The Therapeutic Alliance

The therapeutic alliance, or therapeutic relationship, is a term commonly used in psychotherapy to describe the relationship between the therapist and the client. In medicine, the term generally refers to the relationship between the patient and the healthcare provider. The strength and stability of the therapeutic alliance is an often undervalued and unappreciated factor that can have a significant impact on a patient’s clinical outcome.

I always teach students that the most important part of the initial patient encounter is to establish a therapeutic rapport, which has nothing to do with “getting the diagnosis.” The therapeutic rapport is a term used to describe the mutual understanding and trust that develops between a patient and provider. It’s the most important component of a strong therapeutic alliance and has a powerful influence on a patient’s perception of you as a provider. A healthy therapeutic rapport is one in which the patient leaves the encounter feeling understood, respected, and cared for. This cannot be overstated.

I tell students who rotate with me to stop wasting energy on trying to find the problem and let the patient tell you the problem. That is, simply listen to their story and don’t stress about getting all the relevant information. Patients will tell you what you need to know if you provide the safe space for them to do so. Instead of focusing on the diagnosis, focus on the patient. Sit with them, be present with them, let them know you are there to listen and that you care. Sounds simple, but in the chaotic world of healthcare, this too often gets lost.

I’ve asked numerous patients and random people to explain what they look for in a provider. The most common response (almost 100% of the time) is something related to feeling cared for, respected, and/or listened to. A good provider is one who doesn’t make you feel like a burden on them, who makes you feel important, and who genuinely cares about others (even if they have to play the part sometimes). Some of the best and brightest providers may not be respected and trusted by their patients…and being respected and trusted by your patients is the single most important thing.

When patients present to a provider they are looking for much more than your knowledge and expertise. Patients want to know that their provider cares about them as a whole person rather than a bunch of medical or psychiatric diagnoses and problems. Patients won’t share with you the most important aspects of themselves if they don’t trust you. Those important aspects can be essential to an accurate diagnosis. Just remember that an accurate diagnosis doesn’t help the patient of they don’t trust you or feel comfortable with you.

So, my advice to students is to spend the time listening to patients and only ask questions if you actually want to know the answer. It’s unbelievable what a difference it can make…

If you “don’t have time” to listen to your patient, then you don’t deserve to hear what they have to say. Stay humble.


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