Therapeutic relationship in psychoanalysis

Understanding the Therapeutic Alliance - Psychotherapy Treatment And Psychotherapist Information

therapeutic relationship in psychoanalysis

The therapeutic relationship refers to the relationship between a healthcare professional and a Components[edit]. In psychoanalysis, the therapeutic relationship has been theorized to consist of three parts: the working alliance. return to the psychoanalytic meaning of the terms in order to minimise this danger . Regardless of the therapy framework, emotional responses of clients and therapists to each other can inform the be that the therapeutic alliance is weak —we. It is often the therapeutic relationship between client and therapist which is more important than the theoretical orientation. This book deals with the uses and.

The patient is disorganized, anxious and expresses a mixture of idealization and shame in relation to his mother. The therapist suspects that it may be a delirious thought, as in five years of weekly meetings, this information about his mother had never been reported by the patient or his family members, who were called for interviews at times when the patient was very disorganized and his functioning was seriously impaired.

The patient assigned his difficulties in relationships to his mother's exposure, as if everybody would instantly know about their family ties. His speech during that session was grandiose, fragmented, paranoid. The therapists perceives transference components in his report: The therapist wonders whether she should interpret those contents at that time, whether she should deal with that report as a psychotic symptom acute positive symptoms had already appeared at other times during psychotherapy or whether she should acknowledge the value of the fact that the patient had been able to share a family secret.

She also asked herself to what extent the fact that the report was, or was not, true would make a difference in her listening. After that session, the therapist decides to check the information on the Internet and confirms it in several sites: Novel forms of communication: Freud 12 believed in the analyst's abstinence, neutrality and anonymity as crucial tools to achieve the therapeutic objectives.

This premise is challenged by so much information about patients and therapists available today, which may easily gratify desire and confront fantasy and reality, although virtually.

Therefore, the use that a therapist makes of communication and exposure means, such as the Facebook, remains highly controversial in the psychotherapy milieu.

A study of physicians in France by researchers in the Rouen University Hospital 13 found that most physicians defended the use of the Facebook by healthcare professionals. The interviewees believed that they should keep a private profile in the social network, but changes may occur in the physician-patient relationship when patients find their doctors in the Facebook. Results are similar among American psychiatrists.

Modern Psychoanalysis: Building the Therapeutic Relationship

Ginory, Sabatier and Spencer 14 studied a sample of psychiatry residents of the APA American Psychiatric Association to evaluate their behavior in social networks. The authors reported on some information found in the residents' profiles: Of all interviewees, 9.

therapeutic relationship in psychoanalysis

No resident had ever sent friend requests to patients. When asked how they would turn down a request, Interviewees were also asked about the use that therapists make of social networks as a support to treatment: A resident reported having received a suicide message from a patient in Facebook and contacted the police to check on him.

therapeutic relationship in psychoanalysis

When asked about the study of this matter, only five residents reported having discussed the use of virtual relationships in their training programs in psychiatry. Most did not know of any literature about it. The questions about the therapist's position in face of these situations led to the development of guidelines by the American Medical Association 15 to preserve professionalism in social media Table 1.

Thus, physicians should routinely monitor their own Internet presence to ensure that the personal and professional information on their own sites and, to the extent possible, content posted about them by others, is accurate and appropriate. If the behavior significantly violates professional norms and the individual does not take appropriate action to resolve the situation, the physician should report the matter to appropriate authorities.

If these items are discovered, the website administrator can be contact to remove problematic information. Some patients may experience the psychiatrist's interest in this information as a boundary violation or a compromise of trust. One strategy is to have separate profiles for separate roles, that is, personal versus professional. Psychiatrists or psychiatric residents who wish to post their availability on online dating sites are free to do so, but must be fully prepared for the possibility that patients will see them and have strong reactions.

Psychotherapy training should include considerations of the clinical dilemmas presented by social networking sites, bogging and search engines, as well as potential boundary issues. Based on Gabbard et al. Lisondo, 17 for example, questions whether psychoanalysts and psychotherapists are not being submitted to post-modern demands without reflecting and searching for the meanings of human behaviors, and clarified their position when they affirm that psychoanalysis faces the challenge of investing against immediacy, the lack of reflection, the anti-insight, the feelings of nothing to desire and the loss of ideals.

She concludes by saying that new technologies may be facilitative under exceptional and provisional circumstances of the analytic encounter, but they may be an obstacle because of the limitations that they establish as they impoverish and distort the essence of psychoanalysis.

Analytic work should be nourished, reinvigorated and strengthened, and never perverted. Undoubtedly, cultural and technological advances have brought new possibilities to communications and, consequently, to the construction of bonds between individuals. Changes in the way that we relate to time and space and in the way that we use language have now reached the analytic setting.

Therapeutic relationship

According to Levy, 7 this process is not new, but, rather, a continuum, because digital advances enable communications to continue their movement towards virtualization, which started a long time ago with the oldest techniques, from writing to sound and image recordings and the radio, the television and the telephone. Kowacs 11 points out that the aspects of this new technological reality affect the setting and the dyad relationship, and may also affect the internal setting of therapists or analysts.

