Relationships in psychotherapy
In his textbook, Ralph Greenson (1911 – 79) defines transference as a special type of relationship. It is characterised by feelings towards a person that do not entirely fit in relation to that person, but are rather suited to another (8) – a person from the past. Transference is a repetition, a new version of an old object relationship.
It was his patient «Dora» who set Freud on the trail of the transference phenomenon (9). This concerned his experience of being the object of the young female patient’s admiration, infatuation and love. Freud chose not to take this at face value since, as he said, he was by no means an attractive and charming person! It had to be a case of something else, for example a reactivation of an infantile core in the patient – the child pleading for her father’s attention and recognition.
Greenson also discusses two other relational concepts, namely «the working alliance» and «the real relationship.»
In order to work effectively on their problems, patients must establish another relationship with the therapist alongside their transference reactions. He calls this the working alliance. The working alliance consists of the relatively un-neurotic, rational aspect of the patient’s relationship with the therapist, and is an indicator of the patient’s capacity for purposeful work during the therapy. Greenson claimed that the working alliance could be considered as having the same importance as the transference reactions in the therapist-patient relationship. There is now a sound evidence base for regarding the working alliance, also known as the therapeutic alliance, as the strongest and most consistent predictor of treatment outcome (10).
The alliance may be weakened when the patient, based on his/her life experience, has low expectations for the therapy, a hostile interpersonal attitude and uncertain attachment. The therapist can help to strengthen the working alliance through technical skill, flexibility and the ability to regulate negative emotions – in addition to sensitivity to interpersonal processes, ensuring that the therapy is perceived as uncritical and undemanding, and that it is neither over- nor understructured (10).
Greenson calls the third type of therapeutic relationship «the real relationship». It is elucidated through clinical examples, the main point of which is that problematic traits in the therapist or imprudent interventions on the part of the therapist can trigger realistic reactions in the patient. These must be recognised as genuine by the therapist, rather than being made the subject of interpretations of resistance or transference.
Another definition of the working alliance, proposed by Bordin, is that it consists of three elements: the contact or the emotional bond between therapist and patient; agreement on the goal of the therapy; and agreement on the tasks that must be solved in order to achieve the goal (11). Such a definition may imply that elements of Greenson’s other two relationship types (transference and real relationship) are included in the working alliance concept. It is therefore important to clarify which concept of alliance is being referred to when discussing the importance of the working alliance.