Treatment Alliance Research Articles

Techniques for interviewing the somatising patient.

Liaison psychiatrists need to interview somatising patients in a way which allows a full assessment of the problem. This can best be achieved if the psychiatrist has already discussed with the referring physician the reason for referral and what the patient has been told about it. The medical notes should always be reviewed in detail and independent data obtained from a relative or other informant. During the interview itself the psychiatrist must be prepared to use techniques which deepen rapport with the patient, who may be initially wary or hostile. The psychiatrist should attempt to establish early a treatment alliance. Special aspects of the mental state need to be noted, including the patient's attitude to his/her symptoms and the strength with which somatic beliefs are held. Different approaches may be used according to the nature of the problem and the therapeutic style of the doctor. An awareness of these interview techniques would greatly reduce the chances of fruitless interviews with a hostile patient who believes the symptoms are being dismissed as being 'all in the mind'.

Inpatient Treatment of Schizophrenia in General Hospitals

To improve treatment of schizophrenic patients in short-term inpatient units, the authors review studies of interventions that have been implemented with schizophrenic patients during brief hospitalizations and suggest areas for future research. The review is organized around seven general treatment domains, including the therapeutic alliance, continuity of care, family involvement, procurement of community services, psychosocial rehabilitation, medication compliance, and substance abuse treatment. Because schizophrenic patients have traditionally been treated in long-term settings, little literature exists to inform interventions on short-term units. The authors suggest that general hospital staff strengthen the treatment alliance between patients and outpatient clinicians, aggressively pursue community supports, work to ensure patients' follow-up with outpatient care, and consider depot medications and patient education to promote medication compliance.

Therapeutic alliance in treatment: Refractory schizophrenia

Therapeutic alliance in treatment: Refractory schizophrenia

Perceived treatment difficulty and therapeutic alliance on an adolescent psychiatric hospital unit.

On an 8-bed adolescent psychiatric unit, 69 patients were rated over the course of more than one year [corrected]. A set of rating scales was used to determine the relationships of treatment and therapeutic alliance difficulties with staff ratings of patient qualities, family issues, and treatment outcome. Findings underscore the clinical relevance of treatment difficulty and therapeutic alliance in conceptualizing the therapeutic action of the hospital treatment.

Treatment Alliance and the Chronic Schizophrenic

When something in common can be found to establish relatedness; when therapists can trust that the patients will eventually be able to contain their destructiveness and that on some level they struggle with their pathology, then patients begin to identify with their therapists and with those aspects within themselves. This activity requires that first a climate of safety, based on a frame, be established. Once it is established, the search for the common "thing"--the organizing object--and the ability to work with it can go on with far less distraction. Along the way, therapists insist that words can be used to convey meaning, creating the climate for eventual interpretation. In the case described, the therapist made it clear that he disagreed with the patient's delusional viewpoint, but at the same time was interested in hearing the material as a source of ideas about how the patient experienced her world, and how to discover what remained of her capacity for self observation and nonpsychotic thought. The therapist's acceptance of the need for such a preliminary phase may make it possible for severely resistant patients to become engaged with those treating them.

The therapeutic alliance: a psychoanalytic perspective.

Psychoanalysis has long distinguished between the transference neurosis and that part of the communication between therapist and patient which depends upon a relatively intact part of the patient's ego. It has been proposed that it is this capacity of the patient that sustains the difficult work of dealing with communications which are the consequence of transference, and which often threaten the viability of the treatment. This quality has been referred to variously as the unobjectionable positive transference, rational transference, mature transference, therapeutic alliance and working alliance. The ever broadening scope of Psychoanalysis, along with our greater knowledge of early childhood development, has enhanced our understanding of the many influences affecting the treatment alliances. Newer views of the transference, which stress the significance of the therapists' contributions to the therapeutic dyad, make it clear that the therapeutic alliance can no longer be explained as some simple, reality based, conflict free, motivating force. It involves, rather, a complex interaction of several factors, to each of which one must add the therapists' reciprocal reactions. Psychotherapy outcome research will need to take all of these factors into consideration.

