18: Vulnerable Patients

• Describe the elements of building a therapeutic alliance, eliciting the patient’s narrative, and assessing the patient’s vulnerabilities and strengths.

• Explore critical components of the therapeutic alliance: building trust, conveying empathy, and collaboration.

• Describe the relevance of the therapeutic alliance to the effective care of vulnerable patients.

• List the benefits of eliciting the patient’s narrative.

• Review common psychosocial vulnerabilities and illustrate how identifying them can help create a patient-centered clinical encounter.

• Describe strategies for clinician sustainability in working with vulnerable populations.

Social characteristics—living in poverty, having a low level of education and limited literacy skills, being from a minority background, having no health insurance, speaking little English, among other factors—make individuals vulnerable to contracting illness and to facing overwhelming obstacles in the care of that illness. Vulnerable populations tend to experience these health risks in clusters, making both individuals and communities more susceptible to declines in health. For example, it is not uncommon for an individual living in poverty to have limited literacy skills and no health insurance; to simultaneously have diabetes, heart disease, or depression; and to smoke or to live in a community with limited access to high-quality grocers and safe outdoor space for physical activity.

Clinicians must learn to successfully engage those most at risk by virtue of this clustering. Unfortunately, vulnerable patients experience a triple jeopardy when it comes to health care: they are more likely to be ill; more likely to have difficulty accessing care, and when they do, the care they receive is more likely to be suboptimal. This reflects the mismatch between the psychosocial vulnerabilities that they bring to the clinical encounter and the knowledge, attitudes, skills, and beliefs of the clinicians caring for them, as well as the priorities and policies of the health systems in which they receive care. In this chapter, we focus on the centrality of strong provider–patient relationships to all efforts to improve the health of vulnerable patients. Three essential strategies are recommended to promote a context for effective care for vulnerable patients: building a therapeutic alliance, eliciting the patient’s story or “narrative,” and assessing for the patient’s psychosocial vulnerabilities and strengths. Clinicians can use a combination of these approaches to create more productive and effective interactions and relationships with vulnerable patients (Figure 18-1).

Psychosocial vulnerabilities can affect health and health care, either alone or in concert (see Figure 18-2). The first path is a direct one, a situation in which the vulnerability in and of itself leads to poor health. Concrete examples of this mechanism might be intravenous drug abuse and skin abscesses or intimate partner violence and head trauma. A second path is an indirect one, where the vulnerability attenuates the benefits of medical treatment on coexisting medical conditions; that is, the vulnerability presents a barrier to optimal acute, chronic, and/or preventive care, thereby accelerating disease course. Examples of this include the effects of depression on nonadherence to medications among patients with heart disease, or inability to pay for medications and poor diabetes control. The third mechanism, also an indirect one, is mediated entirely through the therapeutic alliance. In this path, the vulnerability affects components of the relationship or therapeutic alliance with the provider (such as open disclosure, mutual trust, caring, and engagement), thereby limiting the benefits of a collaborative relationship on care. Examples of this include a patient with an undisclosed illness that is inconsistent with a prescribed treatment plan; a physician whose belief systems regarding addiction impedes true engagement with a patient with a substance use disorder; or a patient with depression that impedes follow-through with a prescribed treatment plan, thereby leading to mutual frustration and blame.

What is the Therapeutic Alliance?

In the field of medicine, a therapeutic alliance exists when patient and provider develop mutual trusting, caring, and respectful bonds that allow collaboration in care and treatment. “Patient-centered” and “relationship-centered” care models build on the notion of the therapeutic alliance, and research reveals that patients reporting greater trust, increased satisfaction, and more collaborative relationships with clinicians have increased adherence to medication and treatment regimens and better health outcomes.

Key dimensions of the Therapeutic Alliance include:

• Mutual trust—Patients need to trust in their clinicians’ integrity and competence, and clinicians need to trust that patients enter the relationship trying to do their best.

• Empathy—Demonstrating empathy, or recognizing and understanding the beliefs and emotions of another without injecting one’s own, allows the clinician to connect emotionally with the patient without pity or over identification.

