Transference, real relationship and alliance.

The study of primitive patients, i.e. patients with borderline and narcissistic personality disorders, is utilized to examine the concepts of transference, the real relationship and therapeutic alliance in the treatment of all patients. Self-object transferences are present in the psychoanalytic treatment of primitive as well as neurotic patients. In neurotic patients they form the silent stable framework upon which the neurotic dyadic and triadic transferences emerge. The complex meanings of the patient's real relationship with the analyst are explored. In primitive patients the real or objective qualities of the analyst are perceived after self-object transferences are established. These objective attributes are then available for internalization if they are deficient and needed by the patient. The mature therapeutic alliance derives from the resolution of self-object and neurotic transferences; it requires the patient's capacity to separate the personal or real relationship with the analyst from the transference. Although precursors are visible and utilized earlier, a mature therapeutic alliance is usually not present until the later phases in the analytic treatment of neurotic patients. The therapeutic alliance concept is examined from the vantage point of its tenuous existence in primitive patients, and its slow development in neurotics. Its confusion with self-object transferences is discussed and related in part to the analyst's need to utilize the therapeutic alliance concept to help him with his loneliness and aloneness in his analytic work.