The following is offered in the hope that it will help clients better understand their relationships with the therapist as well as help them better tolerate the ups and downs inherent in psychotherapy. But even more important is the hope that the following will encourage an active partnership between patient and therapist. They can make a more fruitful therapeutic experience together, as partners in therapy.
As Nancy McWilliams (2014), a psychoanalyst, eloquently described the partnership, " We view therapy not as something one person 'does to' or 'provides for' another but as something the two parties undertake mutually under uniquely boundaried conditions" (p. 86). Yes, the therapist has specialized training, knowledge, and experience but none of these offer what the client brings- the long experience of being himself or herself. Therapy is meant to be a collaboration between different but equal partners who meet regularly in the therapist's office to accomplish their jointly defined goals and tasks.
Over the years, much research has been done to tease out what makes psychotherapy work. Results consistently point to the alliance between a patient and therapist as a necessary curative factor (Stricker, 2010). Beyond a doubt, "effective psychotherapy cannot, and does not, exist without a positive relationship" (Norcross & Lambert, 2014, p. 399) between therapist and patient. Upon reviewing studies that used more traditional statistical analyses and also more recent studies that used newer, more refined methods, Zilcha-Mano (2017) concluded that yet again the positive therapeutic alliance has been shown to be an important change agent. She found that it can work in two ways, as an active change agent in and of itself and/or as a therapeutic background potentiating the effectiveness of more specific therapy techniques.
Fortunately only one to three sessions are usually needed to decide if there can be a good enough match to begin the partnership. Patients and therapists alike look for mutual respect and commitment to the effort ahead. The therapist also looks for patience because, although there can be "aha!" moments and quick improvements, progress is most often slow and "is made through a build-up of small but significant therapeutic moments" (Maroda, 1994, p. 49).
Yet even with a good match, the therapeutic alliance may not run smoothly without readjustments. Why may an initial good match not be enough? Why may the alliance not hold? The answers are as diverse as psychotherapy itself; but, nevertheless, a couple of explanations will be offered here.
Firstly, client and therapist may have different goals. One of the early tasks of therapy is to discuss the goals to make sure both are headed in the same direction. Time is taken to clarify and reach an agreement. After it is made, it is periodically revisited. Progress or a lack thereof is gauged and discussed. What is left to be done? Impasses signal that special attention should be paid to what is blocking progress. Sometimes particular goals are no longer relevant and need to be replaced. Or the goals have been reached and treatment is nearly over.
Secondarily, both therapist and client have continuing challenges based on their respective roles. At any one time, the therapist has to decide whether or not an underlying theme needs highlighting and, if so, which one because several themes are often co-occurring, and sometimes are in competition. Should the focus be on the past, present, or future? Decisions have to be made about when to be empathically supportive and when to be confrontational. What, if any, homework should be assigned and what if it is not done? There are times to prompt behavior change and encourage new experiences and other times to build new insights and propose new perspectives. And which is which?
As Wachtel (1982) said, "Practicing psychotherapy is a difficult -if also rewarding - way to earn a living. It is no profession for the individual who likes certainty, predictability, or a fairly consistent sense that one knows what one is doing" (p. xiii).
Neither does the patient have a clear way to go. How does one balance the security of old habits and allegiances with the unknowns related to change and new experiences? It is anxiety provoking to become more aware of self-defeating attitudes and behaviors and to try to build new repertoires. Finding ways to move from the old to the new is not easy and takes time. Furthermore, tension exists between being one's own person who does it "my way" and cooperating with others. Juggling self-determination and relatedness can be confusing, especially in relationship counseling. Often such conflicts are played out through the relationship with the therapist. How much influence should the therapist be allowed? Some find themselves ambivalent about cooperating with the therapist and resist even while wanting improvement.
These and other factors make ruptures in the therapy alliance highly likely, particularly in a longer-term individual psychotherapy. Some misalliances are hard to detect: some may be alarming. Whether large or small, they are usually signaled by withdrawals or by aggressive confrontations on the part of patient, therapist, or both (Safran & Muran, 2000). When these signals occur, it is best if both therapist and client acknowledge and try to repair the rupture. Their negotiations are most likely to succeed when "both therapist and patient struggle to work their way out of the entanglement" (Gorkin, 1987, p. 74). Thus they become true and equal partners in therapy.
Many psychodynamic theorists believe that it is in the repair of such ruptures that there is the greatest potential for deep and abiding change. According to Safran and Kraus (2014), "Ruptures are inevitable events and are regarded not as obstacles but as opportunities for therapeutic change. Ruptures may occur at any time in treatment: they may emerge as single events, over several sessions, or as a repeated theme across treatment" (p. 382). These genuine conflicts between patient and therapist are not to be avoided but are even to be welcomed as opportunities for working through the ruptures, no matter how uncomfortable the process might be for both parties. Successful negotiations can serve as templates for the repair of other important relationships. After all, all important relationships have their ups and downs. To have actual experiences during one's therapy of mending rifts with the therapist without just giving in are very valuable.They show in real time that both separateness and togetherness are possible and disappointments can be withstood. These realizations are in themselves healing.
A successful course of psychotherapy, even with its frustrations and disappointments, contradicts Eugene Oneill's (2006/1952) pessimistic conclusion:"There is no present or future, only the past happening over and over again, now." Together, therapy partners can interrupt the repetition of past mistakes and create more positive possibilities, now.
Gorkin, M. (1987). The uses of Countertransference. New York:: Jason Aronson.
Maroda, K. J. (1994). The power of countertransference: Innovations in analytic technique. (2d ed.) Northvale, NJ: Jason Aronson.
McWilliams, N. (2014). Psychodynamic therapy. In Greenberg, L. S., McWilliams, N., & Wenzel, A. Exploring Three Approaches to Psychotherapy (pp. 71 - 127). Washington DC.: American Psychological Association.
Norcross, J. C., & Lambert, M. J. (2014). Relationship science and practice in psychotherapy: Closing Commentary.y, Psychotherapy, 51(3). 398-403.
O'Neill, E. (2006). A moon for the misbegotten. New Haven, CT: Yale University Press. (Original Work published 1952)
Safran, J. D., & Kraus, J. (2014). Alliance ruptures, impasses, and enactments: A relational perspective. Psychotherapy, 51(3), 381-387.
Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alliance. New York: Guilford.
Stricker, G. (2010). Psychotherapy integration. Washington, DC: American Psychological Association.
Wachtel, P. L. (1982). Resistance: Psychodynamic and behavioral approaches. New York: Plenum.
Zilcha-Mano, S. (2017). Is the alliance really therapeutic? Revisiting this question in light of recent methodological advances. American Psychologist, 72(4), 311-325. http://dx.doi.org/10.1037/a0040435