• Respect—Expressing respect for patients and treating them with dignity are important and require creating a context in which communication can occur as equals.

• Collaboration—Collaboration requires a meaningful partnership in which clinician and patient perceive that they are working together toward a common goal and committed to resolving conflicts that inevitably emerge about treatment goals.

The therapeutic alliance must be broadened beyond the one-to-one relationship between clinician and patient to include other important people (e.g., family; patient navigators/health coaches; consulting clinicians). Health systems can foster or erode the therapeutic alliance based on the policies they promote.

Therapeutic Alliance & Vulnerable Patients

A growing body of evidence suggests that it is precisely with vulnerable patients that the therapeutic alliance can have its most profound benefits. Through a therapeutic alliance, clinicians offer a professional relationship aimed at helping patients feel comfortable to be as open and honest as is necessary to receive the best care. Clinicians are permitted access to the interior of patients’ lives that few other people are allowed. Using this privileged position, they can help build an alliance that empowers patients and reduces barriers to their care.

Empowerment—Vulnerable patients often experience human relationships as broken or disrupted (e.g., due to violence, immigration, mental illness, homelessness, and illness). Through the therapeutic alliance, clinicians can offer a reliable, dependable, and continuous presence that is supportive, accepting, and nonjudgmental. They can provide safety, thus allowing patients to tell the stories of their lives and illness and disclose their vulnerabilities. By examining the patients’ strengths and resources, clinicians can provide a sense of dignity and hope. Through validating their experiences, clinicians can help patients feel less marginalized. In supporting patients as competent and strong, clinicians can help empower them to become actively involved in their care.

Access to care and related resources—Vulnerable patients often face limited access to health care and social services. In part, they may be unaware of what is available and may not have the facility to negotiate complex, bureaucratic systems. Clinicians are in a position to remedy both of these barriers. Through the therapeutic alliance, clinicians can help patients feel safe enough to reveal concerns or problems beyond the presenting problem, which they might not otherwise have done. For example, a patient seeking care for her diabetes may disclose that she lives with an abusive partner, drinks alcohol regularly, or is only sporadically housed. The clinician has the ability to collaborate on treatment plans and to facilitate entry into the various health and social systems that can help address vulnerabilities. The therapeutic alliance can help patients feel assured that clinicians will not abuse the disclosure of information (e.g., leading to rejection or legal action) but will help them access resources critical for their health.

What Can Happen When the Therapeutic Alliance Is Absent?

The absence of a therapeutic alliance can result in serious consequences for the health of vulnerable patients.

Trust—Clinicians often enter into relationships with patients assuming they share the same goals and will trust each other to do their best to attain them. However, many patients enter into the relationship with a degree of mistrust. This may result from personal experiences with institutions in which they have felt betrayed or unwelcome or may be rooted in broader, historical experiences of their community. Clinicians should not automatically assume that they have patients’ immediate, total trust; rather, they should earn it by demonstrating trustworthiness.

Clinicians can indicate their trustworthiness by:

• Being transparent: Vulnerable patients often experience external intrusions into their lives and little privacy; they may not understand why clinicians ask about personal information. Explaining the context of questions that may not seem immediately pertinent to the patient’s concern may dispel patients’ concerns about hidden agendas (e.g., “I am asking about who you live with, not to pry, but to see who might be available to care for you following your operation.”). Similarly, vulnerable patients may believe clinicians are interested in ordering particular laboratory tests, imaging studies, or procedures to learn at the expense of the patient or to increase financial resources. On the other hand, patients may fear that they are being denied particular treatments to save the health care system money. Explaining why one is recommending a particular diagnostic course or treatment regimen can build trust (e.g., “I want you to get the treadmill test, because I think it is the best way we have to know how best to help you and to decide the best treatments.”).

• Following through: Vulnerable patients are accustomed to hearing that something will occur (e.g., appointment scheduled; prescription ordered; referral to social service made) and then learning, for whatever reason, that it did not happen. By taking the extra time to follow-through on promises, clinicians can show patients that they can be counted on to ensure the best care (“I told you I would call when I found out how to help you find housing; here’s what I’ve learned.” “My homework after your last appointment was to find out about Spanish-speaking support groups for patients with diabetes; there is one not too far from your home.”).

