2001 - Theoretical Frameworks For Understanding And Investigating The Therapeutic Relationship In Psychiatry

(2001) l6:557-564 50(PsydiarryPsychiafl hldemiol

R.Mccuire. R.Mccabe' S.Priebe

and for understanding frameworks Theoretical in psychiatry relationship thetherapeutic investigating

... Abntad Backsround: Mental health careis delivered tiroush a relarioiship oetweend clinicianand d Patien is of centralitn Al$o;gh this therapluticrelalionship to be rela care, it appears oortanie for mental health re EmPirical research. psychiatric iively neglectedin and concePts adopted most his for tle search Part and generalmed methodsdevelopedin Psychotherapy icalpraL(ice.Hence,unPackingthe Pretupposirion(Ih-' havi informed researchon rhe therapeutrcrelalionshP to datemay be a usetulfirs! slepin develoPingthjsfielC Mptrodi A review.of the literalu-rewas (arri€d out iP s lfJj six central tleories are identified as framing thr definitionsand methodson this topici role theory,Ps) choanalysis, socialconslructjonism.systemstI€ory. su cial Dsvcholosvand cognitive behaviourism To dal' role inl'on, piichoanaivlis and systemstheory aPpe.' ro be the tiamiwork' most often appliedin researchIr thir field.Ea(h perspecriveoffersa unique emPhasjsir, the analysisof tle lherapeulicrelalionshiP.which is r( di fleded in the empiricatworkfrom eachPersPeclive cussedherein.ConrlusiorsiNoneof fie lheoriesidenrl fied have been fully specifred and comPr€hensivelY investiqatedin psychiatricseltings However'morethan one apiroach may be usedfor lhinldng aboul rela(ior ships.dependineon the treatment siluation Furthe .o".ifi.urion anJ testing of the theoriesin psychialr' piacrice rakingac.ouniofthe sPecificcontexl- is wal rantedto underDinmorepragmalicresearch.Anron8. I linl betweenfundamenrd psychologicaland sociologr cal researchand applied health care researchwould ad vanceour undersGndinSof vthich el€mentsof positivc theraDeuticrelationships are instrumental in imPmving patie;t outcomeand uitimatelycontributeto improving mental health care.

R.Mccune(E).R. MccabeS.Priebe tsychiatrl Uniifor Social& Communiry EasrEm MenolialEosPilar lrndoD !7 3QR,UK !-Maii: ia.mcguire@mdr,qms.a..!*

lntrodudion I hr theraDeuticrelationshipis a fundamentalcompo rrert of mintal health care.It is the meansbv which i. . rn es\ionalhopeslo engjgewith.dnd effeclchangein r rienr,and hasbeeniorlnd to predict treatmenrao lrcrcnceand outcomeacrossa range of Patient diag roses and treatment settings (Olivier_Ma in 1986 l'rank and Gunderson1990;Legeron1991;Priebean( (;rl,rters1993;Brokeretal. 1998)an.i 1995;Gastonetal. nra,jbecomecentralto the quality of life of long tern.arr patiedts(Mccabeet al. 1999).Althoughthe allianc, iorsiructhas provento be a valid onein psychiatry,th( lrel,l has taken on board conceptualframeworksantr rrersures developedfor Psychoth€rapyand genera neJical practicewithout examiningtleir applicabilit\ 1. I'insychiatficsettinqs. expticit analysiisof researchon the theraPeutic re l.rti..nshi; is thereforerequiredwith a view to'unpack thathaveframedth': iltg thetheoreticaipresuppositions rielrnitionsand methodson this conceptto date.Eacl .iefLnition of the prcfessional-patientrelationship i: nctessarilvframed bv a theoreticaimodel, which, ir' turn. informs the methodsusedto assessit. six centra rheorieshavebeen selectedon the basisthat they hav, becn used in researchexaminingthe theraPeuticrela social constru. o: hio: role t}eory, psychoanalysis' andcognjri! lheori.ocialpsychology u .sm,syslems ' , v i o u r i s m . T h e e m p h a isni lsh j s p a p e r i s o n a r e v i e \ .,f ihe theorieswith rcferenceto th€ ti€rapeutic rela tioDship ratler than a review of the theoriesper sr \flrie aomeapproachesmay comPlementone another arr: there miiexist some conceptualove(iaP,eachi. sulrlcientlydistinct to wadant seParateconsideratior .l ough ea.h apptoachmay suggesla Partrcull lh relalionshiP. rhe lberapeutic , ,, hod for a.sestrng brie neLhodsare not exclusiveto any one aPProach.A '. ription ot eachtheorelical modelis made.de6n from eachtheoI relationship o ., of the therapeutjc rrr described,and an accountofm€thods and researcl

