All Therapies Equal, “Therapeutic Alliance” Makes the Difference

Rob Wipond
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Cognitive behavioral therapy, routine care and supportive counseling are all equally helpful — or harmful — to patients experiencing schizophrenia or psychosis, depending on the quality of the relationship that the patient feels he or she has with the treatment provider, according to a study in Psychological Medicine.

The University of Manchester researchers reviewed data from a previous trial involving 308 patients with psychotic symptoms who were put into one of three treatment arms. They found that, across the board, patients felt they improved or worsened in relation to the quality of the “therapeutic alliance” with their treatment provider.

“The implications are that trying to keep patients in therapy when the relationship is poor is not appropriate,” the lead author said in a press release. “More effort should be made to build strong, trusting and respectful relationships, but if this isn’t working, then the therapy can be detrimental to the patient and should be discontinued.”

“This is the first ever demonstration that TA [therapeutic alliance] has a causal effect on symptomatic outcome of a psychological treatment, and that poor TA is actively detrimental,” concluded the researchers. “These effects may extend to other therapeutic modalities and disorders.”

Goldsmith, L. P., S. W. Lewis, G. Dunn, and R. P. Bentall. “Psychological Treatments for Early Psychosis Can Be Beneficial or Harmful, Depending on the Therapeutic Alliance: An Instrumental Variable Analysis.” Psychological Medicine FirstView (March 2015): 1–9. doi:10.1017/S003329171500032X. (Abstract and full text)

Dodo bird verdict given new life by psychosis therapy study (Manchester University press release, April 10, 2015)

