The Therapeutic Alliance

You + Me -> working on your problems.

That is the basic paradigm for treatment.  It assumes that the psychiatrists is competent and professional.  Assumptions about the patient are less clear.  In the ideal situation, the patient is aware of the therapeutic alliance and focused on examining and solving problems.  There are a wide array of problems that can be the focus of treatment.

The approach generally works very well but there are things that can derail it.  In the course of treatment, emotionally loaded topics are discussed.  In some cases the emotions of patients and psychiatrists impinge on the alliance and need to be clarified.  There are boundary issues that often bias treatment in a particular direction.  A common example is a friend or family member referring a person into treatment.  These days there are important factors outside of treatment that bias treatment as indicated in the following diagram.

In this case, the patient and psychiatrist can have an excellent working alliance.  They can be focused on solving problems by applying the best possible evidence based medicine or consensus guidelines, but the best course of treatment that they agree on is not funded by the managed care company or pharmaceutical benefit manager.  A common example these days would be a patient with depression and back pain.  I frequently recommend duloxetine, especially in the case of failed treatment with SSRI type antidepressants.  Even in the case where this treatment is effective for both depression and back pain,  the PBM can either refuse to pay for the medication or make the copay so high that the patient cannot afford it.  On the inpatient side, a common scenario is the manic patient who is not able to function unsupervised at home or in transitional care.  The managed care  company can say that the patient is "not a danger to self or others" and insist that they be discharged form the hospital.  That is probably one of the most frequent reasons for readmission.  In other cases, managed care companies declare that the patient is no longer at risk for suicide.  Their reviewers make this decision based on reading chart notes or talking to the doctor who thinks that the suicide risk is still high.  In the majority of cases they decide against the attending physician - probably the most egregious breach of the therapeutic alliance especially when the patient is as concerned as the psychiatrist.

The government also intrudes at multiple levels.  The biggest intrusion has been by facilitating the development of both managed care and PBMs.  These are businesses that were essentially invented by the government in order to reduce the cost of health acre.  After two decades it is clear that health care inflation is as high as ever, that mental health services have been cut to the bone, and that public mental health services that have adapted managed care strategies have a also dramatically reduced services.  In almost all cases, the government advances a purely political experiment that results in numerous inefficiencies that fails to produce results.  Some common example include failed pay for performance initiatives and a failure to reduce Medicare readmissions based on financial incentives and disincentives.  Practically all of these experiments use the administrators assumption that physicians don't know what they are doing in the first place.  That is probably not the best place to start.

There are many political influences that  are not on the diagram.  Direct to consumer advertising, the media, and various advocacy groups are additional examples.  Psychiatry is unique in that there are a number of causes dedicated to the most negative characterizations or destruction of the field.  That orientation not only precludes any therapeutic alliance but also may lead to intrusions on existing or initial alliances.

George Dawson, MD, DFAPA