• Addressing concerns: Vulnerable patients may experience clinicians as rushed, interested in their own agendas, and nonresponsive to those of the patient. By taking the time to ask and answer questions and focus on what the patient needs, clinicians can indicate that they are interested in helping the patient and can be trusted to care (“While there are many things that I want to talk to you about, what are you most concerned about?” (“I know that I am more worried about your high blood pressure than you are. I also know you are more concerned that you cannot work because your elbow is so painful. Let’s work on both today.”).

Caring—Poor and minority patients frequently receive care in teaching hospitals and community health centers with high provider turnover. Patients may question providers’ motivation and commitment, fearing that they are educational fodder for trainees who will go on to care for the privileged. When clinicians do not offer certain treatments, patients may be suspicious about the clinicians’ willingness to expend resources for them. When clinicians persuasively argue for unwanted treatments, they may fear being used as experimental “guinea pigs.” Rather than risk raising concerns or disagreements with a clinician whose motives they question, patients may choose not to follow-through on recommended treatment or simply not return for care.

Respect—Perceived disrespect and discrimination due to race or socioeconomic status has been associated with lower satisfaction with the health care system and worse health outcomes among patients with chronic illness. Significant proportions of African Americans, Latinos, and Asians and those with lower educational attainment have reported that they were treated with disrespect, were treated unfairly, or received worse care because of their position in society. These perceptions influence whether patients follow recommended advice or delay needed care for chronic illness. Communicating respect is essential to convincing vulnerable patients that clinicians are willing to enter into a relationship based on equality and dignity.

Mutual agreement and collaboration—In the absence of a trusting relationship, true collaboration may be difficult to achieve. Fear of being punished or treated unfairly for speaking truthfully can lead patients to withhold their beliefs and values about a suggested treatment or to refuse to follow through on a recommendation. Clinicians, in turn, feel frustrated and mistrustful when they wonder if they are being misled or if patients really care about their health.

Shared decision making is often promoted as a model for mutual agreement and collaboration. However, research with diverse populations suggests that clinicians and patients, seemingly engaged in the cardinal behaviors of shared decision making, may still not perceive that a collaborative partnership exists between them. Indeed, being treated with respect and dignity may be more important than engaging in shared decision making, and may itself lead to positive outcomes (i.e., higher satisfaction, adherence, and receipt of optimal preventive care).

There are no simple, protocol-like statements or behaviors that we can employ to make another human being feel cared about or respected. However, if clinicians consciously strive to transmit a sense of trust, caring, and respect, along with a desire to enter into true partnership, they increase the likelihood of forming productive relationships with patients. Some guidelines to consider in this process include the following:

• Demonstrate commitment to the relationship. Clearly state your desire to be available to your patients within the scope of your practice (e.g., “I will be your regular doctor. Here is my telephone number with a voice mail; I check it daily and will get back to you as soon as possible.”); be clear about what you will do for the patient between visits (e.g., “I will check into support groups and tell you at our next appointment.”); and follow-through as promised.

• Allow for the humanity of the patient and the clinician to emerge. The humanity of the health care worker and the patient should be expressed and elicited. This may include the sharing of beliefs, values, and feelings as they relate to the clinical issues facing them (e.g., express concern about suffering, “I am sorry you have to deal with this pain;” offer self-disclosure to identify a shared history or common interests with the patient, “As a parent, I can’t imagine how incredibly strong you had to be to escape with your children.”).

• Elicit patients’ stories or health “narratives.” This interviewing approach can provide critical insights into a patient’s illness model, allow for expression of the patient’s humanity, and uncover important psychosocial vulnerabilities (see section “Eliciting the Patient’s Story or ‘Narrative’”).

