Therapeutic relationship

Relapse rates after detoxification are very high. Although extension of the withdrawal period for up to 6 months does not appear to improve outcome (Sees et al. 2000), patients who have received methadone maintenance and who have a good therapeutic relationship have more successful outcomes. 

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... 

Perhaps you have experienced the sense of well-being that a good therapeutic relationship engenders. I know that I have. I had a doctor in New Jersey who had the most wonderful bedside manner. Dr Doubek - I called her Mamie - looked me in the eye when I spoke. She listened, she nodded, she showed concern. She did not seem the least bit hurried or rushed. And I do not know if she is aware of this, but at least once during each visit she touched me briefly on the arm while talking to me. I felt cared for, understood. 

I can t call Mamie s style of interacting with patients a placebo effect, because as far as I know none of the treatments she gave me were placebos. But it did make me feel better, and some of the research I describe in this chapter indicates that it can also promote wellness. For want of a better term, I will call this the Mamie effect . The Marnie effect is the enhancement of treatment outcome that is produced by enhancing the therapeutic relationship. 

We gave patients suffering from irritable bowel syndrome three doses of a therapeutic relationship. The lowest dose was no relationship with the medical practitioner and no treatment at all. These patients were simply assessed and put on a waiting list, with the promise that they would receive treatment some... 

The results of this study showed that we were right about the effects of the therapeutic relationship. Six weeks after the beginning of treatment, patients given an enhanced therapeutic relationship reported significantly greater symptom reduction and better quality of life than those given the low-dose relationship, despite the fact that the difference in treatment was limited to the initial interview. Those in the wait-list group showed the least improvement of all.6... 

Our study showed that enhancing the therapeutic relationship boosts the placebo effect. Other studies have shown that the same thing happens when real treatments are delivered within the context of a caring relationship. When a doctor is warm, friendly, reassuring and confident in the effectiveness of the treatment, patients show greater symptom reduction and recover from illnesses more quickly.7... 

How is it that the quality of the therapeutic relationship can enhance improvement, not only in a psychological condition like... 

Although the therapeutic relationship and positive emotions are clearly important, there are many instances of the placebo effect that they cannot explain. They cannot, for example, explain the effect of placebos in research settings in which students or other healthy volunteers have been asked to participate in return for money or course credit. In these studies there is no therapeutic relationship. Most importantly, emotions cannot explain the specificity of the placebo effect. 

If placebo effects depended completely on the therapeutic relationship and patients emotional states, it would not be possible for the same person to show placebo effects and nocebo effects at the same time. But they do. Sometimes the same person reports both therapeutic benefits and side effects from the same placebo.15 Sometimes the more negative side effects they have experienced, the better they feel. That can happen because the side effects might convince them that they have been given a potent medication. Maybe their improvement was generated by their happiness over receiving what they believe to be an effective treatment for their condition, but this certainly would not explain their experience of side effects. 

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. 

The following six assumptions that professionals have about clients may cause distress in the therapeutic relationship if not challenged. After each commonly held belief is a realistic way to view the concern. When you notice yourself holding one of these errant assumptions about your client, follow this exercise to remind you of the reality of the situation, using the statement of reality to challenge the related errant expectation. See Chapter 5 for more information on challenging errant thoughts and assumptions. 

There are several areas where a therapeutic relationship can typically go wrong and cause ethical concerns. The first area of concern has to do with finances. Since counseling and therapy often involve payment, it is important to try to divorce therapy as much as possible from the financial aspects of the business of therapy. However, this is not always possible, especially if you are in private practice and you are your own accountant, too A rule of thumb is this If you cannot treat a client without bias because bills are not being paid, then you have no business treating the client any longer. A therapeutic referral must be made. There is no possible way that you can give your best effort to a client when you are sore about not getting paid. 

When does it become okay to have a relationship with a former client There is much debate about when it may be ethically okay for a therapist or counselor to have such a relationship, with some professionals expressing the opinion that such a relationship maybe possible, without risk of compromise or coercion, several months or years after therapy has ended. I do not have an easy answer to this question. As a therapist I know there is something unique about a therapeutic relationship that creates or enhances human vulnerability. My feeling is that counselors and therapists must respect the client amid this vulnerability by not taking advantage of that moment. Does this vulnerability between a therapist and a client ever go away I honestly do not know, but a therapist should consider the vulnerability factor in any relationship with a client, even an ex-client, very strongly and deliberately before acting on emotional attractions, even many years after therapy ends. Even if you are convinced sufficient time has passed for that vulnerability to diminish, it may not have diminished from the standpoint of your ex-client. 

An important thing to remember is that you did not invite this violation of the therapeutic relationship, so there is no reason to feel responsible for what has happened or to downplay your rights. Instead, I encourage you to stand up for your rights as a client and consumer so that this type of situation will not occur in the future, to you or to someone else. 

Requests for confirmation of treatment despite apparent lack of effectiveness may be expression of the fact that the patient has already tried to stop the drug but became subjectively worse due to withdrawal rather than the re-emergence of the original symptoms. On the other hand requests for repeat prescription may also indicate a dependence in a therapeutic relationship, the patient needing support and contact. The prescription of a drug is then merely a vehicle which the patient finds acceptable as a reason for approaching the doctor. This may be particularly true for elderly, lonely patients. 

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). 

The therapeutic relationship, or more properly, the alliance, is the fundamental dimension of care. Its effectiveness as a separate therapeutic entity has been shown to correlate positively with the accuracy of the intervention itself, the fit of the theoretical approach, and the proper use of particular therapeutic techniques (Crits-Christoph et ah, 1993 Luborsky et ah, 1985). In other words, how clinicians are with their patients is as important as what clinicians do to, or with, their patients. Poor alliances lead to premature termination of care (Magnavita, 1993), just as good ones, in which patients feel understood, lead to far better follow-up and outcome (Zisook et ah, 1978-79). 

Treat your patients as though the therapeutic relationship matters more than the pills. It usually does. How often have we looked back over cases and the improvements we could or might have attributed to meds, if we had chosen to prescribe them ... 

Rogers CR, Gendlin EG, KieslerDJ, etal., eds. The therapeutic relationship and its impact a study of psychotherapy with schizophrenics. Madison University of Wisconsin Press, 1967. 

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