26 COMMENTS

  1. “Half of clients achieve a beneficial outcome in 5 to 10 sessions, whereas one-fifth to one-third will need more than 25 sessions to achieve a positive outcome…Forty percent of positive outcomes can be attributed to extra-therapeutic factors, that is, factors essentially out of the counselor’s hands.” (Theoretical Models of Counseling and Psychotherapy. Pg. 17, ©2004 by Kevin A. Fall, Ph.D., Janice Miner Holden, Ed.D, Andre Marquis, Ph.D.)
    Knowing a little about the various flavors of counselling can help individuals choose a method which is most compatible with their own belief system. If one approach is not a good fit, a different approach may be more successful. –
    Self- Psychology – Developed by Heinz Kohut who believed the primary function of every human is to relate to other humans, and the sole life-long need is to develop and maintain a self, which is a matrix of ambition and empathy. When the caretakers of a child are neglectful, abusive or emotionally indifferent, the child does not bond well and experiences traumatic empathic failures resulting in an arrested or undeveloped self.
    Adlerian / Individual Psychology – Developed by Alfred Adler as he grew more critical of Freud whom he had once largely supported. Adler believed that all behavior in one’s life will be evidence of moving towards a goal of achieving superiority- and will be characterized by degrees of social interest. Believing that it is not what happens to a person which is important, but how one perceives and uses creativity and experience that defines the human condition. What we take to be true is our reality. He believed there are four priorities in life, Superiority, Control, Comfort, and Pleasing, each of which have costs and benefits, as well as five tasks: love, work, friendship, self, and spirituality. To maximize health one needs to perceive and develop a sense of significance while feeling they are part of the whole.
    Existential Counseling- This therapy grew out of belief that dehumanizing forces were at work in various fields, including scientific, industrial, psychiatric, and political arenas resulting in a compartmentalization – family separated from work, religion distant from the daily drudgery, rigid gender roles, and humans being merely tools of production in the years prior to the first world war. Existential therapy involves a continual emerging, a transcending of one’s past. Mental health is conceptualized as authenticity – an ongoing striving that accepts, and even embraces the givens of life – death, isolation, freedom, and meaninglessness – as they play out in the four interrelated spheres of life,
    Person Centered Counseling – Carl Rogers began Person-Centered counseling during WWII and continued to refine it during his lifetime. He received the APA’s first Distinguished Scientist Award in 1956. He saw humans to be essentially positive with the tendency to grow, heal, and develop one’s full potential. He also believed everyone, to varying degrees, becomes alienated, and it is by affection, affiliation, aggression, and sex that one can once again begin to grow, heal and continue to develop potential. He believed that receiving positive regard from others was more important than one’s own value process. Due to his belief that virtually 100% of positive outcomes in psychotherapy comes from the quality of the therapeutic relationship, he set forth six necessary conditions for constructive personality change – and the 12 steps of the counseling process.
    Gestalt Counseling – Meaning is best derived and understood by considering the individual’s interpretation of immediate experience. Too much thinking gets in the way of true awareness and maturity. “To me nothing exists but the now. Now=experience=awareness= reality.” When one restricts awareness patterns develop which fail to meet needs or are destructive to the self or others. Understanding the world from the perspective of the client, respecting the belief that each person has a unique perception of the self, the other, and the environment is the focus of Gestalt. This understanding of the client’s reality is the key for change.
    Reality Therapy & Choice Theory – William Glasser began developing Reality Therapy during his time at UCLA in the 60’s, evolving it into Choice Theory by the 1990’s. According to choice theory, the five basic needs are survival, love and belonging, power, fun, and freedom. These needs can interact and overlap, and each person has the ability to translate these needs into specific wants – the people, objects, or circumstances that meet their needs. These wants can be revised throughout life. The survival need is the only one which is not completely psychological. To satisfy every other need we must have relations with other people. Satisfying the need for love and belonging is a key to satisfying all other needs. Power needs can be satisfied by a sense of accomplishment and competence. Fun is the quest for enjoyment – a playfulness and deep intimacy. Freedom is part of the desire for autonomy – the ability to make a choice from several relatively unrestricted options. Often this involves creativity.
    To Glasser, people exhibiting maladjustment were not to be considered as mentally ill, but examples of ways people choose to behave when they feel thwarted in the attempt to satisfy any of the five basic needs. What others consider to be mental illness, he saw as ways in which huge numbers of people choose to deal with the pain of loneliness or disconnection in order to avoid even greater pain. Choosing intense symptoms such as depression and anxiety keeps angering under control, and enables people to avoid what they are afraid of doing.
    Behavioral Counseling – According to Behavioral Counseling, behavior consists of voluntary and involuntary behaviors as a result of experiences in the environment; every person is a passive product of his or her environment. Strict Behaviorists believe cognitive events are not significant in producing behaviors, and current behaviors are the result of events which occur before and after the behavior. Positive reinforcement is when reinforcement occurs shortly after some response which increases the likelihood of the response happening again. Negative reinforcement is when a response is taken to avoid something adverse. Dysfunctional behaviors arise from a failure to learned needed behaviors. Behavior changes when environmental contingencies change. Therapeutic punishments can be utilized by counselors to inhibit certain behaviors.
    Cognitive Counseling – Cognitive Counseling was developed by Aaron Temkin Beck in the early 1960’s. Individuals have differing temperaments beginning at birth and these differing temperaments push people in different directions. Individuals are active participants in their environments, evaluating various stimuli, interpreting events and sensations, judging their own responses and actively seek and create goals. Individuals become distressed when they experience a threat to their interests. The greater the threat is perceived to one’s well-being the more intense the distress. Distress is a signal that one is not handling the pressure one faces very well. Much of cognitive therapy is about learning to deal better with the stresses one can face.
    Rational Emotive Behavioral Therapy (REBT) – REBT was developed by Albert Ellis from 1956 to 1993, undergoing several name changes as it was refined. Knowledge is based upon our selective interpretation of the world. How a person perceives people and events impacts how the person feels, behaves and thinks. Every person’s truth or reality is internally defined and experienced. An essential of REBT is being flexible in one’s world view as others have their subjective views which will differ from one’s own. No conclusion can be based on all information, so views will need to be modified as new information becomes available. Enjoying life is a primary goal in REBT, and rational individuals strive to maximize pleasure, but as personal responsibility is also emphasized, short term pleasures must at times be sacrificed for long term goals.
    Buddhist Psychology -In Buddhism it is believed two types of people are prone to develop mental health problems.
    • Those who take on too much responsibility, and consequently spend an enormous amount of time thinking.
    • Those who take on too little responsibility, and spend little time developing their mental abilities.
    It is also believed that individuals have one of five vibrational aspects. One vibrational aspect is not better than any other, but contentment occurs when individuals pursue activities that are in harmony with that aspect. Not being in harmony with one’s vibrational aspect will manifest itself in depression and self-destructive behaviors. The further out of harmony an individual is, the greater the tendency for destructive behaviors.
    Postures and colors can aid in the breaking of habitual patterns, which can be locked in the body for years. These postures and colors are designed to intensify and transmute specific neurotic patterns.
    More about each of these, plus more in Liberty & Mental Health http://www.libertymentalhealth.com

    • Your book bears the title Liberty & Mental Health. The implication is that “mental illness” and “non-freedom” are synonymous. I prefer to believe that, if there are going to be alliances, they can be freely entered into, or withdrawn from. I don’t see how any alliance that is physically imposed upon me without my willing assent can be an real alliance.

