The therapeutic alliance in managed care mental health practice

The author uses Lazare et al.'s "negotiated approach to patienthood" model to address ethical and clinical problems of establishing a therapeutic alliance in the managed care setting. Lazare et al. identified five potential conflicts between therapist and patient that can threaten the therapeutic alliance: conflict over 1) defining the patient's problem; 2) goals of treatment; 3) methods of treatment; 4) conditions of treatment; and 5) the relationship. Case examples illustrate clinically and ethically acceptable ways to work with these conflicts within an expeditious, resource-limited practice style. At times, however, the ethical clinician must act as an advocate for the patient and for change of the system itself.