Is a Therapeutic Alliance a Necessary Basis for Treatment or Is Therapy Entirely Encoded in the Therapeutic Alliance?

• The Case of Gary III - Life in a malevolent world. by Jim Pretzer, 10/25/97
  • Languages used by therapists by Ernest Wolf, Faculty, 11/24/97
    
    

To recognize what kind of a relationship between therapist and patient we are talking about, my thinking starts with the fact that patients pay a fee to obtain it. Here are some of the questions this brings to my mind:

Is this the only relationship this person has in which consistent positive regard is extended to the person? I am thinking right now of the musing of a patient who wondered about why, as she documented it, so many people seemed to love her.

What makes the difference between what the patient does with me and the spontaneous "working through" of transferences that get applied to various others in the patient's life? Surely this repeated experience in life does not reliably result in the kind of personal growth we hope for in our patients.

I cannot gainsay Dostoevsky's belief in the reformative power of love, yet can I offer love in such dimension to patients, especially on the basis that they choose to come to me?

What more do I give my patients (during at most five hours a week and often a single hour)? Do I justify my fees on the basis that I alone can manage a good relationship with those who are willing to pay? Or that I command fees because only I and those like me in the profession are capable of sustained interest in a patient (for forty-five minutes)? At risk of annoying some people, I must also point out that prostitutes say their clients often want more to talk than be physically engaged, especially those who are "regulars."

Is it my role to supply a rarefied quality of wisdom that a patient cannot find through inner resources or the plethora of authorities available in person or through their books?

These questions are behind my strong feeling that while the relationship between my patients and me are fundamental to the work, there is more to it. Obviously, if the relationship is not positive enough for the patient to keep coming, one cannot be useful at all. (And having said that, I will include the fact that once in a while it is the very breaking away that a patient manages that is a freeing act for the patient; but that is not necessarily the most useful way a patient has for resolving a negative transference).

So what more do I think we offer that is useful to patients, regardless of the background theoretical orientation of the therapist?

In addition to the anchoring relationship, each of us provides automatically a framework into which the person can fit together fragments of feeling and thought that have been interfering with a solid sense of being. A good grandparent can sometimes salvage someone's mental health up to this point. We therapists offer one thing more: We help a patient to connect affect with experience.

Help to accomplish this task comes surely from whatever tacit or explicit support for it lies in the relationship. I believe also essential is the sharing of a perspective on the patient's situation that the therapist believes will facilitate the work. This is the part that I believe we offer that is unique in the patient's experience. Even patients such as children and psychotics, who do not arrange for the treatment themselves, if they present themselves at all, hold some notion that they are present in order to "get their heads together." Making inner sense requires integrating the details of existence in terms of a point of view. I may prefer a developmental line of understanding, but this forum is proof enough that there are various frameworks that enable the task.

In earlier times, the priesthood or village wise men served the purpose. I believe that our present day professional appreciation of affect makes us unique historically, too. It is our generation's glory to emphasize our awareness of affect in the very therapeutic process. All of us humans are cognitive beings, also, however.

Research by Strupp concerning attitudes of psychotherapy patients toward the relationship with the therapist in general and others' research about attitudes of medical patients both underscore the importance of a sense of teamwork. I believe that fostering a sense of teamwork is helpful at a fundamental level. That is why Meichenbaum's account of his approach, essentially a mutual questioning of the material, is so appealing to me.

My reflex reaction tends to reveal a know-it-all (don't I wish!), so I really have to try to do better. What I try to remember is that the well put slogan of the 60's--getting one's head together--expresses the goal of treatment. To help someone get there is always a new adventure.

No Replies