Molnos, A. (1998): A psychotherapist's harvest

The (1) attitude of the therapist has paramount importance for the success of any psychotherapy and is at least as central to her work as is the technique she uses. At all times she must be aware of her first duty which is not to harm the patient. She does not attack, does not retaliate, does not destroy, does not seduce. Neither does she collude with the patient's resistance. She accepts and respects the patient's feelings and tries to understand him fully. Nothing should override the patient's best interest or the therapist's common sense.

The therapist must herself be convinced of the effectiveness of what she is doing. If her principal motivation is to help the patient, then she will be free from therapeutic ideology and dogmatism and flexible enough to use a variety of techniques depending on what is helpful to the patient. Her attitude must get across to the patient the conviction that her approach is valid. Beginner therapists might be unsure in this respect but they have an advantage over experienced ones: their enthusiasm and eagerness to do their best to help has a positive effect on the therapy. Confidence, optimism and realism have to permeate the encounter with the patient.

The right attitude will lead to the development of a good (2) rapport with the patient. Rapport can be defined as "connectedness", mental and emotional closeness which, by virtue of our social nature, occurs naturally unless it is inhibited. The first contacts with the patient are crucial for developing rapport. Considerable skill is required on the part of the therapist to elicit all the data needed at the start of therapy while at the same time establishing a rapport with the patient.

A strong rapport can develop very rapidly if the therapist refuses to accept the patient's facade and tries to get really close to his feelings and his true self. Conversely, the rapport can be weakened if the therapist remains too detached, too passive and allows the patient to carry on with a sort of intellectual self-analysis for too long. Fluctuations in the rapport, which the therapist monitors at all times, offer among other things valuable feedback as to the effectiveness of her interventions.

A good rapport between the therapist and the patient is the precondition for the development of the so-called (3) therapeutic alliance. While rapport refers to the patient's and the therapist's capacity to understand each other in general and to relate on a deep level, therapeutic alliance is their unconscious engagement in the task at hand. Both rapport and therapeutic alliance are best left alone and not mentioned or made directly an object of discussion with the patient. The reason is that making them conscious diminishes their positive and much needed strength.

The expressions "therapeutic alliance" and "working alliance" are used in the literature as interchangeable synonyms. I prefer to distinguish one from the other. As I said before, I use the expression "therapeutic alliance" to indicate the unconscious aspects of the co-operation between the patient and the therapist.

In my view (4) working alliance is the product of the patient's and the therapist's conscious determination and ability to work together on the troublesome aspects of the patient's internal world, his relationships with others and or other aspects of his life. No successful therapy can take place without a working alliance which is equivalent to a working relationship in any team effort outside the therapeutic setting.

A good working alliance requires the patient be able to look at himself objectively together with the therapist. To do so, he has to have sufficient trust in the therapist. Good feelings towards the therapist, trust and belief in her abilities and her genuine motivation to help are a prerequisite. This distinction between therapeutic and working alliance is helpful because there can be cases in which despite a shared conscious resolve to work together the patient's unconscious refuses to engage in the process in which case we could say that despite a good working alliance the therapeutic alliance is not strong enough.

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