Therapeutic Alliance: Implications for Practice and Policy
In this issue, Totura and colleagues report on a meta-analysis of studies that evaluated the impact of the therapeutic relationship on the outcome of pharmacologic treatment. Noting that the therapeutic alliance has a powerful effect on outcome in psychotherapy, they wondered whether this would also be observed when pharmacotherapy was a dominant component of treatment. They identified eight studies that met their inclusion criteria. A positive therapeutic alliance had a modest effect on outcome.
The authors point out the limitations of their findings. The studies included heterogeneous groups of patients treated in both hospital and outpatient settings, for example. In some, treatment was not exclusively pharmacologic. Outcome measures varied. Given their primary hypothesis that positive therapeutic alliance would improve outcome by increasing drug adherence, a major limitation is that none of these studies assessed drug adherence.
Given the singular importance of relationships in psychiatry, it would be hard to argue with the authors’ suggestion that further study is warranted. Psychiatrists have few techniques other than conversation; we rely on our ability to talk with people as the primary means of assessment. However, what questions should be addressed and who might best conduct the research are less clear.
The authors posit that therapeutic alliance exerts its effect by improving adherence. However, placebo response rates are often so high in clinical trials that it can be difficult to find a significant advantage for the drugs being studied. This suggests that there is something beyond the pharmacological properties specific to the drugs under investigation that affect outcome. In addition, it is not clear that a “best outcome” for the therapeutic alliance is increased adherence. In shared decision making, for example, one aim is to understand the patient’s goals. Achieving these goals may not be as dependent on drug adherence as many physicians assume. Studies that consider therapeutic alliance as a variable should be designed so its effects are independent of drug action.
Other interesting questions are raised by this study. The impact of the therapeutic alliance might challenge our notions of drug specificity. Psychiatric drugs have long been classified according to the putative disease targets—antipsychotics, antidepressants, and so on. But in recent years, there have been ever-broadening indications for each of the classes of psychiatric drugs. As the authors note, the effect of the therapeutic relationship on outcomes is widely acknowledged in the context of psychotherapy, but this research has led to questions about the impact of the specificity of any given psychotherapeutic modality. Further research in this area might further erode our notions that the specific pharmacologic actions of psychiatric drugs have as much import as currently presumed.
An expanding area in psychiatric research is the inclusion, in both the design and implementation of research, of the perspectives of those who have received psychiatric treatments. Although rating scales of therapeutic alliance are administered to both clinicians and patients, including people with lived experience of psychiatric care in the development of rating scales and design of studies seems especially important when therapeutic alliance is the target of study.
If there are any among us for whom the results of this study might cause surprise, it would be those who have adopted a more mechanistic view of drug efficacy in which a drug’s impact is considered to occur independent of social context. The implications of this research should challenge these notions and raise questions about policies derived from them. For it is only when one thinks these drugs work regardless of context that one could promote a production model of care in which as many patients are seen in the shortest time possible. A contrasting approach is Open Dialogue (OD), which places strong emphasis on the therapeutic relationship. In OD, the entire network of those who care about the patient is invited to meetings. Everyone’s voice is valued and respected. Diagnosis has less immediate primacy and can be understood over time. But these are not 15-minute meetings, and at the outset of treatment these meetings occur frequently. When OD was used with individuals experiencing a first episode of psychosis, researchers reported extremely good outcomes even though only about 30% of patients were ever treated with antipsychotic drugs.
Studies of the therapeutic alliance in pharmacologic treatment are warranted. There is good reason to suspect that we will learn that its effect has less to do with improving adherence to drug treatment than with enhancing other mechanisms of clinical change. It might lead us to reevaluate the wisdom of current practice and policy.