• Search actively for patients’ strengths and resources. We commonly focus on what is wrong or dysfunctional in the patient’s life. Just as vital as the search for deficits is the identification and validation of the strengths and resilience each patient has (e.g., “You have been through a lot of suffering in your life; how have you been able to survive?” “Who gives you the strength to deal with difficult things?”). Reflecting on how the patient has used these resources in previously difficult times can provide a positive starting point for healing (e.g., “You have talked about turning to God when dealing with other major crises in your life; have you thought of doing that now?”). The power for healing does not rest solely with the clinician, but must involve an empowered patient and family (e.g., “Your sister gave you strength to leave an abusive relationship; can she help now in dealing with your diabetes?”).

• Express caring overtly. When patients describe difficult or painful experiences, clinicians can acknowledge the patient’s perspective (e.g., “I can’t imagine how difficult your life has been;” “What you have lived through sounds so frightening;” “I know you’re afraid of going through these tests and treatments; is there anything I can do to make it less scary?”). A number of nonverbal behaviors and verbal statements can also express that we care: (1) body language (e.g., sitting in proximity; a focused, unhurried posture); (2) active listening and reframing (e.g., “It sounds to me that you felt betrayed by the people you trusted most; am I right about that?”); (3) support (e.g., “I know you are trying very hard to live on your own now; I think you are doing great, and I want to do whatever I can to support you.”); and (4) validation (e.g., “You are right to feel that you do not deserve to be abused.”). Caring can also be communicated in a number of indirect ways, such as making an unexpected phone call to follow-up with a patient in crisis (e.g., “I know you had your colonoscopy yesterday, and I wanted to see how you are doing.”). Not all patients (nor all clinicians) are comfortable with touch. Some patients may even believe clinicians are afraid to touch them. Respectful physical contact during painful or uplifting moments can help cement a mutual human connection.

• Create a context for conflict to emerge and get addressed. We need to convince patients that when they have beliefs, opinions, or ideas different from ours, we will welcome discussing them. We must allay any fears patients have that voicing disagreement will incur displeasure or even punishment from the provider. A corollary to this is that patients need to understand that they can change their minds about treatment plans and decisions at any time. Patients need repeated reassurance and reminders that disagreement will not cost them the provider’s regard and care (e.g., “I will not be angry or upset if you disagree; it would be very helpful to know how you really feel, because together we can figure out the best thing to do.”). Building a therapeutic alliance does not require clinicians to deny their viewpoint but to adopt nonthreatening ways of communicating differences with their patients.

• Clarify boundaries. Vulnerable patients may often experience considerable intrusion into their personal lives by government institutions or social service agencies. They may be required to disclose more information than others, and then find it shared across agencies without their knowledge or permission. We should clarify why we are inquiring about certain information (e.g., “I want to ask more specifically about your family because they seem important in your care, and I want to understand how they help you.”) and what is confidential or required to be shared (e.g., “I will keep whatever you tell me confidential unless I think you may harm yourself or someone else; then I must tell others to protect you from any harm.”).

  We should also clarify our own boundaries; it is not uncommon for a relationship between a clinician and a patient to evolve into one of unhealthy dependence or unrealistic expectations. For example, as we learn more about the hardships our patients face and their difficulty navigating the system, we may feel tempted to reach out to them differently than we would for nonvulnerable patients. We may be inclined to give them a pager number or even our home phone because we want to improve access; we might lend them money or give them a ride. While these behaviors might not, in and of themselves, prove problematic, they do represent a crossing of boundaries that are commonly set with patients and signal us to reflect upon and to consider potential consequences. We can avoid creating problematic relationships by remaining mindful of the role we play in the therapeutic relationship and by regularly reflecting on our interactions. Communicating with colleagues about our patient challenges (including boundaries) can provide a critical and supportive perspective as we strive to make appropriate decisions in building the therapeutic relationship.

• Address the therapeutic alliance directly. When caring for a patient who is doing poorly clinically but receiving optimal “medical” management, we should consider if the therapeutic alliance needs attention. We can directly state our desire to have a strong relationship and a real sense of partnership. We can ask if the patient would want any changes in the relationship, reassuring them that speaking honestly is not only acceptable, but essential to working together.

What is the Patient’s Perspective?

