An Application of the Concept of the Therapeutic Alliance To Sadomasochistic Pathology

Abstract

This paper traces the history of the therapeutic alliance concept, examining how it has been used and misused, at times elevated to a central position and at others rejected altogether. The loss of this concept created a vacuum in classical psychoanalysis that has been filled by rival theories. The continuing usefulness of looking at the treatment process through the lens of the therapeutic alliance, particularly in relation to the manifold difficulties of working with sadomasochistic pathology, is suggested. To this end, revisions of the theory of the therapeutic alliance are suggested to address some of the difficulties that have arisen in conceptualizing this aspect of the therapeutic relationship, and to provide an integrated dynamic model for working with patients at each phase of treatment. This revised model acknowledges the complexity of the domain and encompasses the multiple tasks, functions, partners, and treatment phases involved. The utility of the revised theory is illustrated in application to understanding the sadomasochistic, omnipotent resistances of a female patient through the phases of her analysis.

Integrative Clinical Social Work Practice

“…As we have seen, there is signifi cant evidence (Connors, 2006 ;Johnson, 1999 ;Kaplan and Garfi nkel, 1999;Novick & Novick, 1998 ;Roth & Fonagy, 1996 ;Zerbe, 2008 ) a mixture of symptom-focused, cognitive behavioral, supportive, insight-oriented, affect-regulatory, medical and psychopharmacological interventions is often more helpful with a variety of clients than a single, linear approach. Much of this same research has shown that work with a team in which different specialties are provided by different therapists-e.g.…”

“…While some clients fi nd it useful, others fi nd it disturbing and/or distracting from the "real" work of therapy. Novick and Novick ( 1998 ) caution against confusing a professional alliance, which has specifi c therapeutic goals, with a more general, personal relationship. Yet a therapeutic relationship is also an interaction between two people that can make both members of a therapeutic dyad feel vulnerable (see Gabbard & Lester, 1995 ).…”

“…I have found it particularly useful to heed Novick and Novick's ( 1998 ) warning that understanding something about our experiences with a given client does not mean that we know precisely what that client is experiencing. Instead, empathic responses offer us tools for beginning to explore what might be happening beneath the surface of an interaction.…”

“…Attention to the details of these interactions provides an opportunity to sift through and understand a range of emotions and thoughts that a client experiences at a given time, and to differentiate those experiences from our own. Like Novick and Novick ( 1998 ), Parish and Eagle ( 2003 ) emphasize the difference between transference and the therapeutic alliance. They add that a theme that runs through these and many other aspects of any relationship between clinician and client is the issue of attachment.…”

Training Analysis: Oxymoron or Viable Compromise? Training Analysis, Power, and the Therapeutic Alliance

“…Meissner's (1996) unequivocal position about analysis under any condition is instructive: "Unless the patient freely chooses to enter the analytic process and willingly engages in it, there is no possibility of a sound therapeutic alliance" (p. 194). In all cases, but perhaps especially in the training situation, establishing a therapeutic alliance is an ongoing, evolving process requiring specific therapist-patient negotiations and interaction forms related to the requirements of the analytic situation and work and to the engagement capacity of each person (see also Novick and Novick, 1998). Even Thomä and Kächele (1999), who "[pled] for a complete disconnection of the personal analysis from the main body of the psychoanalytic education," also held that "it is indispensable for an analytic therapist to experience for himself/herself the effects of unconscious processes on transferences and defenses in an intersubjective exchange" (p. 34).…”