Therapeutic alliance

Patients requiring detoxification from high or supratherapeutic dosages of benzodiazepines constitute a smaller number of patients, but they are at greater risk for life-threatening discontinuation symptoms, such as seizures, delirium, and psychoses. There has been more experience with inpatient detoxification in this group, but outpatient detoxification is possible if conducted slowly (5% reduction in dose per week), with frequent contact, and in the context of a therapeutic alliance with the patient. Often, such an alliance proves unworkable because the patient s impoverished control results in supplementation from outside sources or early exhaustion of prescribed supplies meant to be tapered. In these cases, as in the cases of patients with a history of seizures, delirium, or psychoses during previous detoxification attempts, inpatient detoxification is indicated. 

Integration of the clinician s and the patient s perspectives, essential for a good therapeutic alliance, should be based on an empathetic rapport that reflects mutual respect and interest, and human feeling between the clinician and the patient. The two of them (with the collaboration of the family as needed) should attempt to reach a joint understanding, as far as possible, of the clinical problems and their contextualization, the patient s positive factors, and expectations about restoring and promoting health. 

Therapists may wish to use these suggestions to guide their conduct with their clients in order to promote a healthy therapeutic alliance. Consumers (drug users seeking treatment) and their families also may wish to use these three goodness-of-fit treatment factors as guidelines when shopping for an appropriate therapist. Consumers will want to consider whether the model of treatment fits well with their own needs and worldviews as well (see Chapter 5 for more details on treatment models). 

Professionals working with a suicidal drug client may wish to determine whether the person meets criteria for Borderline Personality Disorder. Borderline clients often have a history of suicidal behavior and high utilization of health and mental health care services. Most people who meet criteria for Borderline Personality Disorder are women, but not all. As mentioned, some professionals find it difficult to work with borderline clients without becoming very upset or cynical. If you cannot work with such a client respectfully, then it is recommended that a referral be made to someone who can (see Chapter 3). Treating the client with dignity is important if trust and a solid therapeutic alliance are to develop. 

Sometimes you can use your legally mandated course of action to leverage a voluntary admission on the part of a client. If you remind the client that you are now bound to report the incident if she or he is not willing to seek help, then frequently the client will acquiesce and voluntarily seek help. Your responsibility is to make certain that the client actually follows through rather than simply feigning compliance. Obviously this outcome is preferred, since it helps to preserve the therapeutic alliance, whereas an involuntary commitment often harms your relationship with a client. 

Therapeutic alliance. How well client and therapist get along. 

Intake interviews can help to develop the therapeutic alliance. True or False ... 

Many therapists use e-mail to interact with clients. The advantages to this process are that e-mail maximizes client access to the therapist while minimizing the intrusion of client contact into the therapist s personal time. Homework assignments can be discussed and clarified between sessions, and between-session questions answered. In addition, e-mail introduces the possibility that a client can access a therapist hundreds or even thousands of miles away. I am a firm believer that face-to-face therapy is ideal for many important reasons (e.g., developing the therapeutic alliance), but in those instances in which clients are isolated from good care, e-mail therapy can be a very attractive option. This option allows the possibility for equal access to the best available treatment and therapy resources even if those resources are not available to the client locally. In addition, as interactive telephones become more standard, therapy by phone may allow distance therapy to become more personalized, and this medium may ultimately supplant e-mail as a way to seek therapy from a distance. 

The interview might start by asking the child if he or she knows why this appointment has been scheduled. Family members can be asked to join in as the problem begins to be defined. Everyone s perceptions are important for determining the family context of the target symptoms. The definition of these target symptoms builds the therapeutic alliance and identifies for everyone the symptoms that are the focus of potential change. 

The initial assessment begins to establish the therapeutic alliance between the physician and the family. A working partnership with the parents and with the youngster is essential for comprehensive treatment and for compliance. The physician should be a collaborator with the child and family to empower them to effect improvements in their lives. Within this therapeutic alliance, the psychological power of medication treatment needs to be considered (see Chapter 33) to avoid the pitfall of assuming that medication alone will independently transform the identified problems. 

The Multimodal Treatment of ADHD (MTA) Study, a large, multisite study of ADHD treatment (MTA Cooperative Group, 1999), highlights the importance of this therapeutic alliance. When outcome was measured only in terms of the child s inattention, stimulant medication alone did as well as medication plus psychosocial treatment. However, the combination of medication and psychotherapy had the best outcome in parent satisfaction and in reducing disruptive behaviors (Hinshaw et ah, 2000), which are important factors in longer-term compliance with treatment and outcome. 

Baseline impairment—developmental instability, family dysfunction, medical condition, mental status abnormalities, therapeutic alliance... 

While ethical considerations would probably preclude a similar trial in children, it seems that the forces at work in the brief therapeutic alliance studied could be similarly cogent, if not more so, in psychopharmacotherapy with children and adolescents. Until we know more, it seems best to assume that realistic hope and confidence are powerful and useful elements of the process of medicating. 

The other corporate influence is that of managed care. The limits on approval, duration, or nature of therapeutic contact, or covered services themselves have turned prescription writing into one of the only reliable and reimbursable acts therapists can perform on behalf of their patients and their livelihood. The 15-minute medication check that has been established as the industry standard of care reduces the therapeutic alliance to an encounter between a prescriber, or... 

When thinking about medicating, it is the patient, not the drug, that should get our major attention. Such thinking needs to be done in the context of a therapeutic alliance, not the likelihood of reimbursement. Hence we recommend the following ... 

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