“Working Alliance” in Mental Health Promotes Recovery

Rob Wipond
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When people believe they have a good working relationship with a mental health care provider, they are also more likely to feel that they are recovering than when they don’t feel they’re collaboratively engaged, empowered and respected by their provider, according to a study in Psychiatry Research.

Led by University of Haifa psychologist Galia Moran, the researchers found that “the more consumers perceived the provider as employing recovery strategies with them, the more they perceived having a working alliance. In turn, the more consumers perceived having a working alliance with providers, the more their sense of recovery was improved.”

In the study, seventy-two Israelis aged 20-60 diagnosed with a wide range of mental disorders, and nearly half of whom had “substantial reduced work capacity and difficulties in social adaptation,” completed surveys based on the Recovery Assessment Scale, Recovery Promoting Relationships Scale, and Working Alliance Inventory.

“[T]he findings highlight the potential positive contribution of recovery strategies to consumer-provider relationships and mental health recovery,” wrote the researchers. “This is in accord with a previous study identifying similar associations and acknowledging the value of empowerment, self-acceptance, and hope-giving strategies by mental health consumers’ perspectives… Clinically, the study brings attention to the role of recovery strategies and alliance building in promoting recovery processes in psychiatric rehabilitation.”

Investigating the anatomy of the helping relationship in the context of psychiatric rehabilitation: the relation between working alliance, providers’ recovery competencies and personal recovery (Moran, Galia et al. Psychiatry Research. Published online ahead of press August 13, 2014. DOI: 10.1016/j.psychres.2014.08.004)

29 COMMENTS

  1. I respectfully disagree. I believe the study cited may be too superficial to be meaningful.

    I was raised in western medicine where I was taught from infancy that if there was a problem, to go see doctor, trust doctor, doctor will fix it. So, I was deeply brainwashed and had it imbedded in my belief system to seek out and trust authority.

    When I had problems, I went to the mental health system and sought their expertise. I did whatever they told me to do. I journaled. I went to therapy, group, individual and day treatment. I went into the hospital over 20 times and participated in partial hospitalization. I took a daily cocktail of over a dozen drugs for over ten years.

    When I didn’t get better, I didn’t blame them. Obviously, they couldn’t be the problem. The problem must lie with me. They were the experts and I was just someone who was messed up. So, I tried different drugs, more journaling, more drugs, more treatment. I figured that if I just tried harder, I would really be complying with what the experts said and I’d get better. I got different diagnoses as my magical thinking increased. I also got more frustrated.

    We all have many roles in life. I’m husband, father, worker, teacher, student, friend, neighbor, brother, and many more. The harder I tried and the more I did not get well, the more I blamed myself, the harder I tried, the more I didn’t get well, the more I blamed myself and so forth. The viscious cycle lead me to doubt myself more and more until I lost me. I lost my self-worth, my self-esteem, my belief in myself, my self-confidence. I became more and more, mental patient. My primary identity became mental patient. I was one of those who shuffled with stooped shoulders and eyes cast downward. I measured time from cigarette to cigarette. It was so tragically terrible that if my wife or kids needed something and I had therapy scheduled at the same time, I chose the therapy.

    There’s a lot of talk the last several years about recovery. What is recovery? Well, to me, it meant recovering that which I had lost. I recovered me. I regained that lost self. It happened ever so tiny at first. I questioned, meekly, something to do with the therapy. I trembled with fear. But, I didn’t disintegrate. I was still here and just the tiniest increment stronger. I questioned and then challenged and it took years but I finally regained myself. I recovered.

    Yes, a job and other things helped but it wasn’t the therapeutic alliance. I’ve since observed many hundreds of my peers and it seems to be almost universally true that it is necessary to question and challenge. That’s where real recovery, empowerment and growth occur. Maybe at some point a “working alliance” helps too. Maybe someone will find a research calling to dig a little deeper and find out.

    • Thank you for saying this Pat. Your story really resonates with me as I struggle to locate and re-assemble the bits of myself that psychiatry set asunder.

      To me, this is about regaining/reclaiming my personal integrity. I haven’t seen a definition of recovery that does justice to that difficult and enormously frightening task.

      However, I suspect that being able to debunk the myths of psychiatry and throw out any belief that there can be a beneficial “therapeutic alliance” to reach some undefined place/state called “recovery” might be a very big part of it!

  2. I like what you’ve written very, very much.

    You’ve said you trusted your doctors, but – and I say this with great respect – if you trusted them, why couldn’t you challenge what they said/did/prescribed?

    Courage is hard to muster when you’re being kicked.

