Forging & Maintaining a Therapeutic Alliance with Difficult Patients

2. Ipseity

The second core element is to establish ipseity. Ipseity is an old-fashioned word that denotes selfhood.³ In this context, ipseity refers to the sense that a patient, even a difficult patient, has individual beliefs, experiences and thoughts that are distinct from the provider’s. Validating those perspectives without necessarily validating misconceptions is the tough task rheumatologists have to perform in clinic.

Respecting boundaries while forging the therapeutic alliance can be very tricky, especially when there are differences of opinion. Careful, active listening with facilitation is essential to understanding the patient position, as well as the underlying basis of those positions. That takes time and effort, particularly in negotiating the correct path forward.

Fortunately, techniques to establish ipseity are more intuitive than the technical nature of the term would suggest. In fact, rheumatologists are at a distinct advantage because we routinely inquire about how a patient’s symptoms affect their everyday lives. It doesn’t take much more questioning to get to how their disease affects their outlook and vice versa.

In the case of Ms. Miller, she quickly mentioned that her lupus prevented her from gardening, which provided a wealth of information about who she is and the importance of reducing her disease activity enough so she could get back to gardening. When we first met, she felt like she was letting down her friends and family by being unable to harvest and distribute fresh produce as she once did. In subsequent encounters, we were able to discuss her hobby, what vegetables she grew and how the disease affected her life.

3. Partnership

The third major element necessary for a therapeutic relationship is partnership against a common enemy: the disease process itself.⁴ Once commitment and respect for autonomy are established, it becomes essential to articulate that the partnership has an express purpose of controlling disease activity.

There’s a misconception in the general public that doctors are “in the pocket of big pharma,” to quote Ms. Miller. We should take every opportunity to demonstrate what is true—that we are in the pocket of our patients. Because our diseases tend to be frustratingly difficult to control, maintaining the fidelity and strength of that relationship is a challenge. Maintaining a therapeutic relationship requires constant reinforcement that we, together, are doing the best we can to defeat a common enemy.

To this end, I often talk about the mutual vulnerability we share. When bureaucratic and administrative obstacles prevent optimal care, I disclose that information wholeheartedly and mention what lengths I and other members of the care team go to in order to maintain the integrity of the alliance against the common enemy. I let patients know how I advocate for their health and fight on their behalf.

4. Contingency Planning

This leads to the fourth principle of successful therapeutic alliances: contingency planning. Rheumatology patients and their doctors can rarely declare definitive victory. Rather, we must prepare for what happens when the disease progresses or management falters. Understandably, this can breed suspicion and, potentially, ill will in patients, who may expect cure. Worse yet, it may lead to feelings of abandonment when one approach leads to a dead-end. Being honest about the limitations of medicine and proactively planning for contingencies is vital to maintaining a therapeutic alliance.

The strategy I use with difficult patients is to spell out the ifs and whens as much as possible. I write down time frames in which we anticipate changes in disease activity and describe challenges that may get in the way. The most important message is that options exist and the therapeutic alliance can pursue these options. Even when our backs are against the wall, I detail what homework I plan on completing to find a path forward. This provides solace to patients that I, as the physician half of the therapeutic alliance, am engaging in good faith to uphold the alliance.

5. Practicality

The last major principle of building and maintaining therapeutic alliances is practicality. Difficult patients may have a host of other medical and psychosocial issues that can hamper effective diagnosis and treatment. Acknowledgment of these practical limitations as early as possible is an absolute necessity. If nonadherence is an issue, addressing the nonadherence in a practical manner may lead to greater dividends than just dismissing a patient as “difficult.”

For example, referral to mental health experts may be necessary to help patients stay abreast of anxiety or depression, which are common comorbidities of rheumatic disease. Maintaining a low threshold for suspicion of domestic abuse may be life­saving to a patient whose “difficult” behavior seems otherwise inexplicable.

In Sum

In the end, these five principles (commitment, ipseity, partnership, contingency planning and practicality) underpinning the construction and maintenance of the therapeutic alliance are aimed squarely at one goal: the maintenance of hope. More than any procedure or prescription, we rheumatologists can help reduce the hopelessness and isolation that occur due to untreated or poorly treated rheumatologic disease. But this process has to start with the formation of a strong therapeutic alliance, even with initially hesitant and skeptical partners, like Ms. Miller and me.

Finally, though, when I am at an utter loss in developing a therapeutic alliance, I try to find another provider (whether rheuma­tologist or not) to take over care. 

Bharat Kumar, MD, MME, FACP, RhMSUS, is the associate program director of the rheumatology fellowship training program at the University of Iowa in Iowa City. Follow him on Twitter @BharatKumarMD.

References

1. Pinto RZ, Ferreira ML, Oliveira VC, et al. Patient-centred communication is associated with positive therapeutic alliance: A systematic review. J Physiother. 2012;58(2):77–87.
2. McKelvey I. The consultation hill: A new model to aid teaching consultation skills. Br J Gen Pract. 2010 Jul;60(576):538–540.
3. ipseity. Merriam-Webster.com. Merriam-Webster. 2018 Dec 8.
4. Fiester AM. What mediators can teach physicians about managing ‘difficult’ patients. Am J Med. 2015 Mar;128(3):215–216.