Negotiating The Therapeutic Alliance: A Relational Treatment Guide
Book Review published in Psychologist-Psychoanalyst
Authors: Safran Jeremy D., and J. Christopher Muran
Publisher: New York: Guilford Press, 2000
Reviewed By: Diana Fosha, Winter 2003, pp. 30-32
The most consistent finding of psychotherapy research is that “the quality of the therapeutic alliance is the most robust predictor of outcome” (Safran & Muran, 2000, p. 1). Across all therapeutic modalities, nothing predicts good outcome as reliably as the patient’s experience of the therapist as warm, caring, and genuine, and, thus, the patient’s experience of being seen, understood and helped. This has been something of a sticking point for different schools of therapy, as such data seem to strongly suggest that technique and specific ways of listening, understanding and intervening do not matter, and neither do, for that matter, the therapist’s theoretical orientation (gasp!) or level of training.
In Negotiating the Therapeutic Alliance, Jeremy Safran and Christopher Muran turn the problem on its head. Acknowledging the fundamental importance of the therapeutic alliance and its power to effect outcome, they seek to provide a theoretical basis for the therapeutic alliance, and for that, they go to contemporary relational theory. Having done that, they develop specific, explicit intervention strategies and therapeutic ways of being with patients to facilitate its development, foster its operation, and most importantly, repair it when it is ruptured.
Card-carrying members of the relational school, the authors’ guiding assumption is that both the alliance and its rupture are co-constructed. A rupture in the alliance reveals not only the heart of the problem, but also the very nature of the relationship, and can illuminate the contribution of each member of the dyad to the disruption of the therapeutic process. Thus, ruptures in the therapeutic alliance present rich--maybe the richest--opportunities for deepened understanding and therapeutic results of greater substance.
Making the most of the therapeutic opportunities that ruptures present is what this book is about. Central to Safran and Muran’s enterprise is the practice of metacommunication, a therapeutic activity that replaces transference interpretation as a central mechanism of therapeutic action. Metacommunication is “mindfulness in action” (p. 108) in the therapeutic realm. At its best, it involves dyadic mindfulness: it is a collaborative enterprise whereby both members of the dyad reflect on their experiences of the rupture in an attempt to re-establish communication, and thus connection, at a meta-level; when it works, the therapeutic process is not only restored, but becomes further enriched. Safran and Muran show precisely how metacommunicative processes contribute to the establishment and maintenance of a high therapeutic alliance and to the resolution of ruptures. These authors describe a therapeutic practice involving highly sophisticated, clinically rich and complex processes and interventions, which they present in exquisite detail.
Though the book’s subtitle is “a relational treatment guide,” a more accurate characterization of the clinical processes that are precisely detailed here is better captured by the gestalt that emerges from the three gorgeous epigraphs that open the book. The epigraphs are from three masters: a humanistic master (Martin Buber), a Zen master (Ko Sahn), and a relational psychoanalytic master (Michael Balint). Much more than a relational treatment, Safran and Muran’s treatment model integrates relational, but also experiential, humanistic, and Buddhist strands within a relational metapsychology.
Most intriguing to me, and I would guess most novel to an audience defined by shared psychoanalytic assumptions, are precisely the aspects of Safran and Muran’s model that come from outside psychoanalysis. These assumptions, offered matter-of-factly, are, if not quite radical, then by no means mainstream. For instance, Safran and Muran write, the therapist’s ability and willingness to accommodate the patient by working in terms that are more meaningful to him or her can play a critical role not only in building the alliance in the immediate context, but also in helping the patient to develop a more generalized trust in the possibility of getting his or her own needs met in relationships with others” (p. 23; italics, added). The idea of accommodating the patient is a new language for psychoanalysis, relational or otherwise. And a welcome one, to my mind.
Safran and Muran‘s lexicon for describing the therapist’s stance uses terms such as friendliness and affection; kindness, mutuality, directness, presentness, “the absence of contrivance” (a phrase from Buber) and generosity; and genuine openness and humility. Key to the stance is the idea of approaching each therapeutic moment “with a beginner’s mind” (which they see as akin to Bion’s dictum to approach each moment “without memory and desire”). “[I]f your mind is empty, it is always ready for anything; it is open to everything. In the beginner’s mind, there are many possibilities; in the expert’s mind, there are few” (p.36; quoting Zen master Shunru Suzuki).
