Vers une possible évolution fiable et valide de la nosographie psychiatrique moderne ? Analyse critique des origines du DSM-III aux hypothèses actuelles

Background

Diagnostic reliability or inter-rater accuracy, defined as the concordance between diagnoses assigned to a patient by different psychiatrists, was found to be very low in the first studies devoted to the subject since the 1950s. To resolve these inaccuracies, sources of bias in scientific studies, a few psychiatrists from the American Psychiatric Association decided to change the principles of nosography in order to optimise the reliability of psychiatric diagnoses. These days, a scientific study that does not use this official standard will have very little chance of being cited in the international literature, but the scientific basis of the increase in inter-rater accuracy thanks to the DSM-III and following is however lacking: very few studies have compared a diagnosis established in relation to the DSM with a diagnosis established as a result of a non-standardised clinical interview.

Method

This editorial poverty seems to us to convey a confession of failure that we aim to overcome with a return to theory by precisely differentiating the concepts of diagnostic accuracy and validity, the latter considering the existence of the diagnosis itself by integrating its etiopathogenic origins, its clinical “verity” and finally its interest in terms of the therapeutic treatment.

Results

The “atheoretical” notions are no longer relevant in the DSM-V: the validity of the diagnoses should increase through the precise definition of psychopathological and sociological determinants associated with the characterisation of biological and/or neuroradiological markers which will build an etiopathogenic theory of each psychic phenomenon.

Discussion

Classification like this will remain, by definition, reductive: a diagnostic code will never be a subject in that it is not enough just to provide our subjective clinical.

Conclusion

As with our clinical approach, taking into account our individual and societal subjectivities in defining a new nosography seems to us fundamental for the future of psychiatry.     

Using longitudinal data from a clinical trial in depression to assess the reliability of its outcome scales

Longitudinal studies are permeating clinical trials in psychiatry. Additionally, in the same field, rating scales are frequently used to evaluate the status of the patients and the efficacy of new therapeutic procedures. Therefore, it is of utmost importance to study the psychometric properties of these instruments within a longitudinal framework. In the area of depression, the Hamilton depression rating scale (HAMD) is regularly used for antidepressant treatment evaluation. However, the use of HAMD has not been exempted from criticism what has lead to the development of new scales that are expected to be more sensitive for change, such as the Montgomery-Åsberg depression rating scale (MADRS). In general, the reliability of these scales has been extensively studied by using classical methods for reliability estimation, developed for specifically designed reliability studies. Unfortunately, the settings customarily considered in these reliability studies are usually far from the practical conditions in which these scales are applied in clinical trials and practice. In the present paper, we assess the reliability of these instruments in a more realistic scenario thereby using longitudinal data coming from clinical studies. Nowadays, newly developed methodology based on an extended concept of reliability, allows us to use longitudinal data for reliability estimation. This new approach not only enables to avoid bias by offering a better control of disturbing factors but it also produces more precise estimates by taking advantage of the large sample taking sizes available in clinical trials. Further, it offers practical guidelines for an optimal use of a rating scale in order to achieve a particular level of reliability. The merits of this new approach are illustrated by applying it on two clinical trials in depression to assess the reliability of the three outcome scales, HAMD, MADRS, and the Hamilton anxiety rating scale (HAMA).     

Architecture,théorie du soin en psychiatrie et politique. De la forme au sens

When evoking the insane asylum, Esquirol wrote in 1822 : “In the hands of a skillful physician it is the most powerful agent against mental illnesses”, he did not refer only to the architectural space arrangement of the asylum but to its global conception of the care environment, and this notion of care environment is more complex than it seems. The significant link he introduced could lead to confuse that which belongs to care and that which depends on the environment in which it is given. Moreover, history shows this subtle exchange between psychiatry and architecture. Within the research of the therapeutic impact that an ideal society could have on mental illness, the link between moral treatment and the architecture of the classical asylum is well known as is that between the village hospital with institutional psychotherapy. But, on the other hand, who remembers that the debate between Marxism and psychoanalysis within psychiatry had important repercussions on the architectural and environmental modalities provided to care for the mentally ill ?     

