<p>Psychiatry has much in common with the irresistible little girl Henry&nbsp;Wadsworth Longfellow immortalized in a poem that became a&nbsp;household nursery rhyme: &ldquo;When she was good, she was very good&nbsp;indeed, / But when she was bad she was horrid.&rdquo; The same can be said&nbsp;for the mental health profession.</p><p>Despite numerous advances in the past century, the treatment of&nbsp;mental disorders is still in a rudimentary state due to our fundamental&nbsp;lack of understanding of the complex causes of some of its daunting&nbsp;problems. Most mental health professionals now believe that both&nbsp;psychological (psychodynamic) and physical (inherited or biomedical)<br />
factors combine in varying proportions to undermine a person&rsquo;s state&nbsp;of emotional well-being. Most experts also believe that an optimal&nbsp;combination of psychological and physical treatments will provide for&nbsp;many patients the best chance of recovery. Across this wide spectrum&nbsp;of possible combinations, the one factor that appears to be most crucial&nbsp;to recovery is the treatment relationship.</p><p>Many studies of purely psychological treatments have shown that&nbsp;the treatment relationship is the single most&nbsp; important variable in&nbsp;&nbsp;determining therapy outcome. &ldquo;The therapy relationship accounts for&nbsp;why clients improve&mdash;or fail to improve&mdash;as much as the particular&nbsp;treatment method,&rdquo; a major review of &ldquo;Evidence-Based Therapy<br />
Relationships&rdquo; concludes. Thousands of qualitative and quantitative&nbsp;studies have demonstrated that about 75&ndash;80% of patients who enter&nbsp;psychotherapy show improvement, a treatment outcome well above that&nbsp;of many medical procedures. It is self-evident, then, that the treatment&nbsp;relationship must be a powerful force in and of itself. Like any&nbsp;powerful&nbsp;force, the management or mismanagement of the treatment relationship&nbsp;can bring great benefit or harm to the patient.&nbsp;Off the Tracks: Cautionary Tales About the Derailing of Mental Health&nbsp;Care presents dramatic examples, across a broad range of theoretical&nbsp;approaches to mental health care, where the treatment relationship was&nbsp;mismanaged in such a way as to harm mentally ill patients. We are not&nbsp;presenting these examples to condemn psychoanalytic, psychiatric or&nbsp;psychological treatments, but rather to show how these cautionary tales<br />
indicate the necessity of self-monitoring and self-regulation by members&nbsp;of the mental health profession. Because we speak here of a relationship,&nbsp;the extent to which the personality of the therapist is implicated makes<br />
the requirements of the therapist unique in the world of health care.&nbsp;We are not limiting ourselves only to the role of the therapist in purely&nbsp;psychological treatments. In the realm of predominantly physical&nbsp;treatments of mental disorders, clinicians delivering the treatment are&nbsp;psychotherapists as well. Clinicians&rsquo; judgments in choosing a physical&nbsp;approach or a pharmacological agent, determining its frequency or&nbsp;dose, or even deciding how often they see their patients, are clearly&nbsp;related to the relationship as much as to the underlying scientific theory&nbsp;supposedly governing such choices .</p>