Psychiatrist Calls for Increased Attention to Therapeutic Alliance


Sandra Steingard, writing in the journal Psychiatric Services, reviews research finding that the quality of the therapeutic relationship impacts on the efficacy of medication treatment. That is, people taking medications for psychological concerns tend to do better if they have a good relationship with their treatment provider.

Although the original authors suggested that a positive relationship might improve medication adherence, and thereby increase positive outcomes, Steingard notes that they did not actually measure adherence. Thus, she suggests alternative explanations, and even questions some of the assumptions made by the authors.

Dr. Sandra Steingard serves as Medical Director at Howard Center, a community mental health center in Burlington, Vermont. She is also Clinical Associate Professor of Psychiatry at the University of Vermont College of Medicine.

Steingard writes that because placebo response rates for psychiatric medications are so high, “there is something beyond the pharmacological properties specific to the drugs under investigation that affect outcome.” For Steingard, this is the therapeutic relationship, which has been shown in psychotherapy research to be an important factor leading to positive outcomes.

Steingard argues that the current paradigm in psychiatry, which prizes seeing as many patients as possible in short sessions, de-emphasizes the therapeutic relationship. Instead of following this model, she proposes that psychiatrists engage in other approaches, such as Open Dialogue.

Such an approach emphasizes communication between treatment providers, the service user, and everyone who cares about that person. Sessions include all these constituents, and emphasize respect for each voice. This approach, Steingard notes, has had tremendous success—particularly with people experiencing first-episode psychosis. Often, this approach also manages to use medication only as a last resort.

Steingard also questions the assumption that medication adherence is a primary goal of treatment.

“It is not clear that a ‘best outcome’ for the therapeutic alliance is increased adherence. In shared decision making, for example, one aim is to understand the patient’s goals. Achieving these goals may not be as dependent on drug adherence as many physicians assume.”

Steingard also encourages researchers to include, in both the design and implementation of studies, people with lived experience of the psychiatric system. This approach enables those who are directly impacted by practices to have a voice in what those treatments entail.

According to Steingard, research on the impact of the therapeutic relationship could help improve our system of care. If conducted with the inclusion of people with lived experience, it could inform new treatments that incorporate other methods of healing beyond medication management. It might even challenge the accepted practice in psychiatry of quick sessions with many patients, focusing instead on building a relationship to facilitate healing.



Steingard, S. (2018). Therapeutic alliance: Implications for practice and policy. Psychiatric Services, 69(1), 1. (Link)


Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.


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Peter Simons
Peter Simons was an academic researcher in psychology. Now, as a science writer, he tries to provide the layperson with a view into the sometimes inscrutable world of psychiatric research. As an editor for blogs and personal stories at Mad in America, he prizes the accounts of those with lived experience of the psychiatric system and shares alternatives to the biomedical model.


  1. Thanks, Sandra, for pointing out to your peers what sane people innately consider common sense. It’s truly a shame that, what most people consider common sense, needs to be pointed out to the psychiatric industry.

    As to, “It is not clear that a ‘best outcome’ for the therapeutic alliance is increased adherence. In shared decision making, for example, one aim is to understand the patient’s goals. Achieving these goals may not be as dependent on drug adherence as many physicians assume.”

    Especially since adhering to the psychiatric drugs is not beneficial for the majority of patients, since the antidepressants and ADHD drugs can create symptoms that mimic the “bipolar” symptoms. And the “schizophrenia” drugs, the neuroleptic/antipsychotic drugs, create symptoms that mimic both the negative and positive symptoms of “schizophrenia,” via both neuroleptic induced deficit syndrome and antipsychotic induced anticholinergic toxidrome.

    And, of course, having psychiatrists create the symptoms of their “serious mental illnesses” in their patients with their psychiatric drugs is not actually going to be a “goal” of any of their patients. But making people sick for profit is apparently the goal of many of the psychiatrists and mainstream doctors, since such abhorrent and hypocritical behavior is very profitable.

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  2. They have a religious zeal for “medication adherence”. What if it is not medication the doctor is prescribing?

    “positive outcomes”? Schizophrenia Positive Symptoms

    Positive symptoms in schizophrenia refer to an excess or distortion or normal function. Positive symptoms are the ones most typically associated with schizophrenia or psychosis.

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  3. I dealt with five psychiatrists in my journey through the “mental health” system, from beginning to end.

    Out of the five two were verbally and emotionally abusive, one was a good man who didn’t have any idea how to help me because I didn’t want the drugs, one was very patronizing and paternalistic. Only the last one, the youngest one of all, was willing to listen to me as I explained why I ended up in the system in the first place.

    The other four didn’t give a damn about what catapulted me into misery and difficulties; as far as they were concerned this had absolutely nothing to do with why I experienced problems. It was obvious that I had a broken brain and needed the drugs to balance my “chemical imbalance” in that broken brain. I would ask the first four why it was that my broken brain only showed up in my 60’s. I told them that if I had a chemical imbalance it should have shown up a lot earlier than it supposedly did. They didn’t like my questions.

