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

  • Explore the four critical components of therapeutic alliance: shared values and humanity, empathy, trust, 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.


Ms. Sviridov is a 67-year-old woman with chronic arthritis pain, hypertension, prior stroke, diastolic dysfunction, and diabetes. Despite a sizable, guideline-based medication regimen and frequent visits to both a primary care physician and a cardiologist, she has recalcitrant heart failure, requiring multiple hospital admissions. An extensive cardiac workup has been unrevealing. Ms. Sviridov is unhappy with her care and seeks out another primary care physician.

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. Often the suboptimal care reflects a mismatch between the psychosocial vulnerabilities that they bring to the clinical encounter and the knowledge, resources, attitudes, skills, and beliefs of the clinicians caring for them.1

In this chapter, we focus on the centrality of building and sustaining strong clinician–patient relationships to improve the health of our patients. Three essential strategies are recommended to promote a context for effective care for vulnerable patients: (1) building a therapeutic alliance, (2) eliciting the patient’s story or “narrative,” and (3) assessing for the patient’s psychosocial vulnerabilities and strengths (or resilience factors). Clinicians can apply a combination of these approaches to create and sustain more productive and effective interactions and relationships with vulnerable patients (Figure 10-1).

Figure 10-1.

Creating a context for effective intervention in the clinical care of vulnerable patients. The care of the vulnerable patient is optimized when the clinician is able to (a) elicit the patient’s story, (b) assess for vulnerabilities and strengths, and (c) build a therapeutic alliance.


Psychosocial vulnerabilities can affect health and health care, either alone or in concert with the patient’s management of the disease (see Figure 10-2). 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 the intravenous drug abuse and skin abscesses or intimate partner violence and head trauma. A second path is an indirect one (effect modification), whereby the vulnerability attenuates or impedes the benefits of medical treatment on coexisting medical conditions, for example, the vulnerability presents a barrier to optimal acute, chronic, and/or preventive care, thereby adversely influencing the ...

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