Therapeutic misalliances

This paper explores aspects of the psychopathology of the patient-therapist relationship, and specifically defines and illustrates the concept of therapeutic misalliances. After a review of the relevant literature, two extended clinical vignettes are presented in order to explore efforts by both patient and therapist to create and modify conscious and unconscious misalliances. A tentative effort is made to delineate attempts on the part of the patient to "cure" his therapist of countertransference difficulties that have contributed to a therapeutic misalliance. Such efforts are based on the patient's extensive unconscious perceptions of his therapist's difficulties and these are documented in detail. In discussing this clinical material, the following are considered: The means of recognizing therapeutic misalliances from the therapist's subjective awareness and from the patient's associations; the interfering and therapeutically helpful aspects of the creation and analytic resolution of misalliances; the techniques through which therapeutic misalliances may be modified; the motives in both the patient and therapist or analyst that prompt the creation of misalliances; the curative aspects of the patient's positive introjective identification with the therapist and the damaging aspects of incorporative identifications with a therapist who is in difficulty; the importance of the adaptational-interactional framework in understanding the patient-therapist and patient-analyst relationships; and the importance of the therapist's personality and behavior, in addition to his role in providing the patient with well-timed and meaningful interpretive interventions.