Many factors—individual, familial, societal, spiritual, and cultural—shape a person’s concepts and experiences of health and illness. These inform an individual’s sense of responsibility as a patient, expectations of health care providers and family members, and the meaning of healing and recovery. Personal concepts of health determine what preventive and self-care behaviors are considered appropriate, which symptoms seem worrisome, and when to seek help from health care professionals. These explanatory models encompass the meaning of the illness, the presumed cause, its proposed trajectory, the degree of hope of cure, and how treatment should be conducted (see Chapter 15).

The same factors that influence how people think about health and illness also impact other aspects of their lives, and eliciting information about these influences can uncover perspectives important to health care. For example, how individuals make decisions about health care may resemble how they make decisions about parenting or work; the process for how a family decided to immigrate to the United States may be very similar to how they will approach a difficult treatment decision; one’s explanation of life difficulties and the narrative of how one has prevailed over them may illustrate how one will face challenging health problems as well. Illness may be framed hopefully or pessimistically; patients may identify themselves as efficacious or as victims; they may prefer being independent or isolated or they may find strength in support from others.

Importance of Eliciting the Patient’s Perspective

Patient’s perspectives—a complex mixture of very personal beliefs, values, and assumptions reflecting multiple influences—can determine how they develop a relationship with their clinician, and whether they feel understood and respected or misunderstood and discounted. Clinicians, in turn, have their own individual perspectives on health and illness, and ascribe specific meaning to their role as healers. Assuming a shared understanding and not exploring the differences may in fact lead to greater distance and misunderstanding. Eliciting patients’ perspectives allows for accurate empathy and can uncover interests or experiences common to both patient and clinician, thereby reducing the social distance that often impedes the development of a therapeutic alliance.

Eliciting the patient’s story can also improve patient trust, satisfaction, and adherence. It enriches and brings meaning to interactions and allows providers to be more effective and engaged.

Furthermore, sometimes the way people frame their illnesses can cause suffering. Within the context of a strong therapeutic alliance it is possible, as part of the healing process, to recast some narratives. A patient who feels incompetent, for example, might grow, through learning to control his illness, to feel capable and empowered in realms beyond the medical.

Much of clinical training and guideline development focuses on pathophysiology, disease, diagnosis, and treatment. Seasoned clinicians, however, are acutely aware of the gap between the outcomes that are expected (e.g., from reading textbooks or following guidelines) and the outcomes that are actually achieved in practice. While there are many reasons for the observed variation in quality and health outcomes, one of the most important and frequently least appreciated factors is the patient’s social context. A wide range of psychosocial vulnerabilities can impinge on a patient’s ability to carry out the treatment plan and interfere with the therapeutic alliance (see Table 18-1).

When faced with a patient who is doing poorly from a clinical standpoint, many clinicians do not reflect on the psychosocial factors that may be influencing the patient’s course. They may simply throw up their arms and attribute a patient’s clinical decline to his or her social milieu in a global or at times derogatory fashion, referring to such a patient as “nonadherent,” a “difficult patient,” or a “social nightmare,” without digging deeper. Such clinicians often believe that addressing psychosocial problems is “not my job,” stating, “I can’t fix his social problems.” Still others may not have the communication skills to uncover underlying psychosocial problems, or to address them and integrate this knowledge into treatment plans to forge a more genuine, engaged therapeutic alliance.

Screening for psychosocial vulnerabilities is central to caring for patients in any setting and at many points during the process of care, particularly when treatments appear to be failing. Some vulnerabilities will be apparent from the first encounter, whereas others may be hidden. For some problems, it is not until a collaborative relationship has been established that a patient might feel comfortable enough to disclose sensitive information. Similarly, patients may perceive a problem to be irrelevant to their health and neglect to discuss it. When assessing for areas of vulnerability, the clinician should be nonjudgmental, allowing the patient to respond at his or her own pace. Using open-ended questions and responding to patient cues may enable a patient to reveal the important nonclinical factors that may be impeding progress (see Table 18-2).

It is important to raise four important caveats about assessing for psychosocial vulnerability. The first is that in the pursuit of identifying vulnerability, the clinician should be reminded of the importance of simultaneously identifying and acknowledging an individual’s strengths, resilience, and range of resources, such as one’s belief in a higher power or support from a religious community; or the love and support provided by a spouse, friend, or pet. Reviewing and reflecting patients’ past experiences of overcoming difficulty and helping them identify patterns of success is critical to building self-efficacy and developing a therapeutic alliance in the face of vulnerability.

