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Book Review   |    
The Therapeutic Alliance
Theodore B. Feldmann, M.D.
Psychiatric Services 1998; doi:
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by W. W. Meissner, S.J., M.D.; New Haven, Connecticut, Yale University Press, 1996, 385 pages, $37.50

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Psychoanalysis and analytically oriented psychotherapy are grounded in theoretical and technical principles that assist the therapist in clinical work. A thorough understanding of these concepts is essential for successful therapeutic work. Most texts focus on one of two broad areas: the origin of psychopathology, such as drive conflict or structural defects in the self, or the examination of transference, countertransference, and resistance. This book examines an equally important, but often overlooked, component of psychotherapy: the collaborative relationship that is formed between the patient and the therapist.

Dr. Meissner, a respected analyst and teacher, addresses the concept of the therapeutic alliance in a broad sense and provides important insights for therapists of all theoretical orientations. The result is a useful and clearly written reference on the factors inherent in the therapeutic relationship that make it possible to attain therapeutic goals.

The first of the book's four sections deals with the nature of the therapeutic alliance and provides a comprehensive history and definition of the concept. The second section examines the nature of the real relationship between patient and therapist. The third explores developmental aspects of the therapeutic alliance, ethical considerations, and the central role of empathy. In the final section, Dr. Meissner discusses integration of the therapeutic alliance into the analytic process. Included in this portion of the book are the establishment and management of the alliance, its role in interpretation, and its importance in termination. Overall, the text is concise and highly informative.

Dr. Meissner raises the important question of whether “the burden of therapeutic effect [is] carried by interpretation or by aspects of the analytic relation?”In response, he persuasively proposes that the therapeutic alliance is "an essential dimension of the therapeutic relation, and . . . provides the matrix within which therapeutic effects are wrought.”

What is meant by the term therapeutic alliance? Dr. Meissner argues that the therapeutic alliance is a complex phenomenon that encompasses aspects of transference and countertransference as well as both the real and the perceived relationship between the patient and the therapist. Although transference and countertransference are clearly important aspects of the therapeutic process, they are filtered through and influenced by the nature of the therapeutic relationship. The values, experiences, and expectations of both the patient and the therapist exert a strong influence on the manifestations of transference as well as on the ultimate understanding and interpretation of transference issues. Thus, Dr. Meissner believes, a comprehensive examination and understanding of the patient-therapist relationship are essential for successful psychotherapy.

The therapeutic alliance, according to the author, is not a static phenomenon but rather a dynamic process that emerges and evolves as therapy progresses. The developmental histories of both patient and analyst strongly influence the nature of the alliance. Issues such as gender, race, aging, and ultimately death impinge on the analytic situation and the therapeutic alliance. The author argues that these factors demand "reformulation, especially with regard to neutrality and abstinence.” Thus continuous examination of the therapeutic alliance becomes an appropriate, and ultimately essential, task of analytic work.

This is a well-written and comprehensively referenced book that will be of particular interest not only to psychoanalysts but to psychotherapists of all disciplines. The book's most important contribution is that it encourages a critical re-examination of the therapist-patient relationship. Dr. Meissner reminds the reader that psychotherapy is a dialogue, the nature of which must be thoroughly understood in order for positive change to occur. This book is an excellent source of information and is a welcome addition to the literature on psychotherapy.

Dr. Feldmann is associate professor and director of medical student education in the department of psychiatry and behavioral sciences at the University of Louisville School of Medicine in Louisville, Kentucky.




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