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Gutheil, T.G. Havens, L.L. (1979). The Therapeutic Alliance: Contemporary Meanings and Confusions. Int. R. Psycho-Anal., 6:467-481.

(1979). International Review of Psycho-Analysis, 6:467-481

The Therapeutic Alliance: Contemporary Meanings and Confusions

Thomas G. Gutheil and Leston L. Havens

SUMMARY

The concept of alliance has been subject to inconsistent and idiosyncratic usages by different authors. We attempt to clarify this fundamental concept by identifying six categories of alliance, three in analysis proper and three in areas of psychiatry adjoining analysis.

The rational alliance is made possible by the therapeutic split in the ego which allows the analyst to work with the healthier elements in the patient against resistance and pathology; the work of Sterba, Zetzel, Kernberg and Greenson falls within this category. The irrational alliance paradoxically invokes elements of transference, even of pathology, to develop the analyst-patient bond, as the work of Nunberg and Rosen illustrates. In a related form, the narcissistic alliance invokes nonrational, narcissistic bonds to achieve the working relationship.

The existential alliance depends on exclusive commitment to the empathic position; the whole self is involved in the bond; an exemplar is Rogers. The situational alliance, characteristic of the work of Sullivan, rests on the indirect and implicit bond created when the dyad shares a common, external focus. Finally, in the medical alliance, the patient is more acted upon than with; we might thus more properly speak of compliance in this category.

Applying this schema to Kohut's The Analysis of the Self, we clarify certain confusing facets of that work by identifying the narcissistic alliance implicit in his work; this state of relatedness evolves gradually into a rational alliance towards the end of the analysis.

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