Forging & Maintaining a Therapeutic Alliance with Difficult Patients

When I first met Ms. Miller (name changed), quite frankly, I couldn’t wait to get out of the room. I’m sure she couldn’t either. A woman in her 40s with systemic lupus erythematosus, poorly controlled asthma and fibromyalgia, she seemed to have every conceivable symptom. And, worse than that, due to a long history of unfortunate encounters with the healthcare system, including disjointed care, adverse effects of medications and repeated hospitalizations, she was a self-described “difficult” patient who remained reserved and was quite suspicious of me. Every other sentence she uttered was followed by a not-so-subtle loud sigh or a roll of the eyes.

Two years after that first meeting, I could hardly believe she would be smiling widely, enthusiastically extending her hand to shake mine and showing me photos of her children and nephews. In turn, I’ve been eager to see her at our visits and discuss the ways we can address her medical problems.

That repartee did not come easily. There was a lot of give-and-take over the months and years. We mutually engaged in a lot of diplomacy and negotiation over a long period of time, sometimes over large topics and sometimes over relatively minor aspects of care.

This is the common experience of rheuma­tologists, who are experts in managing chronic conditions. Indeed, how to deal with difficult patients is a core, often unspoken, theme throughout fellowship education. Because we, as rheumatologists, are in the unusual spot of being deeply invested in virtually every aspect of physical and mental health without actually being primary care providers, we have to carefully and relentlessly hone our skills in dealing with difficult patients. More specifically, to be successful in our craft, we have to foster and nurture what psychologists term the therapeutic alliance.¹

For both new and experienced rheumatologists, identifying the principles of successful alliances may help us hone strategies to decrease frustration and improve the sense of satisfaction while in the clinic.

This can lead to patient activation, as well as better adherence, health and well-being. Individual strategies to achieve strong therapeutic alliances vary and are dictated by a number of structural and cultural norms, but certain principles can guide the way.

1. Commitment

The first, and most elemental, aspect of the therapeutic alliance is commitment. As physicians, we have to be committed to our patients. That means letting them know their well-being is the most important aspect of our relationship. Certain patients are under the impression, based on previous experiences, that healthcare providers are providing a transactional service.

Refuting the notion that physicians just dispense drugs in exchange for money is extremely important. In fact, it’s vital that we demonstrate how much we value personal relationships and that we actively engage with the utmost sincerity and honesty. Empathic conversation that goes beyond simple documentation of tasks can help patients realize that our role isn’t just to dispense medication but to help them recover well-being.

The use of the golden minute at the beginning of the patient encounter, when the electronic medical record and computers are deliberately ignored in favor of face-to-face conversation is one strategy that has been articulated and studied.²

Other strategies include deliberate articulation of joint responsibilities, using words like “we,” “together” and “cooperate.” At the end of sessions, I often use the phrase, “does that sound fair?” to demonstrate the bilateral nature of our commitment rather than dictation from a doctor.

It is just as important to reinforce that our commitment lasts long after our face-to-face encounters are over. The use of after-visit summaries has become common­place. Consider including contact information, along with information for self-management of chronic disease. When used to their maximal effect, after-visit summaries can advance our commitment once we are no longer face to face. Additionally, if the patient is amenable, more frequent follow-up, at least initially, can also help reduce barriers in management once the patient is out of the room.

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.

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.