The Therapeutic Alliance 


In my day to day practice I like to think about ways to make me a better doctor. Being a better doctor, to me, means being successful at relieving pain, preventing problems, saving lives, and helping people to maximize their human potential, whatever that might be. That might be helping them to be happier in their lives or recognizing when something big must be done to change. It even extends to, for instance, helping people realize why their politics have changed when they have a baby. Politics usually do change a bit. I will post another blog about that someday.

One of the ways that I think that I and other doctors can improve their skills is by developing what I call a Therapeutic Alliance with patients.

A Therapeutic Alliance is a concept of how a doctor and a patient can relate to each other in their day to day activities. It is not explicit. A Therapeutic Alliance is an implicit unspoken agreement between two people, the patient and the doctor, that there will be cooperative work done between them to achieve their goals. What are their goals? Their goals are maximizing health, reduction or removal of pathology, maximizing their human potential, and prevention of morbidity and mortality. A Therapeutic Alliance works toward advancing the interests of the patient. An important component of a Therapeutic Alliance is unfettered communication between the two people about what the medical issues are. What medical issues? History of any problems, the evaluations needed, what do these evaluations cost in pain, time, money, and risk, the medical methods to be used, the risks and side effects of those methods, and the hoped for outcomes. Also, of course, is the prevention of disease.

The biggest obstacle is unfettering the communication. Once the communication is free and easy, almost anything therapeutic is easy to achieve, if it can be achieved at all.

Notice that a Therapeutic Alliance does not require unfettered trust. In fact, I think unfettered trust is dangerous because it will impede the communication of important hesitant feelings. If my patient asks about trust, or even tells me that they trust me implicitly, I will tell them "do not trust me". Why? If the trust is so deep, I may not know that the patient has misgivings about what needs to happen. The patient has to agree to whatever plan is made. They have to agree in order to make it right. If the patient is not agreeable, then however technically correct the medical plan might be, it may not work. I don't want blind trust from my patients. That is a dumb thing to ask a patient to have. Only a snobbish physician demands implicit trust from a patient.

But the therapeutic alliance does require a certain kind of trust. It is the trust that the physician and the alliance itself will work diligently and professionally to achieve the patients goals, as discussed above. That kind of trust needs to be there. We as physicians need to serve the patients interest. The patients interests must come first. The alliance must proceed in a manner that the patient herself would proceed if she had the knowledge base and experience that the physician has. And that also means that the physician will stay within their zone of competency, and the patient must know that.

So, the end result is that there are two (or more?) people in an alliance to achieve goals that serve the patients best interest and no one else's.

A very interesting thing about a therapeutic alliance is that if it ruptures and is then repaired, it can be even stronger than it ever was. Even stronger than one that never ruptured. But a broken therapeutic alliance that remains broken is dangerous. This is because the patient will never agree to even sensible plans, and that means bad outcomes all around.

The concept of therapeutic alliance has been a subject of quite a bit of scientific study. It is easy to read about these things on the web. The last time I read the Wikipedia entry about it it had a paragraph about the ruptured Therapeutic Alliance. That Wikipedia entry also shows that this concept has been over analyzed and made confusing.

A Therapeutic Alliance is a theoretical thing that represents an ideal of how the Art and Science of medicine should work. In reality, there are obstacles. The biggest obstacle is hindered communication. If a patient doesn't understand that I am trying to open the communication, to be a better doctor, then it won't work. Worse yet, if I don't get the kind of trust that I outlined above, then it won't work. Again, I don't want or need blind trust. Just a trust that I will do my best as a physician, as a member of our Alliance, to work diligently. Another common obstacle is lack of time. There is just not enough time to do the things that need to be done. And also, sometimes a Therapeutic Alliance is just unnecessary and waste of time. For instance, women who just want a routine checkup and to get back to their business don't want or need to delve into this kind of thing.

When I was in med school there was very little time devoted to these concepts, and only in the psychiatry rotations. But I paid attention to these concepts and I saw how they could be applied to all of medicine. And I use it in my practice every day.

Generating the therapeutic alliance means unfettering the communications, even on delicate matters, and then doing a good job as a physican with basic things like getting a history, doing a good exam, ordering tests appropriately, making a fair plan, and communicationg all the other things like risks, benefit, and likely outcomes. It seems to me that it is just basic and good medical care.

It is my belief that a good Therapeutic Alliance is a wonderful thing to have.



My next post will be about the basic infertility workup.

Frequently women will be brought to tears every month and they need some help.

Are these blog posts hard to read? How is my writing? please post comments below. Thank you.

Dr John Marcus MD
Obstetrics and Gynecology
Ridgewood NJ, 07450

201-447-0077