The therapeutic relationship, then, is a positive potential that exists when practitioner and patient interact with each other. Understanding it and knowing how to facilitate it is likely to result in benefits for both parties. A critical appreciation of the concept is necessary, however, e.g. Chew-Graham et al. (2004) have seen a problem in what they consider to be an inappropriate elevation of the practitioner–patient relationship such that practitioners may feel compelled to seek to: ‘maintain relationships with patients, even though they felt powerless to achieve useful clinical outcomes and felt forced to collude with illness behaviour that sustained incapacity’. This is the very opposite of a therapeutic relationship and the components and characteristics of the therapeutic approach must be appreciated in detail and in context in order to realize its potential in the consultation.

The Variety of Relationship Models in Healthcare

In discussing the scope of the therapeutic relationship, Agich (1983) refers to Szasz and Hollender’s (1956) classification of the three basic models of doctor–patient relationships:

1. Activity–passivity (the doctor actively does something to the patient, which they passively receive)

2. Guidance–cooperation (the doctor tells the patient what to do and the patient complies)

3. Mutual participation (a collaborative approach).

While the optimally conducive territory for developing the therapeutic relationship would seem to lie with the mutual participation model, Agich (1983) points out that there are times when other models are appropriate, indeed they may be essential, e.g. a coma patient requires application of the activity–passivity model. In fact we can imagine (if we extend the number and types of relationships involved in a particular situation) a scenario where all three models may be employed simultaneously: a practitioner called to a serious accident site may treat an unconscious patient using activity–passivity; direct others at the scene using guidance–cooperation and work with colleagues using mutual participation. The most effective practitioners may be those who are able to move between models as appropriate. We will come back to this notion of adaptability as a key feature distinguishing the practitioner who is better able to form therapeutic relationships later.

Agich (1983) cautions against making the error of seeing the therapeutic relationship as: ‘a free-standing relationship between autonomous individuals which abstracts from all social connections’. The autonomy of both practitioner and patient may be limited or constrained to some degree and the patient’s situation is impacted by numerous influences besides those that might be considered strictly ‘medical’ in nature. While many practitioners, especially in the CAM bracket, make broad claims to ‘treat the cause, not the disease’ and to ‘treat the whole person’ the difficulties inherent in getting to know a fraction of what constitutes the ‘whole person’, let alone getting to anything as singular as the ‘cause’ of a condition (particularly in complex cases), should not be trivialized. In order to gain the fullest possible view of the patient’s situation a holistic approach is essential, but in asserting this we may need to pause for a moment of clarification since the term ‘holistic’ has come to sound trite to many ears due to overuse, misapplication and ill-definition. Gordon’s (1982) take on the nature of holism in healthcare still ranks amongst the most concisely useful:

Holistic medicine is an attitudinal approach to healthcare rather than a particular set of techniques. It addresses the psychological, familial, societal, ethical and spiritual as well as biological dimensions of health and illness. The holistic approach emphasises the uniqueness of each patient, the mutuality of the doctor-patient relationship, each person’s responsibility for his or her own healthcare and society’s responsibility for the promotion of health.

A practitioner who is thinking and working in a manner that is in tune with this definition will be a person who is oriented to make connections between numerous territories of lived experience and who seeks to synthesize these to a focussed point of understanding, direction or action. Such characteristics tend to lead to greater facility in developing therapeutic relationships, since they enable the practitioner to appreciate the patient’s predicament more profoundly.

Looking outside of the narrowly ‘medical’ consultation zone requires a view of how health and medicine are situated within, and impacted by, sociocultural factors. To enable this expanded way of seeing and knowing the practitioner can look to a wide range of relevant fields of study (many of which tend to be overlooked or underexploited by healthcare practitioners of every stripe) such as that of the sociology of health and illness (see Nettleton 2006, for a solid introduction to this field). Part of the challenge of the therapeutic relationship is that it pushes the practitioner to continually develop and reframe their knowledge and skills as they seek to learn from the patient. To intentionally set up the consultation as a laboratory for personal and professional change and development in this manner constitutes a radical political act that may transgress and subvert both the general model that the practitioner was originally trained in and particular protocols that they may be expected to comply with.

