Therapeutic alliance is paramount

As psychologists at the Veterans Affairs Medical Center and the Baylor College of Medicine, both in Houston, we agree with many points raised in a recent article about Dr. Harold Kudler’s presentation at the American Psychiatric Association meeting about the mental health care program at the Department of Veterans Affairs (See at left Related Content: “Greater focus on therapeutic relationship could improve VAMC outcomes”). However, we think the article inaccurately characterizes the role of the therapeutic relationship in evidence-based psychotherapy training and delivery within the VA.

The article states that evidence-based psychotherapy (EBP) training in the VA “typically focuses on mastering specific skills and maintaining adherence to the manuals rather than [emphasis added] on the strength and nature of the therapeutic relationship.” This is an unfortunate yet enduring myth. All of the 15 VA-sponsored EBP training programs specifically focus on the development of a strong working alliance as a necessary component of delivering these treatments. As a demonstration of this focus, the therapeutic alliance is measured as part of ongoing program evaluation efforts.

The VA EBP training programs that treat depression, insomnia, posttraumatic stress disorder (PTSD), and chronic pain all have published results demonstrating that VA-licensed therapists in EBP training are able to build strong initial alliances with their veteran patients that continue to improve over the course of treatment (average Cohen’s d = 0.56) (J Consult Clin Psychol. 2012;80[5];707-18), (J Consult Clin Psychcol. 2014;82[6];1201-6), (Clin J Pain. 2015;31[8]722-9) (Behav Res Ther. 2013 Sep;51[9]555-63), (Int J Geriatr Psychiatry. 2015;30(3):308-15), and (Am Psychol. 2014 Jan;69[1]:19-33).

The article goes on to note that clinical practice guidelines should address therapist behaviors and qualities that promote a facilitative therapy relationship. As Dr. Kudler and his colleagues have noted elsewhere (JAMA Psychiatry. 2016 May 18. doi: 10.1001/jamapsychiatry.2016.0746), the VA/Department of Defense Clinical Practice Guideline (CPG for Posttraumatic Stress Disorder) explicitly states: “A supportive and collaborative treatment relationship or therapeutic alliance should be developed and maintained with patients with PTSD.” (http://www.healthquality.va.gov/PTSD-Full-2010c.pdf: p. 92, accessed on May 30, 2016.)

Similarly, the VA/DOD CPG for the Management of Substance Use Disorders (SUDs) states that the therapeutic alliance “is at least as important as the specific treatment approach selected.” (http://www.healthquality.va.gov/guidelines/MH/sud/VADoDSUDCPGRevised22216.pdf: p. 15.)

In short, VA EBP training has a strong emphasis on the development of the therapeutic alliance as a necessary condition for effective treatment and published results demonstrating the strength of those alliances as well as robust symptom reductions among our veteran patients. We agree with the authors as well as various task forces that the therapeutic relationship should be included in mental health CPGs beyond those mentioned for PTSD and SUD.

Tracey L. Smith, Ph.D.
Houston

Natalie Hundt, Ph.D.
Houston