Once I did a very bad thing.
I had been sectioned a few weeks after my son’s death and a psychiatrist walked in to the interview room I’d been put in and asked me if I thought talking to dead children was normal behavior. I said that when the dead child was yours, I thought it was entirely normal. He informed me that he thought differently.
He then asked me if I thought it would help me cope with my suicidal thoughts if he gave me three months’ worth of Tricyclic Antidepressants. I said I didn’t. He informed me again that his opinion differed from mine.
Bored with this game and it being, in my view, my turn to speak, I mused aloud on his purpose in asking me questions he clearly believed he knew the answers to. I queried whether he lacked confidence in his practice and was looking for a second opinion.
In response, he told me I didn’t seem to understand the doctor/patient relationship and asked, in a loud and very self-important voice “Do you know who I am?”
That’s when I did it. The bad thing. I replied “You mean apart from being a very short man with silly eyebrows who appears to think he’s a lot more interesting and important than he is.”
Yep, I really did. (And you should have seen the effect that had on those eyebrows!)
Why was this so bad? Apart from obviously being rude and unkind, my comments put paid to the development of a therapeutic alliance between Dr Eyebrows and myself, something widely touted as the key to a good therapeutic outcome.
Many research reports have found that a strong therapeutic alliance trumps treatment modality with people achieving good outcomes regardless of whether they are receiving CBT, DBT, IPT, psychiatry, psychology, counseling or ‘lets all dance around a wind chime’ therapy, as long as there is a trusting, respectful relationship between therapist and client.
A 2006 study on the role of therapeutic alliance in symptom reduction found patient contribution to the therapeutic alliance to be a far more significant predictor of outcome than clinician contribution. So, in destroying any potential for a warm, trusting, collaborative relationship between Dr E Brows and myself, according to a large body of research I was undermining potentially the most important aspect of the ‘treatment’ being offered to reduce the symptoms of my disorder recorded on my file as “Normal Bereavement – No Mental Disorder” but now characterized as Prolonged Grief Disorder or Suicidal Thinking Disorder or some such thing.
Using the STAR therapeutic alliance scale, it is clear that my psychiatrist and I had more than a little work to do on our therapeutic alliance:
My assessment against the patient criteria would go something like this:
My clinician speaks with me about my personal goals and thoughts about treatment.
Absolutely. Big tick here. We spoke at length about my foolish and delusional belief that SSRIs had induced my child’s suicide and my inappropriate goals to discredit psychiatry, to warn people of the dangers of ‘treatment’ and to hold accountable the psychiatrist who had drugged my son.
My clinician and I are open with one another.
Open? Like a pub on St Patricks Day we were most certainly open. Neither of us held anything back . . . nothing at all.
My clinician and I share a trusting relationship.
Totally. I trusted him to be a self important buffoon with nothing of use to offer me and he trusted me to be a disrespectful shrew with an elevated sense of her own competence.
I believe my clinician withholds the truth from me.
Not sure. I suspect he failed to tell me that under his rather cheap brown suit he had a tattoo of Mary Poppins with “Practically Perfect in Every Way” written neatly underneath.
My clinician and I share an honest relationship.
Is the Pope a man who wears a rather unflattering dress? Yes. Brutally honest.
My clinician and I work towards mutually agreed upon goals.
We both wanted to get me out of there – he just wanted me sufficiently subdued that I would stop making my outrageous claims to the media before that happened and I was the shrew who refused to be tamed.
My clinician is stern with me when I speak about things that are important to me and my situation.
Stern? Are you kidding? He was more ‘back end of the boat’ than the back end of a boat.
My clinician and I have established an understanding of the kind of changes that would be good for me.
I believe at that time we both thought death by my own hand would be the most appropriate therapeutic goal – why else would he have sent me home to an empty house with a three months supply of Clomipramine? And why would I have promptly taken it all when I got home? Talk about a therapeutic alliance. We were virtually betrothed!
