The Therapeutic Alliance

Viacheslav Yakobchuk/AdobeStock

Medical information has expanded exponentially over the past 3 decades, with all the expected benefits of improved diagnostic acumen and more targeted and effective treatments. In my view, this has come at the cost of a foundational essential in good medical practice: the therapeutic alliance. One treatment approach that Freud did get right is the ideal practitioner’s relationship with their patient of maintaining “evenly hovering attention” while with their patient.¹ Simply put, the practitioner maintains a neutral and nonjudgmental presence while with the patient, attempting to experience the patient’s reality and belief systems despite how much these are in agreement with, or opposition to, their own.

In addition to lowering our own emotional cadence, which otherwise may cloud our assessment and approach to our patient, it reduces the patient’s defensiveness and sends the unconscious message that we accept them. This may help to strengthen the therapeutic alliance. Over the years, my approach has evolved to tell the patient early on in treatment that they are my boss and I am their consultant. Initially, they laugh, assuming I am joking. I assure them my treatment planning approach is that they are the expert in their symptoms, goals, what types of treatments they will accept, and what adverse events they are willing to tolerate—both short term and long term—to achieve these goals. I explain that I am the expert in psychiatry, and I will utilize the evidence-based knowledge of this profession to assess their symptoms and provide treatment options that may help them achieve their goals.

Again, a positive therapeutic alliance is foundational to engaging a patient in treatment and maximizing the likelihood of a good treatment outcome. Over my decades of practicing psychiatry, the following have become my “nonnegotiable” elements of treatment in an attempt to maximize a positive therapeutic alliance and outcome.

Therapy Begins in the Waiting Room

During my residency training in psychiatry, one of my supervisors shared this advice with me, which I continue to follow: Therapy begins when you greet your patient in the waiting room. A lot gets communicated during that initial greeting that can significantly impact our patient’s transference toward us and, subsequently, the treatment course. Our patient will instantly process the quality of eye contact, facial expression, and body posture, and whether we appear stressed or rushed and welcoming vs distant, which will frame the remainder of the appointment and, quite possibly, treatment.

Politics and Religion

Although it can be challenging, a skilled clinician sets and maintains firm boundaries to prevent personal beliefs or opinions from intruding into the treatment relationship. As long as our patient’s beliefs and life choices do not present an imminent likelihood of danger to themselves or others, we must respect them. Deflecting responses to patients when they inquire into our personal beliefs or opinions is a delicate process that should be rehearsed and reframed in a manner that is not insulting nor appears defensive but rather reinforces the healthy boundaries of the professional relationship.

Lack of Competency

When our patient lacks competency, either at the time of the appointment or chronically, it is prudent to document this and discuss all relevant components of our assessment and treatment recommendation with the patient’s legal guardian. For a patient with a neurodegenerative severe cognitive disorder or acute psychosis with poor judgment, the therapeutic alliance extends to the legal guardian, who should be fully engaged in the treatment process. Often, there are cases with gray areas where a consultation with a colleague or legal counsel should be obtained and well documented. One example is a patient experiencing mania in an inpatient unit who begins to recompensate, can engage in treatment planning, and requests discharge against medical advice but whose history and fragile condition are predictive of a likely rapid decompensation once away from the structure of the unit. Such cases require careful assessment and consultation involving all treatment providers and the patient’s outside support system.

Informed Consent

A cornerstone of a healthy therapeutic alliance is ongoing detailed and transparent informed consent. In my experience, the more time spent early on in treatment educating the patient about my assessment of their target symptoms, the often numerous and diverse treatment options that may help them achieve their goals, which of these treatments they would prefer and in what order, and the range of possible future outcomes, and reinforcing that our treatment relationship is a collaboration, the more meaningful dialogue occurs throughout the treatment process.

Once the patient has chosen a treatment, a detailed, transparent discussion of risks and benefits, with the accompanying full documentation, is essential. This includes not only medications but also psychodynamic psychotherapy, mindfulness-based practices, beginning an exercise program, nutritional recommendations, role- playing to coach working on interpersonal conflicts, attending self-help groups, and beginning to reduce the use of a substance that has been identified as problematic.

