[The therapeutic alliance in community mental health services].

BACKGROUND: The treatment of severe mental illnesses is increasingly taking place in a domiciliary setting due to the deinstitutionalisation.<br/> AIM: Theoretical reflection on the influence of home treatment on the therapeutic alliance.<br/> METHOD: Qualitative review of possible effects of home treatment based on own experiences, the scientific literature, and recent handbooks on community mental health.<br/> RESULTS: The therapeutic relationship appears to be an important general factor in the outcomes of community mental health approaches. The working alliance has a more egalitarian and reciprocal nature. It improved when the scope of treatment was defined by the needs of the client. Boundaries concerning both the extent of personal involvement of the caregiver and the autonomy of the client presented important challenges in a context that lacks formal professional boundaries such as those seen in a consultation room or a hospital.<br/> CONCLUSION: Characteristic features of the therapeutic alliance during home treatment pose a challenge to the caregiver in terms of balancing interpersonal involvement and distance. The need to intervene in the personal life of the patient often causes ethical dilemmas. A dialectical form of intervision is proposed to explore the emotional involvement of the caregiver and to systematically reflect on possible ethical issues as a tool for daily practice.