    I’ve looked up these various scales and surveys mentioned in the article and there’s no mention of anything like ‘if I disagree I feel safe asking about it, or sticking up for myself until I get an answer I’m happy with/understand/agree with’.

    You’ve hit upon an important omission. I’d like to read more about this angle as well.

    https://www.niatx.net/PDF/PIPractice/FormsTemplates/Working_Alliance_Surveys.pdf

  3. Does this mean it will no longer be considered “appropriate medical care” for psychiatrists to declare patients to be “irrelevant to reality” and claim, prior to ever seeing their work or actually listening to their concerns, that they are “w/o work, content, and talent,” while poisoning the patient with six drugs that all have major drug interaction warnings? And will declaring a patient’s life a “credible fictional story,” because the psychiatrist realized he was a sick, twisted, deluded psychopath who was covering up sexual abuse of children, ever be considered inappropriate psychiatric care?

    Why are psychiatrists so incapable of mutually respectful relationships? Telling them mutually respectful relationships are important is not going to do any good with psychopaths like the psychiatrists I ran into. They’re incapable of mutually respectful relationships. Plus, helping patients recover isn’t their goal, all they care about is creating “mental illnesses” in other human beings to keep the money coming in. Why waste time trying to teach these staggeringly disrespectful old dogs, new tricks?

  4. The magnanimous provider empowering the grateful service user? I don’t think so. There seems no question as to where the REAL power resides in this type of relationship, and it’s still not with the service user. In fact, if there’s one thing the service user might need to recover from, it’s the power disparity implicit in this kind of a lop-sided relationship.

    As for a good relationship promoting health, I don’t think it works quite so well as no relationship with a service provider whatsoever. Putting bread and bacon on the table of a service provider, as well as shelter in one of the better parts of town, and perhaps a sail boat in the garage, does much more for the service provider than it could ever do for the user. Ditto keeping him or her in business. This is especially true when one of the services being provided is drug maintenance at the expense of physical health.

    Under employment is depressive, not to mention oppressive, as is impoverishment, lack of opportunities, dismal living conditions, poorer quality goods and services, etc., etc., etc. Rehabilitation as opportunity? What is that? Post-education education? Redemption of long delaying gratification, and long delaying social justice as well? Make me laugh.

    Were we not dealing with human beings, as some people think we are not, certainly, a more benevolent shepherd might be able to produce a better quality wool.

  5. I am new on this site and am struggling with my teenager who is refusing his medication and honestly I can’t say I blame him. My son has tried many medications this past year for psychosis disorder. They all had negative effects on him which really didn’t seem to help much of his symptoms. He has been off his meds since June. He is not any worse or better since he has stopped but the doctors continue to stress that this is a progressive illness and he will get worse without medication. My son is 16 now but when he was 6 he was diagnosed with adhd, anxiety and depression. I never medicated him and I have recently been told by different psychiatrist had I medicated him then, it might not have progressed to psychosis. I have blamed myself for not medicating him when he was younger. Now I’m supporting my son’s decision not to take antipyscotics. I want to feel confident in this decision but it’s hard when the experts are telling us its going to get worse. For those that consider yourselves recovered, what does that mean? My son has auditory and visual hallucinations. Do they go away? Do you learn to live with them? Because he is 16 and his brain is still developing is it going to get worse before it gets better?

    • Welcome! It is so inspiring to read how you are supporting your son this way. The story they’ve been telling you about his condition being progressive is a myth. There’s no need to take my word on that. Ask them for proof of it and they won’t have any. In fact, the evidence that does exist suggests that such conditions “progressing” into worse conditions is often a result of psychiatric drugging, as shown in Anatomy of an Epidemic and many other sources . Indeed, the prognoses for many of the states commonly referred to as mental illnesses were once much more optimistic before drugging became the norm.

      The persistence of experiences like hearing voices varies. There are some people for whom voices persist, but they learn to live with them and even value them. I would encourage you to look up the Hearing Voices Network if you haven’t yet. Another consistent source of inspiration and learning is Madness Radio. There are many many alternative viewpoints on “psychosis” and other experiences represented all over this website as well. I’m actually fighting the urge to rattle off too many and overwhelm you! I’m sure you will find no shortage of information here. Thank you for protecting your son from psychiatry. If you continue your research, you will find that you are likely saving him from having much worse problems than whatever he is going through at the moment. Take care and please don’t hesitate to ask around here for more information if you need to. These comments sections can be spotty at times for people seeking support, depending upon who is reading and when and who is able to respond. Hopefully, others will see your comment and reply.