558 resultsfrom each app " ' searchon rhe t-herape" in p'ychorheiar dr.rcred hiweuer,pan ' rr settinesr g a r d i n ' g r e ' e a r . h c b nI d '

Roletheory

"re djscussedMuch re I r orrsbiphas heencon .r",'ta] medkal Praclice r11\asiswiJJbe madererl')'hialtjcsettinSs'

(Byrne and Long 1976itsuijsri rl l '84;PerakyH1995; H;ath 1997iRoteret al. 1997);lrt\Ltr rr, quantitativerating scaleshave alsobeen usc,; rr I' ychiatry (Gelleret al.l976). patjent Dassivitv(charactfrr!1ic )f the paternalistic jr\' model) ani profesiionalPassr\ (.haracteristicof the io Ieadto negative lliLrrl(i been have model) consumer liance,and a high ronr as nor, such outcome, Datient 'early drop out ratein both ileri(r rl lr echcalpracticeand " '76rDocherlyand osv;hiat;i. sexinqs(Gel r . p1a].2000).ingen hie.r., rgAs;Vot fer "1.tG' particulat atlfNrion s increasinglyPaid eral medicine, to the collabomiivemod€l,c! Jtrrcf'lbyvadousjournal r - r lAutoker ic9q: editoflal, Dromotinslh, 'ldLockwoodlqq9r clearvlgsd:CoulteriggqiL" e l 9i A 'ollaborative Sculpherer ai.l999rWilli n, I I ttienlout(omern a aooroa'hha. beenlinked . I " treatment r, rcreased set ir'g vaiietvofpsvchiatri< 'rron al 1997)to (irsenthal | e al adheri'ncJ -et Jed from r'^ a parienl satisfaclionwirl' Psychiaiists in acutesettings(Barkerct al l 996)'to PositweasJr,d ' 'u 'blechantesjn Pa."ssmentsof treatrnent tients' self-ratedcondilion rlr a (i.ry hosPital setting (Priebeand GruytersIoqo r '- eyondthe Pohtical to ior.ectn."".ol empha\i''rP i ' ershiPaPProach evi' emPirical xists :! relalion'l,il tle therapeulic denceIinking it to bett€rfalrftt oLr..om€'

