Establishing the therapeutic alliance

Adolescent Psychiatry,  1999  by Katz, Philip

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The establishment of the therapeutic alliance is one of the major tasks and one of the major challenges faced by adolescent psychiatrists. The therapeutic alliance creates the atmosphere in which patients can expand their capacities for insight and self-awareness, accept information and organization, and, through identification and/or transmuting internalizations, develop the structures necessary for coping with life's stresses and crises. The therapeutic alliance facilitates the exploration of the transferences and countertransferences that arise during the course of treatment, spurring the growth of the observant egos of both patient and therapist.

The establishment of the therapeutic alliance does not always start with the first encounter between patient and therapist. There is often a preset relationship that the patient has developed with a fantasied therapist. I would like to illustrate this point with three case examples.

Edwin decided that he needed psychotherapy early in his 16th year but waited until his 18th birthday to contact me about it, as he wanted to be sure that he could get the Canadian Medicare System to conceal its payments for therapy from his surgeon-father. During those 2 years, he had many imaginary discussions with me, whom he had heard of but never met.

Jack, 17, had tried for a year to figure out how to maneuver his father into ordering him into therapy. Although he felt he needed therapy, he knew that, if he suggested it to his domineering father, father would say no. He took advantage of a minor car accident to paint a picture of himself as a drug-abusing, depressed, somewhat suicidal adolescent. Father decided that Jack should go into treatment and called me about this "emergency," and I saw Jack soon afterward. I expected to find a hostile, angry adolescent. Instead, Jack arrived happy to be there, loaded with things to talk about, and, when we chanced to meet that evening in a restaurant, he introduced me to his friend as his psychiatrist.

Dale was a 16-year-old Aboriginal youngster who was described as being extremely violent and uncooperative. He had been charged with an assault, and the judge had requested a psychiatric assessment. I was asked if I would do the examination immediately and was told that it would take only a few minutes because he would not talk to me anyway. Fortunately, I booked the standard hour. Dale wheeled into the office, asked for a cup of coffee, and talked a blue streak for 90 min, during which time he gave me a mass of information about himself and contracted to come for psychotherapy. Months later, when we discussed what had lead to that unexpected first interview, he told me that, the night before he came to see me, he had decided that he was on the road to jail and that he did not want to follow that road to its end. He decided that he had to let somebody get to know him and help him with his problems and that he would take a chance on me in the interview the next day.

In working with difficult patients, it is helpful to remember that the patient who comes into a psychiatrist's office only occasionally resembles the description given by parents, referring doctors, social workers, and so forth. I had the experience of being on a Child Welfare Board of Review that assessed more than 400 adolescents, all of whom had been committed to a reform school. Almost invariably, it was our finding, on interviewing the adolescents, that they bore very little resemblance to the hardened, callous youngsters portrayed in the charts.

Hilda Bruch (1974) wrote: Whatever he had heard about his patient-to-be, or read in the sometimes voluminous case history, when the first interview finally takes place [the psychiatrist] does well to remember that this is an occasion where two strangers meet, with both having to take the first tentative steps to learn to know one another. It is a time of mutual assessment. How the initial interview turns out depends not only on the patient and his problems, how he presents himself, how he perceives or misperceives the situation, but also on the therapist's openmindedness, his awareness of himself and his feelings and reactions, his confidence in what he is doing, and his sensitivity to the patient's need for help and understanding [pp. 2-3].

In the last few minutes before they meet in the first interview, both psychiatrists and their patients have fantasies about each otherfantasies that, depending on their knowledge of each other, generate emotions of varying degrees of intensity. These emotions are present in all therapists and all patients during those last few minutes before the interview and are remarkably similar. They each come with fear. The patient fears helplessness and loss of control over his personal destiny; the therapist fears helplessness and loss of control over the case. The patient fears a failure to get the help that is needed; the therapist fears failing to enlist the needed cooperation of the patient. The patient fears punishment for not fulfilling the requirements; the therapist fears legal difficulties for not fulfilling the requirements. They both fear the unknown. And, they each come with anger. The patient is angry at having to face the risk of humiliation in surrendering privacy; the therapist is angry at having to face the risk of humiliation should he or she fail to help the patient. Yet, in those first few minutes of the initial interview, despite fear and anger, the therapist must try to allay the patient's fear and anger.