We believe that the success of psychiatric treatment depends upon the quality of therapeutic relationships between mental health professionals and patients. This is not necessarily self-evident. Manualised treatments have been developed on the assumption that operationalised manoeuvres are the ‘signal’ of treatment and that issues concerning the therapeutic relationship are ‘noise’. However, our understanding of the evidence, both scientific and experiential, suggests that the relationship between professional and patient is a critical factor in achieving a good outcome (McCabe & Priebe, 2004).

It seems to us that effective mental health professionals develop personal skills that allow specific treatments to facilitate patients' recovery from mental illness. These skills concern the application of scientific knowledge to complex clinical situations and the management of therapeutic relationships. Weak or ineffective professionals lack these skills, so that they struggle to construct rational and coherent treatment plans, or their therapeutic relationships with patients are of a poor quality. When weak clinicians use the same specific treatments as their more skilled colleagues, the outcome of treatment tends to be not as good.

Therapeutic relationships are profoundly influenced by the context in which they arise. The configuration of a team, and one's position within it, has a major effect on the nature of individual therapeutic relationships. Junior professionals, who have to defer many decisions to senior colleagues, form different types of therapeutic relationships from those formed by autonomous professionals who can be decisive and speak with the authority of experience (although this is not to say that junior professionals are necessarily less effective than their seniors).