The tust apProach,role lirf, r), focusesuPonidentities that defin#commody rc,, r. isedsetof Personsby designedfun(tionsorpdr, Ib"haviourwithregardlo r.n.\ocjalsystem(Biddle sociaiconr'r' a iarricr.rlar 1656).From this Perspe.iir,,lhe therapeulicrelatione - rd muruallylaUdating ship is definedbv rhel, p , n. and patient who are bv the 'olls occupied ''err behaviourpatlerns eachexpectearo extrr ' \l Threecenlralnyleso{ aefin"a *iihln a'soclally behavio, ,\. been identifiedto decommunicarive scdbe different tlempeulj. rol€ relationshipPatterns: lJnd collaboralive' paternalistic, consumi h the au_ emPhdsises ,'nrp r'1 The Daternalistic '. relaiivepassivity of lhe "r rhoflty6ft}ephysiciar, nle*ional is dorninantin patien'r.In tlLi'smodel rr ' r n. ipally asking closedlhe inlerviewing Pro. r^ inlormationandmak ionslpiov' i endedouesr ol t}le Paiienl (8uijs el ine molt decisionsor " 1992;ong et al 1995j trlriual al:1984:Emanual and 1998; Coult€r 1999; \h,iton al.1998: Benbassatet pati€nt variabl€s P5ydoanalysis r9). Some l' l,ockwood and Gooclare f()r lris model of interaction'in mavDredictDreferencc Th€ secondaPProachis ps\'.hoaJrilytictheory,wh€re cluiiire, it ..'"used"eu"titI ' ' i illness,older age,lowerindifficuttiesexiirienced b) a fcr(il areregardedastle come,"lower educatioD,r'd male gender (Geller et resultof disturbancesin earh hic (rp€riencewhich are al.19i6i B€nbassatel al lr98; shelton 1998;Coulter cr) 'lallis'd attitudes'and unretainealin expectations, 1999).Physicianl"riables l,ientifiedas predictingpreflo nfrvly encounteredreare broughr ti,at fears kaown ereniefoi this modelh clu,rt youngerageandmalegenpatterns l lalionshiP in the perperuJi l-he second'consumer- lalionshiDs e( al.l der {Benbassal relarionship Three ,'oS e dufiorily of the palienr (Wolsleinla95i Lana er " based.modelempha'itvDesareidenlifi€dundcrrL ,' 'r' anaiyticmodel:the ,rr Lhe and the relativep;ssivit! ProfessionalThe comtiinsference,the developmcnlai\ ieParativerelatronmunicative interaction is ! | lninaled by the patient, who and the realrelationshtl'. 'The asks most of the qucsri'rrs during th€ interviewing ship, lelatjorrshit rci'resentsthe Patientt transference orocess.and makesmosl . the decisions(Eisenthalet oi ha[''1ualPattetnsrunretranspositjon unconscious (rI 1997; Rot€retal et aI.1981i Setal.1995; ;1.1979;Buijs ind e,,p , io s onto the Profes Shehonl9d8).The th n . ildburiliveor parrnership' solved Droblems, 'rar 'feren(edisiortions profes. or sional, ind the mooe or rro-_hrerarchr(al I\ modelis characlerise that are projectid onto th! ratrrnt (Luborsky 1976; communicativeinteraclilr in lvhich the Patient and 1985ialark'.n 1993iHanly 1994; combineres,,rrrces.contributeinformation Horowitz andMarmar Drofessional et at 19'ls:Il.issner 1999!Horvath Lane 1995; Wolstein iouatlv. and shar€ in th. .lccisjon-makingPrccessto rei'rraliv€. relationshi! The developmenlalir 2000) (Eisenthal et w;rk ioeether "Rotertoward it ,nmmon Soal prolrssional mayprovide r thal ,efers tothe securebasc "c1999) Coulter .,lon lggSi et al.l al. l979l '-' altachmenl daptive Ind for palientslo recover '.ch as inlernallocusof Palienlp\ychologi.all. " 'atholoSical altach_ ' oatrlrn. resultine frorcontrot ari trieh-.ell c ). dre cited as possiblefa(1990; (Gcrh.r!.1r :101; Clarkson childhood tors relatingto-prefercn.r .'r this model (Dochettyand inent in realrclaThe 2000) Ariliot 1998j 1998;kwis Adshead Fiester1985). tionshiD reflectsthe abilit\' ( j $' patient and profes Methodsfrom this pcr.'ective aim to irvestiSaterc" ,bly respondlo one "r', sionl io appropriately "rr..ituationsandlime er' pealinqpallernsacro ' l r .J. licmannerfHarlley \ p.riicipanl-sunderstand anorherrn an undistor.en, pla;neJbv the roles",r, r'1901I )rvathand Luborsky predominately.assessed and Strupp 1983;Clarkson ing of $'em, and h. 'nedicalpractiLe 1993iHorvath2000). i Scneral a-or uing conversation

559 TransGrencepatternshave been investigatedusing Kell)-grid and rating scalemethods in psychotherapy (Piperel al. 1991)and psychiatric(Hentschelet aI.1997) setiiDcs.Patientattachmentstvleshave been assessed usjng tfe RelationshipQuestionnaireto predict treat mcrlt |dherence (Satterfield and Lyddon 1998; (ljechaDowskiet aI.2001).The extent to which the parelationship' lieDlis er4agedin an ego-realitybased'teal rvirhthc professionalhasbe€nmeasuredbyscalessuch asrhe Ps\rhothenpy StatusReport(Frankand Gunderson 199(j),the Scaleto Assessthe TheraPeuticAlliance (Ailen eLal.1984)and the CalifotniaPsychotierapyAl(unpublishedmanuscriptGastonandMarlianceSc.rles m i r rl 9 9 l ) . in ps]chotherapysettings,the quality of patientob ject relarjons,characte sedby }ifelongrelationshippat lerns, predicted therapeuticalliance ratings (Piper et al- 1991).Among a severelymentally ill samplein psychothcrap,v, the comparabilityof intemalised mother and father imagesio the image of the tierapist deter' lnined allianceratings(Hentschelet al.1997).Here,pa rientsi\,iLhan introj€ctedimageof a strongmothertl?e, for instarlce,made use of the softer charactertraits of counselingclinic,selh e thernpist.In a university-based curely artachedindividualswere found to form strong whereasfearfully attachedindibords with counselors, viduals$ere not (Satterfieldand Lyddon 1998).Finally, th€ extentto which the pati€ntis engagedin an e8o-reality baled real relationshipwith the prof€ssionalhas been relrted to better patient outcome in both psy_ chothcrap,vand psychiatricsettings(AIIen et al. 1988; Frankan{i Gunderson1990;Gastonet ai. 1994;Gastonet ai.r9981.

