Is Therapeutic Alliance Over Rated?

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[1], 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.” [2] 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.[3]

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.

 

 References:

[1] 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

[2]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

[3] 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

 

 

30 COMMENTS

  1. Brilliant, bitter and utterly lovely piece.

    thanks

    On a more sober note, Bertram Karom, whose life work is the psychotherapy of people diagnosed with schizophrenia, says he always thinks, at the first session, that he is not good enough a therapist and that he feels very uncomfortable. He says that is how it should be, he is trying to form a trusting relationship with someone who is very scared and who in all likelihood has been treated appallingly by those who they thought they could trust.

    So even if you want to see a counsellor and the counsellor is competent it ain’t gonna be a rose garden 9 times out of ten, although I’d expect people to feel at least a little bit better at the end of the session. But if you don’t feel a bit better by the end of the session you probably never will, so then it’s time to ditch them.

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  2. I don’t know…the only times I got anything useful from therapy happened when I felt the therapist was in sync with what I wanted to do with my life, and that we had a lot of shared values.

    I was a little surprised by how this article came out. I would think in almost all situations where the “patient” is in a place involuntarily, they damn well better kiss the rear end of the doctor. It sounds as if this doctor did not retaliate. Very surprising.

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    • He did Ted, he was pretty mean to me but in retrospect I think it was a good thing that he and I didn’t trust each other. If he’d been kind and respectful to me I probably would have done anything he wanted including taking the mix of TCAs,Benzos and Hypnotics he recommended and a lot of unhelpful stuff around severing attachment to my son. I’m glad that because I didn’t like him or trust him my default position was to be wary of his recommendations and look for flaws in his proposals.

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    • It may seem surprising, but actually docs don’t seem too keen on taking clients who can stand up for their rights in well-researched ways to court. Thanks to Robert Whitaker and psychrights.org, it’s easier to show the doc’s treatment isn’t the most effective or least harmful. Many people communicate with loved ones who’ve passed. Some write very successful, much-loved books, like The Afterlife of Billy Fingers: How My Bad-Boy Brother Proved to Me There’s Life After Death. Over 70% of American adults believe in angels, and over 30% say they’ve encountered them. (Doreen Virtue, Angels 101) I hear the US Supreme court upheld the right to personal religion.

      I had my brain activity measured by a provider of brainstatetech.com after focusing on spiritual beings for 3 years. The temporal lobes are known to mediate spiritual experiences and were the closest area to my emotional centers measured. They were highly balanced, which correlates with symptom relief. The amplitudes of some frequencies and bands were almost perfectly balanced, left hemisphere to right, So they could coordinate information almost perfectly. If psychiatrists aren’t mystical, intuitive-feeling, they don’t experience firsthand how well-ordered that state naturally is.

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  3. In a study of people grieving over lost loved ones, 96% of participants with intuitive-feeling personalities (on the Meyers-Briggs scale) reported after-death contact experiences. 100% of the sensing-thinking participants did not! (Supernormal by Radin: http://books.google.com/books?id=ngETfEp8cSoC&q=Meyers+Briggs#v=snippet&q=reporting%20after-death&f=false )

    How often do psychiatrists see people as patients because they don’t value different, more mystical styles of perception? Therapeutic alliance shouldn’t be conflated with conflict of interest, when patients become disempowered to stand up for their own personal style in favor of the therapists’.

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  4. I don’t want to quibble over terms, or how they are used. What I know is that in my work, it matters whether or not I treat the person I offering support to with respect and dignity.

    It doesn’t take a lot of science to conclude that a person who feels respected and treated lovingly as a full and equal human being will be in a creative space more likely to lead someplace positive, vs. someone who feels disrespected, demeaned and marginalized.

    Treating people with respect is a core value, not a “technique” – and it starts from the second you enter into relational contact with anyone else. When its there between two people, it is often a significant contributing factor to some amazing collaborative accomplishments.

    I think its very important to voice the idea that the “therapeutic approaches” the person receiving services feels he/she needs is a substantial predictive factor on how positive the outcomes are. There’s also something really important to reminding people who are championing one particular fad therapy as “the best and only correct” way to practice that in many cases, the level of genuine empathy felt by the “client” has a bigger correlation to positive outcomes than the magic “treatment” approach does.

    A very beautiful (strange word to use about research, eh?) study that had a big impact on my professional values: Rediscovering fire: small interventions, large effects by Miller (2000).

    Basically, it says the key ingredient to healing partnership with another person is: love.

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    • Unfortunately many therapists seem neither trained nor inclined to treat people in mentally healthy ways which reinforce (and thus increase) people’s inner mental order. This is done very successfully by reflecting back people’s inner harmony– what they do well. Technology from brainstatetech.com that reflects back well-ordered, harmonized brainwave activity as sounds quickly relieves symptoms for good, almost always. Instead, people receive less effective services for years or life.