Insight et lombalgie chronique

The author attempts to clarify the role of psychological factors involved in chronic low back pain. He introduces a so-called « insight concept » as an integral part of the syndrome. The results of a recent study on the subject have brought credit to this theoretical and clinical approach. Twenty-seven patients suffering from chronic low back pain were enrolled in a clinical study which took place in an institution specialized in treatment of such pain syndrome. The principal objective of the study was focused on the predictive consistency of several variables ranging from the personality traits of the patients to the personal and subjective experience of their symptoms. To serve this objective, different assessment criteria were used: NEO PI-R, semi-directive interviews and subjective pain rating scales. (the Dallas Pain Questionnaire, the West Haven-Yale Multidimensional Pain Inventory and the Quebec Back Pain Disability). Furthermore, patients were questioned one year after their treatment in order to estimate the back school’s benefit and impact on their health improvement. This clinical research was done by using the method of the single system design. In a first phase of the results analysis, most of the assumptions involving certain possible psychological factors proved to be groundless in view of the patient’s answers. In a second phase, however, some results presented in this article seem to lead to an alternative conclusion. Not only does insight seem to have played a role as a significant bias in the results, but it may also have modified their progress. Main results stress the divergence of opinions between patients and two other independent evaluators (a doctor and a physical therapist) concerning the improvement of low back pain consecutively to treatment in the back school. Other results show that causal attribution done by patients in regard to their back pain is likely to determine both health improvement and satisfaction with treatment. Finally, according to the results obtained in the NEO PI-R, it seems that the more patients are conscious about their adaptation difficulties and their impulsiveness, the more the back school’s program appears to be beneficial, providing better pain tolerance. As a conclusion, the author poses the question about further investigation of the insight capacities of low-back-pain patients, the way they understand their health problem and their adhesion to the therapy model proposed, in view of optimizing patient’s evaluation and treatment.     

Hyperactivité chez l'enfant : réflexions sur les mécanismes psychopathologiques sous-jacents

Requests for consultations in child psychiatry for cases of hyperactivity with or without attention deficit disorder (ADHD) have increased markedly in the last few years. Hyperactivity is presently the most frequently occurring psychopathological disorder in young children. This change could be linked to the mediatisation of this disorder and to a lowering of the threshold of tolerance to behavior disorders and externalized conduct in a 'hyper-controlled' society. We could also question the subjective character of this poorly defined clinical entity about which there is no strict consensus. Thus, early detection of troubles which would allow us to diagnose hyperactivity before the age of four also beg the question of comorbid diagnoses (oppositional behavior or aggressiveness) and above all questions the interactive system in which the young child is developing. The Anglo-Saxon approach tends to consider hyperactivity as a complete syndromic entity (this is encouraged by the diagnostic criteria - essentially behavioral - of the DSM IV), favoring an organic approach (due to the importance of genetic inheritability). The European approach, the minority approach, does not dissociate the problem from its environmental context and pays more attention to affective problems, to the structuring of the personality and to inter-family relations. This second approach will be developed by the authors, giving preference to two stages, on the one hand (1) that of the process of separation - individuation, symbolization and socialization, and on the other hand, (2) that of the establishment of the process of secondary narcissism, of the role of psychic instances which are the ego ideal, the ideal ego and the superego. They will also consider (3) societal evolution and the functioning of the family, shedding light on the maternal or paternal role in the genesis of problems of hyperactivity. These clinical considerations lead the authors to suggest a distinction between two types of clinical hyperactivity which they will discuss based on their practices and on the literature: 1)“Hyperactivity with early behavioral problems, due mainly to the problematics of separation” and 2) “Attention problems with hyperactivity, anxiety, difficulties at school, due mainly to narcissistic problems.” These two types can be said to correspond in some way to the categorical forms of ADD and ADHD (according to the criteria of the DSM IV): 1) Attention-Deficit/Hyperactivity Disorder Predominantly Hyperactive-Impulsive Type and 2) Attention-Deficit/Hyperactivity Disorder Predominantly Inattentive Type. They are also akin to the findings of various authors who have attempted to reveal the particularities of anxious hyperactive subjects as compared to non-anxious hyperactive subjects, or of behavioral hyperactivity as compared to cognitive hyperactivity. Several principles of therapeutic treatment will be referred to for each clinical type.     