Social(onstrudionisn Social constructionismfocusesupon the prccessby lvhich individualsinterpr€t,organise,and ascribem€anlnt 1(l thei experiencethrough communicationwith oth€rs (Hofman 1993;Lax 1993;Dwivedi and Gardner humanknowi1997iDoan 1998).Fromtlis perspective, edgeis d eveloped, transmittedand maintainedin social 'reality' situations,constructing the basis for shaied (Bergerl]nd Luckmann1991).lncontrastto role theory and psythoanalysis,which emphasisetole expectations and peffeluated transference distortionsbroutht to the theraper',i. int€ra€tion,social constructionismplaces inore ol an emphasison how identities are co-constructed by th€ parties involved.This theory regards krowlcdge as an eventthat is constructedwithin relationships and mediatedthrcugh language(Penn and Frankfurt 1994).From this p€rspective,eachpatient's trp.H li g problemsare examinedwithin t}leirso.io culturnl Dolitical conte)(t in view of the fact that each person lroduces the meaning of his or her own life Hithin a parti.ular social,cultural and politicalconto.l (Hoyi l996iMonk et al.1997).Thiough the tlerapeutic relatiorship, old problematic ttuths may be decon'

slrucledrnd nev/onesre'authoredthrough the co-conslrucliorrofa newlrarrative(Gottlieband Gottlieb1996i SLLmnrers andTudor2000).With tbe aim to exploreeach prticntt understandingof his or her experiencesand tlre rejecrior of the hierarchicaland objectifying tend(n.ies of more traditional therapeuticmodels,social a'Post modern' hasbeer considered consLru.liorism atprca(h 1otherapeuticinteractions(Gotdieband Gott li.b I996rtlean1998). Iiesear(l on the therapeuticrelationshipfrom this pcrspe.livefocuseson the way in which patientsand p r ofessioDal1constructtheir identitiesin relatiot to one arolher (e.9. Cecchin 1993).The Narrative Process Nlodelprolidesa codingsystemtoidentify and evaluate organthe lrocessby which patientsand professionals ise and r€pfesentthe patient'ssenseof self and others inro a meaninSfulstory (Anguset al. 1999).A narrative approachto the deconstructionofthe voicesof schizophrenicfaljents hasalsob€enusedin atherapeuticcon te\t (Iloln1aand Aaitonen 1995,1997,1998;Davieset al. I 999).Pirticipanttext,suchasletterwriting andjourbeen usedto nal entrrcsbetweentherapysessions,have anal)'seihe therapeuticdialoguethat existsbetweenpatients and professionals(Berkery 1998; Epston et al. 1993iPennand Frankturt 1994).The analysisof gen elai medicalpracriceconsultationsusing conversation analvsis(Heath 1997tElwyn and Gwyn 1999)has revcaledasynmetriesin the doctor-patientrelationship, which ma,!be alignedto the 'paternaiisticrelationship' from the pcrspectiveof fole theory.ln contrastto role th eor)',h o$'ever,which emphasisesthe role expectations thar rhepalientandprofessionaleachbring into consDltation,socialconstructionismfocuseson the processby which asymmetryis accomplishedin and through the berween both parliesin con h. re .rJ -.w inreraclion

theory Systems hr s).stemstheory,relationshipsare seenas part of a more or lesscomplexsystemofrelations(and,in theory, the entire .osmos) that may be describedin relational tcrms.The structureand function oflonglasrinS rela tend toward a stateof tionships,from this perspective, equiljbriun by establishingnorms that delimit and re iniorce patierns of behaviour through a homeostatic mcchanism(Watzlawickand Wealdand1977;Clarkson 1993iCaldwell1994).Twoiherapeuticsystemshavebeen consideredfrcm this approa€h,the keyrelative-patientprofessionalsystem,andthe inpatientward system. Thepalient'skeyrelativeis consideredrclevantto the therap€uti.system,in view ofthe fact that patientdpresentingproblemsareoften developedandmaintainedin a systemof interaction within tle family (Bloch et al. 1991;Pricbe and Pommerien1992;Caldwell 1994). by relativesof in Indeed,thelevelofemotion expressed within a fewweeksafter a dirjduals ith schizophrenia hcspihl aclnlissionis strongly associatedwith patient

