Engagement before alliance.

An approach to the psychotherapy of ego-depleted states or with morbid disease involves the commitment of the therapist far beyond a distant psychoanalytic stance. Engagement must occur before a therapeutic alliance and exploration of underlying issues can begin. The patient in a helpless state needs the therapist's concern (both by frequent visits and telephone), active participation with family, and occasionally medication. The 'all out' effort allows the patient to borrow some of the therapist's strength. Within this approach, one may expand or contract goals; many patients went on to further explorative work. This mode stands outside of many of the usual values and canons of psychoanalytic therapy, and many therapists need encouragement when they risk closeness with patients' desperation and/or disease.