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Obstacles to a Therapeutic Alliance: Competing with a Biological Prejudice

March 09, 2020

People in the behavioral healthcare field live inside a bubble. They know they help people and presume the public sees them that way. In fact, unless you are a doctor distributing medication, people don’t know what you do and have low expectations for talking with you. Therapists are taught to manage this in the process of building a therapeutic alliance. That may be a bit too much for a clinician to manage.

Imagine your reaction upon meeting someone who asks you about issues you don’t want to discuss. My question is not based on years as a therapist, but as a consultant to nurses speaking with patients in a disease management program. These nurses avoided personal questions. They imagined how awful they would feel getting such questions. They insisted on only asking neutral nursing questions.

This is a normal reaction. We may be taught that therapy is a special, healing relationship, but that does not mean the public accepts this framework. It is an unusual relationship. One’s primary care doctor never probes in such a way. Yet counselors in our field persist in believing they are warm and helpful people. They rarely think that they may look threatening to some people, useless to others.

“Useless” is the view of people who prefer a pill or nothing at all. Let’s call it biological prejudice. Our personal, intrusive field competes with easier, biological alternatives. Some are not real biological agents but are promoted as such. This is not just a therapeutic alliance problem. It is a threat to our psychosocial model of understanding people. This prejudice casts psychosocial factors as unimportant.

Biology vs. behavior

Our field confronts a stigma, distinct from the one that has long been projected onto our patients. The stigma our field encounters is low expectations about its services. This can be seen in consumer surveys and in images portrayed in the media. Our services are valuable, as proven by research, but our weak reputation impacts the motivation of those buying and using our services.

People need to be introduced to our field in a way that is non-threatening. For this we must answer the question of what our psychosocial services do for people. The answer must be very short, and so I nominate the phrase “behavior change.” Therapy might explore many things along with behavior, yet a need for broad communication demands brevity. Behavior change is as good an oversimplification as any.

If people want stable moods, rational decisions or a healthier lifestyle, they might consider working with an expert in behavior change. This is non-threatening, but how does it measure up to biological solutions being promoted? The obstacles to a therapeutic alliance include bogus biology as well as real biology. There are promises of great biological changes from products and services on today’s market.

Consider the wellness industry. Here are two new solutions being sold: NAD (nicotinamide adenine dinucleotide) will repair cells and increase metabolism; red light therapy boosts energy and mood, and reduces pain. Some nutritional advocates use the motto “food is medicine.” Among the good reasons to exercise is to “boost endorphins.” Meditation may be relaxing, but it also “alters your brain waves.”

This is not harmless. It helps frame expectations for behavioral health services. How will my brain change? People seek our services in a fog of confusion, fear and mistrust. Our historical efforts to reduce stigma and educate the public are fine, but they are overshadowed by pervasive campaigns for both overhyped and genuinely novel biological solutions. They create a biological prejudice.

We need to do several things simultaneously. We must celebrate new biological solutions, but also expose solutions riding the coattails of biology with exaggerated or false claims. We should own all domains where behavior change is needed, and then find better ways to help people make changes. Perhaps most critically, we must celebrate behavior change as a timeless and essential human endeavor.

The importance of a clinical model

The public is unimpressed by research validating the power of psychotherapy. The intrusive, personal nature of the work is surely a problem, but the fact that it is “work” also matters greatly. We have been conditioned to expect biological solutions requiring little work. The psychosocial model can address this by highlighting the social roots of many problems and the endless need for practical solutions.

Behavior change is based on interpersonal communication. This communication focuses on goals, motivation and strong emotions. Communication is not ethereal. It extends into the physical world. Practical, wraparound services are often needed to address functional impairments for severely ill people. Powerful sources of distress, like trauma, are found to be the root of many problems.

Psychosocial problems and solutions will always be with us. Yet they can be pushed into the background as secondary unless we take a stand. There are two distinct models for scientific progress. Biological solutions represent monumental advances of the human intellect. Psychosocial advances, also significant, reflect how our lives are always based on small thoughts and actions every day.

There is an understandable impulse to find bold actions to replace the small ones that comprise our lives. There is an attraction to universal solutions over the partial ones that depend on factors like communication. Solutions that can avoid the inevitable misunderstandings that come with interpersonal communication will always be preferred. It is easy to understand a biological prejudice.

The promotion of psychotherapy-based products

The online company Talkspace has a TV commercial in wide distribution which features Olympic swimming champion Michael Phelps talking about how psychotherapy helped him. The interesting aspect of this is not just the rarity for such an open declaration by a public figure, but the reality that one needs a therapy-based product to promote. Few people go on TV to praise their personal therapist.

We can advertise products and services for sale, but professional services based on trust and reputation are less commonly sold in a public forum. You will find lawyers for accident victims widely advertising their services, but social decorum has limited such self-promotion. How does the public learn about professional services? The answer is through many sources, few of them directed by the profession.

Online platforms for therapy-based products are proliferating. Two notable features of these solutions merit highlighting. Public advertising of professional services is breaking through historical barriers, and the marketing message heavily promotes clinical results for services. New voices are being heard. New forces are shaping expectations for therapy. It may soon appear less peculiar, more powerful.

We should aspire to having strong messaging for all legitimate points of view. The biomedical model has produced transformative solutions that merit outspoken advocates. Psychotherapy has also saved lives, more privately, through the power of communication in a unique relationship. Yet we need empiricism rather than testimonial claims to drive our preferences. We need impartiality rather than prejudice.

Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.

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