560 relapsedurjne lhe firsl 9 month5 follo\^'ingo \ h gc r varlshnand"L,etrlqTb) Membersol tbe lh'r" " ' li' svste"m are not consideredin absoluteterms'b!t ralh€r ' 'm ii a relationalwav,bv compansonwitiin rh' (PIieLc ' 8o are televanl wherebvonlv dtfferences prrebeandPdmmerien laq2;Rait2000)ln $e rrP' (r' staff and patientsare saidto ward svstem,Drofessional e sh oa fv i o u r it r' t t r o t e s r a b l i l h a n d i e i n f o r c e p a l t ebr n o' rl ei (o equilibrium ro one another maint.rinlhe (Caldwell 1994) evolvedsvstem Methodstlat examinethe structuraland fun'tional differencesbetrveenmembersof a therapeuticsystent ihe relalionalatinclude:a two-part questionassessing (Pri'b' l'80r illne\' palienl Loward differences tjtude r l"o4 l9o2:PriebeandGruyl' PriebeandPommerien (Hahn el 1 lot8 clinjcal.asestudies and descriptive \e "eeJ' patienl illnes\ in atritDdetoward Diflerences out'ome professionals kev relativesand Predictedbetter amonedepressiviinpalienrs{Prjebe1989iPr el ' nd commuri t arc Pomm"erie;1992),a;d in psychiatric (PriebeandGruyters1994). tn seneralmedicalpraclice.clinical'ase -dl de seekto forrrr'' orn "criotionsrevealLhatmlnyPatjenLs penlaroryailiancewith the physi(ianfor dcfi' I n lhe ?amilysystem(HaIn et al.1988).

u loDalienlspel(eptionsoltherapyqualny'\ahilell" cerlain dnd slratep,ies influenLe )ip ot "omecoircrve as'o r'' l werenegalively ot exDerlinlluen(eslrategies | 'r' p e r c e P l i o n ' o l l h e r d p y q u a l j l y {|M \aithpdlients 1999). Frieze and

behaviourism Coonitive Dp r' locu(e) noclel Uehavrour ttrecognrrive ririally.

