Formation of the Physician–Patient Relationship
The physician–patient relationship develops during the assessment and evaluation of the patient. The patient observes the thorough-ness and sensitivity with which the physician collects informa-tion, performs the physical examination, and explains needed tests. At each step, the physician’s clarification of the treatment goals and interventions either builds up the patient’s expectation of help and feelings of safety or creates increasing disease for the patient. In many aspects and, in particular, in the physician’s compassion and patience, he/she is like a good teacher, estab-lishing the context in which learning and growth may occur and anxiety decrease (Banner and Cannon, 1997). Alertness to the patient’s fears and misunderstandings of the evaluation process can minimize unnecessary disruptions of the relationship and provide information on the patient’s previous experiences with medical care and important authority figures. These past expe-riences form the patient’s present expectations of either help or disappointment (Smith and Thompson, 1993) (Table 4.1).
Early in the relationship between a psychiatrist and a patient, the patient requests help with his or her pain, uncertainty, or discom-fort. The psychiatrist initiates the “contract” of the relationship by acknowledging the patient’s pain and offering help. In this action, the psychiatrist has recognized the patient’s ill-health and acknowledged the need for and possibility of removing the dis-ease or illness. In this first stage of the development of rapport, the way of relating between the physician and the patient, the physician–patient relationship has begun to organize the interac-tions. Through the physician’s and the patient’s shared recogni-tion of the patient’s pain, the basis for rapport – a comfortable pattern of working together – is established.
The psychiatrist’s ability to empathize, to understand in feeling terms every patient’s subjective experience, is important to the development of rapport. Empathy is particularly impor-tant in complex interpersonal behavioral problems in which the environment (family, friends, caretakers) may wish to expel the patient, and the patient has therefore lost hope. Suicidal patients, adolescents involved in intense family conflicts and patients in conflict with their medical caregivers can often be convinced to cooperate with the evaluation only when the psychiatrist has shown accurate empathy early in the first meeting with the pa-tient. When the physician acknowledges the patient’s pain, the patient feels less alone and inevitably more hopeful (Marziali and Alexander, 1991). This rapport establishes a set of principles of and expectations for the physician–patient interaction. On this basic building block more elaborate goals and responsibilities of the patient can be developed.
For a patient to trust and work closely with a physician it is essential that there be a reality-based relationship outside the conflicted ones for which the patient is seeking help (Rawn, 1991; Friedman, 1969). With more disturbed patients considerable skill is required of the physician to reach this reality-based part of the patient and decrease the patient’s fears and expectations of at-tack or humiliation. Even for healthy patients, the physician must bridge the gap between the patient and the physician that is al-ways present because of their different backgrounds and percep-tions of the world. This gap is an expectable result of differences between the physician’s and the patient’s culture, gender, ethnic background, socioeconomic class, religion, age, or role in the physician–patient relationship. The experienced physician makes communication across the gap seem effortless, using a different “language” for each patient. The student often sees this as an art rather than as a skill to be learned.
The therapeutic alliance is extremely important in times of crisis such as suicidality, hospitalization and aggressive be-havior. But it is also the basis of agreement about appointments, fees and treatment requirements. In psychiatric patients, this core component of the physician–patient relationship can be disturbed and requires careful tending. Frequently, the psychiatrist may feel that he or she is “threading a needle” to reach and maintain the therapeutic alliance while not activating the more disturbed elements of the patient’s patterns of interpersonal relating.
The therapeutic or working alliance must endure in spite of what may, at times, be intense, irrational, delusional, charac-terologic, or transference-based feelings of love and hate. The working alliance must outweigh or counterbalance the distorted components of the relationship. It must provide a stable base for the patient and the physician when the patient’s feelings or behaviors may impair reflection and cooperation. The working alliance embodies the mutual responsibilities both physician and patient have accepted to restore the patient’s health. Likewise, the working alliance must be strong enough to ensure that thetreatment goes forward even when both members of the dyad may doubt that it can. The alliance requires a basic trust by the patient that the physician is working in his or her best interests, despite how the patient may feel at a given moment. Patients must be taught to be partners in the healing process and to rec-ognize that the physician is a committed partner in that process as well. The development of common goals fosters the physician and patient seeing themselves as having reciprocal responsibili-ties: the physician to work in a physician-like fashion to pro-mote healing; the patient to participate actively in formulating and supporting the treatment plan, “trying on” more adaptive behaviors in the chosen mode of treatment, and taking respon-sibility for his or her actions to the extent possible (Ursano and Silberman, 1988).
Important to the reality-based relationship with the pa-tient is the physician’s ability to recognize and acknowledge the limitations of her or his knowledge and to work collaboratively with other physicians. When this happens, patients are most often appreciative, not critical, and experience a strengthening of the alliance because of the physician’s commitment to finding an an-swer. When a patient loses confidence in the physician, it is of-ten because of unacknowledged shortcomings in the physician’s skills. The patient may lose motivation to maintain the alliance and seek help elsewhere. Alternatively, the patient may seek no help.
