Psychiatric providers have long struggled in the context of placebo and nocebo effects that impact on prescribing outcomes. In this chapter, the authors argue for a strategy of collaborative engagement with patients to understand the contributions of history and beliefs to the context of the prescribing encounter as they aim toward working with, instead of against, these complex aspects of the clinical work.

The perspective that a patient has about treatment, especially when it comes to medication, is often very different from that of the psychiatric provider. Providers and patients alike may find it difficult to acknowledge and reconcile these divergences in their perspectives, leading to stuck points and potentially unhelpful or contentious dynamics in treatment. In this chapter, we explore some common types and sources of divergence, as well as some practical steps both providers and patients can take to understand and perhaps remedy them.

With the dramatic progress in the neurosciences over the past few decades, it is a challenge for psychiatrists to navigate this information in ways that allow incorporation and translation of relevant data into their prescribing habits. In this chapter, the authors present a model framework of how to utilize neuroscientific understanding of psychopathology and mechanistic effects of medications to guide management. Examples include use of selective serotonin reuptake inhibitors for depressive disorders and for trauma- and stressor-related disorders, rooted in discussion of how the nervous system is understood to be dysregulated in these conditions. There is also discussion of the biological impact of psychotherapy and how it intersects with the effects of medications. Importantly, caution is advised in indiscriminately applying neuroscientific data in guiding treatment approaches, as the applicability of this knowledge to everyday clinical settings is a continuously evolving matter. Finally, the authors present how prescribers might incorporate the neurobiological dimension into psychoeducation with patients, allowing them greater agency in decision-making regarding their care.

One of the central tasks of a prescriber, whether in psychiatry or other areas of medicine, is to establish a safe, respectful, trusting, and productive working relationship with the patient. What this will require for each patient can be as individual as the person themselves, but demonstrating these values early on in treatment will help strengthen the effectiveness of any treatments you and the patient pursue. In this chapter, we will provide a framework for establishing strong and effective partnerships with your patients – acknowledging not just your respective roles in treatment, but also your shared personhood.

A good therapeutic alliance is the common mediator of effectiveness of many evidence-based psychotherapies, as well as a significant factor in responses to medications and other treatments. Despite its importance, a precise definition of therapeutic alliance is yet to be agreed upon, and concordantly, is challenging to teach. This chapter proposes four components, discusses principles and offers practice points: (i) “empathic resonance”; (ii) a joint investment in a shared task and goal; (iii) the practitioner’s perceived credibility; and (iv) “mutual affirmation”.

This illustrates the theme of patient-centred spirituality by way of two case studies: one of a clinical encounter of the author with a patient in which neither spirituality nor religion was explicitly mentioned, and another in which the author was asked to see a patient because of a specifically religious concern. The first of these is interpreted in light of the work on spirituality in psychotherapy undertaken by Jeremy Holmes who, in turn, takes up the thinking of Donald Winnicott about transitional space. Spirituality is concerned with an ability to adopt a viewpoint outside oneself and to develop humility and a ‘negative capability’. The published views of patients suggest that spirituality/religion are explicitly important to many, even in a secular country like the UK, and that they would like them to be taken into account in treatment. It is proposed that there is ‘no such thing as a patient’, only encounters between human beings, one of whom is professionally identified as a physician (psychiatrist) and one as a patient. The authenticity of the human encounter, albeit within certain professional constraints, forms the basis for an effective therapeutic alliance.

The therapeutic relationship constitutes the heart and soul of the enterprise. Second only to the patient’s contribution, the relationship is the most powerful predictor of, and contributor to, outcome. Its effectiveness cuts across theoretical orientations (transtheoretical) and largely across client problems (transdiagnostic). This chapter reviews evidence-based psychotherapy relationships, primarily with adults in individual treatment. We begin by defining terms and summarizing the meta-analytic evidence on effective relationship behaviors or components (what works). That is followed by a summary of ineffective or discredited relationship behaviors (what does not work). We advance therapeutic and training practices based on this research evidence. The chapter finishes with multiple caveats, concluding thoughts, and useful resources.

