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The concept of the therapeutic alliance has been helpful in the therapist's work with a variety of patients, and has provided a framework for conceptualizing an approach to problems that occur in psychotherapy. However, its utility in the psychotherapy of the more disturbed patient raises some important and complex questions. Do these patients really form a therapeutic alliance early in treatment, or even for long periods of time? Is the emphasis on such a concept in the treatment always useful? Or can the alliance concept sometimes impede our therapeutic work with a large group of patients who are closer to the borderline and narcissistic end of a continuum of psychopathology?
In this paper I shall address several issues related to the use of the therapeutic alliance in psychotherapy. I shall define the group or groups of patients where the concept can possibly obscure and impede the treatment. I shall then describe the dynamic issues related to their treatment that help explain these difficulties and present alternate explanations that formulate why “alliance-building” statements to the patient can sometimes be disruptive and sometimes helpful. I shall also discuss the importance of the real relationship in work with these patients, and the therapist's role in clarifying and at times confronting the patient with it as essential ingredients in the ultimate establishment of a therapeutic alliance with them.
The concept of the therapeutic alliance has been one of the most significant in clarifying an approach to collaborative psychotherapeutic work. Greenson (1965) credits Zetzel (1956) for bringing it to our attention. Greenson's working alliance emphasizes the mutual work to be accomplished in the treatment, but both Zetzel and Greenson stress the collaborative nature of the task involving patient and therapist. This literature also derives from Sterba's (1934) discussions of the alliance between the analyzing ego of the analyst and the patient's reasonable ego, Fe