|Year : 2022 | Volume
| Issue : 1 | Page : 7-11
Does therapeutic alliance help “in search for meaning?” Experiences of working through a “Trilogy”
Department of Psychiatry, AIIMS Kalyani, Kalyani, West Bengal, India
|Date of Submission||21-Jan-2022|
|Date of Acceptance||28-Jan-2022|
|Date of Web Publication||30-Mar-2022|
Dr. Aniruddha Basu
Department of Psychiatry, AIIMS Kalyani, Basantapur, Kalyani, West Bengal
Source of Support: None, Conflict of Interest: None
Background: Therapeutic alliance has been the 'Holy-Grail' of doctor patient relationship but is most discussed in relation to psychotherapy. At times in an individual therapeutic scenario it has been conceptualized as a working alliance to a collaborative plan but more than that it influences the lives of the clients and the therapists alike. Aims and Objectives: Understanding therapeutic alliance and its influence on the client and the therapist. Materials and Method: Three interrelated cases scenarios and the therapeutic alliance has been allegorized through the Shakespearian perspective. Results: In this exposition, a trilogy of three interrelated therapeutic case scenarios culminates in the existential framework. The first gentleman was a middle aged physician who had everything in life and at the end was drinking heavily as he had nothing else to do. In the second a soldier who fought bravely for his country but received no recognition and in lieu lost an arm in an conflict with the insurgents. Thereafter he found drinking as the only way forward. In the third case a gentleman who had alcohol dependence could quit alcohol unlike the other two. The main driving force of the latter was to do something for his son – this 'search for meaning' was lacking in the previous two. In the course it was seen that therapeutic alliance not only influences the life perspectives of the clients but also the therapist alike through an interplay of transference and counter transference. Conclusion: The influence of therapeutic alliance is not only limited to some narrow therapeutic scenarios but extends beyond in a much broader sense.
Keywords: Existential framework, psychotherapy, therapeutic alliance
|How to cite this article:|
Basu A. Does therapeutic alliance help “in search for meaning?” Experiences of working through a “Trilogy”. Indian J Soc Psychiatry 2022;38:7-11
|How to cite this URL:|
Basu A. Does therapeutic alliance help “in search for meaning?” Experiences of working through a “Trilogy”. Indian J Soc Psychiatry [serial online] 2022 [cited 2022 May 28];38:7-11. Available from: https://www.indjsp.org/text.asp?2022/38/1/7/341332
| Introduction|| |
”The secret of care of the patient is in caring for the patient”…
Francis W Peabody (1881–1927)
In medical schools, teachers emphasize upon “caring for” the patient. But what it exactly means is an enigma. Many factors have influenced its understanding – right from the historical development, epistemology, the contextual specificities, and the environment including sociocultural milieu. So, while “caring for” is addressed as “doctor–patient relationship” in Harrison's celebrated Textbook of Medicine – it has been named as “therapeutic alliance” in the realm of psychotherapy. Harrison's textbook says that the ideal doctor–patient relationship is based upon a thorough knowledge of the patient, on mutual trust, and on the ability to communicate. Exactly, the same has been expressed in psychotherapeutic literature as therapeutic alliance. However, both are exactly not the same – therapeutic alliance in psychotherapy has a broader perspective which influences the therapist and the client alike as illustrated in the clinical scenarios below rather than being a mere “doctor–patient relationship” in general medical specialties.
