[Therapeutic alliance: Between rupture and power games, a qualitative study]

The therapeutic alliance (TA) is considered one of the founding pillars of a therapeutic approach. Its breakdown is a complex phenomenon affecting both patients and therapists. The breakdown of a TA involves dynamics of withdrawal or confrontation, or both. This article focuses on patients' experiences of TA breakdown through interviews. What do patients have to say about behaviors that are antinomic to the therapeutic process? How do they understand the breakdown of TA-in a hospital setting or in private care? Is a resolution possible? Analysis of these interviews enables us to draw up a preliminary map of typical situations experienced by patients and the reasons that led them to break off the TA. Methods This study is part of a qualitative social science approach. In the first stage, 5 interviews were carried out by a researcher with experience in psychiatry with people affected (all women) by a breakdown in TA. The data collected was then transcribed, analyzed, grouped by theme, compared by theme, reorganized, merged and prioritized. Results The analysis highlighted five key themes in the factors leading to TA breakdown: the power of professionals, the relationship as symbolic violence, the act of care, the functioning of care institutions and the repair of the alliance. A central element in the discourse of the patients interviewed is the violence provoked by the lived experience of an asymmetry of power between them and the psychiatric setting. Faced with this situation, the patients gradually implement strategies of influence to reduce their powerlessness and adapt the care context to their needs, such as withholding information or lying. These narratives call into question the validity of psychiatric acts of care, and invite us to question the epistemological determinants that led to these standards and acts of care in the first place. Discussion In psychiatric institutions, these results suggest that the determinants of TA are, in fact, not insignificantly linked to power issues at multiple levels. Maintaining or breaking a TA is part of a sociological register in which patients recognize themselves as dominated, stigmatized and marginalized. In this context of oppression, concealing or manipulating the truth appear as necessary and licit acts to escape from situations experienced as unjust and confining. Taking a step back, this type of reaction is not new; it's part of the development of the epistemology of the dominated, a movement in social science theorizing the construction of knowledge among people and groups experiencing domination, and where resistance to oppression constitutes a subversive act of lucidity. Not surprisingly, their perspectives are in the minority, as they also reflect the minority social position of the people who practice them. Conclusion The preservation, or repair, of a solid TA is a priority for any therapeutic relationship. In this context, sensitizing psychiatric staff to the limits of the biomedical-positivist paradigm with which the psychiatric ethos and habitus are deeply imbued could be a welcome prelude to integrating certain points of view from the epistemology of the dominated into the therapeutic relationship. Welcoming these minority perspectives (for practitioners, not patients), has the potential to nurture genuinely new understandings in the TA dynamic, and to (re-)create TA dynamics based first and foremost on the humanity that connects us all, and less on the category to which we belong.