Souffrance psychosociale et risque suicidaire, quelle articulation entre médecine de ville et psychiatrie hospitalière ? Résultats d'une étude qualitative

Mental disorders are now becoming the first reason for consulting a general practitioner. These mental disorders include pathologies identified by psychiatry as well as a series of complaints linked to psychosocial distress. This latter, on the border between social field and medicine, does not benefit of a specialised clinical approach. Nevertheless, suicidal behaviour constitutes one of the complications of psychosocial distress which general practitioners have to face, though they have scant academic knowledge of it. A qualitative study examining an important oral material and 202 medical letters was realized in three of four Breton geographical departements. This study describes and analyzes the clinical attitude of general practitioners and their answers. Based on this study this article approaches the question of the articulation between private practice and hospital psychiatry.     

Du quantitatif et du qualitatif dans l'observation en psychiatrie

The orientation of contemporary psychiatry is eminently quantitative. This prompts a reflexion on its relations with a qualitative orientation. The problems of observations focused on the quantitative and the use of measurement are reviewed. The following items are emphasized : the limitations of the quantitative approach in clinical practise, the qualitative character hidden behind a quantitative test that implies symmetries and permutations, the uncertain character of a diagnostic based only on the quantitative dimension. The principle of measurement is implied in this discussion. In the first place it is evaluated in a general epistemological perspective. Its possible applications are then studied in a restricted epistemological perspective proper to psychiatry. These studies are concerned with the necessary segmentation of the observed facts, the conditions to be respected, and the previous realizations. In conclusion, the necessity of not reducing the observation to the quantitative or the qualitative perspective only seems obvious and it suggests matching the two obeying three conditions : an empathic attitude, registration of the data in an order that conforms to the observed realities, use of logico-mathematical matrices of fuzzy sets and of virtual signposting of functions which help forming a sensible and equilibrated rational clinical course.     

De l’hyperactivité à la schizophrénie ? Discussion clinique, neurobiologique et thérapeutique, à propos d’un cas

The succession of comorbidity or syndromic between Attention Deficit Hyperactivity Disorder (ADHD) and schizophrenia is known by clinicians. However, the causality or interference links between these two pathologies remains obscure. Yet symptomatic similarities, more particularly those relative to cognitive functions, may raise doubts and even lead to diagnostic errors in the case of early disorders during childhood. According to the literature, the dopaminergic system appears to be implied in these two pathologies, on the cognitive and emotional planes as well as on the motricity levels with probable genetic predispositions. However the hyper/hypoactivity, structural or dynamic of the various cerebral areas has not been elucidated yet. Consequently, there are still questions as to the proper pharmacological strategy dealing with symptomatic associations or overlaps of hyperactivity and schizophrenia. To answer this question, the authors studied the clinical case of a 14 year-old teenager. The patient presented characteristic symptoms of hyperactivity and schizophrenia and also some specific syndromes of oppositional disorders and conduct disorders. After a number of diagnostic and therapeutic interrogations, the authors prescribed a methylphenidate treatment associated with risperidone. This was followed by follow-up observations during a period of two years. This study revealed the limits of category-based approach and international classifications as they do not express clinical singularities or possible neurobiological continuums. It also seems to confirm the possible risk of emergence of a psychosis for schizotypal subjects, due to pharmaceutical induction by psychostimulants (methylphenidate). This emergence could be stopped by a combined antipsychotic treatment.     

La clinique des entretiens préliminaires en psychanalyse

Few studies have been made on the practice of preliminary interviews, which are sessions that rely on less psychoanalytical theory than the following sessions, in analytical therapies. However, the first sessions with a new patient matter greatly to all analysts—a fact that our study confirms thanks to therapists’ answers to a standardized questionnaire that we validated in a previous study. The clinical observation data in our recently published study on the practice of preliminary interviews in psychoanalysis were collected empirically in the Department of Psychiatry of the Pitié-Salpêtrière University Hospital among 30 therapists—15 therapists with at least 10 years’ experience and 15 therapists with less than 5 years’ experience. They were asked to answer regarding the preliminary interviews with a patient they had seen two to five times by the time they answered the questionnaire. For this study we used an updated version of our questionnaire, with new to-the-point questions regarding the patient’s meta-communication. Thirty-six items cover five variables chosen according to the therapist’s degree of involvement in his decision to follow that patient. An additional evaluation scoring sheet, with a validated inter-judge reliability, allows the data to be assessed by members of the psychoanalyst group. The results of the evaluation scoring sheet are the “objective” aspect of the research. The questions regarding the five variables we focus on, allow the therapists to evaluate whether or not they feel they have answered the questionnaire. Their own assessment of their clinical work is the “subjective” aspect of the study. Though the patient’s meta-communication is slight during the very first sessions, all of the therapists involved in this study are able to spot it as one of the most promising elements for a psychoanalysis to be possible. The clinical data allow us to speculate that the psychodynamic hypothesis is worked out on the basis of what is heard of the patient’s meta-communication abilities. This is supported by psychoanalytical theory on the one band and on the other band by what the analyst’s experiences in his understanding of transference and counter-transference.     