The book evolved out of training manual, and as a result, one of its major strengths is the richness and abundance of clinical material. The numerous vignettes reflect the complexities and imperfections of real live therapeutic process and beautifully illustrate in action the very ideas and principles the authors propose. Explicit, detailed and alive in the writing, the clinical vignettes breathe off the page. Safran and Muran write with the authority of long clinical experience. These are therapists who have been in the trenches of intensive psychotherapy, who have banged their heads against many walls and know from the gut just how lousy it feels to be stuck. They have thought about these matters deeply and the reader benefits from their experience.
Eschewing both the cookbook perils of many training manuals, and the lack of specificity of many texts on technique that talk the talk but don’t walk the walk, this is that rare how-to book which articulates principles, details interventions, as well as the rationale for them, and then shows them in action. You can read the actual words to use to put these principles into action, something students will specifically appreciate. Regarding training and supervision, Safran and Muran emphasize that learning their model involves learning to use the self, and often learning about it in ways one does not always welcome. While the authors affirm the value of both book learning and skill training in intervention, they emphasize the fundamental importance of personal work.
My favorite was the chapter on therapeutic metacommunication, a must read for beginners and seasoned clinicians alike. No therapist I can think of, no matter how senior, would not find some gems, some new tricks, some useful new angles here–for, after all, who could not use some help in the detection and management of maladaptive interpersonal patterns, with particular emphasis on their enactment within the therapeutic relationship?
In this chapter, Safran and Muran articulate both general and specific principles that should inform stance and technique. Throughout informed by so well knowing that during an impasse “patients typically feel alone and demoralized,” these principles constitute a book of therapeutic grace, an explicit guide to how to avoid various all-too-common therapeutic sins, a step-by-step guide for how to promote within ourselves as therapists the kind of mindfulness--and generosity-- that, at its best, our work requires. In speaking about adopting a tone of skillful tentativeness during the exploration of an impasse, for instance, they show how tentativeness translates into an invitation to the patient who is feeling stuck and hopeless to collaboratively understand what is taking place. Their third principle, do not assume a parallel with other relationships is an important one to highlight to an analytic audience. They matter-of-factly state that “the therapist’s premature attempts at pattern identification are typically experienced as blaming by the patient” (p. 109) and that “[i]nterpretations that are offered in the context of a therapeutic impasse too often are delivered in a critical and blaming fashion that reflects therapists’ frustrations and their attempts to locate responsibility for the impasse in the patient rather than in the therapeutic relationship.” If therapists heeded just these statements, drop out rates from psychodynamic treatments would be cut in half. Such gems are delivered modestly, simply, and without fanfare. On the other hand, it is worth noting the self-assurance and unequivocal nature of Safran and Muran’s tone: it is in places such as these–and there are countless instances like them—that the sure hand of clinical experience shows itself.
But there are also some subtle jangles in the text. The epigraphs from Buber, Balint and the Zen master are all about the inseparability of self and other in relation. And while in many places in the text that kind of relationality is lived and breathed, in others, Safran and Muran interestingly focus on disembedding (a loaded word for a theory where Oedipus once reigned supreme). It is in the disembedding from a relational configuration gone bad that Safran and Muran find the mechanism of change they most want to formally highlight. Change comes from stepping out, not stepping in.
It is also interesting to note that the book starts out with mindful hope and openness, “All situations are workable provided that one fully acknowledges and accepts what the situation is. Even the position of being stuck is a position that is workable once one accepts it and ceases to fight against it.” (p. 119). The book ends, however, in a tone of resignation, with optimal disillusionment as the leading construct. While, as good dialecticians, we all know we are always oscillating between inseparability of self and other, on one hand, and stark existential aloneness on the other, it is nonetheless worth musing about this trajectory.
While probably multidetermined (or with as simple an explanation as different sections being written by one or the other of the two authors), it occurred to me that this trajectory might reflect the return of the repressed phenomenon, in this case, the psychoanalytic custom of leaving well enough alone. Or more formally stated, the principle of analyzing the negative, but not the positive, transference (i.e., therapeutic alliance), allowing the latter to work its magic procedurally. It is striking that if, in Safran and Muran’s model, ruptures are exquisitely and richly mined, repairs–and their relational meaning, dynamics and experiential consequences—are not.
