Psychological issues in improving adherence and alliance

From an intersubjective point of view, adherence to therapy can be defined as a multi-dimensional phenomenon which occurs through the dynamic interaction of different variables which pertain both to the doctor and to the patient. In psychiatry, the relationship between doctor and patient is the core of the therapeutic program because it ensures the therapeutic continuity. The context where the prescription happens is within the “therapeutic field”: a dynamic doctor-patient relationship that goes beyond the symptoms, gathering multiple factors in an intersubjective balance. In this model of complex prescription, focused on relationship, the attachment styles emerge as central points: as the therapist (and the drug) represent attachment figures and the patient is a caregiving “object,” each of them enters the relationship with their Internal Working Models (IWM) and behavioral patterns, which must be taken into account in the construction of a prescription to optimize adherence. Even in patients suffering from psychosis, the quality of the therapeutic relationship is a key determinant of outcome and attachment styles influence the quality of therapeutic relationships. A good doctor-patient relationship is important in the construction of adherence, and must include alliance with caregivers and family members, as well as with paramedical staff. Subjective well-being and quality of life are core issues as well in pursuing adherence to long term pharmacological, psychological and rehabilitative treatment programs.