The terms ‘healthcare practitioner’ and ‘political radical’ may strike us as antithetical. The dominant conventional medical services deliver the healthcare messages and practices sanctioned by the government and its departments – so that healthcare workers become agents of the state. This places limits on the autonomy of the practitioner. Medicine is an inherently conservative profession – both in its modern and traditional forms. Necessarily so, one might argue, since new approaches and techniques should only be added to the canon once they have been tried and tested. Yet conservatism may both mask and maintain useless or harmful attitudes and practices. It can be very hard for healthcare practitioners (whether conventional or CAM) to see beyond the edges of their own medicalized worldview – within this they live and breathe and have their professional being. Practitioners are restricted by their auto-medicalization, just as society at large is conditioned and constrained by notions of what is medically appropriate and acceptable. In his seminal critique of conventional medicine, Ivan Illich (1976) described the nature of the problem:

During the last generations the medical monopoly over healthcare has expanded without checks and has encroached on our liberty with regard to our own bodies. Society has transferred to physicians the exclusive right to determine what constitutes sickness, who is or might become sick, and what shall be done to such people … The social commitment to provide all citizens with almost unlimited outputs from the medical system threatens to destroy the environmental and cultural conditions needed by people to live a life of constant autonomous healing.

Since Illich’s attack, mainstream medicine has delved more deeply into the body as increasingly penetrating techniques and conceptualizations (e.g. the MRI-revealed body and the genomic body) have been developed. Ever greater reliance on technical means of understanding and reading the body undercuts attempts made elsewhere within medically-related fields (such as public health) to increase patient autonomy since the definitive answers to Illich’s questions (‘what constitutes sickness, who is or might become sick, and what shall be done’?) still rests with medical experts. We may query, by contrast, the extent to which CAM has been successful in proposing alternative ways of comprehending the body and to what extent it has promoted an ethos valuing greater personal empowerment to evolve. For medical doctor, columnist and noted CAM-critic, Ben Goldacre (2008), CAM is merely part of the problem, another group contributing to the ‘medicalisation of everyday life’:

Alternative therapists, the media, and the drug industry all conspire to sell us reductionist, bio-medical explanations for problems that might more sensibly and constructively be thought of as social, political, or personal.

General discussions about the role of CAM are flawed where they presuppose that CAM represents a coherent and organized alternative schema to mainstream medicine, i.e. that it is a discrete entity fit for comparison with its supposed antithesis. To proceed in such a way would be to make a category error. ‘CAM’ is essentially a definition of exclusion – which is to say that all healthcare practices outside of ‘conventional/mainstream’ medicine (i.e. the dominant model) are bracketed as ‘CAM’. Closer inspection reveals the heterogenous nature of the individual therapies constituting the notion of CAM, and differences between the agendas and messages of corporate interests (manufacturers of CAM remedies) and particular groups of practitioners. It may be more accurate to join Kelner and Wellman (2000) in viewing CAM as: ‘a complex and constantly changing social phenomenon which defies any arbitrary definition or classification’. How can we gauge the impact of such an amorphous entity on models in the consultation? Most texts that set out lists of the characteristics of CAM assert that a mutual participation model is used by its practitioners, e.g. Fulder (1996) provides eight ‘unique features of complementary medicine’, one of which is the ‘patient as partner’. What is the nature of this partnership though, and how can we know if it has been achieved? In suggesting answers, it may be helpful to return to Illich (1976), noting the distinction he draws between:

… two modes in which the person relates and adapts to his environment: autonomous (i.e. self-governing) coping and heteronomous (i.e. administered) maintenance and management.

The former mode Illich associates with positive individual ‘powers for healthcare’ contrasted with heteronomous adaptation within a ‘physician-based health-care system’, which is prone to become ‘sickening’ to the extent that it:

… tends to mystify and to expropriate the power of the individual to heal himself and to shape his or her environment.

We can briefly note here that the gradual shift in medicine from paternalistic (heteronomous) to patient-centred (valuing patient autonomy) models that we will explore shortly, reflects what Taylor (2009) has described as a: ‘shift that has occurred … from a culture where beneficence is the dominant ethical principle to one in which autonomy is valued as highly’. (Note: Beneficence inclines to paternalism where attempts to benefit an individual are made against their will.)