Discernement, lucidité, conscience et insight en psychopathologie et en pratique expertale

Insight is a polysemic word coming from the English language. It has been used for a long time by psychoanalysts and from now on in clinical psychiatry. The insight rating scales explore diverse aspects of the awareness of having a mental disorder and the need to be treated. For many decades, meetings and publications on this topic can be found in the Annales Médico-Psychologiques (cf. the meeting of March 2002). The new trends try to fragment and quantify the diverse dimensions of consciousness, awareness and insight. To be rigorous insight should be defined by the items, the score, and types of such or such rating scale. French psychiatric experts are required by legal regulations to assess the “discernement” of indicted persons (offence and crime) (article 122-1 of Code penal). Otherwise insight rating scales are useful for diagnosis, follow up, and to improve therapeutic alliance and compliance.     

La pratique des entretiens préliminaires de psychothérapie psychanalytique: Critères d’évaluation - Étude quantitative

The practice of preliminary interviews is a field that researchers have little looked into until today. However, it is during those very first sessions between “the analyst and the analyzed” that is born the possibility of working out a psychoanalysis. This study deals with the practice of preliminary interviews in psychoanalytical therapies, based on the results of an empirical research that was carried out at the Pitié-Salpêtrière University Hospital and involved 30 therapists. The data for this study were collected, thanks to the therapists’ answers to a validated, standardized 36 items-questionnaire regarding what they could “hear” during the first sessions with their patients. The questionnaire was completed by 15 therapists with at least 10 years’ experience and 15 therapists with less than 5 years’ experience, and they answered regarding a patient they had seen two to five times. It covers five variables chosen according to their degree of involvement in their decision to follow that patient. An evaluation scoring sheet allows the psychoanalyst group to score the session, which has been tape-recorded. The results of the evaluation scoring sheet are the “objective” aspect of the study. The five questions regarding the five variables allow the therapists to evaluate whether or not they feel they have answered the questionnaire. Their own assessment of their clinical work is the “subjective” aspect of the study. The study focuses on the therapists’ mental work during the initial phase of the treatment: on what basis is the decision to follow a patient made? How important is the patient’s meta-communication skills at the beginning of the treatment and what do they mean to the therapist? Does it account differently for more or less experienced therapists? And what can we say about the analysts’ objectivity (the practice itself) and subjectivity (their feelings about the practice)? The data of our study show that, for all the therapists involved, the patient’s ability to meta-communicate matters very much to psychoanalyst. A comparative study allows us to account for the gaps or the overlapping between the objective and subjective aspects in both therapist groups. Finally, we noted that therapists with at least 10 years’ experience and therapists with less than 5 years’ experience functioned differently.     

Psychiatrie et psychanalyse

There are three different domains of Freud's heritage that help to understand the relationships between psychiatry and psychoanalysis in the past and today, even after the development of international classifications, biological psychiatry and cognitivism.The first is the concept of man being defined by the unconscious. This idea was considered revolutionary at the time and still is today. However it was not accepted by all psychiatrists depending on their cultural background and their theoretical options. It is a very profound concept but cannot apply to everybody.Psychotherapy is the second technique. Many psychiatrists may reject it but, nevertheless, although they do not practice it themselves, they are willing to propose it to their patients.The third technique deals with Freud's writings on preconsciousness. It can be a significant help in identifying illnesses and in an understanding of psychic functioning. It can be used by all psychiatrists, even those lacking a psychoanalytical background. Psychiatric practice would be impoverished if this technique was not used.     

