In Brief: Who Needs the Therapeutic Alliance?
The Carlat Psychiatry Report, Volume 19, Number 3, March 2021
Oxytocin levels tend to fluctuate in synchrony when people are in strong, connected relationships, from the mother-child bond to romantic partnerships. A new study extended that to the therapist-patient dyad by comparing the change in oxytocin levels for patient and therapist during each session of psychotherapy for depression. The greater the synchrony in the oxytocin flux, the better the therapy outcomes.
Oxytocin synchrony was lowest when therapists were working with patients who had severe relationship or attachment problems. Earlier studies also found poorer therapy outcomes for these patients, which raises a challenge that I often hear patients express: “How can talking to a therapist help if I’m not good at communication and relationships?”
One answer comes from a large NIMH trial of depression, which found that socially isolated patients did better with an interpersonal than a CBT approach (Sotsky SM et al, Am J Psychiatry 1991;148(8):997–1008). Another trial found that the therapeutic alliance did not predict outcomes for adolescents with ADHD when the sessions had a clear agenda and skill-building goals (Boyer B et al, Behav Ther 2018;49(5):781–795).
Attachment-oriented approaches can work well for these patients, but the work is more difficult and not well suited for a 12-week course. Patients do better when psychotherapy builds on their strengths, and if attachment is not one of them, a structured approach is a good place to start.