This chapter commences with a brief description of the complexities conceptualising goals in psychodynamic psychotherapy as they differ across different schools. In addition, some goals are inferred rather than being explicit. Nonetheless, the author goes on to delineate goals which are relevant to early, middle, and end stages of a course of psychodynamic therapy. These include promotion of a positive alliance, a description of ‘common factors’ in therapy, and also some relevant technical goals. Final stage goals consist of management of the ending and enabling the ability to mourn the lost good object of the therapist. An alternative framework to conceptualising goals is presented in terms of symptom relief, life adjustment, personality change, and use of relevant procedures as being necessary. Clinical vignettes are used to illustrate these concepts. Finally, there is a brief section on current contributions from neuroscience specifically related to psychodynamic psychotherapy.

It is one of the remarkable but also unsettling characteristics of psychodynamic psychotherapy that its course is not rigidly predetermined; this allows things to emerge in therapy that neither the therapist nor patient could have anticipated. What focus the work takes and what therapeutic approaches are most useful for each patient need to be found out along the way. This does not however mean it is impossible to give direction or that there is no structure to therapy. In this chapter, we aim to provide orientation to clinicians who are embarking on their first courses of therapy. We integrate theory and technique to offer a longitudinal perspective on how matters can play out over a course of therapy. Firstly, we discuss the formation of the therapeutic alliance and the development of a psychodynamic formulation. The central part of this chapter looks at the therapeutic relationship as a vehicle for change. Finally, we discuss the late phase of therapy and the dynamics of separation from the therapist, and how this can be both a challenging but productive period.

In this chapter, we highlight key approaches to building strong therapeutic relationships with Black female clients. We also review the challenges that therapists may face in building strong therapeutic relationships with Black women and provide strategies to overcome these challenges. We discuss the occurrence of microaggressions in therapy and provide specific strategies for how to frame conversations about micro-aggressions to validate historical and present client experiences both in and outside of therapy.

Limited reparenting is a cornerstone of schema therapy. It is a style of interacting with clients in which the therapist aims to give the client experiences of having their emotional needs met directly within the therapeutic relationship. The therapist here serves as a ‘healthy model’ or template of caring, self-control, and guidance that, over time, is internalised by the client into their own ‘Healthy Adult’ mode. The core ingredients of limited reparenting include offering care, guidance, empathic confrontation, and limit setting. The aim of this therapeutic relationship is to provide corrective experiences that ‘kick start’ the emotional development of the client. Based on a thorough assessment and conceptualisation, limited reparenting offers a specific roadmap to harnessing the power of the therapeutic alliance to promote schema change.

The chapter outlines an evidence-based approach for clinical psychologists to select and provide group treatments. The process begins with selecting the appropriate treatment programme and then selecting the appropriate patients for the group. The chapter will identify principles for selection and assessment as well as how the use of interpersonal interaction as a therapeutic tool in the here-and-now context of a group can be an inherent advantage of group interventions.In addition, it outlines practical steps for implementation of a group that includes pre-group orientation, enlisting patients as informed allies, providing guidelines about how best to participate, clarifying the format and duration, setting ground rules, anticipating problems and instilling optimism among members. The chapter concludes with a consideration of how monitoring of process and outcomes can enhance outcomes.

Clinical psychological practice is founded upon the therapeutic relationship. A science-informed practice then requires that the elements used to build that relationship have an evidence base. Thus, the chapter reviews the empirical foundations of the therapeutic relationship and what steps can be taken to build a therapeutic alliance that correlates positively with beneficial treatment outcomes. The chapter outlines in practical steps how strong therapeutic relationships can be built by evidence-based practices that strengthen the alliance in an empathic manner. It illustrates key skills of building empathy through encouraging, re-stating, and paraphrasing communications in a manner that conveys to the patient an understanding of the content and the emotion behind what is communicated. The chapter concludes with a discussion of problems that can arise in the therapeutic relationship and practical steps to manage alliance ruptures.

The chapter describes how to manage ruptures in the therapeutic alliance. It opens by outlining a conceptual model to understand the ruptures and proceeds to consider the ways that ruptures may manifest at different points in psychotherapy. One way to respond to some ruptures in alliance in via enhancing motivation and therefore the technique of Motivational Interviewing is described in detail; outlining the steps of expressing empathy, developing discrepancies (between actual and desired outcomes), avoiding argumentation, rolling with resistance and supporting self-efficacy. The chapter reviews ways to manage the assignment and review of homework exercises so that they are a productive element in clinical psychology practice. The chapter concludes with a close examination of psychotherapeutic process; defining what “process” is, and how to work with transference and countertransference.