Cohesion, Alliance and Outcome in Group Psychotherapy

Cohesiveness has been viewed as the group psychotherapy equivalent of the therapeutic alliance in individual treatment. Although researchers have attempted to study the concept of cohesion in group treatment, understanding of this so-called "curative" group factor remains quite primitive. In this study of 12 time-limited psychotherapy groups, with a total of 90 nonpsychotic outpatients, we explore the relationships between cohesion, alliance and treatment outcome. Our cohesion measure is a new instrument, the Harvard Community Health Plan Group Cohesiveness Scale, developed for use with group therapy videotapes. To measure alliance we have modified the Penn Helping Alliance Scale (Group Alliance Scale) to be scored from videotapes of group sessions. Both of these instruments use trained observers to make ratings for the group-as-a-whole. The outcome battery for patients in these groups included a widely varied set of measures, enabling us to view change from a number of perspectives. Our findings indicate that cohesion and alliance as measured here are related concepts. We also find that both cohesion and alliance appear to have strong relationships with improved self-esteem and reduced symptomatology for patients in these groups. In addition, it appears that outcome is most related to cohesion in the first 30 minutes of a group session. Implications of these and other findings are discussed.

Changing psychic structure through treatment: criteria for change.

The author outlines his clinical observations during the "middle game" of psychoanalysis, leading to recognition that structural change is taking place. "Middle game," "structure," process, and content are defined and critically discussed. Illustrative clinical vignettes are offered. The presentation emphasizes the importance of an active and resolving transference "struggle"; in addition, more traditionally noted criteria are briefly touched on, e.g., development of observing ego and treatment alliance, changes in dream function and communication, and the reviewing of the neurosis and transference during the termination phase as instances of mourning and working through. The concept of optimal psychobiological function in the service of a homeostatic principle is discussed.

Presidential address: contributions of the group psychotherapist to education on the psychiatric unit: teaching through group dynamics.

ABSTRACTGroup dynamics are the elements that make group psychotherapy unique. When applied to the inpatient group, they illuminate various aspects of milieu treatment. Because of this linkage, the therapy group can be used to educate trainees about (1) systems dynamics on the psychiatric unit and their administrative implications, (2) the vicissitudes of the patient's treatment alliance with the hospital staff, and (3) the psychodynamics of severe psychopathology. In the group, individual defensive operations stand out with special clarity. Their expression is fueled by the group's dynamics. Here, internal object relations are reenacted and the defense of projective identification becomes vivid. The focus of this paper is not on the teaching of group psychotherapy itself, but rather on the use of this modality for the general training of future professionals.

Maintaining the therapeutic alliance with Ms. T. in the initial phase of treatment

This paper addresses the difficulties in developing and maintaining the therapeutic alliance with a patient who regularly sought consultations with other therapists during the initial phase of treatment. Separation individuation theory illuminated her approach-avoidance behavior as enacted inside and outside the treatment room; a behavior reminiscent of the ambitendent toddler of the rapprochment subphase of development. Separation-individuation theory aided the therapist in the management of her countertransference, thus avoiding the undermining of the tentative treatment alliance.

An innovative approach to assessing outcome of long-term psychiatric hospitalization.

The failure of research on long-term hospital treatment to show consistent relationships between length of stay and treatment outcome may reflect a need for more refined measures to evaluate long-term treatment. The authors developed an individualized method of assessing improvement in patients' major areas of impairment over the course of treatment. Using the new approach and two more traditional methods, the authors evaluated the outcome of 37 discharged long-term patients of a private psychiatric hospital who had been rated at admission and discharge on 21 variables related to ego function; affective symptoms; risk of suicide, self-destructiveness, and violence; substance abuse; level of treatment alliance; and, at discharge only, on overall level of improvement. Although the traditional methods failed to show a correlation between length of stay and most of the variables, the individualized approach found that a longer hospital stay was related to greater improvement in areas of most impaired functioning.

The impact of patients with chronic character pathology on a hospital inpatient unit.

Inpatient psychiatric facilities are admitting an increasing number of young patients with chronic character pathology. Hospitals must explore the impact these patients have on the treatment facility and the risks inherent in their treatment, including the possibility of decreased milieu specificity, increased staff regression, and loss of cost-effectiveness. These risks are system responses that go beyond individual staff countertransferences. Possible remedies include refined indications for inpatient psychiatric treatment, tailoring of milieu functions to fit individual patient needs, explicit accountability of administrative and supervisory structures, and involvement of families in the formation of the initial treatment alliance.