    • Mommyof3

      I agree with the points made by Uprising but I would add another point to consider. Some people are more sensitive to the effects of pot smoking and the mind altering drug that it contains, THC. You might want to discuss this issue with your son and show him some of the scientific articles that show a correlation between psychosis and pot use.

      Another issue to consider would be whether or not you son experienced trauma as a child. There is a connection between trauma and psychosis and it could be helpful for him to speak with a trustworthy therapist who works with trauma victims without pushing drugs; EMDR is one such therapy approach that can be helpful with trauma victims when he is ready to address those issues.

      I have worked with more than two dozen psychiatrists over the past twenty years and have ZERO trust in modern psychiatry. Your care and careful concern for your son shines through. Keep critically educating yourself and your son, and you will eventually find the right support and path for him.

      Richard

    • Hi Mommyof3,
      Welcome to Mad in America!
      Plenty of experts disagree with the “experts” who have tried to use scare tactics to bully you into drugging your son. For starters, here’s an article by psychiatrist Robert Zipursky refuting the myth of psychosis as a degenerative illness.
      http://schizophreniabulletin.oxfordjournals.org/content/39/6/1363.full

      However, brain tissue loss does occur, but psychiatrist and long-time editor-in-chief of the American Journal of Psychiatry stated in the New York Times that it’s the “ANTIPSYCHOTICS” that cause tissue loss. (She sat on her findings for years because she feared the information would cause people to stop taking the drugs!)
      http://www.nytimes.com/2008/09/16/health/research/16conv.html?_r=0

      You may also find solace in a book written by renowned British psychiatrist Joanna Moncrieff – The Myth of the Chemical Cure:
      http://www.amazon.com/The-Myth-Chemical-Cure-Psychiatric/dp/0230574327

      Finally, I think you will find great encouragement in this brilliant and inspiring 14-minute TED talk by FORMER schizophrenia patient Eleanor Longden:
      http://www.ted.com/talks/eleanor_longden_the_voices_in_my_head

      Good luck educating the nincompoops who are “advising” you!

    • Dear mommyof3, you’re in a really difficult spot but I believe you’re doing the right thing. The decision to take a drug or not should always belong to the individual who takes it and your son is surely able to tell you how he feels about that. Actually, the claims of doctors that anti-psychotics will stop his hallucinations from developing are not backed by any science – instead the opposite seems to be true, the long-term drug use makes it worse (read the “Fat Lady has sung” article on MIA). And if the drugs don’t make any difference for him even now, there is really no point taking them, especially given the side effects (and the risk of sensitization to psychosis).
      As to how to deal with his visions, I can’t tell you because I have never had any, but having read and talked with people who had such experiences it can work out either way. For some people hallucinations disappear with time or at least their frequency and severity diminish, others learn to live with or even enjoy them (I guess that depends on what these visions are). From what I’ve heard it’s important to talk about them and not push the person to suppress the experience in order to appear “normal”. It also looks like both trauma and chronic stress not only cause psychosis but also exacerbate the visions – avoiding and learning to deal with stress could help (some people recommend CBT or meditation for psychosis). If one can identify and deal with the underlying causes which triggered the problem in the first place that could also help. Maybe joining some local Hearing voices group would be helpful, if you have one somewhere where you live… Finally there is also evidence that use of some illicit substances causes hallucinations, pot being the most well known so that obviously has to be avoided. I think it’s a very individual thing but I’d guess that acceptance of the experience is key to relive the stress and learn how to deal with it in daily life. Hope it helps.

  6. @uprising @Richard d. Lewis

    Thank you so much for your responses. I greatly appreciate it. My son has experienced trauma and was abusing heroin. For a year now he attends a school for mental health which has benefited him as for as academics and his therapist is there 5 days a week. He likes his therapist but she pushes medication on him all the time. She said recently, how can we help you if you refuse treatment and he said just talk to me. I will never take antipsychotics again. He also attends a substance abuse program. We have had disputes about marijuana. So I will definitely find some literature on psychosis and pot. As far as the trauma. He really hasn’t opened up about it yet. Maybe seeing someone that specializes in that field will be more helpful. I didn’t know that a specialist for trauma existed. Thank you for that info. He suffers EXTREME anxiety. He is taking Lexapro, Bus bar, and recently started taking a mood stabilizer. What are your thoughts on this type of medication?

    • Yes, unfortunately a person can be immersed in the mainstream “mental health” system and never hear a word about trauma. I’m a trauma survivor with more than one psychiatric diagnosis, and for me the only “treatment” of any kind that has ever been at all helpful has been talking to a trauma therapist. I’ve had terrible experiences with people who billed themselves as trauma specialists, too, so this is not a blanket endorsement of them, but I think if your son can find a good one it could be very helpful to him. As Richard said, some people find EMDR helpful. I have.

