Therapeutic alliances: Conveying our sacred calling
Research found that a positive and hopeful relationship is a common ingredient of successful psychotherapy
Before modern medications and managed care, we tended to focus more on our relationships with patients. The goal was to establish a therapeutic alliance. Perhaps the idea of this kind of physician-patient relationship was what philosopher Martin Buber described as the “I-Thou” interaction. Instead of the “I-It” relationship where we mainly look at reducing symptoms, “I-Thou” recognizes the authenticity of the other and recommends reciprocity and respect.1
After Buber, research found that a positive and hopeful relationship is a common ingredient of successful psychotherapy of any theoretical persuasion and technique.2 Because the therapeutic alliance is crucial even during a brief medication check—and likely will enhance compliance—maybe we need to bring Buber back into prominence. Here’s how:
The nature of our work. Shortened time and reliance on medication can make us feel as if we are doing factory work. Think of psychiatry as much as a calling as a career.
The greeting. One of the most rewarding clinical experiences I’ve had occurred when a new patient came into my office. Before I could ask how she was feeling about seeing a new psychiatrist, she quickly said how pleased she was that I was her physician. Thinking that she might have looked up some of my writings on the Internet, I asked her why. She said that she had noticed that I smiled when I greeted my patients in the waiting room, as if I was happy to see them.
Look at your patient, not your computer. When my practice was transferring from paper to electronic records, I tried to talk to patients as I typed. One patient joked, “Hey, Doc, who are you talking to on that computer?” I got the message. I used to be able to scribble notes as we talked. Now, I maintain eye contact when I begin the session, and leave the computer until the end.
Know who your patients are. Find out what is most important to each patient, and refer to it often. What gives meaning to patients’ lives despite their psychiatric disorder will give meaning to your relationship.
You’re in this together. Make clear the limitations you are working under. Indicate that despite these obstacles, you will do whatever you can as a partnership. You may even want to apologize at times for what you can’t do, but would like to.
Saying goodbye. Always leave time for questions. Given the trend for less frequent appointments, which can make patients feel rejected, ask them if coming back at a later date seems acceptable. Let your patients know you look forward to seeing them again. Be sure to close with a handshake or other culturally appropriate gesture.
Dr. Moffic reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Scott JG, Scott RG, Miller WL, et al. Healing relationships and the existential philosophy of Martin Buber. Philos Ethics Humanit Med. 2009;4:11.-
2. Frank JD, Frank JB. Persuasion and healing: a comparative study of psychotherapy. Baltimore, MD: The Johns Hopkins University Press; 1993.