        • That is exactly what I meant. Even given the horrific physiological effects of the drugs, I’d still wager that if you compare folks getting the same script based on their relationship with their psychiatrist, the ones with the more compassionate psychiatrists would win, not only because they’d actually listen more when the person said it wasn’t working or complained of intolerable “side effects,” but also because having someone listen is therapeutic in and of itself. I think this would be especially prominent in cases of “active placebos” like antidepressants.

          On the other hand, it’s been shown that a friend who is a compassionate listener is about as helpful as any therapy, so maybe the better comparison would be “compassionate psychiatrist” to “any other compassionate person.” In that case, I’m sure the psychiatrists would lose, even the “good ones,” as long as drugs were the primary intervention.

          — Steve

          • Steve – Do you think that this is also about the result to expect, this practitioner by practitioner shift toward more intentional listening that Whitaker’s efforts makes likelier in each case? Could it have been his goal?

  2. This is one of those things where I wonder why we had to pay someone to do research to figure this out. It seems inherently obvious that seeing a therapist you don’t like isn’t going to help and may make things worse. And this is not the first time that the therapeutic alliance has outweighed the school of therapy applied. Basically, people need kindness and respectful listening. It’s not rocket science.

    — Steve

    • Exactly. All this “therapy” thing is simply a substitute for human relationship. This is also the reason why I can’t stand it (it feels to me like what prostitution is to sex in a loving relationship) but I guess some people need it.

  3. This conclusion goes way back. When I was a psychology grad student, one of the most discussed issues was that the results of therapy were the same across all theoretical approaches. It didn’t make much difference what kind of therapy it was. Therapy worked out well, the better the interpersonal relationship between the therapist and client.

    I think, going a little further with this idea, that it shows that people in severe mental/emotional distress are healed by emotional support. From the Quaker retreats to the Soteria houses, people get better when they are cared about and treated with respect and kindness.

    Respect and kindness…how hard that is to find in the “mental health” system. No wonder “mental illness” becomes chronic. You are upset, unhappy, not functioning well, and you are drugged and given the message that you are semi-subhuman (maybe not so semi) and will have to be drugged for the rest of your life.

    How can people believe that this is what society should provide to troubled people? I think it is because psychiatry has become a kind of cult, a belief system in which people believe the profession’s claims, even in the face of what they really do.

  4. Mental patients have been given a right to treatment, but they have been given no right to decline, or refuse, such treatment. This legal situation creates all sorts of havoc when it comes to ‘discontinuing’ treatment that is ‘detrimental’. We don’t, according to the experts anyway, have the right to do so.

    For some people, the ‘sick’ role just doesn’t suit them. The problem is no other role may be readily available for them. When there isn’t a “therapeutic alliance”, one person is suffering from another person or persons’ disapproval. Of course, the appropriate insight, change the milieu, is not the kind of insight this milieu of experts may be likely to come up with. If your therapists disapprove of you, of course, the outcome is not always going to be approval.

    Disrespect and cruelty are built into the law. Change the law, and we could have some actual alliances, or break ups, if that’s what it takes. Right now, the law itself works to sabotage potential therapeutic alliances.

    • In the state of Oregon, unless you are civilly committed, under order of a judge, you have the right to refuse services.

      But perhaps you are talking about the very problematic and oft abused short term case where someone ends up in the emergency room, and is determined by authorities there to be an immediate danger to themselves or other people int he community, and is held involuntarily and can be hospitalized involuntarily under authority of psychiatry for a brief period of time (brief averaging 2-3 days but in rare cases can extend for longer or can evolve into a civil commitment proceeding, with commitments lasting for 180 days with the possibility of being renewed.)

      Because that is a big problem, and that power to hold someone in the ER as a safety risk is frequently abused. So is the mechanism of civil commitment.