Le rapport du sujet au langage : vers une approche des « phénomènes de style » dans la clinique des névroses

The present article questions a paradox specific to the clinical approach: how to reconcile the advantage in identifying structural indicators enabling a diagnostic to be elaborated, while also deriving the consequences of the limits of the structuralist hypothesis in order to aim at the indeterminate? Exploring the link between language, clinical structure and subjective position affords a way of highlight the structuring function of language in so far as it separates the body from its pleasure, thus simultaneously bringing out the subject. However, this link also reveals the antinomy between the universal and the singular, for which the notion of “style” constitutes an issue to be situated at the very core of the constitution of the subject and the social link. In its very prolongation, the notion of “phenomenon of style” emerges on the horizon as a possible specificity of the neurotic subject's relation to language. Indeed, J. Lacan showed us a tension at the origin of style: this both involve an effect of structural determinations, and that of a subjective choice in ethical terms. J. Lacan first explored the question of style in order to elucidate psychosis phenomena, but it also concerns, though not directly, neurosis. Through this approach, we hope to address the enigma that is constitutive of the subject in inventing its own neurosis, while simultaneously considering the traces of the movement that pushes a subject to invent words to express the unspeakable.     

Improper study design precludes valid effect estimates in important suicide prevention research

The observational study design for estimating accuracy of diagnostic tests for suicide risk in clinical work is not ideal, due to the effects of directed suicide prevention to the high‐risk group. This is an example of the confounding by indication and protopathic bias, which lead to misinterpretation of the accuracy terms sensitivity and specificity. The simple arithmetic mechanism presented here, forces the conclusion that the accuracy estimates sensitivity and specificity, applied in open prospective trials of surmised diagnostic tests for suicide risk, cannot be normally interpreted as accuracy estimators. Further, the related concept “prediction of suicide” is shown to be fundamentally illogical and should not be used in the present context. All these statements reveal a far‐reaching problem within the suicide prevention research: Conclusions regarding the usefulness of diagnostic tests of suicide risk in the vast previous research since decades deserve reinterpretation. Diagnostic tests per se, can possess highly qualitative properties in estimating important suicidological aspects regarding a patient, but, when studied in an open design study, it cannot be demonstrated. This problem concerns rating scales and any biological and psychological tests in medicine, when confounding factors, for example, suicide prevention, influence the outcome because of the test result per se.     

Incertitude et clinique transculturelle

In Quebec, transcultural psychiatry has made use of several theoretical approaches, and simultaneously been inspired more by European ethnopsychiatry, all-dominating American psychiatry, and critical North American anthropology. Through its questioning of several dominant approaches, it aims at providing fresh impetus for thinking, but runs the risk of recreating other certainties associated with competence and expertise. However, uncertainty is encountered on a daily basis in transcultural clinical practice. It can be viewed as an epiphenomenon, or as an instrument which in spite of certain dangers can play a major therapeutic role. Based on the experience of a clinical research team, the argument is put forward that uncertainty that is defined and contained within a clinical context can aid in treating the patient's condition, modify the approach by altering the power relationship, provide greater flexibility, and confer a role to ambiguity in the ethical questioning that is part of the clinical context.     

La confusion des sexes : un écueil et une chance pour la clinique

This article has an objective: relieve the « natural evidences » concerning sex in 2006. These « natural evidences » will be twice criticized: first, opposing scientific data, which give them a new complexity; second, examining throughout several level of observation. Decomposing and complexing sex category, it should be possible to show that many certitudes are indeed, not strongly established. While taking account of the new men and women constitutions, and the many opportunity of combining them, this article would like to show a contemporary psychiatry must not ignore or — it would be the same — deny them in categorizing this kind of subjectivity in a pathological section, with perversions, as if they have to be excluded of our reflection because of escaping from a model seeing the world only as heterosexuality and dichotomy. It will be time, then, to ask what could replace the classical representations on which our clinical argumentation relies.     

Psychogenic psychoses. A review of the clinical picture, genesis, prognosis and therapy

The concept of psychogenic psychosis has always been regarded with scepticism, since it seems to harbour a contradiction in itself: Psychogenic mental disturbances are amenable to a rational approach, that is to say, they are understandable, whereas psychoses are incomprehensible mental disease patterns in respect of their content and course. Nevertheless, psychogenic psychoses have been described fairly often ever since scientific psychiatry came into being; in fact, they are being diagnosed quite frequently in some countries. For the purpose of helping to clarify these theoretical and practical difficulties, the article explains the history of the concept, the clinical patterns of manifestation, and the course of psychogenic psychoses, as well as the concept of their origin. An attempt is made to reconcile the immanent contradictions, and to demonstrate that this is actually a fruitful extension of the scope of the theoretical fundamentals of psychiatry.     

