Patient—therapist relationship

Central to appropriate pharmacological treatment of PTSD is the restoration of some sense of control over turbulent emotions. When medications are appropriately used, in the context of a solid and safe patient-therapist relationship, the improved emotional control can serve as a sort of antidote for what is otherwise a feeling of powerlessness. Ultimately, the ability to face painful realities with a degree of mastery is at the heart of recovery from PTSD. 

In the context of psychological treatments, cultural differences between the therapist and patient (such as in language, values and expectations) are important determining factors for patient satisfaction and the therapeutic relationship between patient and therapist, which will subsequently determine prospective treatment adherence (Jackson et al, 2007). In a similar way, the use of psychotherapeutic strategies deriving mainly from western theoretical orientation can have limited usefulness in patients from different cultures. Therefore it is generally necessary... 

Of even greater importance, the success of any therapy, including pharmacotherapy, depends on the relationship between patient and therapist. The nature and quality of the interaction between the clinician and the patient, flavored by both of their cultural backgrounds, values, attitudes, and expectations, serve as the backdrop against which drugs work, or fail to work. Attention to and successful management of transference and counter-transference are key to the success of not only psychotherapy, but also pharmacotherapy. The importance of culture in this respect cannot be disregarded. 

Perhaps it is my background as a psychotherapist that leads me to be concerned about the widespread practice of deceptively giving patients placebos. As a therapist, I learned that one of the principal factors in the success of treatment is the relationship between the doctor and the patient. Trust is one of the central components of the therapeutic relationship, but trust has to be earned. When it is betrayed, it is lost. So my concern is as much practical as it is ethical. When doctors deceive their patients, they violate their patients trust. In the long run they will lose it and, in so doing, they will lose one of the most effective weapons in their clinical arsenal. 

Mental and physical health professionals may consider referring clients and patients to a music therapist for a number of reasons. It seems a particularly good choice for the social worker who is coordinating a client s case. Music therapists use music to establish a relationship with the patient and to improve the patient s health, using highly structured musical interactions. Patients and therapists may sing, play instruments, dance, compose, or simply listen to music. 

Psychopharmacotherapy is the combined use of psychoactive medication and psychotherapy. Brent and Kolko (1998) define the latter as a treatment modality in which therapist and patient collaborate to ease functional psychopathological impairment through attention to (1) the therapeutic relationship, (2) the patient s behavior, thoughts, attitudes and affect (the working diagnosis), and (3) the social context and development (this is especially salient in the work of the child and adolescent psychiatrist). 

Since the patient s heightened suggestibility is such a major factor in psychedelic therapy, it is helpful for the therapist to be familiar with the literature of clinical and experimental hypnosis.2 Aaronson (1967c) is probably correct in stating that there must be important relationships between the hypnotic and the psychedelic states.3 However, phenomenological differences are great, and in psychedelic therapy the patient should be a much more active participant than the patient in hypnotherapy. 

Because it is difficult to learn about interpersonal relationships in an individual session, some therapists begin to take the drugs with their patients to maximize the empathic process. This kind of activity limits the number of people... 

In my own experience, if there are well-intentioned family members, then working with the family is the most effective way of helping a disturbed individual restore his or her relationships with other human beings. It is far better if other family members, rather than the therapist, become the patient s primary resort and the place where relationship is recovered. 

So it is especially important for therapists to keep in mind that they can help almost all their clients by starting with a warm, welcoming, and caring relationship. Especially for disturbed patients who have already been overwhelmed by psychiatric pessimism, make clear how optimistic you feel about being able to help them to live better, happier, more productive and loving lives. 

Again, what makes this possible with disturbed patients is the utopian quality of the therapy setting, including its limits, its safety, and the skills of the therapist in maintaining a genuine relationship with people who tend to drive others away. 

Values matter. In our personal lives—our relationships with family and friends, and in our choice of work and recreation—I believe in individual liberty. People should not accept emotional or physical bullying or coercion in their personal or professional lives. In the political realm, the problem of individual freedom obviously becomes more complicated, but in our personal lives, it can be straightforward. In our personal lives, we should respect each other s freedom. As therapists, we respect the freedom of our patients, and we encourage them to respect the freedom of others (see my discussions of liberty, love, and oppression from an individual and societal perspective in Breggin 1988, 1988-1989, and 1992a). 

Therapists will naturally vary in how much they emphasize relationship, insight, historical reconstructions, and learning new principles or behavior. Similarly, patients will vary in how they feel about different therapists and their therapeutic approaches. 

It is foolish and self-serving for therapists to believe that any particular patient must benefit from their relationship and their kind of therapy or accept being medicated. Yet the grip of drugs is so powerful in the mental health field that it is a common delusion among therapists that the patient s choice lies between their particular therapy or a drug. 

