In the psychoanalytic literature the working relationship or therapeutic alliance is described as the relationship between the therapist in role and the patient’s observing ego. The working alliance is therefore the collaboration between the therapist and the healthy part of the patient—the part that can join the therapist in observing and reflecting.
At the start of therapy, this part of the patient’s psychological makeup may be small and fragile in contrast to the floods of affect the patient experiences. Therefore, our interpretive approach begins with attention to the experience shared between patient and therapist.
Use of this interactive process depends on the capacity of the patient to trust someone without excessive idealization, which is a particular challenge for borderline patients.
In the early phase of treatment, the relatively high dropout rate by borderline patients compared with other patients is a serious consideration. It`s important, that a review of treatment completion by patients with BPD indicated that the following were important factors in dropping out:
- high impulsivity,
- anger,
- anxiety,
- lack of commitment to treatment,
- low motivation to change,
- higher experiential avoidance,
- poor therapeutic alliance.
In a large study comparing dialectical behavior therapy and general psychiatric management, the strongest predictor of dropout was poor therapeutic alliance (Wnuk et al. 2013). One of the most robust findings in all of psychotherapy research is the importance of the early therapeutic alliance in relation to treatment process and outcome (CritsChristoph et al. 2013).
In Transference-Focused Psychotherapy (TFP) knowledge of the attachment difficulties of borderline patients suggests that forming a treatment alliance with them is more complicated and more difficult than forming one with neurotic patients. In addition, most of the literature indicating the importance of the early alliance refers to treatments of brief duration.
TFP, by definition, focuses on the relationship between patient and therapist. The relationship is complex in that on one level it is real and on another level it is a creation of the patient, based on how the patient’s internal representations of self and other determine his or her perception of the therapist. Ultimately, it is the therapist’s exploration of these latter perceptions that helps the patient advance to a more stable psychological structure. In clinical practice, the therapeutic alliance with borderline patients often develops not gradually but through a series of crises.
For instance, at the beginning of treatment, a patient may accuse the therapist of indifference or insufficient empathy, when in fact these reactions reflect the activation of early patterns of rejection linked to painful childhood experiences.
The therapist’s ability to withstand such accusations and transform them into material for joint exploration becomes the foundation for strengthening the alliance.
Another common example is when a patient abruptly terminates therapy after the first signs of emotional closeness with the therapist.This reaction may express a fear of dependency or an overwhelming sense of shame associated with the need for acceptance.
When the therapist recognizes these processes in time and discusses them as a defensive response to the anxiety of intimacy, it helps preserve contact and transform a destructive impulse into reflective inquiry.
Thus, in Transference-Focused Psychotherapy (TFP), working with the therapeutic alliance involves not only maintaining collaboration but actively examining moments of its rupture. Each crisis of trust becomes an opportunity to demonstrate to the patient that relationships can withstand emotional tension without collapse—an experience that gradually fosters integration.
(c) Yuliia Holopiorova,
Ukrainian Association of Transference-Focused Psychotherapy