Even a novice in psychotherapy knows the importance of therapeutic alliance – and attempts have been made even to find its counterpart in case of digital patient–therapist interactions. Qualitative studies have emphasized its centrality, and meta-analysis has proven it as a robust predictor of response to psychotherapy. But this “Holy Grail” true to its historical traditions was born under controversial circumstances. Though Sigmund Freud emphasized upon the importance of “rapport” which later came out to be an important component of therapeutic alliance, psychoanalysts like Brenner and others refuted its very existence in the era of “one-person” psychology. With the advent of object relations and ego psychology, therapeutic alliance assumed its pivotal role. Greenson and Bordin hypothesized a similar concept with a subtle difference, namely “working alliance,” which would consist of three components, namely an agreement on goals, an assignment of task or a series of tasks, and the development of bonds. This working alliance reached a more “structured” shape in the era of collaborative empiricism of cognitive behavior therapy. The humanistic paradigm with its focus on unconditional positive regard and empathy made therapeutic alliance the central tenet around which all therapist–patient interactions revolved. Similar to its historical development, in an individual clinical condition also, the “water” of therapeutic alliance is marked by ebb and flow till it finds its own way and finally becomes the mainstream of doctor–patient relationship. In this background, a trilogy of three individual scenarios viewed from different psychotherapeutic perspectives which culminates in the existential framework where both the client and the therapist “search for the meaning” in their own lives is illustrative. This trilogy illustrates the personal lived experiences of the author, hence he would like to narrate in the first person.
The first case is Mr. X, 60-year-old gentleman who had been a physician in the United States (US). He had been the topper from premier institutes well known and deeply respected in his fraternity. He attained his early education in India and thereafter migrated to the US. In his personal life, he was satisfied – he had a very “cooperative” wife who had mostly taken the responsibility of rearing their three children. He would consider himself to be financially and professionally very secure. But deep somewhere he had a repentance that he could never visit his mother in her last days who was dying in India while he was running after success. And now he has no more milestones to achieve in life. For the last 2 years, he had been drinking alcohol unlike his previous self. In fact, he had taken the first drink at the age of 58 years. As I interviewed him, I could find no signs and symptoms of depression. He appeared to be unrealistically optimistic in life and say that I do not have any further expectations! This individual was remarkable to me – in general as per our standard teaching and Cloninger model, we conceptualize alcohol dependence as early and late.… But he had taken the model for a toss! He has late-onset dependence, but he hardly has any syndromal depression, anxiety, dementia/cognitive deficits, no major psychosocial issues, mood fluctuations…… nothing…. He left me perplexed…. I could not fit him into any of the known models. Moreover, I wondered that if as a teetotaller, he can suddenly turn to alcohol…. Then I can also face the same fate in my later life. We both share similar insecurities……. He did not serve his mother at her death bed.… I too have left my mother to care for herself alone back in my hometown… The specter of turning to an “alcoholic” myself in later life spurned within me an intense anguish. I discussed this with my supervisor who encouraged me to take up this case, maintain therapeutic boundaries, and study the flow and ebb of therapeutic alliance that is to unfold in the next few sessions.
As per the current convention and norm, I started with a cognitive behavioral paradigm and decided to bury the unconscious under the “efficacious” edifice of the cognitive triad ……. But as in Shakespeare's Hamlet… The Ghost… it did arise all of a sudden in the very initial scene only.
The appearance of hamlet's the ghost: “Never play God”
Initially very excited in the first few sessions, I would reflect to my supervisor how “obedient” he is to my instructions – he follows them “word by word”…. But my supervisor would not be convinced. His comment “are you sure?” would appear sarcastic to me…. and I started to work with Mr. X more intensely… in terms of exploring more of his emotions and thoughts … I would apply structured instrument after instrument (readiness to change questionnaire, different craving questionnaires) to validate my proposition that I have understood him. I would hypothesize that he is suffering from empty nest syndrome and to relieve himself he is drinking…… But deep somewhere I would feel “insecure” regarding my relationship with him….is it a recollection of my own childhood relationship with my parents?…… I would shudder to think. Once during the sessions, he had told me that throughout his life, he had loved himself the most.… He had never cared about his parents… In fact, he did not come for his mother's funeral… his children were mostly reared by his wife…. He said that he has everything but “nothing”……. Is his lack of ability to form proper object relations or attachment shaping my relationship with him? As I would introspect……. His brother who was a senior faculty in the institute and my peers who would appreciate me for retaining such a “learned” patient. I thought that probably things are smooth… let me do a little “here and now” psychotherapy……but as I would smoothly sail through the sessions, one word of caution would repeatedly ring in my ears…' never play God'. During this time my supervisor also cautioned me about the middle phases of psychotherapy where the bonds of therapeutic alliance are at risk. But I remained buoyant-boasted that he would come on time and be excessively compliant to the homework.
