So You Thought You Had a Therapeutic Alliance?

Abstract
Research has repetitively shown that the quality of the therapeutic alliance is one of the most robust prognostic indicators of a positive therapeutic outcome. Nowhere in psychotherapy is the work of engaging and sustaining a therapeutic alliance more arduous than in the treatment of people with dissociative identity disorder. The traumatic severing of self into a multitude of identities presenting as different ages and genders,often with unique racial identifications and sexual orientations, make the task of creating a therapeutic alliance exponentially more challenging than when working with trauma survivors with a coherent sense of self. Additionally, dissociative chasms between parts of self can be fiercely defended, deflecting the therapist's best attempts to reach for and maintain a therapeutic relationship with all parts of self. Some parts of self will be prone to hide out. Other parts of self will be likely to center themselves, blocking the therapist's ability to notice others.Fierce competition and bids for special attention can be expected. Therapists are vulnerable to being overwhelmed and exhausted by the diversity of relational expectations which echo the patient's history of traumatic relational demands. The extreme, severe, chronic sexual and physical abuse coupled with neglect and betrayal trauma most often seen in DID enters the relational field evoked both by the the invitation to attachment and the deep-felt dependency inherent in all therapeutic relationships. Alliances are built in the breach and repair of mistakes and misunderstandings inevitable within the context of these treatments. Therapists new to this work often feel startled and unprepared for the chaotic movement of intense affect and traumatic enactments which flood the field. Learning how to make meaning and stay curiously and compassionately engaged are skills which can be learned. The first step may be in giving up whatever grandiosity we hold about our abilities to create a therapeutic alliance in the work before us.