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It is the purpose of this paper to look into the ontogeny and maintenance of the therapeutic alliance, in other words the birth, care and feeding of an aspect of the working relationship in psychoanalysis. While this phenomenon inevitably touches upon many facets of psychoanalytic theory, it is intended to concentrate upon only a few of the dimensions of interaction involved, while avoiding any rigid discrimination between functions: there are those of drive and drive organization, ego defense and ego synthesis, cognitive and affective parts of learning, primary and secondary process in development. All of these are involved in the ontogeny of the therapeutic alliance, and each of them in its maintenance. It is thus difficult to make a rigid distinction between therapeutic alliance and a combination of transference, identification, and a conscious, intellectually determined objective, namely “getting well”. Similarly, although there can be no useful separation between the “diagnosis” and “treatment process”, the discussion will be confined to the opening contacts between patient and analyst. Since this involves the general case of the continuously changing, communicative relationship between a doctor and a patient, it is hoped to indicate an additional bridge between strictly psychoanalytic treatment and other modalities of psychotherapy.
Unfortunately space does not permit a review of the pertinent literature, which can therefore only be mentioned briefly. Numerous implications appear throughout Freud's work, especially in “The Ego and the Id”.1 Sterba2 first referred to the phenomenon in 1929 in connection with the healthy aspect of the ego, and specifically dealt in 19343 with the concept of part of the ego “splitting off” to form an alliance with the therapist. Other important contributions were made by Hartmann,4 Bebring,5 a later paper of Freud,6 and most recently Zetsel.7,8
The main thesis is that there is a useful parallel between