To me, he was a poster boy of cognitive behavior paradigm….but to my utter disgust my supervisor would ask me to read Wolberg's “resistance” – I felt humiliated when in the class he asked to consider Mr. X's overcompliance as “resistance.” But I was aware of the positive countertransference that I had developed – I would prepare well for the sessions and would call him at the end of the day so that I could give him some time “extra”…. These continued for a couple of sessions where we discussed different triggering events …. Nonchalant about what is going to happen within the next few days……
The “rupture:” Hamlets “play within a play” and the conflict
He suddenly informed me that he is better and he plans to move back to the US. I tried to persuade him – gave him documentary evidence in a vain attempt that cognitive behavioral therapy (CBT) requires 12–16 sessions as per a standardized manual. He appeared quite stubborn in his decision. I tried to understand this as an Apparent Irrelevant Decision or some other deep-rooted dynamic interplay.… his brother came to me and requested to use my powers as a therapist to refrain him…. But I was equally helpless as the therapeutic alliance which I boasted of had been “ruptured” or it was an “acting out” on part of the client. Also, it was probably through the therapeutic alliance that he was re-living his relationship with his mother – he would leave me prematurely as he had done with his mother.
I was left with the dilemmas what to do…. To persuade him or to let him go…. similar to Hamlet's conflict….or a similar repressed anger which was to misfire some day. I wondered if.
“To be or not to be”
As a bewildered ship in the rough waters of therapeutic alliance, I went to my supervisor for guidance – who with his characteristic wisdom calmed me and said “what we want to do with clients is often irrelevant for the client”– rather “just observe how the situation unfolds.” As I fell back on Hamlet, and with my supervisor's guidance, I understood the significance of “to be or not to be” and with a “directionless” direction, I again started sailing in quiet waters. As per discussion with Mr. X, I terminated his therapy on the CBT note. Subsequently, my supervisor asked – “did you ever ask what he wanted in his life? I was not able to answer…. probably he wanted me to realize it myself sometime later.
“The trailing…. The rest is silence”
A few months later, his brother informed me that he had again started drinking excessively leading to a fall and finally death. As his last words, Mr. X had said to his brother…. “I have nothing to do next… I have achieved everything…. let me drink…. let me drink”…… I was not that surprised by relapse because sudden unexpected decisions in therapy are a harbinger of relapse-but drinking to death? Something I had not expected…. somewhere probably I missed the Shakespearian psychodynamics of Hamlet underlying the great tragedy……” the rest is silence” as were the last words of Hamlet…. and silently I started to ponder about how I could have understood him differently….
The second individual in this trilogy is Mr. Y, he was a 50-year-old retired army man. He was referred for heavy drinking – he would abstain for few days but again relapse repeatedly. When I delved deep into his life, I found that he was a dedicated and hardworking soldier who dreamt of a gallantry medal 1 day. Five years back, he was sent on secret mission against the terrorists. He fought successfully and led his regiment – but in the blast, he lost his right arm. His senior officer who had only co-ordinated the mission and was miles away from the operation was awarded a medal for gallantry which was his childhood dream. He got only a compensation check instead. He was initially angry but later accepted his fate. He came back from the battlefield without his arm and more than that without his medal – neither any formal acknowledgment. With the hand – some compensation money he brought property, married off daughters and ensured monthly cash – and what was left for him to do in future…… he did not have any answer. As an avid reader of Shakespearian tragedy “King Lear,” I found reverberations of this gentleman in the tragedy of Cordelia who was banished from his father's kingdom in spite of her honesty as compared to her sisters.
The passive aggression or anything more?
