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:

1. Intentional empathic attachment by the therapist;
2. Meaningful collaboration on important tasks and behaviors;
3. Emotional exposure in safety, and emotional containment as needed;
4. The client experiences being heard, cared about, and accepted unconditionally;
5. The therapist provides a strong positive “holding environment” within “intersubjective space” (Winnicott);
6. A social and psychological environment of mutual respect, compassion, and trust exists;
7. The therapist may become a secure attachment (re-attachment) figure in this emotionally intimate process;
8. The therapist’s “unconditional positive regard” is experienced and projected into the psychodynamic space (Rogers);
9. The therapist may improve attunement with the client’s inner experience, emotions, and needs (Kohut); and,
10. 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:

1. Providing direct emotional support verbally and non-verbally;
2. Holding a delicate balance in idealized projections;
3. Rapid repair of emotional ruptures, and taking responsibility for same;
4. Various forms of direct and indirect validation;
5. Careful, strategic use of silence;
6. Maintaining empathic understanding despite any negative countertransference;
7. Working to improve “experience-near empathy” (Kohut);
8. Acting on opportunities to improve the quality of object relations here and now;
9. Serving as a “good mother” (or father) figure (Klein); and,
10. Careful ongoing reflection on emotional, verbal, projective, transference, and countertransference processes.

Desired Self-Development Outcomes for the Client:

1. Improved insight;
2. Improved self-confidence and sense of security;
3. Improved skills in mindful awareness;
4. Reduced fixations on negative cognitive, emotional, and behavioral experiences in the past and present;
5. Improved internal structure as well as object constancy and relatedness;
6. More positive introjected experiences in therapy and in life;
7. Reduced repetitive defensive and emotionally reactive patterns;
8. Stronger, more positive sense of personhood; and,
9. 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  

New Edition of Mindful Happiness in Production…Coming soon