My clinician is impatient with me.
Yes, I believe he was. Most of the day, nearly every day for a period of almost 2 weeks. Hold on a minute . . .
My clinician seems to like me regardless of what I do or say.
Oh my goodness, no. Not at all. Not even a little. Not for a minute. I cannot stress enough how very little the man with the extraordinarily malleable eyebrows did not like me.
We agree on what is important for me to work on.
Um…no. He thought the focus should be on my attitude. I thought it ought to be on perfecting a ‘raise dead children’ spell.
I believe my clinician has an understanding of what my experiences have meant to me.
Oh my goodness, no. No. No. No. Not in any way or to any degree. No.
You get the picture. Warm, trusting, collaborative our relationship was not.
So, given that so much emphasis has been put on the importance of the therapeutic alliance in treatment adherence and outcomes you would think that the pairing of Mr Bombastic and Bad Jelly the Witch would predict poor outcomes and that I had undermined my well-being with my unnecessarily disrespectful comments.
Well, maybe not.
Interestingly, a recent study looking at the impact of early therapeutic alliance on suicidality showed that while “suicidal ideation tends to remit across appointments, early therapeutic alliance is not associated with this change.”  The authors cite several studies, which have found that therapeutic alliance is unrelated to clinical outcomes in the first few treatment sessions and have suggested that therapeutic alliance comes after clinical improvement occurs in treatment.
Another interesting study from 2007 found that whether patients received their preferred treatment influenced the development of the therapeutic alliance where patients stated a preference for, and then engaged in, talking therapy. The authors found that
Among patients initially preferring psychotherapy, those receiving psychotherapy experienced increases in their alliance over time, whereas those receiving active medication or placebo experienced decreases. Among patients preferring pharmacotherapy, there were no differences in alliance development whether they received psychotherapy, active medication, or placebo.
So, the therapeutic alliance may arise from respecting the treatment preferences of patients and achieving good outcomes for them, rather than good outcomes arising from the therapeutic alliance. In my case, the lack of therapeutic alliance between my psychiatrist and myself meant I was the only person in the hospital who was not medicated. Pretty good outcome if you ask me.
This sits well with my theory that too much trust in the doctor/patient relationship is not a good thing, particularly in the initial stages of treatment. That patients may be at risk where shared goals and high levels of trust are established too quickly and that a degree of discomfort, mistrust and divergence of views are beneficial at least in the early stages of the relationship. I think, and the research would seem to support, that we should wait until our clinicians have produced some results for us before we start trusting them, aligning our thinking with theirs and ending sessions with bear hugs. I think trusting too early risks lack of informed consent, failure to question and agreement to harmful interventions, and that we should be cautious about the notion that we have to like our clinicians in order to get good results from treatment.
I would after all not bother too much about the degree of warmth and fuzziness the ironmonger down the road brought to our business relationship . . . at least until after he had shown he could fix the leak in my cauldron.
 Rebecca McGuire-Snieckus, Rosemarie McCabe, Jocelyn Catty, Lars Hansson, Stefan Priebe 2007 A new scale to assess the therapeutic relationship in community mental health care: STAR Psychological Medicine, 37, 85-95
Craig J. Bryana, Kent A. Corsob, Meghan L. Corsoc, Kathryn E. Kanzlerd, Bobbie Ray-Sannerude & Chad E. Morrowf Therapeutic Alliance and Change in Suicidal Ideation during Treatment in Integrated Primary Care Settings Archives of Suicide Research Volume 16, Issue 4, 2012
 Iacoviello, Brian M; McCarthy, Kevin Scott; Barrett, Marna S.; Rynn, Moira; Gallop, Robert; Barber, Jacques P. Treatment Preferences Affect the Therapeutic Alliance: Implications for Randomized Controlled TrialsJournal of Consulting and Clinical Psychology Issue: Volume 75(1), February 2007, p 194–198