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.
Pathways by which psychosocial vulnerabilities affect health and health care in the clinical encounter (see text for details).
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
CASE ILLUSTRATION 2
Mr. Jackson is a 52-year-old man with type 2 diabetes, hypertension, and end-stage renal disease. He receives care intermittently at a public clinic. He was recently referred for dialysis but missed his appointment for evaluation. He was a construction worker and now is unemployed; he lives alone and is episodically homeless. He is African American and has two sons living in the area.
He was admitted to the Family Medicine Service of a county hospital and found to be in diabetic ketoacidosis. During the admission, the inpatient team rediscusses his need for dialysis. His initial meeting with the Renal Team ends with him becoming angry and refusing dialysis. The resident assigned to his care urges him to reconsider, and he becomes withdrawn. She attempts to arrange dialysis again, and the Renal Team, citing his history of alcohol use, his intermittent homelessness, and his lack of follow-through, declares him a “poor candidate” for dialysis.
The resident meets with Mr. Jackson to better understand his thinking. Initially he remains distant; as she expresses her concern for helping him receive the best care, he is able to express his anger at the medical system over the years. He feels he has not been given information about his illness in a manner that he understands; he is unable to implement the many self-care suggestions, given his living situation; and feels that doctors have only been interested in him if they can “learn medicine” by experimenting on him. The resident expresses her concern and regret for how he has been previously treated and offers to do her best to help him now. He is able to talk about his experience with diabetes, his fear about dying, and his desire to change. She expresses her appreciation for his willingness to be forthright and offers to become his primary care physician. She also offers to advocate for him with the Renal Team to initiate dialysis both in and out of the hospital.
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).