Maintaining motivation and preserving the therapeutic alliance as tools to overcome treatment-resistant depression

Thus far, this text has focused on the understanding and application of a broad range of interventions to improve outcomes in treatment-resistant depression. Understanding the breadth of psychopharmacologic and psychotherapeutic interventions permits tailoring treatment to specific patient characteristics to ensure the greatest response. However, there is another dimension to treatment-resistant depression that must be considered. In this age of biological psychiatry the rapid expansion of understanding of depressive illness and treatment options tends to capture increasingly more of both therapists’ and patients’ attention. It is important not to lose sight of the most commonplace, yet highly effective, mechanism of behavioral change—the therapeutic alliance. This chapter will develop the concept of therapeutic alliance and how it relates to treatment resistance in depression. We will consider how the treatment relationship can deviate from one of working alliance into unhealthy alliance and how this can contribute to treatment resistance. We will consider interventions to enhance therapeutic alliance and motivation to achieve the best outcome in treatment-resistant depression. Finally, we will consider the effect of telehealth and other technology-based interventions on therapeutic alliance.

We will use the term therapist to describe the physician or other provider offering the full range of psychotherapy, pharmacotherapy, and other interventions throughout this chapter. This is in deference to the fact that most of the literature around therapeutic alliance grows from psychotherapy theory and research. Therapy for the purposes of this chapter will include the full range of somatic interventions in addition to psychotherapy and other psychosocial interventions. Treatment resistance can broadly be thought of as biologically caused or behavioral or interpersonal. Biological treatment resistance would be manifested as poor response to adequate trials of medications at correct doses and treatment durations. Behavioral or interpersonal treatment resistance would be manifest as missed appointments, dropping out of treatment, not taking medications as prescribed, or not accurately reporting symptoms to the therapist. What we will show is that the concepts drawn from the psychotherapeutic relationships are broadly applicable regardless of the treatment modality.

Understanding the therapeutic Alliance

… therapeutic alliance is not only a prerequisite for therapeutic work, but often may be the main vehicle of change.

Therapeutic alliance, or working alliance, describes the reality-based nature of the relationship between therapist and patient. The primary elements of the therapeutic alliance are commonly identified as goal, task, and bond ( ). A therapeutic alliance is present with a patient whether the treatment is medication or psychotherapy. It is the working together and the interpersonal and behavioral elements of that task. Goal refers to the shared goals of the patient and the therapist. Goals in the therapeutic alliance can include specific symptoms from which the patient seeks relief. They can extend to understanding of thought distortions and interpersonal dynamics, or they can explore challenges with closeness or warmth ( ). Task refers to those actions taken by both the patient and therapist to make progress toward therapeutic goals. For the patient, this may include taking medication in right dose and time and free and honest reflection in psychotherapy. Therapist tasks include attentive listening, putting aside biases to develop an understanding of the patient, accurate inquiry for information in assessment and appropriate prescribing. Bond refers to trust and attachment required of both patient and therapist to maintain an interpersonal relationship and continue to carry out the agreed upon tasks ( ). Bond is the emotional attachment and interpersonal behaviors that allow the patient to feel safe in the relationship, trust the therapist, and experience empathy from the therapist. The therapist should have a feeling of working together jointly, commitment to the patient’s well-being (even when the patient may not be able to sustain that hope) and a caring emotional attachment that maintains the separation and objectivity to provide effective therapy ( Box 40.1 ; ).

Box 40.1

Clinical example: Goal, task, and bond

Therapist: So, reviewing the symptoms you have described, and your history of medication trials, it seems you have had this depression to some extent for much of the last 18 months.

Patient: Yes, I am really hoping you have some better ideas on medications. I don’t feel like they do anything.

Therapist: Let’s talk a little bit about what you think better is going to feel like. Are there symptoms or other parts of your life as it is right now that you think need to get better?

Patient: This lack of sleep is really overwhelming me. No matter how much I try to get sleep, I am always up and down all night, and then I just can’t function because I’m so tired.

Therapist: Anything else?

Patient: I don’t know. I just feel so overwhelmed with work and the kids. I mean, they spend all day at daycare, and then I am so exhausted when I get home. I just want to lie down for a while, but I can’t. If I do, then I just feel guilty when they wake me up because their video ended. Seriously, what kind of mom is that?

Therapist: That suggests several goals we might focus on in the near term. One is we need to ensure you are getting restful sleep. The other seems like we need to work on some of your thoughts and feelings about balancing work and home. Do those sound like reasonable targets to you?

Patient: That sounds pretty good.

Therapist: Getting there is going to take some effort on my part and also on your part. I can offer a couple of suggestions for medications that might work best for you. I would also recommend we start a course of cognitive-behavioral therapy to get at some of those thoughts and feelings. That’s going to require some commitment on your part. You’ll need to take the medications as prescribed and keep me informed of how they are working. Also, it may seem like a lot, but I would like you to come to weekly psychotherapy sessions at first so we can get to work.

Patient: Weekly, that seems like a lot.

Therapist: It’s a commitment for both of us, but when you are here you will have my full attention. I want you to understand that this relationship is about me using my skills to help, and you being present to allow this process to work. We can space things out once we start to see some improvement.

Patient: OK .

Measures of therapeutic alliance examine both patient and therapist perceptions of working together. The Working Alliance Inventory (WAI) has been adapted over the years into several different versions, but all have in common measurement of both the therapist and patient assessment of their alliance ( ). Other measures of therapeutic alliance include the California Pharmacotherapy Alliance Scale (CALPAS) ( ), Helping Alliance Questionnaires (HAq-II) ( ), and the Vanderbilt Psychotherapy Process Scale ( ). Although designed for research these scales may be used in clinical settings to inform the therapist on the quality of the therapeutic alliance. The WAI includes items from Greenson’s original conception of the therapeutic alliance, while the CALPAS incorporates additional features such as patient commitment and idealization of the therapist, and therapist understanding ( ). Almost all of these scales incorporate subscales that assess dimensions of goal, task, and bond.