Second, vulnerability is context dependent. For example, in countries with universal health care coverage, lack of insurance simply does not contribute to vulnerability. Conversely, absence of interpretation services may exacerbate the effects of limited English proficiency when compared to settings with medical interpretation; presence of a methadone treatment program or a mobile treatment van in one’s clinic may mitigate the untoward health effects of heroin addiction and housing instability, respectively. As such, the effects of vulnerability on health care can be influenced by altering the context in which caregiving takes place, which most frequently means adapting the clinical encounter. This suggests that when caring for vulnerable populations, clinicians and systems should also perform self-assessments, and carefully explore the ways in which the caregiving context can be adapted to best attenuate (or even eliminate) the health effects of vulnerability.

Third, in the process of assessment, the clinician should be sensitive to the concerns of patients with respect to shame and stigma. It is clear that a number of factors listed in Table 18-1 may elicit feelings of shame, such as having limited literacy, being marginally housed, having mental illness, or being addicted.

Fourth, after identifying vulnerability, the clinician should not forget the important step of exploring with the patient, in a supportive and nonjudgmental manner, how the vulnerability may be affecting health and care and how to mitigate these effects. Only by doing so can the clinicians develop a more effective treatment plan while simultaneously enhancing the therapeutic alliance.

There are several additional strategies that may be especially useful in developing and sustaining a therapeutic alliance with socially vulnerable patients. These include showing patients in concrete ways that you care (i.e., “going the extra mile”); advocating for patients with the myriad bureaucracies with which they struggle; connecting them to appropriate community resources (e.g., immigration lawyer, domestic violence counselor, exercise groups); networking with others, including family, friends, public health, and community resources, so as to encourage them to support the patient’s efforts to achieve health; and engaging in self-disclosure to narrow social distance and encourage the sharing of personal stories.

Building a therapeutic alliance with vulnerable patients comes with both special rewards and challenges. Working with the underserved allows a clinician to apply his or her skills to assist those who are most in need, fulfilling one of the basic humanitarian ideals in medicine. Developing a therapeutic bond with patients that do not represent the “typical patient,” or that many consider too difficult to manage, can be rewarding in and of itself, often involving a process of shared discovery and reflection.

It is not uncommon, however, for even seasoned clinicians to be overwhelmed by the many challenges inherent to caring for vulnerable patients. Developing patterns of codependency, such as repeatedly “rescuing” patients from the decisions that are in their control, may be a prelude to clinician “burnout.” In addition, the work environment plays an important role. Although clinicians in underserved clinical settings report serving higher proportions of medically and psychosocially complex patients, they are more likely to report a chaotic work environment and less likely to feel in control. In these contexts, clinicians who perceive high proportions of challenging patient encounter have higher odds of burnout and reduced job satisfaction.

Clinicians should be aware of signs of “burnout,” such as exhibiting their anger and frustration at patients or staff, or developing an overly passive style of patient engagement.

To minimize burnout and maximize sustainability, clinicians caring for vulnerable populations may draw on personal, interpersonal, and environmental supports. In a qualitative study exploring why clinicians work in underserved clinics, clinicians cited the importance of personal motivators (such as opportunity for personal growth and concordance of service with self-identity and mission-based values); career motivators (such as work–life balance and loan repayment assistance); and environmental factors, primarily supportive interprofessional colleagues and teams.

Clinicians who have been able to sustain therapeutic relationships with vulnerable patients and maintain fulfilling careers in the care of vulnerable populations tend to (1) elicit patients’ agendas so as to establish an understanding of patient expectations, (2) set realistic goals for what they can accomplish and share these goals with their patients, (3) limit what they aim to accomplish in any given encounter and see their work with patients as evolving over a long period of time, (4) continually clarify boundaries, (5) maintain a sense of curiosity and discovery about the patients’ clinical and personal profile, (6) acknowledge that many of the problems experienced by vulnerable patients are structural/societal in nature, and not always a result of patient choice, (7) engage in public health-related or social advocacy efforts to affect structural determinants of health, (8) seek the advice and support of colleagues who share common ideals and practices, and (9) engage with interprofessional colleagues to draw on their expertise as part of an integrated team. Health care systems wishing to recruit and retain clinicians caring for vulnerable populations should provide opportunities for clinicians to develop these intrapersonal and interpersonal skills and enhance the clinical resources that allow clinicians to feel successful in this work.

