The Therapeutic Alliance: What It Is, Why It’s Important, and How to Establish It
Essential Concepts
Be warm, courteous, and emotionally sensitive.
Actively defuse the strangeness of the clinical situation.
Give your patient the opening word.
Gain your patient’s trust by projecting competence.
The therapeutic alliance is a feeling that you should create over the course of the diagnostic interview, a sense of rapport, trust, and warmth. Most research on the therapeutic alliance has been done in the context of psychotherapy, rather than the diagnostic interview. Jerome Frank, author of Persuasion and Healing (Frank 1991) and the father of the comparative study of psychotherapy, found that a therapeutic alliance is the most important ingredient in all effective psychotherapies. Creating rapport is truly an art and therefore difficult to teach, but here are some tips that should increase your success.
BE YOURSELF
While there is much to be learned from books and research about how to be a good interviewer, you’ll never enjoy psychiatry very much unless you can find some way to inject your own personality and style into your work. If you can’t do this, you’ll always be working at odds with who you are, and this work will exhaust you.
CLINICAL VIGNETTE
My friend and colleague, Leo Shapiro, does both inpatient and outpatient work. He’s a character, no question about it.
As a patient, you either love him or hate him, but either way, what you see is what you get.
Two examples of Dr. Shapiro’s unorthodox style:
1. Walking down the hallway of the inpatient unit, Dr. Shapiro spotted the patient he needed to interview next.
“Hey, what’s wrong, does your face hurt?”
Patient: “No, my face doesn’t hurt.”
Dr. Shapiro: “Well, it’s killing me!”
The patient chuckled, and the rapport was solidified.
2. The Shapiro thumb wrestling ploy:
An angry, depressed man was demanding to be discharged, prematurely according to staff reports. Dr. Shapiro agreed that discharge would be risky, partly because the patient had developed little in the way of rapport with anyone.
Dr. Shapiro: “I understand you want to be discharged?”
Patient: “Of course, this place is stupid, no one’s helping me.”
Dr. Shapiro: “If you can beat me at thumb wrestling, I’ll let you leave.”
Patient: “What?!!!”
Dr. Shapiro (putting out his hand): “Seriously. Or are you afraid of the challenge?”
Patient (reluctantly joining hands with Shapiro): “This is crazy.”
Dr. Shapiro: “One, two, three, go”
Dr. Shapiro quickly wins, as he always does. “Well, I guess you have to stay another day. See you tomorrow.”
Patient (smiling, despite himself): “That’s it?”
Dr. Shapiro: “What? You wanna talk, OK, let’s talk.”
A significant exchange ensued, and the patient was in fact discharged that afternoon with appropriate follow-up.
No, I’m not endorsing the Shapiro technique. It works great for him, because that’s his personality, but it would be a disaster for me, a mellow Californian at heart. The key is to be able to adapt your own personality to the tas at hand—helping patients feel better.
BE WARM, COURTEOUS, AND EMOTIONALLY SENSITIVE
Are there any specific interviewing techniques that lead to good rapport? Surprisingly, the answer appears to be “no,” and that is good news. A group of researchers from London
have studied this question in depth and published their results in seven papers in the British Journal of Psychiatry (Cox et al. 1981a,b; 1988). Their bottom line was that several interviewing styles were equally effective in eliciting emotions. As long as the trainees whom they observed behaved with a basic sense of warmth, courtesy, and sensitivity, it didn’t particularly matter which techniques they used; all techniques worked well.
have studied this question in depth and published their results in seven papers in the British Journal of Psychiatry (Cox et al. 1981a,b; 1988). Their bottom line was that several interviewing styles were equally effective in eliciting emotions. As long as the trainees whom they observed behaved with a basic sense of warmth, courtesy, and sensitivity, it didn’t particularly matter which techniques they used; all techniques worked well.
No book can teach you warmth, courtesy, or sensitivity. These are attributes that you probably already have if you are in one of the helping professions. Just be sure to consciously activate these qualities during your initial interview.
There are, however, some specific rapport-building techniques that you should be aware of:
Empathic or sympathetic statements, such as “you must have felt terrible when she left you,” communicate your acceptance and understanding of painful emotions. Be careful not to overuse empathic statements, because they can sound wooden and insincere if forced.
Direct feeling questions, such as “How did you feel when she left you?” are also effective.
Reflective statements, such as “You sound sad when you talk about her,” are effective but also should not be overused, because it can seem as though you are stating the obvious.
What do you do if you don’t like your patient? Certainly, some patients immediately seem unlikeable, perhaps because of their anger, passivity, or dependence. If you are bothered by such qualities, it’s often helpful to see them as expressions of psychopathology and awaken your compassion for the patient on that basis. It may also be that your negative feelings are expressions of countertransference, which is discussed in Chapter 13.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