The author, therefore, recommends the use of negative capacity, 18 which makes it possible to accept non-knowledge, such as the questions about the maintenance of framing in this new context. The instant satisfaction of curiosity on the Internet feeds fantasies of omnipotent control by the patient using the virtual invasion of the therapist's life. Feelings of exclusion and abandonment temporarily cease to exist.

Limits are abolished, and gratification is immediate. However, the author argues that the use of telephone, internet and other means of distant communication enable the maintenance of the patient-therapist alliance established face to face in the case of prolonged travels, disease and certain types of professional activity.

These resources make it possible to give continuity to the therapeutic process. The task of the contemporary therapist is, therefore, to increase setting flexibility without losing its essential characteristics. How to buffer the impact of change and keep ethics and quality in analytical work?


We believe that, if the external setting becomes more flexible, the therapist should preserve it intact internally by keeping the capacity to deal with the transference signs instrumented by technology, as well as with neutrality, abstinence and possible anonymity.

The understanding of the dynamic unconscious, the cornerstone of psychoanalysis, has not changed, despite all the current technological armamentarium.

therapeutic relationship in psychoanalysis

A solid framing anchored in psychoanalytic theory and good practice enables the dyad to understand and interpret new situations according to psychoanalytic theory. According to Lisondo, 17 elasticity demands permanent mental work and self-observation, so that the alliance in not lacerated or disfigured.

Despite all the elasticity so far incorporated into the therapeutic setting, not all authors are in favor of the changes discussed here. Lisondo 17 actively criticizes new technologies in analysis and psychotherapy and claims that these resources tend to prevent patients from reaching primitive mental states that are accessible and visible in reality, through preverbal and verbal language according to Freud's second topography, but not in virtual reality.

therapeutic relationship in psychoanalysis

According to the author, in telephone treatments, the access is limited to the verbal level; in those via Skype, the lower body and the environment are not seen; and webcams and VOIP do not ensure good overall perception. The author also claims that it is in the access to these states that lies the origin of human representations and symbols to be achieved in adult life, and gives the example of non-neurotic patients, who need an intimate face-to-face relationship in which sensorial signs may be dreamed, intuited, understood and transformed by the analyst.

The same author wonders what happens, when computers are used, to the contemporary concepts that invest intensively in the therapeutic relationship, that is, third analytical, analytic field and intersubjectivity, which construct the fine and delicate affective tuning. According to Trotta, 19 the individual involved in a virtual analytic process may develop omnipotent fantasies of sidestepping time and space or, in other words, sidestepping the principle of reality. Such questions stress the need to be careful when using technologies for psychoanalytic techniques, so that the perception of professionals are not hampered when doing their work.

Therefore, a new challenge arises: Using the technology available to supervision, Abbas et al. Those authors believe that inexpensive, widely accessible Internet-based training methods seem to offer a wide range of benefits and few limitations.

Although further studies are necessary, they suggest that the web-conference supervision model may become the central vehicle of global dissemination of psychotherapy skills. Distance supervision is not a novelty, as it was first conducted by Freud by means of his correspondence with Fliess, which may be compared with today's emails.

Understanding the Therapeutic Alliance

However, is it a modality open to errors and communicative problems due to the limitation of access to the nuances of verbal and body language. In email messages, the seminar theme was developed at the same time as participants appropriated the use of the Internet as the space of the teaching model used to think about psychoanalytic clinical practices.

By means of electronic dialogs, the group was able to examine their own contradictions about the psychoanalytic setting: When analyzing dynamic psychotherapy teaching and supervision experiences that follow technological innovations and may use them, useful and productive results seem to be confirmed.

Technology, in all cases, has been used to reduce distances and spread knowledge without, however, abandoning the fundamental principles of psychoanalytic techniques or neglecting confidentiality and all other ethical issues that this activity requires.

Moreover, relational issues between supervisor and students should remain important, whereas the possibility of working without face-to-face contacts between them has never been recommended.

Final considerations The inclusion of new technologies in the setting of psychoanalytic psychotherapy seems to be greatly controversial. Online treatments, for example, may also be controversial, although they may potentially help patients that would otherwise not have access to face-to-face psychotherapy due to geographic distance, difficulties in locomotion or fear of changing psychotherapists.

Therapeutic relationship - Wikipedia

The vignettes described above seem to indicate that there are no differences between showing a conventional photo album to the therapist or bringing it to the session as digital photos in a tablet. The meaning of the act alone does not change just because the means used to perform it has changed.

When the patient with the videogame continues playing online during the session, would it not be only a new, perhaps more disturbing because unusual, form of the old, familiar resistance? When possibly placed in the position of the third person, the one excluded, the therapist might feel cheated and left alone by the patient. Still, in the same scene, the patient may be telling the therapist something that still cannot be understood as his own. In the case of the patient in vignette 3, the technology available seems to favor the overflow of the patient's anxiety through easy and continued access to the therapist.

