Cyclical dynamics in the therapy room: The interactive role of the therapeutic alliance in psychotherapy process

The last decades have seen an exponential trend toward a relational reconsideration of psychoanalysis (Greenberg & Mitchell, 1983), that has drastically influenced aspects of both psychotherapy theory and research. On the theoretical side, indeed, the therapeutic process has been reformulated under an intersubjective perspective, and it is now conceived as a “specific psychological field” created by the interplay between the patient’s and therapist’s subjectivities (Stolorow, Brandchaft & Atwood, 2014). On the research side, the construct of therapeutic alliance as a relational dimension has become very important. Accordingly, recent conceptualizations define the therapeutic alliance as an “intersubjective negotiation process” (Safran & Muran, 2000) that interacts with the other variables of the therapeutic process (Roth & Fonagy, 2013), although little is still known about the precise dynamic involving these key dimensions. On these grounds, the present doctoral thesis aims to explore the role of the therapeutic alliance in the therapeutic process, by means of an intersubjective perspective in both group and single-case studies. The first part of the thesis investigates the interaction between therapeutic alliance, technical interventions and metacognitive functioning in groups of patients, by focusing in a first study on the earliest stage of the treatment and, in a second one, on the more advanced stages. Results of both studies show that technical interventions and therapeutic alliance are associated in specific interactive patterns that can be differentiated in three different levels of therapeutic alliance: a positive, a neutral and a negative level. Furthermore, in these interactive patterns, metacognitive functioning plays a specific role of mediator depending on the level of alliance. The second part of the thesis includes two single-case studies, involving a patient with an anxiety disorder diagnosis and with a deferential behavior toward the therapist. The first study specifically focuses on the patient’s collaborative alliance and its association with defense mechanisms, therapeutic relationship and therapist’s technical interventions. On the contrary, the second study focuses on the investigation of alliance ruptures and their interaction with transference patterns and defense mechanism. Results show that the intersubjective approach applied on the deferential behavior, on the one hand challenges the real authenticity of patient’s collaborative process, and on the other hand suggests that ruptures may provide a better understanding of the patient’s transference and defense mechanisms. Overall, this doctoral thesis indicates that the therapeutic process can be conceived as an interpersonal cyclical dynamic that involves both technical and relational factors. In this sense, the therapeutic alliance may be considered as a medium, by means of which other variables operate during the therapy.