Diffi rr' and behaviour' Eeliefsysrems Ink b'etween lhe "' i as person are regarded a bv exDerienced ar'l b lhinking ot quenceof dysiunciional Paltelns lhe therapeulicrelatr^r'l;l ti.u;o'rr (Eniiehr 1997J. hasbeeninvesiigatedfrom this aPproachusingtwo cot ceDts:the sef-:oncept and causal schemata Bchal ioirrism focuseson riinforcing patterns of behaviour that may facilitateorimpede thi developmentof a good workine relationshiP. The"self(onceDiis describedas a structural rcr'' of sell andor ' thalmakesup onessense sentation ;re said1obe motivaledto ' individudls lablished. (Fiskeand I )r'' theirsell-con(ePtions lain and veriJ_y 1991IThe'self'mavbe bestunde$tood asa socra con_ wilh other rl\l' ceDIlhat is derivedIrom interactionc (ontinually revisefI n'\ is con(epl This rairet ai.2001). uir ' throughtheoscillalion sellreflexively sociailyand J subieciive.observine l and lhe objectjveobserv' I e Socialpsy(hology (M;ran er ai.2001).A patientwho is unwilling! ' may r€srstIn(orprrrrrrrs services sasedin Dsvchialric 'orrle I SociaipsychologyemPhasirslhe inlerPe-rson"l on the ba' l dr rheir sell-concepl i'i.ral lll'ne'ssinto modelsareoffered'ror'Ih 5 o{humaninterac''lion.two ther"r''l ill Here' as themselves reqard lhev do not definedb' o'ial relationship tle IheraPeutlc approachr pt''et ' lo need tle reflect may resisrance Parient! "iit'une", ona the iherapeutictelationshipd' fin J bv by presenied meaninein tde face of newinformation socialGflr.rence. g " or'' ofholdir with theaim menrali'ealthprofes.ionals socjal €xchantetheoryspetifie-sthe ex'hangc"' ran rl i_ ol lhe organisdtion old constructJtlal maintain eibleor intaneibieresouriei that rhepatientand profe'(osnitive svstem(Safranand Segal1998)Resisl l ( ru ' onlert' therapeuli rhe qiive in and receive iionai may i.io.oorotine mentai illnessinio the self (oncepr n ) of'resource' n "vl e r....dinJ tJ Lhisrheorv,six classes alsob'emotiviedbythe fearof socialstigmatisationlnlo\e'rdlt s' witiin an interPersonal(ontext: exchanee-d deed.denialof illniss and socidls1i8mawereide"r if "l intorm;don. monev'Pood: and services(For bnl loa carenursesin Soulh\V' e eP t a l . l 9 9 6 )l n l } l e t i e r a p ' u r i ' o n - bv communilymentalhealth (Funt 1 9 7 4l .9 8 O i S c h a a and F y i999) a! kev barrieis to effectivecare text.tle Drofessio;almav providethe patienr'viLl ore' Departinenlof pnrth"t-o.", for the "onducted t"..ut.h (watmth,comfort).staiui' (retard) good' 1 "c'lic* that 800/col revealed Kingdom United in the iion),'information' (interpretation,insight, fe€dba'k) H€alth peoole believethat iaring a mentalhealthor' h to socia1serrices vouns andlor services(form-filling for access of F1e'rh {Departmenl ro aiscriminalion i"m iiit teia (ilcome) or accommodation)ir exclange for'money' eory 2001). and sialus{Drestigeoresleem).Socialinfluen'-Il be Causalschemas,whichrepresentan individual's ro irflriie caiabiiitv ot the professiond emDhasises (( lL' effe' and cause regarding "nJethe oatienron thebasisof his/heracces'lo I rrl c_ lielsandassumptions and lacobsonla84rFiskeand Ta\In' Beriey lq72t r\h''P I971, et social ulat t.t6r.ce" or Perceived Power to analyse prolesslonal aP used been the profes'onal may 1991), have al.1996r.From thi; per*pe(live. basisof attributionsol Pa_ on the to Droaahes Datients thebasisofhiqorhcr ocial ,lso;nfluence theDdtient_on illness (Brewin l9sE) ln their for responiibility iient ries' arr"l bv ;xhibiLingPosilivepersonal altra
561

victims,drug addictsrD(l froslitutes werepronounced dead more quickly thlrn p.rtients regarded as respectablecitizens'bl s1:i1l,:Lnri resourceswere allocated 'deseningness'. accordingto moral con.elt jors of Thus, a professional's resporsclo a fatient maybeinfluenced, in part,by th€ir causals.ieD:s about illnessand their perceptionof a paiie.l\ rcspL,Dsibility for their illness. It has been suggestedlhirt elli.ient mentalfunctioring dependsupon the sele.Lior(,f relevantmaterial and the exclusionof unwr lcd nraierialfrom enteing con - by flexiirl. .rc it alory and inhibitorymechsciousness (Brewin anisms and Andrc\as1000). Meanwhite, behavioLrfjsrn tocuseson reinforcingpar terns of behaviourthat lnav lacilitateor impedethe developmentof a good \1',:)rkjn!relationshipthrough the processof conditionirg (Schaapet aI.1996;Horvath 2000).From this perspe.live,l echniques'havebeendevelopedto ideDtifypo5irj!€lytil1dnegativelyreinforcing behavioursin therapeotr.ift cractions.Themoment-tomoment effectsofthcrapisi \,{rbal statementsand therapist verbal consequer.eso! client verbal responses havebeen analysedlo idenlif\ potentialtherapistvari, ablesthat may b€ sl'neDrljcrlly alteredto producepatient change,namely:fositiverntecedentstimuluscontrol and generalised r.inforcement variables (Procaccino1998).A .oa.hc(l client'method has also been developedr.r'hercilients rate int€ractionswith their coDnselorfrom '!er') low r apport'to'veryhigh rappo ', and has been ruccesslnllyused in professional tmining programnresfor counseling (Sharpley and Ridgway1992).