He started drinking heavily – I initially thought he was suffering from depression, detoxified him, kept him in the in-patient ward for 2 months with regular breath alcohol checking. He was so compliant, so motivated and was taking treatment so seriously. On assessment, he did not have any iota of depression. He would regularly perform yoga, attend all relapse prevention sessions, be compliant to family session and disulfiram therapy. But at the end of the day, nothing would work – neither disulfiram nor family supervision. He would go back and would again relapse. I admitted him thrice, the last time I discharged him – I asked him what next? As a therapist, I tried to conjure hope in him – but in a death-cold tone, he responded…. “no nothing”…. what he was up to?
When I pondered, what these two individuals had in common? Both Mr. X and Y were well established in their lives – none had any internalizing and externalizing disorder…. neither anybody had any peer pressure or severe psychosocial adversity. These two individuals remained “un-understandable” to me – I could “fit” them neither in cognitive behavioral nor psychodynamic framework. Wondered whether the second gentleman was in a perpetual bereavement about the loss of his limb – the “bottle” acting as a symbolic “replacement” for his limb, a bottle of alcohol construed within the “internal working models” of grief? Alcohol as a transitional object or alcohol forming a part of his object relations or simple conceptualizing his alcohol consumption as a passive aggression. But is this not just empty theorizing? Fitting individuals into some alien theories! I continued looking for satisfactory answer to my queries as the tragedy of Hamlet and Cordelia continued to haunt me in my own journey through life–as I moved from one institute to another in search of job.
The holy trinity: “Father, mother, and son”
This was Mr. Z a 50-year-old gentleman – his whole family was under my treatment… first came his son…. He was suffering from anxiety symptoms. He would be terrified whenever he would hear his father involved in brawls – otherwise, he was a gentle child, had some mongoloid features, loved music, and as per IQ, he had mild subnormality. He was doing well with simple behavioral measures but would deteriorate whenever his father would come in intoxicated state. His mother (Mr. Z's wife) was suffering from clinical depression. She reported her stressors – “alcoholic” husband on the one hand and son on the other hand. She improved considerably with antidepressants. She requested to intervene for her husbands' alcohol usage and gambling, but she cautioned us that he had resisted any treatment in the past and had undertaken a literal “head-on collision” with the treatment services in the past.
I could happily fit Mr. Z into my long-practiced lore. He had externalizing traits since the beginning, he was short tempered and had several temperamental vulnerabilities in contrast to Mr. X and Y. But little did I know that this “usual” patient would turn out to be my master teacher…… recollecting the words of wisdom written in walls of medical schools…. “patients are your best teachers.” Mr. Z was alcohol dependent and involved in several illegal activities. He would rationalize that he needed to amass huge money to care for his handicapped son and in the process he needs to be involved in gambling. He is an episodic drinker and gambler – as per his initial claims – at the first visit he was in precontemplation. I accepted and respected his standpoint and requested him to observe the relationship between his drinking and his sons' emotional problems and wife's sufferings. I lamented to my trainees about his poor outcome (by this time, I have become a faculty supervising trainees).
The eureka moment!
To my utter surprise after a couple of months he came a changed man – abstinent probably the first time in his life, being compliant……. I questioned to myself, what had caused this miracle? Though his family attributed it to the doctors and the trainees to the expertise of their supervisor, I only know that I am clueless. He responded calmly and wisely: “sir….you are right…my drinking and gambling are deteriorating him…. I have only one last resort to live to earn for my son…. if alcohol deteriorates him……. what is the point? If I am abstinent I have my son to look forward to?” As I listened to him all my hitherto preconceived disliking for him based on the stereotype of dis-sociality disappeared and I started having reminiscences of my two previous clients – Mr. X and Y. Did they have something to look forward to in their lives? Both Mr. X and Y had achieved everything, but they had no “unfinished work” unlike Mr. Z. Working through this case, the therapist was reminded of Shakespearian drama of The Tempest – the realization of Prospero who though have lost his royalty was ready to do anything for his daughter Miranda's future.