In any case, CAM practitioners are not immune from the tendency to ‘mystify and expropriate’ – a potential pitfall for all healthcare professionals. We can suggest, nonetheless, that a key criterion in estimating a practitioner’s success in establishing healthy partnerships with patients has to do with the extent to which they are able to empower autonomy and minimize dependency on other-administered ‘maintenance and management’. CAM practitioners have an edge here, which may have less to do with the founding philosophies of their particular modality and more to do with the fact and implications of their ‘excludedness’, especially with regard to what Sharma (1994) has called the ‘institutional context’. The differing operating conditions for conventional and CAM practitioners significantly affect their respective capacities for professional autonomy, as Sharma explains:

… most orthodox doctors operate within a bureaucratic context and … this has an inevitable effect on the relationship between healer and patient, being conducive to a hierarchical definition of relationships. Individual physicians may have their own characteristic ways of handling patients and may hold different views on how much information patients ought to be given, but the pressures of the institutional context will do much to determine the range of behaviours which are either permissible or productive both for doctors and patients.

While complementary therapists:

… tend to work in settings characterized by a non-hierarchical ethos and minimum of direct control from either superiors or equals. Thus they appear to have the clinical autonomy and freedom from managerial interference which orthodox doctors hold as an ideal …

Two lacks, then, may help engender two positive characteristics in CAM therapists: the lack of statutory authority given to CAM practitioners encourages a less authoritarian style; and the lack of a bureaucratic context enables them to act with greater autonomy. These characteristics (non-authoritarian; highly autonomous) are facilitative of more equal relationships with patients and condition the nature of these relationships. Such an outcome is not inevitable, of course, but the initial conditions of practice set for CAM practitioners make it easier for more autotomizing styles of practice to emerge. Sharma comments that:

What transpires in the complementary therapist’s consulting room need not be so very different from what transpires in the GP’s surgery … But to the extent that the complementary practitioner usually operates quite independently of the state’s interest in the bodies and health of its citizens there is always the potential for a very radical difference.

The logical conclusion of this line of argument, namely that the non-statutory nature of CAM therapies constitutes a strength (although one that may be offset by a number of weaknesses, such as a lack of accountability); adds a further critical dimension to the discussion of the regulation of CAM professions opened up in the previous chapter. Considerations in this territory relate not only to outcomes for patients but for practitioners themselves, as Moynihan and Smith (2002) make clear as they reflect on the extent of biomedicalization and its impacts on conventional practitioners:

Doctors and their organisations understandably argue for increased spending – because they are otherwise left paying a personal price, trying to cope with increasing demand with inadequate resources. Indeed this is one of the sources of worldwide unhappiness among doctors. Although seen by many as the perpetrators of medicalisation, doctors may actually be some of its most prominent victims.

It is worth noting that ‘trying to cope with increasing demand with inadequate resources’ constitutes a definition of the cause of professional burnout – a condition characterized by ‘exhaustion, cynicism and sense of inefficacy’ (Maslach 2003). Approaches that enhance patient autonomy are more sustainable for the practitioner and for national economies such that these two factors are likely to increasingly drive mainstream healthcare in the direction of a patient-centred model of practice and service provision.

At this point, let us add to Szasz and Hollender’s (1956) three basic models of doctor–patient relationships by considering later contributions to this subject area in order to better appreciate its scope. In discussing the ‘struggle over the patient’s role in medical decision making’, Emanuel and Emanuel (1992) outlined four models of the physician–patient relationship:

1. Paternalistic (alternatively called the ‘priestly’ or ‘parental’ model): Here the practitioner determines what is best for the patient, with little explanation given to the patient and minimal patient involvement. The patient is expected to assent to the practitioner’s decisions.

2. Informative (also known as the scientific, engineering or consumer model): In this model, the practitioner aims to ‘provide the patient with all relevant information, for the patient to select the medical interventions he or she wants, and (then) to execute the selected intervention’. In this model, the practitioner is a provider of facts, which the patient interprets according to her values. There is ‘no role for the physician’s values, the physician’s understanding of the patient’s values, or his or her judgement of the worth of the patient’s values’.

3. Interpretive: In contrast to the informative model the practitioner’s aim is to ‘elucidate the patient’s values and what he or she actually wants, and to help the patient select the available … interventions that realize these values’. Information on the options is provided in conjunction with assistance based on appreciation of the patient’s values.