Beyond eclecticism.

Biopsychosocial eclecticism is incomplete because it does not address the important issues of differential causation and treatment staging. Psychiatric serialism goes beyond eclecticism to consider biological, psychosocial, and existential-moral parameters as equipotential and hierarchical. What this means in practice is that, after forming a treatment alliance, the therapist must always assess the evidence for a biological substrate of disorder and, where feasible, administer the appropriate biological treatments. On a stable biological platform, psychosocial interventions can then be utilized to promote the goals of lieben and arbeiten, and an existential therapy relationship can be forged to promote personal integrity.

The selection of special educators and learning disability specialists.

The process that should determine the selection procedures for learning disability specialists is conceptualized. The base represents the essential qualities necessary for all special educators before they are admitted for training in the field. The second level represents qualities that can be taught and enhanced, and the third are the style of behavior and the temperament that can and should be matched with the child to form “a treatment alliance.”

Accountability and confidentiality in psychotherapy, with special reference to child treatment

This article elaborates on the changing socio-legal milieu and its impact on psychologists as psychotherapists. In particular, the issues raised include the conflict between professional autonomy and public accountability, and the growing problem of maintaining confidentiality. After a broad discussion of the dilemmas posed by such issues, the article makes special reference to the problems inherent in treating children. Since minors usually do not come to psychotherapy of their own volition, it is necessary to determine whether their individual needs conflict with the needs and interests of parents, society, and the law. The article discusses how children caught in special circumstances, like divorce situations, particularly tax the therapist's mettle and ingenuity in steering between the need for an effective treatment alliance, and the increasing impingement of third parties on the treatment relationship. The article concludes with some guidelines and a challenge to ourselves as a profession.

Should general hospitals accept involuntary psychiatric patients?: A panel discussion

The issue of whether involuntary patients can be treated safely and effectively on inpatient psychiatry units of general hospitals is addressed from several points of view. Parallels are drawn between contemporary reform efforts and 19th century hospital psychiatry, and the danger of repeating errors of the past is pointed out. An account follows, illustrating the recent planning process for mental health care in Massachusetts and recommending the active participation of psychiatrists in that process. Also discussed are the differences in the process of establishing a treatment alliance with voluntary and involuntary patients. The practical considerations in the development of a locked unit in a general hospital are explored, with respect to its effect on reimbursement, the private practice model, and the length and appropriateness of stay. In conclusion, the shared concern is stated that, in respect to making the transition from one system of care to another, safeguards be built in to protect and expand good treatment.

Adolescent Psychiatry: Developmental and Clinical Studies

Flaherty, Editor's Introduction. Part I: Adolescent Development and Creativity. Krumer-Nevo, Mythology, Sexuality, Aggressiveness: Adolescence and Creativity. Brockman, Gustav Klimt (1862-1918): Arrested Adolescent Development in a Revolutionary Artist. Part II: Special Section: Difficult Challenges, Creative Solutions. Rosner, The William A. Schonfeld Address: Saving Adolescents. Williamson, Bell, Dwyer, & Frierson, Toward a Better Juvenile Justice System: A City-State Partnership. Frierson, Dwyer, Bell, & Williamson, The Mandatory Registration of Juvenile Sex Offenders and Commitment of Juveniles as Sexually Violent Predators: Controversies and Recommendations. Dwyer, Bell, Frierson, & Williamson, Use of Assessment Data for Research in Juvenile Justice: An Exploratory Study of Sex Offenders. Bratter, Sinsheimer, Kaufman, & Lubbock, Residential Treatment for Gifted and Self-Destructive Adolescents: The John Dewey Academy. Bratter, Advocacy: Its Impact on the Treatment Alliance with Gifted, Self-Destructive, and Drug-Abusing Adolescents. Bratter & Sinsheimer, Confrontation: A Potent Psychotherapeutic Technique with Difficult Adolescents. Flaherty, What's Old is New: Motivational Interviewing for Adolescents. Feinberg, Adolescent Choice in Disputed Custody: The Role of the Forensic Psychiatric Consultant. Harmon, Talking About Sexual Side Effects: Countering Don't Ask Don't Tell. Part III: Clinical Skills Are Not Enough: Psychiatric Enigmas. Kemph & Voeller, Reactive Attachment Disorders in Adolescence. Stahl, Shapiro, Hertzig, & Turchin, Clozapine Doesn't Work: Two Case Reports of Treatment-Refractory Adolescent Sugar, Discussion of When Clozapine Doesn't Work: Two Case Reports of Treatment-Refractory Adolescent Schizophrenia. Stahl, Shapiro, Hertzig, & Turchin, Drs. Stahl et al. Respond to Dr. Sugar's Discussion.