      Therapists caught in a pattern of not focusing on people’s mental order often resist facing they haven’t been treating people in the healthiest ways. They must model seeing people’s mental order so our culture recognizes this is healthiest. They often feel caught in the socio-economic structure, unwilling to risk loss of professional status to admit it’d have been healthier to focus on what’s been going well with people all along.

      This skill can be learned once people realize focusing on people’s inner strengths or harmonious order increases them. The opposite should only be done as a last resort in self-defense. People can only connect with that which can connect – and only harmony connects, as only harmonious bio-waveforms can join and amplify. This is what occurs in truly loving states.

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  5. It feels very counter-intuitive to me to be suggesting that warm, respectful, collaborative relationships can be harmful but I guess what I’m trying to say is that when we keep our distance and wait to see whether the therapist is competent not just nice, we keep ourselves a little safer than if we trust too much, too quickly and run the risk of trying to please and being less able to critically assess treatment plans, approaches etc. Sometimes I think the emphasis on therapeutic relationships can be a bit like falling in love with someone totally unsuitable but being blind to their faults or incompatibility.

    Really just saying I found this hard to write to and am not sure I’m convinced but thought it was a useful discussion to have.

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    • Quite right, that’s what I was trying to say above. If you’ve been treated appallingly why trust people until they have shown they are worth trusting?

      I thought it interesting that the Dr wanted to send you home where you would be isolated and lonely with some pills to take when that was probably one of the worst things he could do. I’ve been saying for a few years now that psychiatry on the whole offers drugs and neglect in the community. Here you just confirmed it in the worst possible way.

      The responsibility of achieving a real therapeutic alliance is the job of the worker, not the client. This guy did the opposite, that classic service provider trick of trying to get you to fit his ideas and perhaps blamed you for not fitting in.

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    • If people aren’t being treated in truly loving, healthy ways, they should exercise their right to protect themselves from that. Protecting is loving, as is showing them they can’t get away with hurting people. At least in the US, treatment can only be forced through the courts. People who can assert their perspective in ways that can be understood as sensible and supportable can prevail in court. I was inspired to learn this by reading Fight Back and Win by civil rights lawyer Gloria Allred. The court battle is probably the most widely respected battle, as it enforces respect for rights peacefully.

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    • Thanks Richard. In my life, if you don’t laugh you’re going to do a whole lot of crying and using sarcasm helps me laugh at things I’m sick of crying over. As for being thought provoking, I’m still trying to make sense of the world following my son’s suicide and I’m not at the point of having the right answers just hoping to ask some of the right (or at least interesting)questions.

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  7. Hi Maria,

    Wow, I didn’t know you were held in a mental hospital after psych meds caused your son to commit suicide. What a horrific irony.

    By the way, I made the mistake of initially trusting a regular doctor initially only to find how wrong I was. So your point about hold back trust is a good one.

    AA

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    • Yep was sectioned twice after Toran died. Found to have no mental disorder both times but that didn’t stop them from locking me up and trying to ‘treat’ my grief. Toran’s suicide was all over the papers and on TV and I was saying in interviews the drug killed him and being sectioned may have been an attempt to undermine my credibility. Would be nicer to think they were genuinely concerned that I may kill myself but sending me home to an empty house with enough drugs to do the job doesn’t seem like very good suicide prevention.

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      • Wow, I am speechless as to what happened to you.

        This may not be the best analogy but your situation reminds me of people who lose loved ones to the abuses of tyrannical governments only to end up jailed by them for trumped up charges.

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      • If they found no disorder can you take them to court for detaining you without good cause? It is important for the population as a whole to uphold rights to care about lost loved ones, while remaining free, through the courts. This is very meaningful to most people and they are empowered by good examples.

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  8. Thank you for this very raw and honest snapshot of your process. I find it very reminiscent of the inner dialogue I’ve had while healing from past therapies.

    I feel that a big part of the shift, here, is to reassess to whom we, as a society, turn for support and guidance. For me, trust is a cornerstone to healing, and it can be so difficult to re-gain the sensation of trust in our bodies when hurting from feeling as though we’ve been betrayed in or by life. Certainly, it seems that whatever betrayal may have been the original trauma, it seems to be inevitably repeated in mental health care–at least for the most part, from what I’ve seen and experienced.

    Best wishes to you, Maria. You’re courage moves me tremendously.