publicsafety,prebiiitation,stabilityral|.r : :) change, ventionof relapse,accr! ! f. !clvices),avariablesetting (inpatient hospitalc,outf, rcllt wards, day hospitals, supportedhousingand h, r r nd of6cevisitswith comand the formal munity mentalhealth!r1L r .)lessionals) statutoryrole of profes! 1r .ls The professionals, who attemptto engagewith rnf aliy ill patientswhoseclin;cal diagnosesand symfrl , severityvary, come from differ€nttraining backgr'(,r..ls (psychiatrists,psychologists,communitypsych:ur! rurses,socialworkers,oc' cupationaltherapists,sritr. l workers).Therelativeap' plicability of th€ varior. rrcoretical approacheswill probablydependon thc 1lr, iteutic actionsand aimsof the professionalwithjn ,ri, iionshipat differentpoints of time over the coursc(,1 nl one rclationship.More over,the fact that any inrl\ uJl may haverelationships withanumberofdifferel,I ol.ssionalsatanyonetime, which are intedependc,r',. ill also be impoltant. The extent lo which the throi r :ai modelscan accorrmodatethe flexibility of thc Llrl rsesettingsand situations that inevitablyoccuri 1,.,, rirtryhasyettobeinvestigated.Supervisionan.l t;r;rlrrg in psychiatryis often eclecticor atheorcticaiilr,),,:\er, the compledty of the settinSsand the hiSh rlJr,r .. of confoundingfactors .hvaclearerandconsistent maybepreciselythercas(,r' theoreticaifocusis nec(lfa r , Lrnderstand the processes that predrctdifferentoul, ( ;e. and alsofacilitatepra. tical interventions.Ar .)f . i1 tleory - perhapsdifferent theoriesfor differen| | . rchiatric contexts- would makeitpossibleto link lrirjr :rg andsupervisionto a full backgroundof specificr1,., elicaland empiricalworL while an integntion oaI lrt Lreoreticalmodelswould be ideal,it would probabh f,,.rc difficult to achievebeDir(u5sion cause each model nol o: r requires very different methodologicalapproa.l:(. iu research,but also may Each approachmay oil.r a unique emphasisin the imply differentviewsof r,! .cne.At a later stageofreanalysisof the therapcuticrelationshipin practice.A search,whenmethodson tl r lrrpicareadvanced, it may roletheory approachmrybc usefi{ to assess patientand be clearerv/hichelemenr\(. r positivetherapeuticrelaprofessionalalignmentio diltrent rolerelationshippattionshipmaybe parti.Lrlarl, alplicableto eachparticu terns.Psychoanalysis nra) ol eI insightinto fifficult'belar settingandwhich elcn. r rs aregenericacrossall sethaviou! wheretransferen.edistortionsarcbroughtinto tings. play in the relationslit (Hertsch€let al.1997).A social In order to advan.ellr' .eglectedfield,where relaconstructionistapprolch na) provide insight into the tionshipsmay be fragllr a!r.:unrewardingforboth clinpossible tension betNecrrlh( narative that patients iciansand patients,thc th., rics and their implications b nt into tle consullationand the professional'sunneedto be turther spe.ilif(l rd empiricalytestedin rederstandingof ilness (Launcr 1999).A systemicapsearchto determinelh.ir 1 lue in clinical practice.In proach emphasisesthe proiessional\ awarenessof naturalisticstudies,assessD, ntsof the relationshipmay his/her structuraland f nctr)nal relationshipwith the be testedfor tleir progrnsr : \'aluewith respectto espatient in rclation lo thc pati.nt's significantotlers. A tablishedoutcome crit..r ,. an approachadapted by socialpsychological atp! (' achm ay emphasise th€ tangimost researchin this fiei(i i, date(e.g.Frank and Gun ble and intangiblegood\ exchdngedin the tlerapeutic de$on 1990;N€aleand Ro:, nhe& 1995).Incontrolled context and the social inllutnce strategiesemployed studies,modelsof the lh.1.:.,cuticrelationshipmay be (Schaap€t al.1996).A cognitii€-behaviourapproach usedto designspecificinlLrrcntionstarteted at both a may provideinsightinlo tl]e Lnrkbetweenbeiiefsystems mofe positiverelatio.slrif , nd a better outcome(e.t. and behaviourcontribuling 1()-or detractingfrom, the Priebeand Gruyters 199! -r other interventionstud developmentof a good \i ork ir g rclationship. ies,includingrandomis.J. .lrolledtrialsofne\{drugs, ln comparisonto irs\'.hotherapt psychiatryis an psychologicaltreatmcnt\ r: I healthse ice con{igumarea that is complicatr'db)' heterogeneoustreatment tion, it may be usetul1! ii( | j.lrine the extentto which goalsand components(c.9.lrcatment adherence, reha- the therapeuticrelatior!hrf i r mediatingfactorin im-

