Early relationship struggles: A case study of alliance formation and reparation

Abstract

Aim: A good alliance established during the early sessions of psychotherapy will most likely lead to a good outcome. As a result, there is much to learn from a case in which both the patient and therapist regarded the alliance as being poor for an extended period (the first 15 sessions), yet still managed to develop a solid and stable alliance and reach a successful completion of therapy. The aim is to give a close inspection of this reparation process. Methods and analysis: Ratings on the Working Alliance Inventory (WAI) were used to guide the strategic selection of a case in which a depressed woman in her thirties sought help from an experienced senior male psychotherapist. A detailed analysis of the therapeutic dialogue brought forth what the parties expected from each other and how they responded to explicit and implicit expressions about how to proceed. Post-termination interviews revealed their subjective configurations of events in therapy and their corresponding reflections. Findings and discussion: Important steps and hallmarks of the alliance formation and reparation were identified: (i) Early in the process, incompatible expectations about what the relationship could achieve led to repetitious struggles. (ii) Their conflicting notions came forward in a more open dialogue about two specific issues (her medication and sick leave). (iii) Through the recognition of different viewpoints they were able to expand on their interactional pattern and develop playful ways to explore her decision making in everyday life. (iv) Temporary breaks seemed to consolidate her autonomy. (v) Late in the course of therapy, the therapist introduced a literary metaphor that seemed to further consolidate the alliance.

Keywords:

• case study
• therapeutic dialogues
• rupture and repair
• working alliance