Basic Psychoanalytic Concepts: IV. Counter-Transference

In previous papers in this series we have discussed two concepts which have been used in connection with aspects of the relationship between the patient and his doctor. These were the treatment alliance (Sandler, Holder and Dare, 1970) and transference (Sandler, Dare and Holder, 1970). Although these two clinical concepts originated within the psychoanalytic treatment situation they are capable of extension outside it. Both relate to and emphasize processes occurring within the patient and tend to stress one side of the relationship only. Even the concept of treatment alliance, although nominally appearing to include the roles of both patient and doctor, has tended to be regarded from the point of view of processes and attitudes in the patient; the aspect of the therapist's attitudes, feelings and professional stance have to a large extent been omitted. However, in recent years more attention has been paid in psychoanalytic and other writings to the relation of the doctor towards his patient. Just as the term ‘transference’ is often used loosely as a synonym for the totality of the patient's relation to his therapist, so is the term ‘counter-transference’ often used in a general sense (both within psychoanalysis and outside it) to describe the whole of the therapist's feelings and attitudes towards his patient, and even to describe facets of normal, non-therapeutic relationships (Kemper, 1966). Such a usage is very different from what was originally intended, and as a consequence confusion has arisen about the precise meaning of the term. It is the purpose of this paper to examine the concept in the light of its origins and development within psychoanalysis and to comment briefly on some possibilities of its extension outside the psychoanalytic treatment setting.

Basic psychoanalytic concepts. 3. Transference.

In a previous paper in this series (Sandier, Holder and Dare, 1970a) aspects of the doctor-patient relationship were discussed under the general heading of treatment alliance. It was pointed out that the concept included features which have been at times referred to as ‘transference’, and the purpose of the present paper is to consider some of the further meanings of the latter term.

Basic psychoanalytic concepts: II. The treatment alliance.

Psychiatry and other medical disciplines have been paying increasing attention in recent years to the relationship between patient and doctor, and psychoanalytic concepts have been applied in order to formulate various aspects of this relationship. One of those most commonly applied is that of transference, which is now often loosely used as a synonym for relationship in general. The concept of transference will be discussed in detail in a further paper in this series, but a distinction has always been made within clinical psychonanalysis between transference ‘proper’ and another aspect of the patient's relation to the doctor which has been referred to in recent years as the ‘therapeutic alliance’, ‘working alliance’ or ‘treatment alliance’ (Zetzel, 1956; Loewald, 1960; Stone, 1961, 1967; Gitelson, 1962; Tarachow, 1963; Greenson, 1965, 1967; Friedman, 1969). The concept has been used in connection with the psychoanalytic treatment situation to describe aspects of what is familiar to all as the ‘therapeutic contract’ between the patient and his doctor (Menninger, 1958), and has been defined as ‘the non-neurotic, rational, reasonable rapport which the patient has with his analyst and which enables him to work purposefully in the analytic situation …’ (Greenson and Wexler, 1969). As far as the psychoanalytic situation is concerned, it has been maintained that the recognition of the difference between treatment alliance and other aspects of the patient-analyst interaction (such as transference) leads to an increased understanding of the processes which occur in that situation and, in particular, of those which enter into therapeutic failure. It is the purpose of this paper to examine the treatment alliance concept as it has developed within psychoanalysis and to consider its applicability outside the psychoanalytic treatment situation (Sandier, Dare and Holder, 1970).