Starting, increasing, decreasing, or tapering off any prescription medication requires a comprehensive discussion, as many variables are involved in pharmacological treatment. Often, I have the patient schedule a follow-up 30-minute appointment soon after deciding on a medication trial to allow the time necessary to have this discussion. Starting a medication is a significant commitment by both the patient and the prescriber, and it often involves reviewing the pros and cons of different classes of medications and other members of the same class with different considerations.

Continued Treatment Evaluation

I have learned over the decades that occasionally my initial diagnostic formulation may be incorrect, and I share that possibility with the new patient up front. This is simply a result of the complexity of the numerous factors—genetics, adverse childhood events, substance use, brain neurodevelopmental changes, confounding medical conditions, significant trauma, psychosocial stressors, and others—that can impact the mental health of a person throughout their life. I have changed, modified, added, or removed what had been an established patient’s diagnosis on many occasions. It is imperative to inform the patient of this planned change and document the reasons for the change in detail.

Additionally, reviewing a patient’s medication regimen (including all prescription medications from any provider, nutritional supplements, and herbal remedies) and discussing possible dosage adjustments, or a slow taper and trial off of a medication if appropriate, should be a routine part of ongoing treatment. The practice of deprescribing medications to achieve the lowest dose of the fewest medications is often neglected in traditional medicine and should be an ongoing component of good patient treatment.

Risky Behaviors

As an intern, I worked with a resident in internal medicine who told me that when he started his own private practice, he would only accept patients who did not smoke cigarettes. I was perplexed by this requirement then, and I remain equally perplexed today. The history of humanity is a history of individuals engaging in risky behaviors for a long list of reasons, many of which are out of the patient’s control or due to ingrained cultural factors. Risky behaviors include the many substance use disorders that are common comorbidities to primary psychiatric disorders. Refusing to treat a patient who smokes cigarettes, has a substance use disorder, or engages in other behaviors considered risky violates our ethical oath to “do no harm.” Similarly, criticizing, judging, threatening to terminate treatment, and other punitive approaches serve only to deflate the patient’s self-esteem further and reinforce the feedback they likely get from others in their life who judge these behaviors harshly. I avoid ultimatums, as they put the provider in the position of having to make a polarized decision. Future success is more likely to occur with sincere concern about the risky behavior with compassionate guidance. The practices of motivational interviewing and harm reduction, complemented by psychoeducation and recommendations for other supports such as a 5-step program, can strengthen the therapeutic alliance and increase the possibility of moving toward recovery.

Inviting Significant Others to Meet

Often, our patient is unaware of significant symptoms that are readily apparent to others. Two common examples are hypomanic episodes in an individual with bipolar disorder, and significant and disabling symptoms of obsessive-compulsive disorder in an individual whose symptoms began before age 5 and feel like an inherent part of their identity. If I think my diagnostic competence could benefit from receiving input and observations from a patient’s significant other, friend, or family member, I ask them to consider inviting this other person to join us for an appointment. Other situations where this has proved helpful include when family or friends tell the patient that they should not take the medication I am recommending or that I do not really understand the cause of my patient’s symptoms. During these meetings, it is essential to ground oneself in “evenly hovering attention,” as emotions are usually high. Not uncommonly, the patient, their significant other, and I will all benefit from such a session.

Concluding Thoughts

Without a doubt, the current structure of psychiatric practice in clinics expects high productivity, and often appointments are limited to 15-minutes. Many of the approaches discussed here could improve the quality and depth of the therapeutic alliance with our patients. There is always an opportunity to bring in some element of these approaches in each appointment, which can continue to strengthen that alliance. We welcome your input on your own nonnegotiable aspects of treatment that have helped strengthen your therapeutic alliance with your patients.

Dr Miller is Medical Director, Brain Health, Exeter, New Hampshire; Editor in Chief, Psychiatric Times; Staff Psychiatrist, Seacoast Mental Health Center, Exeter; Consulting Psychiatrist, Insight Meditation Society, Barre, Massachusetts.

Reference

1. Thomä H, Hohage R. Fluctuations in the “evenly hovering attention” and their therapeutic processing. Article in German. Z Psychosom Med Psychoanal. 1984;30(3):232-237.