Maybe, before the existence of WhatsApp, this same patient would leave innumerable messages in the office's answering machine and would also call the therapist's home.

Would the therapist's interpretations be very different in either case? Again, resistance and transference issues are clear when the patient in vignette 4 sends a Facebook friend request to the therapist, trying to move her out of her position and making her a "friend," and when avoiding discussing the request and the subsequent feelings about the fact that the therapist did not respond to that request.

In the same way, in vignette 5, the "failure in meeting" between therapist and patient and the different understandings of how to get in contact illustrate the confusion of transference and countertransference in the therapeutic process. In this vignette, the therapist used the network to get in contact with the patient, the same network that the therapist in vignette 6 uses to decide whether what his patient reported during the session was a painful revelation of a family secret or a delirious idea that should only be dealt with as a manifestation of the patient's inner world.

The basic concepts of psychoanalytic theory have proven, as seen here, to be extremely useful to understand the changes in the ways to express feelings and communicate ideas between patients and therapists. Technology and psychoanalysis have the same prerogative: Oliveira 24 points out that it is necessary to effectively find out how this range of basic psychoanalytic concepts operates in this new environment.

Based on the considerations above, we believe that the use of technology, in addition to providing a new packaging for old issues, provokes effective transformations in the psychoanalytic psychotherapy setting, and it can no longer be separated from the clinical work conducted in the office.

Technology does not seem to change the essence of the work conducted in psychodynamic therapies, but is an instrument of inclusion and accessibility, as long as its use is guided by well based psychoanalytic rules. Therefore, therapists should try to understand the meaning of what is happening in psychotherapy at the same time that they evaluate their own behavior, be it more or less active, in respect to the use of new technologies. Regardless of the form that therapists choose to deal with the use of technology in the clinical practice, they should identify whether it is an increase of communication between patient and therapist, a bastion, an expression of resistance, a difficulty of countertransference or an enactment, among other possibilities.

As psychoanalytic psychotherapists, we have to accept the advances brought by the passing of time and be open to constant innovation, as well as willing to face possible disillusionments at contemporary society. At the same time, we need to recognize the suffering and the symptoms that emerge in this contemporary form of subjectiveness. We should promote constant reflections about these generational differences. Because of these changes, research and studies in this area should continue carefully and spurred by curious learning, so that clarity, integration and progress are maintained, instead of obscurity, fragmentation and regression.

Lipovetsky G, Charles S. Oxford University Press; Roles may be switched. The patient has the opportunity to see how one might do it differently and to practice it. There are many less formal opportunities for the therapist to model effective behavior for a patient, including healthy self-disclosure and healthy boundaries.

Over time, the therapist models to the patient how to be his or her own therapist, which the patient internalizes and uses between therapy sessions and long past the period of formal sessions. Sometimes, patients need more than simple validation in order to attempt a new attitude or behavior. They need actual encouragement and the sense that someone with more knowledge the therapist believes they can do what they are setting out to do.

Active praise and encouragement can be effective reinforcing agents to encourage change. However, the therapist must balance that with remaining accepting and neutral about the outcome.

When the patient fails, the therapist must also be there to pick them up and help them try again. There is always a kernel of truth or reality in the transference. The patient does not create this out of thin air, but is picking up on something going on in the therapeutic relationship.

However, transference also is regressive, and, to that extent, it is exaggerated or distorted by the childhood pattern. It often serves as a resistance to therapy. It may be a reason for the patient to quit therapy if it is not adequately understood in a timely way.

It recreates, in the form of a drama, what cannot be remembered and discussed in words adequately yet. Typical examples of transferences are: Once expressed, they can be analyzed as the pattern of loving that has trapped the patient in their unhappy romantic life. The patient sees the therapist as a critical, demanding, unsympathetic figure who mirrors the strict parent from childhood.

The patient works hard to please the therapist and get approval. The patient sees the therapist as bigger than life, representing either an experienced powerful parent or the wished-for powerful parent who will protect the patient child and help them feel special within that relationship. There are many, many varieties of transference. Freud noted that in the end, successful psychoanalysis or therapy will depend upon the handling of the transference. If it can be recognized, elaborated, and understood, first by the therapist and then by the patient, therapy will be successful.

If not, the therapy will founder on the misunderstandings that arise. The therapist is human, and like the rest of us, has thoughts, feelings, fantasies, and behaviors based upon early childhood relationship patterns. This can lead to overt acting out with the patient or can be subtle and go unnoticed. As with transference, countertransference does not come out of thin air, but represents some truth about the patient and the relationship, often about a covert transference the patient is having to the therapist.

It can be useful and even necessary for a therapist to get supervision to better understand ongoing countertransference. It needs to provide adequate safety, privacy, and intimacy for the patient to gradually open up their private, internal world. The therapist must be caring, empathic, and non-judgmental.

Only a truly engaged therapist will be able to make a difference in the life of a patient who really needs therapy.