      I have been on multiple psychiatric drugs and for a long period of time. (I am not taking them any longer, and though I have trauma-related difficulties, they are much less than I had while on the drugs for over a decade, and most of my current challenges stem from the debilitating withdrawal syndrome that no psychiatrist ever warned me about.) For me, there is no question that they made my trauma problems worse in addition to causing long-term physical problems and almost killing me. It is standard procedure in psychiatry to throw every drug available at a traumatized person and then blame the increasingly poor outcomes on “resistant underlying diseases.” Putting people – especially young people – on multiple psychiatric drugs is dangerous for them and is setting them up for failure. I actually developed an alcohol addiction because of the psychiatric drugs I was given. (I realize that might sound counter-intuitive, since there is a growing trend towards giving psych drugs to people with substance abuse problems, but that is what happened.) So I would suggest talking to your son about the possibility of safely tapering off these other drugs. The Harm Reduction Guide to Coming Off Psychiatric Drugs is a good place to start, imo: http://willhall.net/comingoffmeds/.

      Speaking from my own experience, I think it is also important that your son understand that even though his distress is real, the standard medical model explanation for it is false. He does not likely have a disease or a broken brain. It can do awful things to a person’s self concept to believe such things. As is often said, “The question should not be, ‘What’s wrong you,’ but rather, ‘What happened to you?'”

    • All psych drugs can have mental side effects. As for psychosis ADHD drugs are the worst but some mood stabilisers and anti-depressants actually cause anxiety (certainly Prozac did it for me) so I’d be very careful about any psych drugs (or any illegal drugs). The crucial thing however is not to take him off the drugs abruptly – if you decide to stop them you have to do that extremely slowly else the withdrawal may trigger nasty symptoms, psychosis being one of them. I don’t know about these specific drugs but you may want to check on-line forums for people who are withdrawing from psych drugs. This is one resource I know about:
      http://www.theicarusproject.net/HarmReductionGuideComingOffPsychDrugs

  7. @Suzanne Beachy

    Thank you!!! I did come across some information yesterday about the brain tissue loss. Is it true that episodes of psychosis hardens the brain tissue? I have a lot to learn myself. I have been following doctors orders and allowing them to educate me. I’m also a member with NAMI online and they agree with the doctors. I have observed my son on a lot of different anti psychotics and they did not help his symptoms at all. It turned him into a zombie and he still struggled with the same symptoms. If I thought it helped in anyway I probably wouldn’t be here looking for alternatives. I’m just afraid that what if this does get worse. I never medicated him as a child for his adhd, anxiety and depression and now this. Am I making the best decision for him? I been told maybe if I had medicated him when he was younger, he wouldn’t have abused drugs which lead us here to psychosis. I will definitely start educating myself more and I appreciate you all giving me feedback

    • Mommyof3,

      Welcome! I do not know much of your situation, but I do hope you stop letting the doctors blame you. Refusing to put your child on amphetamines (ADHD drugs) as a small child was a wise move, and is not the cause of your son’s psychosis. Personally, I’m disgusted doctors would actually blame you in such a disingenuous manner. I would say the cause of the psychosis may have been the heroin, or pot, if he uses that, and /or the trauma issues. Antipsychotics can also cause some people to become psychotic.

      But, the good news is people can heal from adverse drug reactions, so my guess is that your child will be able to heal. Although, I agree dealing with the trauma is important, support groups can sometimes be helpful with trauma issues, too.

      I do want to warn you of an antipsychotic withdrawal issue, since your son has been taken off of antipsychotics. It’s known as super sensitivity psychosis, and doctors will absolutely deny this often worsening of symptoms is a withdrawal effect of the antipsychotics, and claim it is a return of the “disease.” So if your child does go through a worsening of symptoms, don’t lose hope, his brain is in the process of repairing the damage done to it by the antipsychotics. But he can recover.

      My best to you and your son as you make your way along this likely difficult journey, but you’re doing the right thing. Antipsychotics are “torture” drugs, and I do not think there is any actual valid medical evidence proving that psychosis actually causes brain damage. I think that’s just an assumption the psychiatric industry made, after they examined brains of schizophrenics that had been on antipsychotics for years. And, as Suzanne mentioned, Nancy Andreasen’s research proved that it was the antipsychotics which cause the atrophy of the brain. My prayers are with you and your son.

