy

In this study, we investigated the personality variable quality of object relations (QOR) as a moderator of the relationship between the pattern of the therapeutic alliance and treatment outcome in two forms (interpretive, supportive) of short-term individual psychotherapy. In a sample of 72 psychiatric outpatients who completed interpretive therapy, QOR emerged as a moderator for the outcome factor general symptomatology and dysfunction. For high-QOR patients, an increasing level of alliance was directly related to benefit, whereas for low-QOR patients, a decreasing level of alliance was directly related to benefit. An explanation for these findings emphasized the importance of patients repeating their typical pattern of maladaptive interpersonal behavior in the therapy sessions in the context of the therapist working with the transference. In a sample of 72 psychiatric outpatients who completed supportive therapy, QOR did not emerge as a moderator. These findings in combination with evidence from previous studies suggest that QOR should be investigated as a moderator variable in future studies of short-term psychotherapy.     

A narcissistic defence against affects and the illusion of self-sufficiency.

A narcissistic defence against affects, unlike isolation, is a defence against an object relationship. Object relations are strengthened by the sharing of genuine affects so that the failure to share feelings or the presentation of false feelings creates distance between the self and other objects. The defence is similar to that of denial in that it entails a modification of the ego's own structure. We have suggested that this modification consists of a precocious but fragile establishment of a sense of self. The defence may occupy a sector of the personality or reflect a more massive structural arrest. When there is this structural arrest, we believe that this narcissistic defence forms the basis for the narcissistic character disorder described by Kohut and the false self of Winnicott. This precocious sense of self leading to an illusion of self-sufficiency may also be found in other disorders, including the borderline patient, but the borderline patient, in contrast, suffers from a failure of internalization which leads to object hunger in contrast to the denial of object need of the narcissistic disorder. We suspect that the environmental trauma that may contribute to the narcissistic disorder is less severe as compared to the borderline states and may consist of the mother's failure to accept the child's separateness and autonomy, resulting in a fear of the mother's intrusiveness. The fear of the maternal object's intrusiveness contributes to the relative inability to form a therapeutic alliance in the psychoanalysis of narcissistic character disorders. The analyst's interpretations are experienced as dangerous, not necessarily because of their content but due to the fear of the analyst's intrusive influence. Our understanding of the means of effecting therapeutic change must be modified in patients with narcissistic character disorders for, in contrast to the 'classical' neurotic, analytic progress is not obtained by means of interpreting the transference neurosis in the context of a working or therapeutic alliance. Although we acknowledge that the psychoanalysis of narcissistic disorders can lead to significant therapeutic gains, such analyses may prove to be interminable if the gains do not also result in the establishment of a transference neurosis and therapeutic alliance.     

Modèle systémique de l'alliance thérapeutique

This article presents Pinsof's (1995) systemic model of therapeutic alliance. Pinsof's systemic model of alliance sees the therapy as an interaction between the systems of the client and those of the therapist. This model is composed of two primary dimensions: an interpersonal system dimension and a content dimension. The first focus on four levels of the alliance between and within the therapist and patient systems. The dimension of content includes three qualities of alliance that cut across the four interpersonal dimensions. We studied the notion of alliance profiles, institutional alliance and the notion of split alliance because the alliance is born and evolutes inside the interaction between the systems of the client and those of the therapist. Thus clients develop an alliance not only with their own therapist but also with the systems in which the therapist operate.     

The Play Relationship and the Therapeutic Alliance

Abstract

This article examines the function of play in normal development and within the treatment relationship in both child and adult psychotherapy. Noting its developmental function and the natural role that play has as a mode of communication with children, the author emphasizes the centrality of play in the construction of the therapeutic alliance. The therapeutic alliance is characterized here as a libidinal attachment, a new object relationship through which developmental experiences involving play may be revivified and, ultimately, may lead to the forging of more enduring and successful adaptations. Two detailed clinical vignettes furnish illustrations of the ways in which play themes and scenarios develop in therapy, and how their association to the therapeutic alliance and transference relationship may be understood and interpreted.     

Freud's "analytic pact": the standard therapeutic alliance

Freud's "analytic pact," as the final therapeutic model he evolved (1937, 1940), places the fundamental rule in a two-person structural framework that operates in a continuum between the inner reality and outer reality of both patient and analyst as these come to center in the analytic situation. To Freund's basic definition of psychoanalysis as related to resistance and transference, a third component is added, the collaboration that has been a feature of the treatment since the beginning. The alliance postulated by the pact relates a helpful physician to a sufferer in a carefully regulated operational field and atmosphere suitable for a particular technique and therapeutic goal. Actually the alliance may be described from the aspect of component combinations as described in different frameworks--structural, topographic, developmental, realistic, adaptive, etc. In diverse forms of analytic or analytically oriented forms of therapy, selected aspects of the alliances receive greater prominence--but a fully informed analytic therapy retains contact with all the elements involved. Organizational aspects of the fundamental rule with respect to the flow of associations and the transient and structured interactions of patient and physician are examined with regard to their dynamic and linguistic features.