Psychodynamics of Alliance – Therapeutic Relationship Enhancement
This post includes basic considerations, processes, and clinical skills necessary for developing a strongly positive clinical alliance and therapeutic relationship in therapy. Here the alliance is required for any substantial change in psychotherapy, and the therapeutic relationship rides the quality of the initial alliance to expand and inter-penetrate the emotional b0nds between the client and the therapist. The combination of strong initial alliance and highly positive therapeutic relationship is a powerful enhancement for personal growth and positive change in therapy. However, it is doubtful that these factors alone will bring about meaningful change in the problem/s that brought the client into therapy. Without them, there will be no meaningful change.
Emotional Bonding and Therapeutic Presence Requires:
- Intentional empathic attachment by the therapist;
- Meaningful collaboration on important tasks and behaviors;
- Emotional exposure in safety, and emotional containment as needed;
- The client experiences being heard, cared about, and accepted unconditionally;
- The therapist provides a strong positive “holding environment” within “intersubjective space” (Winnicott);
- A social and psychological environment of mutual respect, compassion, and trust exists;
- The therapist may become a secure attachment (re-attachment) figure in this emotionally intimate process;
- The therapist’s “unconditional positive regard” is experienced and projected into the psychodynamic space (Rogers);
- The therapist may improve attunement with the client’s inner experience, emotions, and needs (Kohut); and,
- Within safety and trust both projection and projective identification occur (Alonso) as reciprocal introjective processes to ensure the potential for “going on being” (Winnicott).
Additional Specific Behaviors by the Therapist:
- Providing direct emotional support verbally and non-verbally;
- Holding a delicate balance in idealized projections;
- Rapid repair of emotional ruptures, and taking responsibility for same;
- Various forms of direct and indirect validation;
- Careful, strategic use of silence;
- Maintaining empathic understanding despite any negative countertransference;
- Working to improve “experience-near empathy” (Kohut);
- Acting on opportunities to improve the quality of object relations here and now;
- Serving as a “good mother” (or father) figure (Klein); and,
- Careful ongoing reflection on emotional, verbal, projective, transference, and countertransference processes.
Desired Self-Development Outcomes for the Client:
- Improved insight;
- Improved self-confidence and sense of security;
- Improved skills in mindful awareness;
- Reduced fixations on negative cognitive, emotional, and behavioral experiences in the past and present;
- Improved internal structure as well as object constancy and relatedness;
- More positive introjected experiences in therapy and in life;
- Reduced repetitive defensive and emotionally reactive patterns;
- Stronger, more positive sense of personhood; and,
- More effective views about self in the world of interpersonal life.
Caution: Most psychodynamic and psychoanalytic therapies place primary emphasis on the clinical relationship between the therapist and the client, and less emphasis on actual cognitive and behavioral change in presenting problems. Therefore, it may be a moral (not ethical) question as to whether a therapists uses only these approaches. It may be best to integrate them with a well researched evidence-based therapy. For supportive reviews see the work of Mark Solms, Edward Tronick, and C.A. Alfonso, R.C. Friedman, & J.I. Downey (Eds.) (2018). Advances in Psychodynamics Psychiatry. For a strong critique see Richards, A. (June, 2018). Psychoanalysis in trouble…Psychoanalytic Review, 102(3), June, 2018.
By David Rapp, Brian Tobin, and Anthony R. Quintiliani, PhD., LADC,
Author of Mindful Happiness
“experience near empathy” (Kohut), “unconditional positive regard” (Rogers), “hovering attention” (Freud), “the holding environment” in “intersubjective space” (Winnicott), and compassionate awareness to emotional distancing, separation, and dispassion is no easy task. In more in-depth clinical interactions, the process of projective identification between therapist and client may drain your emotional resources; sometimes being “as if” you were the experiencer of your client’s pain and suffering can take a serious toll on your own emotional resources. At time the therapist’s own emotional life lacks the quality of connection experienced in the therapy session. Success in setting emotional boundaries is a very important self-care skill. It may determine your success, failure, joy, or misery in the clinical work you do. It will definitely prevent most case of “burn out.”
helping skills. We suffer just like other people do. Hopefully, our training and experience have given us a bit of a positive edge here. Here are some things you may wish to consider to improve your own level of self-compassion.
may be sexual, physical, or emotional. This form of abuse is so destructive because the child has no cognitive/executive/verbal ways to understand and respond to the experience. The long-term bio-psycho-social-spiritual effects of PVT are quite difficult to treat effectively. One reason for this is that some therapist are determined to utilize their favorite approaches (mainly forms of pure talk-therapy and psychodynamic holding) despite the limited effectiveness that these forms of therapy results in. Still worse for the client is generic talk therapy, often a mixture of various talk-therapy components but no actual evidence-based method of helping. Remember it is our obligation to Do No Harm and to use therapeutic interventions beyond alliance that are effective. There may be moral if not ethical implications here.
outcomes. In the interest of research, of course other therapies have been found to be effective with trauma. To mention a few, these are EMDR, DBT, PET, and, Briere’s self-trauma therapy with slow, complete exposure work. MBSR and ACT may be helpful regarding emotional dysregulation in traumatic re-experiencing and self-empowerment. Of course effective attachment therapy with very specific object relations correctives is also helpful.
positive thoughts and emotions. When we get stuck in negative cycles of thinking, feeling and doing our right brain and limbic area dominate. A very old mindfulness belief is that you are not your thoughts, your emotions, or your behaviors; these parts of you are simply associated with your life experiences. When a client learns to defuse a though it means they have changed its linguistic structure and removed it from being cemented into their CABs, or cognition-affect-behavior cycles. In all good therapies, especially Cognitive-Behavioral Therapy and various mindfulness therapies (MBCR, DBT, MBCT, MBRP, ACT), helpers often work on truth-analysis of unhelpful, repetitive, negative thoughts patterns – especially those embedded into CABs cycles of ineffective experiences. Self-medication, isolation, and avoidance are commonly associated with these realities. Sometimes this work includes meta-cognitive analysis regarding your thoughts about your thoughts or the patterns of your thoughts. The clear logic is that the words we often tell ourselves in times of stress or fear are NOT often true. Of course, if indeed you are seriously endangered best to allow your limbic brain area to save your life. The list below will note various approaches used to defuse thoughts from our experience of being, our CABs cycles.
example: “I am so worthless” helps solidify your brain plasticity about personal meanings and images. Try this: “Sometimes I feel worthless” or “When really bad things happen, I can feel worthless” or “My unpleasant feeling can relate to feeling less worthwhile.”