Therapeutic Alliance in General Psychiatric Care

Abstract: The main aim of the thesis was to study different aspects of the therapeutic relationship in general psychiatric care, within various routine psychiatric settings with a variety of diagnostic patient groups and different staff groups. The first study investigated the patients' opinion on what constituted good psychiatric care. One outpatient and one inpatient sample were interviewed. The main result for both samples showed that it was the quality of the relationship between the patient and the therapist/staff, and being understood by the therapist/staff that formed the most central aspects of good care. The findings indicated that the relationship should be characterised by warmth, empathy, understanding, sufficient time, and being provided for, and the clinician should be able to enter into the patient´s feelings and to understand his or her unique method of communication. For the inpatient group the analyses also pointed to stability and structure and relief of pressure as main categories. Study II investigated how patients in a psychiatric inpatient ward perceived the therapeutic relationship and the ward atmosphere, the interrelationships between these phenomena, and if demographic and clinical factors had any influence on the therapeutic alliance. The results showed that the ward atmosphere factors 'support', 'programme clarity', and 'spontaneity' were important ingredients in establishing a therapeutic alliance and also that older patients and patients with a high level of psychosocial functioning established a better alliance, while patients with personality disorders tended to develop a weaker alliance. Study III examined client factors of relevance for the establishment of the therapeutic alliance and for dropout in a routine psychiatric outpatient setting. Several variables correlated with the helping alliance and the 'cold/distant' factor, 'motivation' and the 'interpersonal sensitivity' factor were the most important factors for establishing the alliance. Moreover, it was the alliance as perceived by the patients, and not the staff, that proved to be the most essential variable. The results also showed that early dropout was predicted by low helping alliance, low age and the 'cold/distant' factor. The all in all results of the thesis clearly showed the importance of the quality of the therapeutic relationship in general psychiatric care and that the most important factors for establishing a good alliance were relationship factors. When investigating the importance of patient factors for the establishment of the therapeutic alliance and early dropout, the results taken together showed that socio-demographic factors (except for age), diagnosis and problem severity were of minor importance. Instead, patient factors relevant for the relation and interaction with the clinician seemed to be of more importance.