Wednesday, September 20, 2017

Therapeutic Alliance - A Better Diagram

I posted on the therapeutic alliance about 5 years ago.  The goal of that post was to point out how psychiatric treatment occurs - specifically the idea that the physician and the patient need to collaborate and define a set of diagnoses and/or problems to work on.  They have to agree on the problems and also the plans to resolve (or not) resolve them.  In the case of a chronic illness  with no clear resolution, the goals are focused on optimizing function.  The is basically the ideal treatment model for any physician and any treatment - the only difference is that psychiatrists are trained to attend to the relationship between the patient and the physician in very specific ways.  That includes the concept of transference and countertransference or the emotional reaction and associated thoughts of the patient to the physician and and the physician to the patient based on their past experiences.  By attending to those patterns psychiatrists can develop insights into what is unfolding in the relationship and in some cases use defensive patterns to assist in the diagnosis and treatment process.

I had a few ideas about how I wanted this diagram to differ from the diagram in my previous post.  First, I wanted it to reflect treatment continuity.  Ongoing treatment is a dynamic process of multiple events across time in the case of ongoing care. It can also involve single cross sectional interventions that require a patient to complete a prescribed treatment and contact the physician if the problem is not resolved as expected.   There are several hard stops to a medical treatment process - cure, improved function without cure, increasing disability, care refusal, and death to name a few.  I decided to leave those implicit and not alter the basic diagram.  Second, I thought that triangles demarcating the physician-patient decision space would be a good idea because they are more open structures and were used in a recent example of how graph theory may be useful in neuroscience.  Third, I wanted to avoid jargon.  There are numerous conceptualizations of the conscious state of the patient and the physician and what that implies for the communication - but I distilled it down to the communication and collaboration parameters as noted above.  There is implicit informed consent in this model. There are far too may people who see physicians and adopt a passive role.  In some cases they request that the physician make important decisions for them: "What would you do if you were me?" The role of the physician is to communicate the information that the patient acts on with all of the attendant risks.

The general model is a good one for all medical specialties.  Psychiatrists are be trained to attend more the the relationship and overcome obstacles to treatment. A basic example would be the person who consults with a physician but who is skeptical of the physician's motivations or intentions.  In many cases this results in a disagreement and the relationship is terminated without the patient receiving treatment.  A psychiatrist should be capable of recognizing what is occurring in the interview and at least being able to point out the reality of the situation to the patient.  That reality is depicted in the diagram at the top.  I frequently tell people that I have no interest in telling them what to do or even prescribing a medication that they do not want to take.  My appropriate role in the model is to give them the best possible medical advice about resolving problems the we both agree on and that might benefit from treatment.  It is their role to decide among the options and consent to treatment.  Not consenting to any treatment is always an option.

The model also implies that both parties are competent to interact and make decisions.  In the case of physicians, states have a vetting and licensing process that is focused on public safety and it does a good job of removing most unsafe or incompetent physicians.  In the case of the patient, there are various contexts in which substitute decision-makers are engaged in the process including guardians, conservators, and judges.  The legal process to make that determination varies widely from state-to-state and even county-to-county within the same state.

George Dawson, MD, DFAPA

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