Considération critique sur l’extension de la bipolarité, psychopathologie des mouvements d’humeur et de l’euphorie morbide

Objectives

From manic-depressive psychosis to bipolar spectrum, today's psychiatry allows us to observe a widening of bipolar criteria. This article aims at studying this evolution, its consequences with a critical look and the psychopathology of mood changes and morbid euphoria.

Methods

All of our considerations refer to current data on bipolar disorders (review with Medline and Science Direct) compared with studies from classical psychiatrists (Kraepelin, Ey) and various authors inspired by psychoanalysis (Freud, Racamier) and phenomenology (Binswanger, Tellenbach, Tatossian).

Results

Many contemporary authors encourage clinicians to detect bipolar disorders from symptoms, early signs and attenuated or atypical expressions. The concept of a widened spectrum is supposed to be closer to clinical reality and it would be an opportunity to diagnose this disease and its deleterious consequences better and thus to set up an appropriate therapy at an early stage. Other authors, on the other hand, deplore a dilution of bipolar disorders together with harmful diagnostic inflation around a concept that has become too heterogeneous to be effective, that subjugates or interferes with other pathologic entities in an excessive manner and abandoning a psychopathological approach. In this view, we shall analyze the nosographic shifts of bipolar disorders throughout the history of psychiatry, from manic-depressive psychosis to bipolar disorder and spectrum. We shall then scrutinize the autonomy and limitations related to bipolar disorders as opposed to normality, confusing clinical presentations and other major mental diseases: Psychosis, depression, pathological personality, anxiety, impulse-control, attention deficit-hyperactivity, addiction and psycho-organic disorders. This work shall first introduce a discussion on the concept of bipolar disorders for children, and then through the case of some historical figures. Then we will deal with the contemporary social factors that are currently furthering the extension of this diagnosis. Last, this article sheds a light on psychopathological specificities of mania – the cornerstone in bipolar disorders – mood changes and morbid euphoria.

Conclusion

We think that classic psychiatry, phenomenology and psychoanalysis would act as a guiding light through this debate and could help the clinician in this daily practice. Mood variations require a careful clinical observation and a rigorous set of interpretation, before being specified too excessively or hastily as a symptom of a real bipolarity.     

Ten-year review of rating scales. I: overview of scale functioning, psychometric properties, and selection

OBJECTIVE: As part of the Journal's 10-year Research Update Reviews, a series of articles will be presented on the role of rating scales in child and adolescent psychiatry. The first article in the series summarizes principles underlying scale functioning. METHOD: Sources were reviewed regarding testing theory, scale development, variability in scale functioning, psychometric properties, and scale selection. The extracted information was adapted to issues in child and adolescent psychiatry. RESULTS: Rating scales can make major contributions to understanding youths' needs. They provide easy and efficient measurement of psychopathology and quantify underlying constructs for comparison across youths, time, and applications. Although multiple factors may affect a scale's functioning, these factors can be understood and managed by considering the goals of measurement and basic psychometric principles. CONCLUSIONS: Potential users of rating scales should not blindly assume that a well-known scale will meet the measurement needs for a particular application. Rather, they can relatively easily educate themselves regarding the appropriate use of rating scales. This article provides the background information needed to evaluate scales for intended applications. It will also assist in reviewing the individual scales presented in subsequent articles in this series.     

Alliance thérapeutique avec les mères et évolution clinique des enfants d'un hôpital de jour

This two-year prospective study in a French child psychiatry day hospital assesses relationship between therapeutic alliance and clinical progress. Thirty-three 3-10 year-old children (18 with pervasive developmental disorders and 15 with mixed behaviour disorders) were assessed regarding their symptom status and developmental progress, while receiving multi modal intervention package. Independently, the treatment staff assessed the therapeutic alliance with the parents by standardized ratings on the French modified Helping Alliance questionnaire from Luborsky. The statistical study shows that a mother's good therapeutic alliance correlate significantly with the social functioning improvement but not regarding the symptom status. As North-American therapeutic alliance adult's studies, this first child psychiatry unit study seems to show that the parent therapeutic alliance is a predictor factor of child outcome independently of age and pathological child status.