Transference is the tendency we all have to see someone in the present as being like an important figure from our past (Freud, 1958). This process occurs outside our conscious awareness; it is probably a basic means used by the brain to make sense of current experience by seeing the past in the present and limit-ing the input of new information. Transference is more common in settings that provoke anxiety and provide few cues to how to behave – conditions typical of a hospital. Transference influences the patient’s behavior and can distort the physician–patient rela-tionship, for good or ill (Adler, 1980).
Although transference is a distortion of the present reality, it is usually built around a kernel of reality that can make it diffi-cult for the inexperienced clinician to recognize rather than react to the transference. The transference can be the elaboration of an accurate observation into the “total” explanation or the major evidence of some expected harm or loss. Often the physician may recognize transference by the pressure she or he feels to respond in a particular manner to the patient, for example, always to stay longer or not abruptly leave the patient (Sandler et al., 1973).
Transference is ubiquitous. It is a part of day-to-day experience, although its operation is outside conscious aware-ness. Recognizing transference in the physician–patient relation-ship can aid the physician in understanding the patient’s deeply held expectations of help, shame, injury, or abandonment that derive from childhood experiences.
Transference reactions, of course, are not confined to the patient; the physician also superimposes the past on the present. This is called countertransference, the physician’s transference to the patient (Table 4.2). Countertransference usually takes one of two forms: concordant countertransference, in which one empathizes with the patient’s position; or complementary coun-tertransference, in which one empathizes with an important figure from the patient’s past (Racker, 1968). For example, concordant countertransference would be evident if a patient were describing an argument with his or her boss, and the psychiatrist, perhaps after a disagreement with the psychiatrist’s own supervisor and without having collected detailed information from the patient, felt, “Oh yeah, what a terrible boss”. Similarly, complementary countertransference would be evident if the same psychiatrist felt, “This person (the patient) does not work very hard, no wonder the boss is dissatisfied,” and felt angry with the patient as well. Paying close attention to our personal reactions while refraining from immediate action can inform us in an experien-tial manner about subtle aspects of the patient’s behavior that we may overlook or not appreciate. In the preceding example, the psychiatrist with the concordant countertransference might be identifying with the patient’s subtle need to fight with authority. The psychiatrist with the complementary countertransference might have identified with the patient’s boss, seeing only the patient’s more passive wishes.
Countertransference occurs in all “sizes and shapes”, more or less mixed with the physician’s past but often greatly influenc-ing the physician–patient relationship. The wish to save or rescue a patient is commonly experienced and indicates a need to look for countertransference responses. When a patient is seriously ill, such as with cancer, we may increasingly want to treat the patient more aggressively, with procedures that may hold little hope, create substantial pain, and perhaps even be against the patient’s wishes. The physician’s feelings of loss of a valued per-son (in the present and as a reminder of the past) or feelings of failure (loss of the physician’s own power and ability) can often fuel such reactions. More subtle factors, such as the effects of being overworked, can result in unrecognized feelings of depri-vation leading to unspoken wishes for a patient to quit treatment. When these feelings appear in subtle countertransference reac-tions, such as being late to appointments, becoming tired in an hour, or being unable to recall previous material, they can have powerful effects on the patient’s wish to continue treatment.
Major developmental events in physicians’ lives can also influence their perceptions of their patients. When a psychiatrist is expecting the birth of a child, she or he may be overly sensitive to or ignore the concerns of a patient worried about a significant illness in the patient’s child. Similarly, a physician with a dying parent or spouse may be unable to empathize with a patient’s concerns about loss of a job, feeling that it is trivial.
All people, including patients, employ mechanisms of defense to protect themselves from the painful awareness of feelings and memories that can provoke overwhelming anxiety. Defense mechanisms are specific cognitive processes: ways of thinking that the mind employs to avoid painful feelings (Freud, 1966). They are often characteristic of a person and form a style of
cognition (Shapiro, 1965). Common defense mechanisms include projection, repression, displacement, intellectualization, humor, suppression and altruism (Table 4.3).
Defense mechanisms may be more or less mature depend-ing on the degree of distortion of reality and interpersonal dis-ruption to which they lead. This patterning of feelings, thoughts and behaviors by defense mechanisms is involuntary and arises in response to perceptions of psychic danger (Vaillant, 1992). The patient’s characteristic defense mechanisms, the cognitive proc-esses used to lower anxiety and unpleasant feelings, can greatly affect the physician–patient relationship. Defense mechanisms operate all the time; however, in times of high anxiety, such as in a hospital or during a life crisis, patients may become much less flexible in the defenses they use and may revert to using less mature defenses.
The patient’s mental status is a major determinant of the forma-tion and nature of the relationship with the physician. A young, healthy patient with an acute disorder has different needs and expectations than a somewhat older person who comes for help with a condition that has been present for a number of years. Both differ from the older adult who comes to the physician expecting that the future will be filled with physical and emotional losses.
The patient’s mental status in this case was the focus of and major factor in the structure of a long psychotherapy that greatly assisted the rehabilitation of interpersonal skills and the understanding of his cognitive limitations and newly changed cognition. The ability to work with an empathic listener while confronting limitations and feelings of shame and embarrass-ment is a special opportunity of the well-formed doctor–patient relationship.