8 Psychotherapy8.7 Psychotherapeutic psychiatry
8.7.2 Therapeutic relationships, transitions and endings
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Written by Resident Doctor Committee · Published
New in the 2027 syllabus
The College added this topic for exams from January 2027.
Building the relationship
A therapeutic relationship combines respectful interest, reliable boundaries and a shared understanding of what clinician and patient are trying to achieve.
The working alliance has three parts: the bond, agreed goals and agreed tasks. Quiet attendance does not prove cooperation.
Early engagement: ask about previous care, expectations, worries and practical barriers, including any experience of coercion or discrimination.
Consistency means communicating dependably and explaining the reasons for decisions, while adapting to the person's changing needs.
Rupture and repair
Sign | Possible response |
|---|---|
Withdrawal, or seeming to agree without taking part | Ask whether the plan fits the person's priorities |
Anger or challenge | Explore what the person sees as the failure, while keeping boundaries |
Missed contact | Check for practical difficulties and what the appointment means to the person |
Conflicting accounts within the team | Compare views and agree one coherent response |
Repair may mean admitting a real mistake, changing the plan or clearing up a misunderstanding. Do not treat every difficulty as the patient's pattern.
Countertransference (the feelings the patient stirs up in the clinician) can help you reflect on the interaction. It does not justify acting on irritation, a wish to rescue or an urge to reject.
Continuity and ending
Transitions can bring back experiences of loss or abandonment, especially when past relationships have been unreliable.
Planned endings: raise the ending early enough to explore feelings, review progress and identify continuing needs.
Handover: name the receiving clinician or service, share the agreed plan and state who is responsible in the meantime.
Unexpected endings: be honest and make a practical continuity plan, even when the preferred clinician cannot stay involved.
A relapse plan records warning signs, coping strategies, support and how to ask for reassessment. It supports autonomy without suggesting that future help is unavailable.