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In this chapter, we will cover the following key learning objectives:

  • 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 points of resilience and illustrate how identifying them can help create a patient-centered clinical encounter.

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



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’s new primary care physician asks about her life. She describes an active singing career and a rich family life in the past, and the importance of her church. She acknowledges that profound depression and concern over the welfare of her drug-abusing son, however, now interfere with caring for herself.

Ms. Sviridov’s physician suggests he make a home visit. Exploring her initial refusal, he learns that her son deals drugs from her apartment. Eventually, with the support of her physician and adult protective services, she is able to demand that her son leave. She receives support and assistance from home-health services and her church group. Her conditions stabilize, and she is not rehospitalized.

Social characteristics—living in poverty, having a low level of education and limited literacy skills, being from a community that has experienced racism and discrimination, 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 ...

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