Conceptual unclarity has surrounded psychotherapy research efforts to define and measure the therapeutic alliance. A precisely defined conception of the therapeutic alliance is offered that focuses on the patient's active collaboration in the tasks appropriate to the treatment process. The therapeutic alliance is thus distinguished from patient characteristics and attitudes as well as from therapist contributions to the formation of the alliance. The importance of the therapeutic alliance as a change measure in process research is underscored, and its place as a primary indicator of outcome is developed.Finally, the special relevance of the therapeutic alliance to the investigation of the therapeutic change process with borderline patients is outlined.

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The effectiveness of transference interpretation in the psychodynamic psychotherapy of patients with borderline personality disorder has been highly controversial. Both highly expressive approaches that stress the value of transference interpretation and supportive strategies that eschew transference work have been advocated in the literature. We review this literature and identify three emerging trends in thought: (1) Primarily interpretive approaches should be reserved for patients with greater levels of ego strength. (2) Whichever technique is used, a strong therapeutic alliance is the foundation of treatment. (3) Expressive and supportive techniques should not be juxtaposed as polarized opposites; supportive interventions often pave the way for transference interpretation. Our psychotherapy process study revealed that transference interpretations tended to have greater impact--both positive and negative--than other interventions made with patients with borderline personality disorder. We conclude that such factors as neuropsychologically based cognitive dysfunction, a history of early trauma, patterns of object relations involving interpersonal distance, masochistic tendencies, and anaclitic rather than introjective psychopathology are among the patient characteristics that influence the impact of transference interpretation on the therapeutic alliance. Bias toward expressive technique and countertransference issues appear to be relevant to the therapist's difficulty in shifting to a more supportive approach when indicated.

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These results suggest that patients with severe personality disorders benefit from intensive inpatient treatment. We found no evidence that hospitalization of such patients is associated with regression or deterioration of function.

The authors draw attention to the problems of establishing and maintaining a therapeutic alliance in the psychotherapy of the borderline patient. They elaborate an extensive methodology designed to study the manner in which shifts in collaboration occur in response to therapist interventions. This report demonstrates how one particular borderline patient increased his ability to collaborate with the therapist in response to a transference focus in the psychotherapy. Methodological problems are noted as are directions for future research. Only a series of patients studied with this or with similar methodology will allow for a sophisticated and empirical rationale for choosing a particular form of psychotherapy for a particular kind of borderline patient.

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On an 8-bed adolescent psychiatric unit, 69 patients were rated over the course of more than one year [corrected]. A set of rating scales was used to determine the relationships of treatment and therapeutic alliance difficulties with staff ratings of patient qualities, family issues, and treatment outcome. Findings underscore the clinical relevance of treatment difficulty and therapeutic alliance in conceptualizing the therapeutic action of the hospital treatment.