THERAPEUTIC ALLIANCE

Therapeutic alliance refers to the mutual collaboration established between a psychoanalyst and a patient to overcome the neurotic or psychotic resistance that blocks change and the healing process. Freud provided a clear description of this in his Outline of Psychoanalysis, "The analytic physician and the patient's weakened ego, basing themselves on the real external world, have to band themselves together into a party against the enemies, the instinctual demands of the id and the conscientious demands of the super-ego. We form a pact with each other. The sick ego promises us the most complete candor—promises, that is, to put at our disposal all the material which its self-perception yields it; we assure the patient of the strictest discretion and place at his service our experience in interpreting material that has been influenced by the unconscious. Our knowledge is to make up for his ignorance and to give his ego back its mastery over lost provinces of his mental life. This pact constitutes the analytic situation" (1940a [1938]).

Following his theorization of "resistance," Freud abandoned contemporary psychotherapeutic thinking to begin developing "psychoanalysis." The discovery that his patients unconsciously refused to provide themselves with the means for improvement, no matter how much they asked for it, was to lead him to his description of the "secondary benefit" of the illness and his understanding of the need to support the work of therapy through positive transference in order to overcome the unconscious obstacles represented by negative transference or the resistance to change.

"Healing is achieved through love," he wrote on December 6, 1906, in a letter to Carl Gustav Jung. This belief was often repeated and led Freud, during his therapeutic work—as exemplified in his work with the "Rat Man" (1909d)—to encourage, through words or signs, the confidence of his patients and their attachment to him.

On several occasions Freud mentioned this "analytic pact" concluded between the conscious ego of the patient and the therapist. Freud did not fail to point out the constant shortcomings, the most important of which has to do with the transference neurosis, which, if it is not recognized and analyzed, risks blocking the patient's associative process. The patient then "behaves as if he were not in treatment, as if he had not concluded a pact with the doctor." (1916-17a)

Subsequently, a number of analysts have described the modalities of an alliance that is essential to overcoming the inherent difficulties associated with therapy. Richard Sterba, in 1934, described the split in the ego that would allow the analyst to appeal to his patient's powers of reasoning to fight against his impulses and repression. But it was Edward Bibring who first referred to the "therapeutic alliance" (1937) between the analyst and the "healthy" part of the patient's ego. In this he was faithful to Freud, who wrote that same year in Analysis Terminable and Interminable : "The analytic situation consists, as we know, in our alliance with the ego of the person-object to conquer the unconquered parts of his id and therefore to integrate them in the synthesis of the ego. The fact that such a collaboration often fails in the psychotic provides, in our judgment, an initial point of support. The ego with which we are able to conclude such a pact must be a normal ego" (1937c).

After the Second World War the concept of a therapeutic alliance enjoyed considerable success in the United States when Elisabeth Zetzel, in 1956, made it a component of psychoanalytic technique, especially during the initial stages of therapy. She compared the therapist's attitude to the mother's intuition toward her infant and made this alliance the condition for the emergence and resolution of the transference neurosis (1965).

This approach, felt to be too thoroughly infiltrated with Kleinian thought, was criticized by Ralph Green-son, who, the same year, proposed the notion of aworking alliance. The term was used for subjects capable of object relations (thereby excluding overly narcissistic personalities) and is described as "a relatively rational, desexualized transference phenomenon," capable of controlling aggressive impulses (1965). But Greenson also insisted on the fact that this working alliance, based on the "mature and rational" ego, was established outside the analysis of transference and necessitated actions or comments by the psychoanalyst on the reality of the relationship (for example, recognizing that the patient's criticism is justified rather than interpreting the need to criticize the analyst). Several authors judged Greenson's concept to be outside the framework of analytic neutrality and abstinence (Jacob A. Arlow and Charles Brenner, 1964; Mark Kanzer, 1975, for example).

The question arises of the limits of action for the psychoanalyst, a question presented in terms of the weight of his reality in the therapeutic relationship. Just how far can the maintenance of positive transference, or the appeal to the rational by a split part of the ego—which in its theorization is very similar to the concept of the "conflict free ego" integral to ego psychology—get, before outside factors present the emergence of, or submerge, the psychic reality that the psychoanalytic situation is in fact supposed to promote? It was Joseph Sandler (1973) who insisted on this distinction when he emphasized the necessity of a therapeutic alliance sustained by interpretation alone.

Alain de Mijolla

See also: Greenson, Ralph; "Outline of Psychoanalysis, An"; Psychoanalytic treatment; Technique with adults, psychoanalytic; Transference in children; Transference relationship.

Bibliography

Bibring, Edward. (1937). Contribution to the symposium on the theory of the therapeutic results of psycho-analysis. International Journal of Psycho-Analysis, 18, 170-189.

Greenson, Ralph R. (1965). The working alliance and the transference neurosis. Psychoanalytic Quarterly, 34, 155-181.

Sandler, Joseph, Dare, Christopher, and Holder, Alex. (1973). The Patient and the analyst: The basis of the psychoanalytic process. New York: International Universities Press.

Zetzel, Elisabeth R. (1956). Current concepts of transference. International Journal of Psycho-Analysis, 37, 369.

——. (1965). The theory of therapy in relation to a developmental model of the psychic apparatus. International Journal of Psycho-Analysis, 46, 39.