Best Possible Clinical Alliance

Winnicott’s Ideas – Best Possible Clinical Alliance

To develop and maintain a strong clinical alliance it is best to follow some of the well-known clinical advice on this topic.  Rogers, Kohut, Winnicott and many others have suggested just how to do so.  Here are some general clinical recommendations for enhancing the clinical alliance.

1. Develop authentic respect for the client.
2. Share power and responsibility for the outcomes – all the outcomes.
3. Maintain a cooperative and supportive demeanor. Smile!
4. As much as is possible maintain “unconditional positive regard.”
5. Utilize deep, contemplative listening with clear mindfulness.
6. Be reasonably flexible regarding real-world client situations.
7. Directly reinforce HOPE as you push gently for increased self-efficacy.
8. Be very patient!
9. Be in authentic compassion for the client’s pain and suffering, and allow your own reactions.
10. Use evidence-based approaches in your psychotherapy, while also being creative.
11. Always apologize when you have made errors, harmed the frame of psychotherapy, or unintentionally harmed the client – DO NO HARM is the rule.
12. Support the client’s belief and relief from his/her spiritual understandings and practices.
13. Be nice! Treat the client as you would like to be treated.

Now let’s examine some more complex ideas and practices as recommended by W. D. Winnicott.  In this brief article I will only note the suggestion without much detail.  If you have questions, please feel free to email them to me at anthony@mindfulhappiness.org  Here is his list.

1. Work hard to assist the client in improving their “sense of self” in “going-on-being” as a “good enough” person.
2. Stabilize the client’s “secure base” (Bowlby) in a “secure holding environment” within the therapy dyad.
3. Allow the defenses of the “false self” to exist as you enhance “object constancy” in the clinical relationship.
4. Support the client’s true self development “as a potentiality” in the therapy.
5. Pay mindful attention to the client’s mind-body presentations, realizing that both cognitive/verbal/executive parts of self are as important as emotional(sensation)/experiential parts of the self. People communicate consciously and unconsciously via multiple areas of human functioning.
6. Learn about and respond appropriately to the client’s interoceptive world as false and true selves activate in object related transferences. Here sensations, emotions, inner feelings may be very important.
7. Use stronger empathy and conscious projection within the empathic relationships as to allow safety in regression into the client’s past object related/attachment failures.
8. Experiment actively by being a good “transitional object” in “potential space” so the client can utilize you as an outside object in a real relationship. Hope for strong internalization by the client.
9. Foster the client’s security, safety, trust and courage in your clinical interactions.
10. Maintain a tight therapy frame regarding time, space, expectations, payment (within reason), roles, boundaries, etc.
11. Use the process of projective identification consciously in therapy (not clearly noted by Winnicott but suggested indirectly).
12. As Winnicott noted “stay alive, stay awake.”

Its will not be easy to implement all of these alliance-holding strategies.  However, the more mindful and skilled psychotherapists are about them, the better the strength and resilience of the clinical alliance will be.  Work hard; accept the rewards; be happy!

For more details refer to Fromm, M. G. and Smith, B. L. (Eds.). (1989). The Facilitating Environment: Clinical Applications of Winnicott’s Theory. Madison, CN: International Universities Press, pp. 6-8, 25-26, 55-87, 77-78, 145-171, 489-515.

By Anthony R. Quintiliani, PhD., LADC

From the Eleanor R. Liebman Center for Secular Meditation in Monkton, Vermont

Author of Mindful Happiness  

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