    I agree totally that it’s the relationship between two people that makes the difference as to whether a person may move herself/himself forward to search for health and well-being. The most helpful person to me was a young therapist who was just beginning his practice. I appreciated him, not so much because he was a “therapist” (I don’t have much respect for titles in my old age) but because he cared about me as a person. It’s the human connection that makes the real difference for me. If I know that someone actually cares about me then I can begin the work of trying to make things better for myself. Then I can admit that I am worth all that hard work; I can admit that I’m worth saving because someone else believes in me. There came a point in my journey through the system that I believed that I wasn’t worth saving and that all was lost and at that time I ran upon this young “therapist”. I credit him and the young psychiatrist with helping me decide that I wanted to take up my life and live, rather than walking out into traffic on a busy city street.

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    • This is why I actively support Open Dialogue, which no one in the “hospital” where I work has ever heard about. Can you believe this? I mention it in meetings with various staff and everyone sits there with blank looks on their faces. However, I must admit that the state in which I live is well known for being ten years behind everyone else when it comes to things like this.

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  4. There has been research into what are known as “common factors” and the dodo bird effect that shows there are factors common in various therapies suggesting the therapeutic alliance is the most significant factor predicting positive change in therapy. See an article I wrote “Another Brick in the Wall” ( or “A Meta-analysis of Outcome Studies Comparing Bona Fide Psychotherapies: Empirically, ‘All Must Have Prizes’” ( Also look at the research in “The Heart and Soul of Change.”

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  5. Thank you, Sandy.
    You have courage to continue trying to reach your colleagues. I think that the quality of a therapeutic relationship has proved the most significant variable regardless of particular approaches used, except perhaps for psychiatrists who so seldom engage relationally. Shared decision making is a lofty goal which is virtually impossible given power differentials that usually are not acknowledged nor addressed. When I entered treatment, I didn’t benefit from a placebo effect. My trust in my psychiatrist and his authentic compassion for my experience contributed to my adherence to a negative narrative and destructive drugs for far too long.
    If we could meet as equals, perhaps we might co-design ways to learn together without assigning meaning or judgment to another’s experience. In our culture a “therapeutic alliance” too often enables social control and maintaining systems that oppress in the name of helping. Rather than encouraging psychiatrists to practice Open Dialogue, I think we should be changing our social relationships and culture, so that mutual listening, hearing, questioning, reflecting, learning, and holding are a shared way of life rather than another treatment modality. Of course there would be no payment structure to cover such human sharing, and we would need to grow and sustain ourselves differently. My dream of non-hierarchical relationships and approaches to solving conflicts may induce others to label me unrealistic and ignorant, both of which are true given the current authoritarian, morally bankrupt systems that harm people and the environment. I choose not to accept the current systems as given, and I invite others to practice a different way of engaging to connect and create different ways of living together.
    With warm respect,
    Berta Britz

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  6. ScottEv January 13, 2018 at 12:29 am
    “There can be no authentic therapeutic alliance when psychiatric coercion is involved in psychiatric treatment.”

    Exactly. How do these bazaar propositions (that fail to include the fact that there isn’t a shred of science upholding the existence of the DSM, drugging people for imaginary improvable “diseases”) dare to suggest that any such “therapeutic alliance” is remotely possible in the sea of lies that this industry is awash in? If the truth was known or told as per legal informed consent, Steingard’s notion of a “therapeutic relationship” would be laughed out of the room as the complete and utter sham it is.

    The more I read here at MIA, the more I fear for the future of the humanity which functions almost exclusively on pretending the lies don’t exist and shoving these irrational contradictions into the faces of people who know they do. Why? What is the purpose of the exercise? To see how many of us can tolerate it without screaming?

    What is happening here, meets the definition of “crazy making”, in that the lies were exposed to us, that we grasp and see through the lies and then we are asked- in the very same space – to pretend we don’t know the lies and are asked to entertain, implausible BS about the very “relationships’ with the very people who are profiting from the lies and pretend that they are somehow here to help us and that if we only had good relationships with our abusers, that we would be somehow miraculously healed despite their ugly fraudulent slurs (dx’s) against us and their dirty toxic “treatments’ justifying their slurs against us.

    This is EXACTLY like telling children raped by their fathers and women beaten by their husbands that they themselves are the problem; that they are “mentally ill” and that they have “relationship issues” with “authority figures”.

    So much of what is being written here at MIA of late is increasingly toxic and disturbing, but this is particular egregious. Love your abuser.

    The real sickness in the world, is the ability of this industry to keep lying through its teeth, to keep inventing absurd, illogical, deeply disturbing contradictions to the lies as if we have no idea how twisted it all is.
    God help us because these people are deeply unwell at the core of their beings.

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