For instance, in the example of Ashley and her therapist (pages 95-98), the way out of an impasse turns out to be the therapist’s somewhat impulsive self-disclosure: something about what Ashley says “gets” him, and in turn, his self-disclosure “gets” her, and gets the breakthrough. Given the authors’ otherwise unwavering commitment to moment-to-moment micro-analytic processing, what they say about why this startling turn of therapeutic events is best left unexplained is somewhat surprising: “While in some situations, this type of retrospective analysis can be helpful, in others, it can be a way of diluting or undoing something genuine that has taken place in the relationship…the compulsive need to analyze everything, itself needs to be analyzed” (p.97).
Understanding what about the therapist’s comments touched Ashley in such a way as to overcome the impasse would seem to be as great a metacommunicative opportunity as is the impasse itself. A strand of my own work has been devoted to exploring the experience of repair and success with as much care and skill and intrepidness as is usually devoted to rupture and failure (see Fosha, 2000, Chapter 8 on the healing affects). My guess is that if repairs were as fully explored as ruptures, the trajectory of the book would be less dichotomized with hope at the beginning and “mature” resignation at the end.
Commenting on the larger aspects of this issue, Adam Phillips notes: “Development in psychoanalytic theory is always described as a process in which, at each stage, the child is encouraged to relinquish something with no guarantee that what he or she is going to get instead will be better. This is a hard school and we might wonder what it is in us that is drawn to stories of renunciation, to ideologies of deprivation….” (p. 744; italics, added). Increasingly, it appears that psychoanalysis can accommodate alternatives to the deprivation scenario, including perhaps even scenarios of healing, celebration, love, and transcendence (e.g., Bollas, 1989; Davies, 2002; Grotstein, 2000). While Safran and Muran provide many examples of clinical work not based in scenarios of deprivation, the metacommunication of their text has not yet fully unpacked the potential residing in the clinical work itself.
There is a not quite explored, and potentially very fertile, tension in this book between a clinical practice informed by the experiential, humanistic, and Buddhist traditions (as well as by relational psychoanalysis) and a relational theory arising from a psychoanalytic practice. Safran and Muran do not explore the implications of their clinical methodology for relational theory itself, and I wish they would; they have the potential to make as original a contribution to relational theory as they make to the practice of psychotherapy. Mark Epstein (1995) also wrote about the resonance between Zen and psychoanalysis, but it would be wonderful to have Safran and Muran, steeped in relational theory and rigorous psychotherapy process research, take on these matters and follow them into the realm of metapsychology.
Having said that, Safran and Muran have made a substantial and original contribution to the field, accomplishing what they set out to do: providing a theoretical rationale for the therapeutic alliance and providing a treasure trove of highly specific tools of both attitude and action (stance and technique). If these insights are incorporated into one’s clinical practice in a mindful and authentic way they are bound to do precisely what they are meant to do: strengthen the therapeutic alliance, activate the powerful forces of therapeutic healing, and thus better allow what each of us does to be more potent and more helpful.
References Bollas, C. (1989). Forces of destiny: Psychoanalysis and human idiom. London: Free Association Books.
Davies, J. M. (2002). Whose bad objects are these anyway?: Repetition and our elusive love
affair with evil. Paper presented at the First Meeting of the International Association for
Relational Analysis and Psychotherapy: “Relational Analysts at Work: Sense and Sensibility.
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Epstein, M. (1995). Thoughts without a thinker: Psychotherapy from a Buddhist perspective. New York: Basic Books.
Fosha, D. (2000). The transforming power of affect: a model of accelerated change. New York: Basic Books.
Grotstein, J. S. (2000). Who is the dreamer who dreams the dream? A study of psychic presences. Hillsdale, NJ: Analytic Press.
Phillips, A. (1997). Making it new enough: Commentary on paper by Altman. Psychoanalytic
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Reviewer Note Diana Fosha is associate clinical professor at the Derner Institute of Advanced Psychological Studies, Adelphi University and the author of The Transforming Power of Affect: A Model for Accelerated Change (Basic Books, 2000). She is in private practice in New York City.
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