    • Mommyof3, you’re talking about your sons “adhd, anxiety and depression”. How many mental illnesses can a teen possibly have? Reading your account I’m pretty sure that your son never had any mental illness other than distress from whatever trauma he’s dealing with which caused emotional and possibly behavioural problems which then got labelled with whatever a given psychiatrist picked from the DSM.
      Btw, ADHD drugs are essentially amphetamines (some of them are pure meth) and amphetamine is very well known to CAUSE psychosis. So you likely avoided even worse problems by not giving him the drugs.

  8. Dear Mommyof3- I held my breath reading your post. I’m grateful for the advice our MIA community has shared with you. I think the most important tip I can share with you is your son needs to be educated how drugs, especially the mind-altering cannabis (more accurately now ” skunk” varieties most use) effect their young, developing brain. Heroin has terrible physiological effects especially during withdrawal, but IMO, cannabis use on the young brain can ( to some brains) can and is leading to psychosis, schizophrenia (especially the younger age when used), and depression. I will add a definite other horrifying outcome from cannabis use- suicide. How do I know? I lost my bright star, my first-born son at age 25, after 27 hellish months he endured with two ‘episodes’ of psychosis, 18 months apart, locked up in two different psych hospitals where no human being should ever end up. If I can help anyone, realize this drug is NOT the drug of the hippie days – just do your own research. IGNORE the so-called MH experts. They got it wrong with my son as the paradigm of care in MH is “medicate for life, program/ brainwash mental illness for life”. DRUGS, psychotropics- illicit or prescribed, change the neural pathways. But depression from DRUGS is real and in my naivety as my son was off ALL drugs, he tested neg for all substances yet he took his own life:(. I was sooooo ignorant about the effects of drugs, how long withdrawal can last( for months) and a stat I never knew until it was too late for my son. The highest risk of suicide from cessation of cannabis is 6 months- exact window of time my son unfathomably exited his precious life. And yes, trauma, is real, and the cause for many emotional stresses. BUT IMO kids using ” recreational” drugs trigger these brain changes…. and they have no idea the hell they are inflicting upon themselves, and their family.

    Pls follow your maternal gut, listen to your intuition. Moms are not wrong!! You found us, a good start. Your son will be bombarded with the MH paradigm of care- medication- as this is engrained in the counselors, teachers…. I urge you to keep educating yourself. I have made contact with researchers around the globe. One of the best educational websites is Cannabis Skunk Sense, a charity in the UK, to help parents and young people realize the dangers, for some brains, using the very strong THC varieties of weed. Kids, no matter what country, have NO idea what they are using “recreationally” with their peers. The U.S. lags so far behind in educating its citizens!!!! Even the cannabisandpsychosis.com website in Canada has excellent educ info, geared to their young citizens. BUT warning the website is embedded in the MI angle which please overlook. It’s the educational knowledge you seek to gain. Best to you, and your son, I’ll be holding you both close to my heart.

  9. @mommyof3-

    https://www.madinamerica.com/2014/08/extend-your-childs-adhd-summer-drug-holiday-to-infinity-and-beyond/. This MIA article by Michael Coorigan Ed.D will help you realize how wrong the so-called “experts” are who berate you for not medicating your son, yrs ago.

    For me, it’s been quite overwhelming as I’ve found out so many truths along this journey we parents are on. I ask you to try your best to take time for yourself now. You need to stay with (+) energy to help your son now. I try to go hiking, get a massage, and starting some meditation too- because these issues are awfully taxing to our souls.

    • @larmac

      I cant express how sorry I am for your loss of your son!!! Thank you for being apart of this community to help other parents going through this. You are inspiring!!! It is extremely hard when your child is not well and you can’t kiss them to make it better. I so desperately want to fix this for him. Sometimes he makes comments like ” he would rather have a terminal illness than to spend the rest of his life like this”. I continue to tell him it is going to get better. This won’t last forever. I don’t know if that is true or not but I pray for him daily and just hope that it will get better. He has had relapses with substances and I know the damage it does to him. He had an episode 2 days ago and has not been himself all week. My first gut instinct is that he did drugs. I test him and he comes up negative but I have noticed that he doesn’t have an episode right after using it will happen a couple of days after using. Some drugs are out of your system after 72 hours. When he is experiencing withdrawal that’s when the psychosis sets in. Its hard too because I’m dealing with a 16 year old. He is very intelligent and knows a lot about his symptoms but I think at times he don’t care. He just wants relieve even if its temporary. It’s heartbreaking.

  10. Sounds like one more piece of evidence that recovery within the mental health system is basically an effect of positive social interaction rather than anything else. Given what we know about the real reasons for most “mental illness” – not very surprising.