This book does not focus on these other treatment modalities. It simply focuses on a non-MD therapist and a physician working together to care for their common patient. However, the non-MD therapist could be a psychologist, a social worker, a marriage and family therapist, a psychiatric nurse, or a counselor. When we refer to physicians, we could mean a family physician, a psychiatrist, an internist, a pediatrician, or an obstetrician-gynecologist. To simplify matters, we refer to the therapist and the physician throughout this book. This book is primarily intended for therapists who want to build collaborative relationships and learn the biological information they need to communicate with physicians. 

Substance use disorders (SUDs) are collectively the most common coexisting condition that therapists will see in their patients who present with relationship problems, depression, or anxiety disorders. SUDs are common and often unrecognized, at least in the initial evaluation of the patient and family. This chapter does not propose to be a comprehensive treatise on the management of SUDs. It focuses on some features germane to the collaboration of physicians and nonphysician therapists in treating SUDs. We discuss alcoholism first, as the most common and the prototype of the SUDs, and then touch on selected features of several other types of SUDs. 

Regardless of the clinic s or practice s financial structure, therapists need to be sensitive to their patients financial situations. The changing financial landscape of health care and the inequity in reimbursement between physicians and therapists can make this aspect of care challenging. Nevertheless, such care and concern can gready enhance both the therapeutic relationship and the success of the therapy as a whole. 

Factors that may confound this decision include (1) the match among the patient s preference, the therapist s preference, and the availability of a psychiatrist versus a primary care doctor (2) differences in the ease of referral, cost, and waiting time for a first appointment (3) the degree of flexibility of choice the patient s insurance offers and (4) the influence of preexisting professional relationships that either the therapist or the patient has with specific physicians. 

At times, patients want therapists to choose the physician they will see. If their insurance allows that freedom, we are happy to comply. We maintain relationships with different types of physicians, each with different strengths. At times, two psychiatrists may be equally qualified but have different areas of expertise. We hope that our patients benefit from onr detailed knowledge of possible referral sources. We try to match the patient with the physician by thinking about the personality of the patient and the physician s interview style. In addition, we often offer to call our colleague, to say that we are sending a specific patient. We hope that this process communicates to the patients that they can expect the same kind of caring, professional behavior from our respected colleague that they have come to expect from us. We find that these personal relationships provide a safe, calm context in which patients can consider their treatment options. 

Therapists train and practice in a world that is very different from that of physicians. Because therapists contact with physicians is often limited, they rarely have opportunities to immerse themselves in the culture of medicine in order to learn about the roles, customs, and beliefs of its members. Just as it is important to be culturally competent with patients from ethnically diverse backgrounds, knowledge of and appreciation for medical culture is also helpful and can strengthen collaborative relationships. 

By overcoming cultural differences and successfully managing cross-disciplinary relationships, therapists can help improve a patient s adherence to a treatment regimen that includes medication (Frank, 1997). Patients often appreciate the collaboration of their doctors because it is such a stark contrast to what they are accustomed to in health care. 

Triangulation comes in many different forms. Avoiding this trap is easier with strong, unified, collaborative relationships. With that aim, it may prove beneficial to have an initial joint session with the physician and/or patient to prevent triangulation and cultivate communication. Fostering the collaborative relationship allows a therapist or physician to respond to triangulation attempts with a restatement of the treatment mission, a recommendation to the patient to direct concerns to the appropriate person, or in the above example, education about the differences between psychiatric evaluation and therapy. 

These are just a few questions a therapist can consider in understanding the family structure, particularly the interactional patterns that help shape it. For example, an overfunctioning spouse may be attempting to make a treatment decision for an underfunctioning patient. In such a case, a therapist would not want to alienate the spouse or support the patient s sense of powerlessness in the relationship. The therapist would want to acknowledge the spouse s efforts to be helpful and attempt to give the patient a voice in his or her own care. 

The responsibility of caring for a patient usually falls on members of the family. Thus, they are not simply uninvolved bystanders. For example, it is not unusual for family members to prompt the patient to make the initial appointment with the therapist or physician. Because of the stigma of mental illness and the patient s worries about burdening family members, the family may not be fully informed on the health status of the patient. This lack of knowledge may be related to conflictual relationships in the family and a patient s preference to keep family members uninformed. 

We have suggested that therapists must expand their interests and influence to other factors that have an impact on clinical care the patient s family, the clinic s organizational structure, the finances of therapy, and the physician-therapist-patient relationships. These factors can influence the outcome of therapy as much as the specific medication or specific psychotherapy techniques used. 

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