Therapeutic Alliance: Implications for Practice and Policy

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In this piece for Psychiatric Services, Dr. Sandra Steingard comments on the implications of a recent meta-analysis demonstrating the positive effects of the therapeutic alliance on pharmacologic treatment outcomes.

“If there are any among us for whom the results of this study might cause surprise, it would be those who have adopted a more mechanistic view of drug efficacy in which a drug’s impact is considered to occur independent of social context. The implications of this research should challenge these notions and raise questions about policies derived from them. For it is only when one thinks these drugs work regardless of context that one could promote a production model of care in which as many patients are seen in the shortest time possible. A contrasting approach is Open Dialogue (OD), which places strong emphasis on the therapeutic relationship. In OD, the entire network of those who care about the patient is invited to meetings. Everyone’s voice is valued and respected. Diagnosis has less immediate primacy and can be understood over time. But these are not 15-minute meetings, and at the outset of treatment these meetings occur frequently. When OD was used with individuals experiencing a first episode of psychosis, researchers reported extremely good outcomes even though only about 30% of patients were ever treated with antipsychotic drugs.

Studies of the therapeutic alliance in pharmacologic treatment are warranted. There is good reason to suspect that we will learn that its effect has less to do with improving adherence to drug treatment than with enhancing other mechanisms of clinical change. It might lead us to reevaluate the wisdom of current practice and policy.”

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