”In search for meaning” – I had hardly thought about this perspective…. I was preoccupied with the psychodynamic and the CBT schools of thought…. I had delved so much into their past that I neglected their future…. what they want in their lives? What they look forward to? Mr. Z taught this to me with such kindness that I felt indebted but do I need to pay back…. he not only taught me the formulations of Mr. X and Y but also something more….
This was similar to the realization of Shakespearian philosophy…. Hamlet, King Lear, and The Tempest all in chronology in Shakespeare's life which culminated in the realization “We are such stuff/As dreams are made on; and our little life is rounded with a sleep.” We are often held up in the trivialities of our materialistic life and we often loose the “sight of the forest for the trees” – pondering too much on meanings in day-to-day life rather than finding the real “meaning of life.”
In this context, I went back to the library and read the book – “Man's Search for Meaning” by Victor Frankl. Till a day back, logotherapy was only the subject of a short note in examinations – but now I can visualize every page of his book unfurling in front of me. Man needs more than material comforts to carry on in his life – even the harshness of the concentration camps could not subdue Dr. Frankl's indomitable courage to live a life – such intense uncertainties and death anxieties lead to newfound meaning which gives the person courage to tolerate the Capos in concentration camps or for individuals with addictions overcome the neurochemical imbalances as we understand from the inferences of neurobiological research.
I hypothesized – if Mr. X and Y had found “meaning in life,” they might not have gone back to alcohol repeatedly. Probably this was what my supervisor wanted me to realize not only in psychotherapy but also in my own personal and professional life. That was a turbulent time in my career – I was going through a tough phase searching for a regular government job…… but what next?…. is it only month salary, biyearly increments, reimbursements, conference visits or is there something more? Or is it about generating services in underserved areas, starting community clinics, teaching students, contributing productively to research. These were the questions which this trilogy made me ponder over again and again – as Victor Frankl illustrates – it is “search for meaning” which drives life and success rather than success itself.
We would like to thank Dr. S. K. Mattoo, Former Professor and Head, Department of Psychiatry, PGIMER, Chandigarh, for supervising the psychotherapy session.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Safran JD, Muran JC. Has the concept of the therapeutic alliance outlived its usefulness? Psychotherapy (Chic) 2006;43:286-91.
Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J. Harrison's Principles of Internal Medicine. 19th
ed. New York, NY, USA: Mcgraw-hill; 2015.
Newhill CE, Safran JD, Muran JC. Negotiating the Therapeutic Alliance: A Relational Treatment Guide. New York: Guilford Press; 2003.
Horvath AO, Luborsky L. The role of the therapeutic alliance in psychotherapy. J Consult Clin Psychol 1993;61:561-73.
Martin DJ, Garske JP, Davis MK. Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. J Consult Clin Psychol 2000;68:438-50.
Brenner C. Working alliance, therapeutic alliance, and transference. J Am Psychoanal Assoc 1979;27 Suppl: 137-57.
Hougaard E. The therapeutic alliance – A conceptual analysis. Scand J Psychol 1994;35:67-85.
Muran JC, Barber JP, editors. The Therapeutic Alliance: An Evidence-Based Guide to Practice. New York: Guilford Press; 2011.
Watson JC, Kalogerakos F. The therapeutic alliance in humanistic psychotherapy. In: The Therapeutic Alliance: An Evidence-Based Guide to Practice. United Kingdom:Guilford Press;2010. p. 191-209.
Horvath AO. The therapeutic alliance: Concepts, research and training. Aust Psychol 2001;36:170-6.
Cloninger CR, Svrakic DM, Przybeck TR. A psychobiological model of temperament and character. Arch Gen Psychiatry 1993;50:975-90.
Rotstein S. Hamlet and psychiatry intertwined. Australas Psychiatry 2018;26:648-50.
Wolberg LR. The Technique of Psychotherapy, Parts 1 & 2. New York : Grune & Stratton, Inc/Harcourt, Bra; 1988.
Frankl VE. Man's Search for Meaning. United Kingdom: Simon and Schuster; 1985.
This paper has won the Balint Award at the XXVIII National Conference of Indian Association for Social Psychiatry, Imphal, 26-28 November 2021.