An effective approach to treating addiction hinges on the practitioner’s ability to engage and maintain patients in a high-quality therapeutic alliance. One recent study found that improvement in the quality of the therapeutic alliance during treatment contributes significantly to decreased alcohol use.1 Another review concludes that the content or model of therapy has little effect on improvement of substance-related outcomes, but the interpersonal qualities of the therapist—especially the capacity for empathy—can have significant effect.2 Furthermore, recent research reflects favorably on Freud’s early pronouncements that patients must be active collaborators in their treatment, and psychoanalytic constructs are critical to investigating the effect of the therapeutic alliance on treatment outcomes.3
Establishing a therapeutic alliance certainly involves controlling countertransference and maintenance of emotional neutrality because open, affect-laden displays of frustration, even disagreement, result in the patient’s perception that he or she is being judged. Such occurrences cause discord and degrade the therapeutic alliance. Beyond this, practitioners must be able to present feedback regarding their knowledge of addiction in a non-dictatorial manner while maintaining a highly personal relationship that allows them to show genuine satisfaction when their patients make positive health-oriented decisions.
The concept of the “holding environment” is probably the best metaphor for capturing the qualities of a good therapeutic alliance.4 The mother-child bond is based on love. The holding environment is created out of a mother’s desire to appropriately meet her child’s needs at each stage of development. Such nurturance includes supporting responsible behavior, self-reliance and, eventually, independence.
The therapeutic alliance is based on a practitioner’s personal mission to help others, genuine empathy, and respect for the patient’s autonomy and well-being. It is critical to express the belief that patients have the capacity and responsibility for the quality of their lives. This approach to treatment provides a powerful meta-message that patients are expected to develop self-efficacy, or the ability to be self-sufficient and assume responsibility for their own behavior.
In one recent report, self-efficacy is repeatedly shown to be an important predictor of treatment outcomes, and it is recommended that research efforts be stepped up to understand how it can be enhanced in treatment.5 When the therapeutic alliance is based on these principles, patients (with the possible exception of those with severe antisocial and narcissistic disorders) recognize the value of the therapeutic relationship and reciprocate with respect and positive regard.
Motivational interviewing (MI) is the most effective psychosocial model for establishing the therapeutic alliance because the practice of MI reflects elements of the holding environment, including concern without judgment, a desire for patient success, and empathy.6 In fact, empathy is the most important practitioner quality for success in psychotherapy.7
When MI is used, patients view the practitioner differently from others in their lives who offer advice without understanding or simply attempt to coerce them to change. Concomitant with empathy and a non-judgmental attitude, MI practitioners relate to their patients as equal partners in the treatment process. Referred to as egalitarianism, this quality de-emphasizes the power issue associated with the classic physician-patient relationship and reduces patient resistance. This sense of equality also provides the patient with a clear indication that MI therapists do not consider themselves to have any authority over or responsibility for patient decisions and, importantly, for treatment outcomes. An MI-based approach reduces defensiveness and engenders trust; patients become willing to explore their ambivalence over maintaining the status quo versus initiating behavior change in their lives. The principles of MI are to:
• Express empathy
• Develop discrepancy between current behaviors and broader goals
• Avoid argumentation
• Roll with resistance
• Support self-efficacy
These practices promote a spirit of MI that is capsulized in Table 1.
Dr Kelly is Clinician Emeritus, University of Pittsburgh School of Medicine, Western Psychiatric Institute and Clinic, Pittsburgh. He reports no conflicts of interest concerning the subject matter of this article.