Negotiating the Therapeutic Alliance: A Relational Treatment Guide

The quality of the therapeutic alliance is the most powerful predictor of success in psychotherapy. Given the inevitability of stresses, strains, and breakdowns in that alliance, the identification and repair of these difficulties are among the most important skills for the psychotherapist to acquire. The publication of Negotiating the Therapeutic Alliance will make it easier to communicate this skill to trainees and colleagues.

This book is an unusually thoughtful and pragmatic contribution, with excellent theoretical material illustrated by useful clinical transcripts. Safran and Muran and their colleagues have conducted years of research on the therapeutic alliance in both Canada and the United States. They have developed a model of psychotherapy based on their synthesis of contemporary thinking in relational psychoanalysis. Their discussion of the therapeutic alliance and its vicissitudes draws heavily on this school of thought.

The authors divide difficulties into 1) disagreements on tasks and goals and 2) problems associated with the relational bond. They discuss and illustrate how to recognize these problems and how to “metacommunicate” (communicate about the transactions or implicit communications that are taking place) in a manner that brings the problem into focus between therapist and patient. They organize ruptures in the alliance into subtypes characterized by either withdrawal or confrontation. For each subtype they propose a model in which recognition of markers of such ruptures is followed by a sequence of interventions. These interventions are not cookbookish; instead, they are process-oriented, and their precise form will emerge from the unique context of each psychotherapeutic endeavor. The valuable and cogent descriptions of the stage process model could enrich any psychotherapy curriculum.

The book’s seven chapters discuss the history of the therapeutic alliance and its recent reconceptualization, the authors’ fundamental assumptions and principles in their approach to psychotherapy, understanding alliance ruptures and impasses, therapeutic metacommunication, stage process models of resolution of alliance rupture, brief relational therapy, and a relational approach to training and supervision. The authors display a gift for expressing difficult concepts with clarity. They say so much so well that I found myself wishing they had written a longer and more comprehensive text.

Negotiating the Therapeutic Alliance is steeped in the concepts, values, and world view of relational psychotherapy. It is less a freestanding study of the therapeutic alliance per se than a guide to approaching psychotherapy from a relational perspective. For the reader who embraces the relational paradigm, this may be congenial. However, for readers unfamiliar with the relational paradigm, those who find the relational perspective a useful addition to our understanding but not sufficiently comprehensive to serve as the cornerstone of the psychotherapeutic endeavor, and those who are strongly committed to an alternative model, some of the authors’ emphases, omissions, recommendations, and examples may seem problematic and/or off target.

Nonetheless, this book has so many strengths, addresses so many important issues so well, has so much wisdom, and offers so much of value to those who teach psychotherapy that it belongs in the library of every mental health professional who practices or teaches psychotherapy.