Psychotherapy research has demonstrated that a strong therapeutic alliance is associated with clinical success on a variety of issues and treatment approaches.1,2 This alliance exists when a clinician and patient develop a collaborative bond and come to an agreement on treatment goals and tasks.3 The ability to work purposefully together will only develop after a clinician and patient have established a relationship of trust and positive regard. Inevitably, situations arise during the course of therapy that can test the process of successful mental health treatment. While these purported ruptures can feel particularly overwhelming for both clinician and patient, the process of working through challenges can lead to therapeutic breakthroughs and, ultimately, a strengthened alliance.4
Risk assessment is one such situation with the potential for rupture. As mental health professionals, we must regularly assess whether a patient is in imminent danger of hurting himself or others, and whether the patient is unable to care for self, necessitating hospitalization. In suicide risk assessment, it is essential to assess both protective and risk factors in order to get a full picture of the potential danger.5 While the appropriate course of action is clear in some instances, there are also cases that fall into a gray area. When treating patients whose circumstances are not simple and clear-cut, the clinician must carefully weigh the risks, benefits, and alternatives to hospitalization, as well as create a space for dialogue about these factors with the patient.
In the age of managed care, the path to hospitalization is not a simple one. It can be a delicate matter to anticipate what the experience of involuntary hospitalization will be like for the patient, to decide how much information to disclose to the patient, and to obtain proper informed consent from him. The process of evaluation and admission in the emergency department (ED) can be a traumatizing experience. Patients must often sit in crowded waiting rooms with others who are also in the midst of mental health crises. The environment can be chaotic, with patients yelling, crying, or acting in aggressive or provocative ways. Psychiatric patients are often required to surrender their personal belongings, and they may feel like they are being temporarily imprisoned. In addition, ancillary and supportive staff may be fatigued and appear hurried and disconnected. Comprehensive evaluation by the proper mental health staff can be an arduous process that may feel intrusive and impersonal.
When the clinician believes a patient’s life is in danger, the patient’s clinical condition and suicide risk assessment must supersede concerns for the secondary effects of hospitalization. In many situations, it is important for the clinician to discuss openly with the patient the potential implications of an emergency hospital admission. Engaging in an honest dialogue before the decision to hospitalize a patient can preserve the foundation of trust. The therapeutic alliance can be strengthened when the clinician invites the patient to discuss the processes, goals, potential setbacks, and concerns related to an emergency hospitalization. The clinician should assess what the patient knows about hospitalization and what they would like to learn. After providing the patient with the necessary information, the clinician should elicit the patient’s interpretation of the information in order to gauge levels of understanding and address any confusion.
The patient’s individual attachment styles, psychopathology, and life experiences should be considered before having a conversation about hospitalization. Assessing these factors allows the professional to anticipate possible patient responses to hospitalization. The process of hospitalization, if “prescribed” by the clinician, has the potential to cause irreparable harm to the relationship if not properly discussed and explored, both before and after the ED crisis visit. Alternatively, when correctly addressed, hospitalization can function as a curative intervention that communicates deep caring and concern for the patient’s well-being.
Following an emergency crisis visit, the clinician and patient should explore what hospitalization means to the patient, and the clinician should give the patient space to discuss her thoughts, feelings, and emotions. The patient should also be encouraged to discuss any positive and negative feelings towards the therapist that may have emerged in connection with hospitalization. Exploring these topics when the patient is not in a state of intense distress can serve to build a trusting relationship and increase the patient’s feelings of agency and autonomy.
Dr Briggie is a Staff Psychologist at the Center for Motivation and Change in New York, NY. Ms Kreiter is a Research Assistant at the Family Center for Bipolar at Beth Israel Medical Center in New York, NY. Dr Ascher is a Postdoctoral Fellow in Addiction Psychiatry at the University of Pennsylvania Perelman School of Medicine in Philadelphia.
1. Lambert MJ, Ed. Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6th Edition. Hoboken, NJ: John Wiley & Sons, Inc.; 2013.
2. Norcross JC, Ed. Psychotherapy Relationships That Work, 2nd Edition. New York: Oxford University Press; 2011.
3. Bordin ES. The generalizability of the psychoanalytic concept of the working alliance. Psychol Psychother. 1979;16:252-60.
4. Safran JD, Muran JC. Negotiating the Therapeutic Alliance: A Relational Treatment Guide. New York: Guilford Press; 2000.
5. Simon RI. Assessing protective factors against suicide: questioning assumptions. Psychiatric Times. 2011;28(8):35-37.