Harvard Mental Health Letter

In Brief: Therapeutic alliance and treatment preference

In Brief

Therapeutic alliance and treatment preference

In controlled clinical trials, patients are assigned to treatments at random, so some inevitably don't get the treatment they prefer. A new study shows that their disappointment can make it more difficult to establish a therapeutic alliance, the working relationship between patient and therapist that is probably the most important influence on the outcome of therapy.

In the four-month study, 75 depressed patients were assigned at random to psychotherapy, the antidepressant sertraline (Zoloft), or a placebo. Before the trial began, they were asked whether they preferred talk therapy or medication. The quality of the therapeutic alliance (as judged by the patient) and the severity of the patient's depressive symptoms were measured with standard questionnaires before, during, and after treatment.

At the start, about 50% of patients said they preferred talk therapy and 50% preferred medications. Among patients who preferred talk therapy and received it, the quality of the alliance improved for the first two months and then remained steady. If they were given medication instead, the quality of the alliance with the care provider did not improve, and if they were given a placebo, it decreased for the first two months.

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