Presenter:
John R.
Graham, M.D., CM, FRCPC, FAPA, Clinical Professor of Psychiatry, University of New
Mexico, Albuquerque, NM
Location:
Hartford Room, The Commons Building, 2nd
Floor, The Institute of Living/Hartford Hospital
200 Retreat Avenue, Hartford, CT 06106
Abstract:
Psychotherapy
and psychoanalysis have been under assault with insurance companies, review
organizations, business, and government representatives making decisions that
impact medical judgments. A survey of psychiatrists practicing in New Mexico
identified and prioritized 67 problems interfering with optimal patient care.
Insurance problems comprising 34 items form the largest of eight clusters in the
survey. Clinical practice has been eroded with access denied those without
insurance coverage, discriminatory policies, and obstacles to payment of
claims. Managed care organizations like to whittle dedicated professionals down
one service denial after another, one more obstacle after another, reducing
morale and contributing to professional malaise.
When patient
and therapist meet there are external forcing factors outside the treatment
relationship and internal factors within the therapeutic interaction shaping
outcomes. I will describe comprehensive diagnostic evaluation as the
basis for matching treatment methods with patient needs. Careful definition of
a therapeutic focus is described as the vehicle measuring progress from
entry to treatment outcome. Factors establishing a working alliance include
what the patient brings to the encounter, the therapist’s style and
competencies, the psychological glue of the interaction, and shared
agreement on the goals and techniques of treatment. Misalliance is discussed in
this same context. Professional responsibilities in the patient-focused work may
require the therapist to use creative aggressive strategies to assist the
patient in extracting maximal benefits from third party insurance organizations.
Difficulty
conducting clinical trials in psychotherapy, differing “schools of thought”
trying to explain why good things occur, and complacency about rigorous study
inside our black box documenting patient outcomes have contributed to the
dearth of evidence-based reports on effectiveness of psychotherapy. Psychiatry
and the mental health professions representing patients and families in their
communities must renew their professional values and uncompromising standards of
care reinforcing our contributions to comprehensive patient care.
Learning Objectives
At end of this presentation the
learner will be able to:
- Select at least one patient, one
clinical interaction, that will benefit from careful study using descriptors
on working alliance.
- Identify at least five problems
interfering with contemporary clinical practice.
- Differentiate between external
forcing factors and internal factors within the patient-clinician interaction.
- Define therapeutic focus as
an organizing principle in patient-focused inquiry and attainment of treatment
outcomes.
- Describe factors within the
patient, the therapist, their interaction, and the shared goals of treatment
influencing treatment outcomes.
- Describe misalliance and
outline corrective steps to get patient on the pathway to optimal function.
- Understand the challenge of needing
shared language to describe observable phenomena in psychotherapy and
maintaining an attitude of inquiry about neurobiological discoveries related
to psychotherapy and psychoanalysis.
- Renew professional values on the
guidelines for thorough diagnosis and realistic goals for psychotherapeutic
treatment.
Bibliography prepared by
the IOL Medical Library. Call 545-7276 for information.
Books
Fisher JE & O’Donohue WT.
Practitioner’s Guide to Evidence-Based Psychotherapy. Springer Publishing,
2006. WM 420 P8955.
Gelso CJ & Hayes JA. The
Psychotherapy Relationship: Theory, Research, and Practice. John Wiley &
Sons, 1998. WM 420 G321p.
Articles
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Benchmarking the effectiveness of psychotherapy treatment for adult depression
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<2> Baldwin SA et al.
Untangling the alliance-outcome correlation: exploring the relative importance
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<3> Quirk MP et al.
Personality assessment in today's health care environment: therapeutic alliance
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Levels and patterns of the therapeutic alliance in brief psychotherapy.
American Journal of Psychotherapy. 61(2):109-29, 2007.
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<7> Couture SM et al. Do
baseline client characteristics predict the therapeutic alliance in the
treatment of schizophrenia? Journal of Nervous & Mental Disease. 194(1):10-4,
2006 Jan.
<8> Missirlian TM et al.
Emotional arousal, client perceptual processing, and the working alliance in
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Psychology. 73(5):861-71, 2005 Oct.
<9> Graybar SR. Leonard
LM. In defense of listening. American Journal of Psychotherapy. 59(1):1-18,
2005. (ELECTRONIC FULL-TEXT FORMAT)
<10> Hilsenroth MJ et al.
The development of therapeutic alliance during psychological assessment: patient
and therapist perspectives across treatment. Journal of Personality
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