      • Maybe there is some kind of confusion here. What I am talking about is the law that allows for detention and civil commitment. However civil civil commitment sounds, that’s only because it’s not a matter of utilizing the criminal court system. A system that relies on a higher standard of proof to begin with, and a system in which due process may have some real meaning.

        In the criminal justice system, you have the presumption of innocence; in the mental health system, you have the presumption of “sickness”. Once a person has becomes “commited’ of “sickness”, and serves their sentence, a diagnosis of “wellness”, or remediation, is still not assured. The court, civil and criminal, can use whatever it wants to use against the person so defamed and abused. It’s on their record, said person commited a “sickness”.

        I have a problem with the idea of locking up non-criminals under medical pretenses. I don’t know about you, maybe you have some sort of fanciful thinking that this kind of medical punishment benefits the persons so punished in some way, shape, or form. From what I’ve seen, the situation of the person so punished, following such punishment, is more likely to deteriorate than it is improve.

        • “Mentally ill” are sadly not the only victims of “medically-based” punishment. Here is what is happening now to pregnant women:
          http://www.democracynow.org/2015/4/2/20_years_in_prison_for_miscarrying

          It has nothing to do with healthcare or protecting life – it’s social control, just like psychiatry is. I’m just waiting for a special disorder for pregnant women who don’t want the child to prevent them not only from seeking abortions but also from deciding about anything regarding their bodies.

          Similar outrage is happening to women in labour – there are thousands of stories of women being traumatized by otherwise normal labours by abusive doctors and nurses. If you’re wife/gf is pregnant – make sure you or some other trusted person is present with her in the hospital – that is the best way to prevent such situations.

          We’re going backwards on human rights and civil liberties.

          • This is very true. The parallels between psychiatry and obstetrics are quite common and most alarming. Unnecessary interventions that increase morbidity and mortality are promoted intensely, helpful non-intrusive interventions are demonized and discouraged, and anyone daring to critique the holy writ of the orthodoxy is subject to social ostracism and high legal risk. It’s actually more legally risky to recommend laboring in a bathtub than it is to do an unnecessary C-section. But most “consumers” are completely ignorant of all this until it happens to them personally.

            — Steve

          • Many women also opt for C-section from the fear of labour and not just the pain but the whole demeaning atmosphere and being hopeless. It feels safer and easier to sleep through the whole thing. It can have negative long-term consequences for the woman and the baby but who cares.

            On the other hand women who have to deliver a dead fetus are not given an option for C-section while such an experience can traumatize a woman for life. Offering C-section as an option with informed consent regarding risk for future pregnancies etc. should be common sense but because the doctors know better what’s good for you – you have to go through physical and emotional pain of delivering a dead baby with no say on the matter.

            I’m not even going into the treatment of women in labour because that can take not one book but a whole library. I have a psychologist friend who used to work with women who had difficult pregnancies. She told me that many of her “clients” (I hate that word) were women who had completely normal pregnancies and uncomplicated labour but they were traumatized by the staff – doctors and nurses.

            Apparently praying on the weak who can’t defend themselves is not only a domain of psychiatrists.

  5. I disagree with the result (to an extent). Therapists I have had were extremely good and caring, and I think its true that what works in one therapy will work in another.

    But what I needed was specific to psychotropic drug (dopamine supersensitivity) withdrawal syndrome and CBT(/Buddhism) was ideal. Thankfully, I did get this help that I needed to survive (and from nice people as well).

    I’ve not had the negative experience some people complain about in therapy either (at least not in non medical therapy), and there was no ‘controlling’.

  6. The abstract says this is the first time its ever been seen that therapeutic alliance has a direct effect on outcomes. That is nonsense. It’s one of the most consistent findings around.

    Here’s another one:
    http://www.ncbi.nlm.nih.gov/pubmed/10822741

    Wish I had a free link to the full text. It basically says that some people responded dramatically to therapeutic support in just a few interactions while others could work with a therapist for months on end and not see any improvement. And the distinguishing feature seemed to me how much the individual believed that the therapist had genuine empathy and love for the client. Yeah, the article published in Psychology of Addictive Behaviors journal used the word love. Said it should be the foundation of any useful interaction.

  7. I’d hope it were common sense that mutual trust is vital for progress in healing support. For psychotherapy, I’d also expect social and relationship competence from a clinician. Without that, I don’t see how they could have a healthy relationship with a client, as the relationship issues of the therapist would more than likely repeat within the clinical relationship, unbeknownst to the client.