56i Ande6on H,GoolishianH (1993)The clientis experlra not_know'ng lpp.oactrto fterapy.In: McNameeS'Ger8enKJ (€dt Th€rapvas $cial co.structio! Sage,London (1999)TherarrativeProce$codDgsys Anlu5 'r.n:L.lrvin H,HardtkeK researchapplicationsand inllications fo' PsvcholleraPv Diactice.lClin PsYchol55:12551270 T w ; e x " m p l en r d i n ' n h e r h e t . P e u r h r l l d ' e i n \ n r D B r . 2 0 or o " , , n r e e n i v e . o e D r i e ' i h e r d pJvC ' i nP ' v c h o l r b l:8 - r 0 !- ) 1 " ' ' . " . . ' i ( i o o o )c . i n - i n s ' n ' o , m e(Ao n r r r r o t ' R e n i n SB V l i2t-J22 r . l r D A .s u l d r w . n o P 'sSh e r S ' l l sH . 8 8 i n ' o nl O t t e l lv r l c a 6 P & !\y r e n s r t r w ! o s d r d : . r t . r e c e ' \ P nd o r P < y . h r ar'J s B ' I .hiatrY 168:641-646 f o\ ' p l r Con
piovins outcome.Indeed,in a tandomised controlled for depn' ol pharmacorherapy tual te;linelheeffiLacv .ion(weis;eral.1997i. ir wasioundtharIhelheraPeuri rlliance accountedfor between21 and 56% ofthe vari ancein outcome.It may thereforebe usefulto sPecili and analysethe therapeuticrelationshiPas callyassess pot;ntially mediating- or confoundinS fa'tor in existing trials.

j! Adnowledg.n.nt Thi. hreraturerflrev Pdrl ot ' I vea P ".I rundedoi,"e loin, Resrd"n Boa'd.r5r' Brlholoreris H^

Reference5 ldshead G (199s) ?svchiatic staff as anachment figlres: U'd'r ' {andre manaeemenrprcblem' in ps}chralr:( ser\ne( i b 4 o o l 7 ? B r ' P \ v ' h i d r r v L s h ro l : t u . h n l r r $ e o r y allen ic. Nsom Gn,GabbardGO (1984)Scaieto a$6s ine $sd peuiic "ltiunce f.on a p.yctrodalltic P€BPeclive lull Mfll 383-400 nirqer Clin 43: D B"skll'R,CovneL lo33rAse$rentof " \llen C:D€erine pturic Jli;(e' r rheP'v"brath ho\Pra rJ eu P'r'"hid \ 29t 299

cie.hm@ski P5,Karonwl, Ru$o il. walker EA (2001)Tle Patie'r Drovider.elationship: anachhent fteory atd adherenceto treat ;en n dabets.A; l?rY.hiarv i t8. 29 3t . l r n \ o n P L l 9 9 OAJ d u l l r P l n r l y o f P ' ) c f o t J l e r a P e ur el nl d r r o n ' h i P A lPsvcholheraD]7 148-l6l L ] € r k r o n P ( l c 9 l r o ; P s F h o t h e , a P\ya ' h u r i r l n d o n {:learyPD ( 199e)lbe in;easin8 imPorianceof Patienrsuwe'. B Ii |7212.720-721 c o ' r i e .a , r o g q p r o r . n . l i . - o r P l r r n € r ( h i PP n r r e ! h a ! e8 r c w ' u ddthere-r ho qoins ba.k bM ) / tt2: t te- 1zr D"\ie\ P. Thonas P,-r?ua"r . (lgeal Didlogi(al e_Ea8'menrw v o i r . : d t n s e . r ' t e s l u d v B r M e d P s y ( h o l / 2' - a 1 8 7 Dear RG (1e9s)iostmode.tisn andbrief treatoe : a more incll sive dodel. Crisis iniervenlion and time linited irealn€nt 1: 101-112 Jd-dnenl of Heal$ L2oolr lsnotan e and ,Pdr breed' men qeJrh u/"b \i'P Un rP hedlLhd.<-m,nation Depairmenrol

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rso 356