Negotiating the Therapeutic Alliance: A Relational Treatment Guide

In the subtitle the authors refer to their book as a “guide.” Later in the text they describe it as a manual. Manuals on how to do psychotherapy have always somewhat put me off, since I have always experienced psychotherapy (whether in the role of patient or therapist) as a most unpredictable and hard-to-formulate enterprise. The authors, to their credit, are sensitive to this matter and address it immediately. They say they do not want to produce a “cookbook” that would mechanize the therapy process but rather wish to “strike a balance” between, on the one hand, treating new cases as unique and, on the other hand, refining existing theory and technique by relating it to the new situation.

They have succeeded admirably in striking that balance, and in the process have produced a very rich book (or, if you will, manual) that I would recommend to clinicians from all schools of psychotherapy. Their central focus is, as the title indicates, on the therapeutic alliance, and more specifically on how clinicians can resolve ruptures in that alliance. Another way to say this is that the authors are describing and discussing various ideas and techniques for resolving the inevitable and often highly distressing transference–countertransference binds that occur in psychotherapy. They particularly emphasize the importance of therapists' focusing on their own contributions to the binds and, further, exploring and negotiating difficult moments in the relationship directly with the patients—something the authors refer to as “collaborative inquiry.”

There are a number of wonderful and clearly written chapters in this book. The first one presents a historical review of the notion of the therapeutic alliance and then reconceptualizes it from a relational perspective, which asserts that a central change mechanism in psychotherapy is the negotiation and resolution of ruptures in the alliance. The authors then offer a very useful taxonomy of interventions for addressing ruptures, accompanied by helpful vignettes illustrating their ideas.

The second chapter is a review and summary of the ideas of leading relational thinkers. Readers interested in learning about these ideas and the issues under development by this school of psychotherapy, as well as its historical origins, will be especially pleased by this chapter. The next chapter tackles the omnipresent problems of resistance of therapeutic impasses. The authors distinguish between intrapsychic, characterological, and relational views of resistance, demonstrating familiarity with thinkers from all schools of psychotherapy on this topic. In keeping with their central theme, they stress the importance of therapists' understanding their own contributions to enactments and impasses by paying vigorous attention to their feelings and countertransference experience.

Following the discussion of ruptures and impasses is a chapter on “therapeutic metacommunication.” This term refers to procedures designed to help therapists disembed from relational cycles that are being enacted by focusing on the transactions and implicit communications taking place between therapist and patient. The goal of metacommunicating is to articulate the therapist's implicit sense of the interaction in order to initiate an explicit exploration of what is being unconsciously enacted. The authors provide a succinct and specific set of principles (e.g., “emphasize awareness rather than change,” “explore patient's experience of interventions”) to keep in mind as one uses this kind of communication when conducting therapy.

The most original chapter in the book describes a stage-process model for resolving alliance ruptures. Stage-process models of psychotherapy are designed to help therapists recognize stages that are likely to recur in therapy and thus provide facilitating interventions. The authors list two basic rupture subtypes: withdrawal and confrontation. Patients vary in their use of these coping strategies but are likely to present a predominance of one type of rupture over another. The authors indicate that it is important to be sensitive to the specific qualities of a rupture and its stage in order to help clarify patient tasks and provide appropriate interventions. They acknowledge that models like this are oversimplifications of the processes they are striving to capture. However, the notions presented and the clinical illustrations are first rate and well worth consideration by clinicians looking for new ways to think about ruptures in the therapeutic process.

The authors have also dedicated a chapter to explaining and demonstrating the application of their ideas to a short-term therapy process they call Brief Relational Therapy. The discussion is clear and sophisticated, but they do not adequately address what I see as the complex matter of differential diagnosis and short-term therapy. People recovering from trauma and certain kinds of depression often profit from short-term treatment. However, the picture is complex. For instance, Ablon and Jones¹ in their analysis of the NIMH-sponsored Treatment of Depression Collaborative Research Program found that positive outcome in brief therapy correlated with pre-treatment patient characteristics of being accepting, compliant, and agreeable. Patients with personality disorders, on the other hand, are known to be difficult and often require intensive and long-term therapy. I would recommend that these authors apply their impressive research, writing, and clinical skills to addressing more fully the issue of differential diagnosis and the relational approach to treating the more formidable psychiatric disorders.

The authors believe that the training of therapists is most critical and consequently devote an entire chapter to the topic. They stress the importance of training therapists to deal specifically with negative processes and therapeutic impasses. They also emphasize the experiential side of training over the conceptual and the value of self-exploration as a primary vehicle for learning. The ideas presented in this chapter are very creative and stimulating, and I would strongly recommend it to all training programs and institutes. In fact, I would recommend this book to all clinicians. It should be especially useful for beginning therapists, and experienced clinicians should also find it valuable because it provides such a clear, comprehensive discussion of the relational approach to psychotherapy.