sign up for an annual subscription to receive CME credit for this activity and more! Learn more Here.

Link to show on: iTunes, Google Play, Stitcher, Overcast, PlayerFM, PodBean, TuneIn, Podtail, Blubrry, PodfanaticWhat is a therapeutic alliance?The therapeutic alliance is a collaborative relationship between the physician and the patient. Together, you jointly establish goals, desires, and expectations of your working partnership.Every interview with a patient, whether it’s for diagnostic, intake, evaluative, or psychopharmacology purposes, has therapeutic potential. The treatment starts from your first greeting—how you listen, empathize, and even how you say goodbye.  It’s built from a partnership and dialogue, like any other relationship. It’s not built from medical interrogation. It’s not about pulling medical information to be able to make a diagnosis. We have to make it a positive experience for patient, so they can begin to talk about what's negative in their lives.The therapeutic alliance is full of meaning, and it uses every emotional transaction therapeutically. If they get angry, sad, or have fear you will abandon them, as a therapist, it’s our job to figure out how to help them through that feeling within the relationship. The doctor can express desire for the patient to share, in real time, how the patient is feeling, even about his or her relationship with the doctor.Why do we care?We all know that some talk therapists have better outcomes than other talk therapists. What’s interesting though, is that some some psychiatrists’ placebos worked better than other psychiatrists’ active drugs. One study of NIMH data of 112 depressed patients treated by 9 psychiatrists with placebo or imipramine, found that variance in BDI score (a score that measures depression) due to medication, was 3.4% and variance due to psychiatrist was 9.1%. One-third of psychiatrists had better outcomes with the placebo than one-third had with imipramine.  Another book argues that the therapist is more important to outcome than theory or technique. Many other studies have shown that therapeutic alliance directly correlates to success rates.What builds a therapeutic alliance?Research shows there are a few things that grow therapeutic alliance:ExpertnessFacilitating a greater level of understandingWhen residents are worried they are an imposter, I tell them that humility is good, but realize that you have experience that most will never have, medical school, being highly educated, being around vast different ways of thinking and reflecting on the world...ConsistencyStructuring your office to run on time.Being consistent to respond to refill request, lab results, or patient’s questions.Non-verbal gestures Eye contactLeaning forwardMirroring of emotion occurs naturally when people pay attention to emotionMaintenance of the therapeutic frameA dual relationship (eg, dating) breaks down therapeutic alliance. Patients will test the frame. It can be helpful to say, "There will be positive and negative feelings between us and what will be safe is to talk about them."Empathy, attunement, positive regard Patient: “Therapist is both understanding and affirming."Patient: “Therapist adopts supportive stance.”Patient: “Therapist is sensitive to patient’s feelings, attuned to patient, empathic.”Research has found that for beginning therapists, setting and maintaining treatment goals is harderResearch has shown that strength of therapeutic bond is not associated with level of trainingTherapist should appear alert, relaxed and confident rather than bored, distracted and tiredFoundational concepts of the therapeutic allianceOur profession gives us a privileged glimpse into the human heart and mind. Each patient is idiosyncratic, unique, precious. Each patient has unique strengths which we should place focus on.  Some therapists can be in a hurry to find out what's wrong, but we should also want to find out what's right with our patients.Our own f