4. Deliberative: This model sees the patient’s health-related values as open to discussion, such that the practitioner is able to suggest ‘why certain health-related values are more worthy and should be aspired to … the physician aims at no more than moral persuasion; ultimately, coercion is avoided, and the patient must define his or her life and select the ordering of values to be espoused’.

A summary of these four concepts, with correlations including the view taken of the patient’s autonomy is provided in Table 2.1.

Table 2.1 Comparing the four models of the physician–patient relationship

It is interesting to consider these models in the light of the evidence-based medicine (EBM) discussion, which we began in the previous chapter and will return to again below, particularly around the original definition of EBM as: ‘the integration of best research evidence with clinical expertise and patient values’ (Sackett et al. 2000). In applying the four models to a hypothetical clinical case, Emanuel and Emanuel (1992) largely interpret ‘information’ and ‘facts’ as research so that their discussion focuses on the three territories of EBM, with difficulties in the patient–practitioner relationship occurring particularly when research and/or clinical expertise are emphasized to the detriment of due attention to patient values.

Each of the four models is problematic when viewed as representing a single and permanent way of being as a practitioner. Rather we can assert, as earlier, that the most effective practitioners are likely to be those who are able to move between these models as appropriate – frequently within the course of just one consultation. These are not models of practice, then, but caricatures of practitioner strategies that can be deployed and combined as a given situation requires. As Emanuel and Emanuel (1992) point out, even paternalistic behaviour can be appropriate in situations of medical emergencies.

In selecting which of the four models might generally be preferred as ‘the ideal physician–patient relationship’, Emanuel and Emanuel (1992) choose the deliberative model, rejecting allegations that it merely represents ‘a disguised form of paternalism’ – this reading is far from safe, however, since the model suggests that practitioners occupy a position of definitive moral and epistemological authority and little recognition of the role of uncertainty is made. The central issue of uncertainty, that lies within and between the practitioner’s and the patient’s views of how to proceed in a given situation, tends to be overlooked in discussions of ‘shared decision-making’ models such as the deliberative.

Shared decision-making (sometimes called ‘partnership-centred’ medicine) is held as a key tenet of patient-empowering, non-paternalistic relationships but the balance of power and influence is open to question in this concept. The informative model would appear to let decisions rest entirely with the patient but these are in fact limited by the options made available by the practitioner and the manner in which they have been presented; it also tends to leave the patient exposed and unsupported. The interpretive model helps the patient to make their own decisions, providing support but risking excessive deferment to the patient’s wishes; while the deliberative model allows the practitioner to be fully engaged in recommending the best course of action but with the danger that the practitioner’s worldview and agenda may hold sway over the patient’s.

The types of autonomy afforded to the patient within Emanuel and Emanuel’s (1992) four models all stand in relation to various ways of negotiating conventional medical care but they are equally relevant in CAM practice. Any discussion of patient autonomy is incomplete of course without referencing ways in which people may care for their wellbeing independently of healthcare practitioners through self-care measures, and the degree to which autonomous healthcare is facilitated or hindered by socioeconomic, political and cultural influences. A full discussion of these factors is beyond the scope of this book but we will return to limited discussion of them at various points in the text.

Kaba and Sooriakumaran (2007) have proposed a time line for the evolution of the doctor–patient relationship beginning with ancient Egypt (c.4000–100 BCE) where the paternalistic priest–supplicant relationship is said to form the basis of the practitioner-relationship; through the Greek enlightenment (c.600–100 BCE) where it is proposed that the roots of the mutual-participation model lie; and on through medieval Europe and the inquisition (paternalism revived) and the French revolution (partial egalitarianism shifting emphasis from activity–passivity to the guidance–cooperation model) to the modern era, where the ‘emergence of psychology’, including psychoanalytical and psychosocial theories, has led to a refocusing on the patient as a person. The practitioner–patient relationship, they argue, has fluxed from one pole to the other, with a general trend of movement from a practitioner-centred to a patient-centred approach.