A strong therapeutic alliance creates a trusting context for patient care, contributes to a higher quality of care, and can improve patient safety. Building a therapeutic alliance, eliciting the patient’s narrative and assessing for vulnerabilities and strengths are critical to creating this context. Fostering the therapeutic alliance requires developing trust, conveying empathy, and collaborating about treatment goals. Depending on the skills, attitudes, and orientation of clinicians and the systems in which they work, the clinical encounter can increase social distance and exacerbate the effects of vulnerability on health, or it can lead to productive engagement with patients to mitigate or even eliminate the effects of vulnerability on health. Though it may be especially challenging to develop and sustain a therapeutic alliance with those who are socially vulnerable, the benefits to patient and clinician can be profound.

• Vulnerable patients often experience fragmentation and disconnection in their lives and in their health care.

• The therapeutic alliance is an important means to reduce the effects of vulnerability on health outcomes.

• Eliciting the patient’s story or perspective is an effective means to uncover health beliefs, develop shared meaning, enable empathy, and enhance the therapeutic alliance. It also serves to uncover patient vulnerabilities and reveal patients’ resilience.

• By identifying vulnerabilities and acknowledging these to the patient and to other clinicians involved in the patient’s care, clinicians will be better equipped to develop effective treatment plans.

• Though it may be especially challenging to develop and sustain a therapeutic alliance with those who are socially vulnerable, the benefits to patient and clinician can be profound.

Eliciting the Patient’s Perspective

• Let patients know that hearing their perspective is important to you.

• Explain that you think discussing family, coping styles, and their personal story is important to patients’ health.

• Take the time necessary, and use the time well.

• Set a climate of interest, concern, and calm.

• Use an inquiry style that fosters more, not less, information.

• Maintain a high degree of curiosity; be aware of patients’ verbal or emotional cues.

• Follow up on cues—such as “It seemed that talking about that brought up some feelings for you. Why is that?”

• Use open-ended questions and reflective statements.

• Discover the patient’s explanatory model.

• Ask the Kleinman questions:

  What do you call the problem? What do you think has caused the problem? Why do you think it started when it did? What do you think the sickness does? How does it work? How severe is the sickness? Will it have a short or long course? What kind of treatment do you think you should receive? What are the most important results you hope to receive from this treatment? What are the chief problems the sickness has caused you? What do you fear most about the sickness? (Kleinman, 1988)

• Consider the interpersonal context of patients’ general health care framework.

• Focus on the meaning of what patients are saying.

• Avoid using technical, medical jargon.

• Do not try to gather the entire perspective in one appointment, but try to gain some insight every time.

1. Discuss clinical experiences you have had with vulnerable patients in which the presence or absence of strategies such as building a therapeutic alliance, eliciting patients’ narratives, and assessing for vulnerabilities and strengths influenced the process and perhaps the outcome of their health care.

2. Consider what structural and health policy changes would need to be made to better incorporate the strategies of building a therapeutic alliance, eliciting patients’ narratives, and assessing for vulnerabilities and strengths into the day-to-day clinical care of vulnerable patients.

3. What are some of the most surprising or fascinating nonmedical pieces of information you learned about the last patient you cared for and how did it influence either the treatment plan or your relationship with the patient and his or her family?

4. Discuss how personal beliefs, values, and assumptions about vulnerable patients affects your ability to create a context for effective care using strategies such as building a therapeutic alliance, eliciting patients’ narratives, and assessing for vulnerabilities and strengths.

5. What special rewards and challenges have you encountered in caring for vulnerable populations and what strategies would help you sustain therapeutic alliances with your patients and families?