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  9. My first contact with my son’s young consultant psychiatrist was first class. My son nearly managed to commit suicide thanks to the drugs and its side effects another psychiatrist had put him on without even telling him the drug was an atypical antipsychotic. As soon as I pointed out that I blamed the antipsychotic for what happened, the atmosphere in the ward changed and all psychiatrists closed ranks and promptly labelled my son “severely mentally ill”. My son’s friendly psychiatrist stopped discussing anything with me. He actually went on three weeks unexpected leave and returned once my son had been discharged. Somehow I suspected that my son’s psychiatrist had been told by higher powers not to discuss what had happened with me but deep down he knew what I was telling him was true. The therapeutic alliance was nipped in the bud.

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  10. Great article, Maria. I, too, try to use humour to see me through all this. Trouble is, I’m just not as funny as you are.
    I think when we’re dealing with emotional rather than medical issues, a therapeutic alliance can be enormously helpful but still, as you suggest, be approached with caution. There is something very odd to me about the guy on the other side of the desk being “designated sane,” leaving you, of course, to be the “designated insane.”

    I saw my psychiatrist recently and we continued the same battle we’ve been having for years. I said that my depression had lifted due to my moving into my own place (from a fraught environment), focusing on exercise and good nutrition, working part-time, going back to university, etc. He corrected me: No, it was due to Lamotrogine. I take Lamotrogine (Lamictal) for my epilepsy which I developed in response to ECT, which was coerced. Trouble is, I felt better way before I started the drug but I didn’t want to split hairs.

    I stressed that the single most important factor was moving out and creating a warm, inspiring, safe place for me to blossom in. He said, no, a “simple move” wouldn’t account for it and called me “misguided.” I basically said “Same to you, buddy.” And this is actually a shrink that I like!

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  11. Maria
    Well written, witty and moving article but I’m not sure exactly what your point is. It’s seem obvious that a relationship with an emotional boob, with the typical narrow-minded views of a shrink, is not going to
    be helpful to someone of your intellectual independence. But I don’t see how that refutes the idea that
    “a strong therapeutic alliance trumps treatment modality” as you imply. The logical and valid converse of that idea is that a weak alliance also trumps modality since it’s hard to imagine anything that therapist could have done that would have helped you.

    Your story demonstrates the weakness of their research methods, although you do not explicitly say this. I think your point is that had you been less self-confident (i.e. someone else) you might have “contributed more” to the “therapeutic alliance” and thus you might have felt or reported that the therapy was effective even if it undermined your self-confidence, even had it weakened your ability to be self-assertive, even had it made you dependent on drugs. That’s a strong indictment, but you stop short of saying it.

    Therapy is greatly over-rated. There are few studies that assess the harm it can do to people–yet Thomas Szasz, R. D. Laing and Erving Goffman and many other great writers and/or therapists have shown its destructive effect on those outside the prevalent social norms–particularly those who get the worst labels.Your story also illustrates the agonizing effect of having to suffer such imbecility right after a personal tragedy. Even
    when it’s not an adjunct to drugs, individual therapy is at best a substitute for community and friendship which are often difficult to find in our society–particularly in rainy day weather, Nowadays as John points out above
    psychiatry offers drugs and isolation in the community.
    Seth
    Seth Farber, Ph.D.
    http://www.sethHfarber.com

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  12. I loved the article, and I think I get your point: you would be foolish to enter into a therapeutic relationship with a guy like this! He can’t be trusted, he doesn’t like you or care about your goals, he wants to push you around and have you think like he does. I totally respect you for telling him to stick his head “where the sun don’t shine!”

    I would absolutely agree: folks should expect results from a therapist, and trust should only grow over time when it is earned by the therapist as a human being. The NORMAL position one should take in a new relationship is one of caution. Many people are hurt over and over again because they can’t set this kind of boundary early in a relationship, and so are unable to objectively observe whether or not trust is merited in this particular person’s case.

    When I am working with clients with abuse/trauma backgrounds, I often start off by saying that I don’t expect them to trust me, that I wouldn’t trust me either, and that I hope over time to EARN their trust by my behavior. It may well be that the process of effective therapy itself leads to the trust that the therapist earns, and that this trust is only earned after results are seen by the client. This seems very healthy to me, and something we should encourage. The idea that you should open up to a total stranger just because they have a degree or assigned role in your life is foolishness. Trust is something you earn over time, and clearly your psychiatrist didn’t earn a shred of it. He earned, and appropriately received, your contempt.

    —- Steve

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    • Well, said Steve: “It may well be that… trust is only earned after results are seen by the client… The idea that you should open up to a total stranger just because they have a degree or assigned role in your life is foolishness.” If psychiatric practices entrain people to trust strangers based on degrees or roles, in many cases they entrain them to trust predators. That’s the exact opposite of mentally healthy! Predators would fund and promote systems designed like that!

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