Mead and Bower (2000) have discussed the ambiguity concerning the meaning of ‘patient-centredness’ and have identified five ‘conceptual dimensions’ that they propose as constituting a model for it that distinguishes it from the biomedical model. These are:

1. Biopsychosocial perspective: ‘broadening the explanatory perspective on illness to include social and psychological factors’

2. The patient-as-person: ‘understanding the individual’s experience of illness … (and) as an idiosyncratic personality within his or her unique context’

3. Sharing power and responsibility: ‘concerned to encourage significantly greater patient involvement in care’

4. The therapeutic-alliance: ‘(which) has potential therapeutic benefit in and of itself’

5. The doctor-as-person: ‘emotions engendered in the doctor by particular patient presentations may be used as an aid to further management’.

This formulation represents a sort of ‘coming-out’ of conventional medics as sensitive, feeling people who are open to the subjective elements of the consultation – a vulnerable circumstance that Mead and Bower (2000) immediately defend by proposing ways in which patient-centeredness can be measured!

McWhinney (1996) contends that: ‘The essence of the patient-centred method is that the doctor attends to feelings, emotions and moods, as well as categorizing the patient’s illness’. It may seem extraordinary to those outside of medicine that such activity stands in need of emphasis – at least to those who have only had positive experiences of conventional medical care – don’t all ‘good’ practitioners do this? The ability and capacity for practitioners to work in a patient-centred way is influenced by their philosophy of practice and institutional context, as we have previously noted, so that healthier relationships with patients depend in large part on practitioner education and the operating conditions for practice – where either are narrow or constrained it will be difficult for patient-centred practice to emerge. The battle to end paternalism has a long way to go in conventional medicine (Coulter 1999: ‘Paternalism is endemic in the NHS’) and as CAM therapies gradually enter the mainstream, each modality will need to guard against being subsumed into the still predominantly paternalistic ethos of its culture.

Patient Expectations: Clarification and Challenge

One way of rationalizing the therapeutic relationship is to suggest that it arises when patient expectations are met. This is a rather lopsided take however, since the core of a positive relationship lies in its mutuality. Furthermore, any given individual patient may have expectations of the clinical encounter that are obstructive to establishing a therapeutic relationship, i.e. if those expectations are too tightly focussed; poorly informed; unrealistic; unduly pessimistic or optimistic. The therapeutic relationship may be most clearly in evidence, and most productive, when patient expectations are transmuted during the course of the practitioner–patient interaction. The door needs to be left open for transformative elements such as surprise and revelation to enter, i.e. for learning to occur on the part of both patient and practitioner.

Expectations vary between patients depending on the nature of their predicament, their experience, character and preferences and the role in which they cast the practitioner. A patient may, for example, visit a conventional doctor with a primary desire to receive a diagnosis but not treatment and then visit a CAM practitioner with the opposite priorities. Practitioners need to cultivate openness and flexibility in approaching each patient as an individual. A key question to ask of patients could be: ‘What especially would you like me to help you with?’

The fit between the patient’s expectations and the practitioner’s comprehension of them is frequently a poor one. Britten (2004) has pointed out the dangers that lie in this territory: ‘Inappropriate assessments of patients’ expectations can result in actions deemed unnecessary by the doctor and unwanted by the patient’. There is no reason to suspect that the situation is necessarily any different in CAM consultations. False perceptions of patient’s expectations may lead to a sense of pressure to meet these expectations on the part of the practitioner – even when they consider them unfounded or inappropriate. Britten (2004) cites studies that suggest that: ‘… pressure from patients may be stronger in the doctor’s mind than in the patient’s mind. Doctors may be making inappropriate decisions for the sake of maintaining relationships with patients without checking whether their assumptions about patients’ preferences are correct’. Therapeutic practitioners need to be on guard against this type of misunderstanding and adopt the strategy of repeatedly asking questions to clarify patients’ expectations, desires and wishes. Asking such clarifying questions can move both practitioner and patient out of their comfort zones and occasionally, this type of question may lead to profound moments of insight that can catalyse reflection and change. The potential for such crucial episodes to have negative outcomes is diminished when questions are phrased non-judgementally. An example:

Practitioner: ‘So, would you like me to prescribe something for your migraines or would you prefer for us to tackle it in some other way?’

Patient: ‘I’d rather not take a medicine if I can help it, even a herbal one, but what other ways are there?’

Practitioner: ‘Well, is there anything you can think of that would help you cope with the migraines better?’

Patient: ‘Well if life calmed down and I could get more sleep … if I could get more time to myself …’

Practitioner: ‘Can we talk about ways in which you might find more time?’

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