Transference plays a significant role in treatment outcomes. Transference represents the patient’s perceptions of the patient-therapist relationship that are an echo from the past, expectations from the past that mold the present, and are derived from past relationships. Such expectations typically involve repetition of past relationships in ways that do not match the actual present situation ( ). The recognition and use of transference is also important in pharmacological based treatments. Patients’ transference, such as being reminded of an untrustworthy parent, can contribute to ruptures in the therapeutic alliance which at their worst lead to termination of treatment. Therapeutic ruptures can manifest as withdrawal, in which the patient moves away from the work of treatment by missing appointments, or confrontation, in which the patient expresses anger or dissatisfaction with the therapist or attempts to pressure or control the therapist ( ). Recognizing risk for a rupture in the relationship and knowing how to repair ruptures are important skills for therapists to learn and can be highly important to successful outcomes of treatment ( ).

Relationship between therapeutic alliance and treatment outcome

The quality of therapeutic alliance is related to outcome in depression treatment, whether that treatment is medication, psychotherapy, or the combination. Krupnick and colleagues demonstrated that the therapeutic alliance had a significant effect on treatment outcome for treatment with CBT, interpersonal therapy, imipramine, and even placebo ( ). In both cognitive therapy and medication management, a stronger therapeutic alliance is associated with lower treatment dropout rates ( ). Comparing medication and placebo in clinical trials for depression, a positive therapeutic alliance is associated with greater symptomatic improvement. This effect is greater for placebo than active medication ( ). Interestingly, there appears to be an interaction between the perceived therapeutic alliance, the act of taking a pill (either drug or placebo), and improvement in depressive symptoms ( ). Meta-analysis has shown that the therapeutic alliance has a small to moderate effect size on psychotherapy outcome regardless of when in therapy it is measured or whether perceived by therapist or patient ( ). The alliance is also significantly associated with the time to relapse after a successful cognitive-behavioral therapy ( ). One can imagine a good therapeutic alliance will encourage a patient to return to treatment earlier and to report early symptoms to the therapist. The benefit of the positive therapeutic alliance is not limited to psychiatric diagnoses. The positive therapeutic alliance between patients with chronic low back pain and their physical therapist is associated with greater improvement in pain and reduced disability over 8 weeks of treatment ( ). It may be that in such treatments, the patient is more likely to accurately report symptom changes and to carry out prescribed exercises. This is a fascinating effect to consider as it is not difficult to draw parallels between the hopelessness patients with chronic low back pain experience with that experienced by patients with treatment-resistant depression. Strong therapeutic alliance appears to be associated with fewer suicidal thoughts and less self-harm behaviors ( ).

Certain patient characteristics seem to contribute to the effect of the therapeutic alliance on treatment outcome. Patients who demonstrate a higher degree of submissiveness or low interpersonal agency appear to benefit from a more positive therapeutic alliance in treatment of depression ( ). This may be due to a tendency to withhold constructively disclosing negative feelings toward a therapist and instead engaging in behaviors leading to therapeutic rupture. In addition to patients perceiving a more positive therapeutic alliance, it has also been shown that greater agreement between therapist and patient rating of the therapeutic alliance is associated with greater improvement in depressive symptoms in psychotherapy ( ). The therapist and the patient have a shared view in such relationships rather than a discrepant one. Therapeutic alliance has been shown to mediate the effect of the personality traits of agreeableness, extroversion, and openness on treatment outcome in major depressive disorder ( ). Patients with depressive symptoms as a result of a personality disorder may respond better to psychodynamic psychotherapy, a psychotherapy in which the therapeutic alliance is a key focus of the work, equal to that of transference ( ).

In contrast, a negative therapeutic alliance may contribute to treatment resistance in depression. An unhealthy alliance can emerge as the result of patient or therapist factors. For the patient, a negative alliance may be part of the patient maintaining the sick role as part of their identity, as part of oppositional stance toward the therapist’s efforts to help them get well, and inability to develop trust in the therapist. The therapist may fail to appreciate and address psychosocial stressors if only focused on medication management and physical symptoms. The therapist may also introduce distance into the therapeutic relationship with a treatment-resistant patient, with feelings of pessimism and failure to help, leading to a weakened therapeutic alliance.

Techniques to improve therapeutic alliance and enhance motivation

The establishment and maintenance of the therapeutic alliance is an ongoing, iterative process that requires focused work on the part of both the therapist and the patient. A “set it and forget it” mindset is unlikely to be successful, as each interaction between the patient and therapist has the potential to change the direction and tone of the alliance. At all phases of treatment (assessment, initiation, continuation, and termination), the therapist should evaluate the strength and nature of the alliance, and adjust treatment techniques to enhance and sustain the alliance. These efforts take place both in the foreground (in the content of sessions) and in the background (in the therapist’s way of relating to the patient and responding to the patients requests).

There are several frameworks and techniques that therapists may help foster a productive therapeutic alliance with a patient with treatment-resistant depression. There are some common therapist-level factors to keep in mind, which can strengthen or impede the therapeutic alliance. The concepts presented here are by no means a comprehensive summary of effective strategies for building the therapeutic alliance. Rather, they are intended as foundational guideposts to help therapists establish both a frame of mind and a way of working with patients that enables the development of a trusting, supportive therapeutic alliance that motivates change ( Table 40.1 ).

Table 40.1

Techniques to improve therapeutic alliance.

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