CAM lab - Publications: The Therapeutic Relationship Under Fire

CHAPTER 4

THE THERAPEUTIC RELATIONSHIP UNDER FIRE

Merrijoy Kelner

In Complementary and Alternative Medicine: Challenge and Change edited by Merrijoy Kelner, Beverly Wellman. Harwood Academic Publishers, a subsidary of Taylor & Francis, 2000

The relationship between doctors and their patients is currently receiving a great deal of attention. Plays, films and books are featuring the travails of patients who seek medical care and depicting physicians as emotionally distant, abrupt, pompous, insensitive and even incompetent (Consider for example: Wit an off-Broadway hit play by Margaret Elson, Patch Adams a film starring Robin Williams, and a recent Canadian book, Operating in the Dark by Lisa Priest). Indictments of medicine and the physicians that practice it are cropping up everywhere in North America, the United Kingdom and Europe. The notion that something is seriously lacking in the doctor-patient-relationship seems to have become thoroughly embedded in contemporary Western culture (Pietroni 1987).

At the same time that patients are criticizing the way their physicians relate to them, we are witnessing a remarkable and widespread surge of interest in complementary and alternative medicine (CAM) and an increasing use of CAM practitioners (Eisenberg et al, 1993, 1998; McGregor and Peay, 1996; Lloyd et al, 1991; Thomas et al, 1991; Mills and Peacock, 1997; Lewith and Aldridge, 1993; CTV/Angus Reid Group, 1997). One of the reasons that has been cited for the current attraction to CAM practitioners is that they are more empathic and collaborative than physicians and take a greater interest in the individual psycho-social aspects of their patients' lives (Bakx, 1991; Oths, 1994). Patients are said to choose CAM practitioners because they seek a more satisfying therapeutic relationship (Brinkhaus et al, 1998). It has also been suggested that the high degree of rapport that exists between the alternative practitioner and his/her patient has a powerful placebo effect and may indeed be the key factor in the ability of these practitioners to help their patients (Ernst, 1995). However, the assumption that CAM patients have more positive and valuable relationships with their practitioners than do patients of family physicians has not yet been subjected to rigorous research (Mitchell and Cormack, 1998). It is a notion that requires serious examination rather than stereotypical thinking.

This paper will explore the nature of the therapeutic relationship between patients of family physicians and patients of selected alternative practitioners and compare the way these two sets of patients perceive and describe their practitioners. Based on the assumptions noted above, it can be expected that patients of CAM practitioners will be more likely to describe their therapeutic relationships in a positive manner and to depict them as collaborative, empathic and personal.

Models

Models of the therapeutic relationship have been developed almost exclusively on the basis of the doctor-patient-relationship. The three most commonly mentioned models are: the paternalistic, the shared decision-making, and the consumerist. This paper looks not only at the doctor-patient-relationship, but also at patient relationships with a range of alternative practitioners, and examines the extent to which the existing models can be applied to them.

The models reflect a variety of therapeutic relationships and assume different degrees of importance depending on what is happening in the society as a whole. As values shift, information explodes, chronic illnesses increase and health care costs keep rising, models that were useful for understanding therapeutic relationships in the past, become less applicable. Now they need to be modified and expanded in order to more accurately reveal the dynamics of these relationships in the current environment.

The Paternalistic Model

Beginning in the 1950's, Parsons (1951) posited the relationship between physicians and their patients as the functional interplay between two social roles with inherent duties and responsibilities. The patient assumes a "sick role" which exempts her/him from the normal obligations of life, but in turn, is obliged to comply with the physician's prescribed treatment and to strive to recover. While the patient always has the option to refuse treatment, s/he is not involved in the process of choosing among treatment options; the physician decides on the preferred option and then presents it to the patient. Parsons later revised his model to acknowledge the patient's participation in decision-making in the context of chronic illness (Parsons, 1975), but he still viewed the relationship as essentially a paternalistic one.

Paternalism, or medical professional dominance as it has been called by some, (Freidson, 1970; Phillips, 1996) means that the physician can override the choices of the patient when he/she judges that it is for the patient’s own good. Authority is granted to the physician by the patient because of his /her expert technical knowledge; knowledge that is not available to the patient. The physician 'owns ' the technical expertise, while the patient's knowledge of the situation is discounted as irrelevant. Gender, age, educational and ethnic differences usually serve to exacerbate this imbalance of power (Haug, 1979; Emanuel and Emanuel, 1992). In this model of the therapeutic relationship, physician-patient interaction is said to be characterized by limited and didactic communication on the part of the physician, reluctance to give sufficient information to the patient about his/her condition, the use of medical jargon in discussions with the patient, and evasion of direct questions about diagnosis or treatment (Skipper, 1965).

The Shared Decision-Making Model

Szasz and Hollender (1956) have termed this the model of mutual participation. In this shared approach, the physician's expertise lies in his/her clinical knowledge, while the patient's expertise stems from knowledge of the contextual facts about his/her own personal situation. The role of the physician is to assist the patient (or the client) to make the treatment choice that is most appropriate through an understanding of how the medical information relates to his/her unique situation. This kind of encounter is particularly suited to the management of most chronic illnesses, where the patient's own experiences provide important clues for therapy. The patient accepts responsibility for carrying out changes in lifestyle recommended by the practitioner as part of the therapy. Such a model requires that there be ongoing dialogue between physician and patient (Katz, 1984). Several authors have delineated variations on the shared decision making model. Some of the best known are the contractual model outlined by Veatch (1972), Emmanuel and Emmanuel's (1995) deliberative model and the conversation model advanced by Katz (1984).

This model developed as a reaction to medical paternalism, encouraged by concurrent social movements such as the growing emphasis on individual rights, the civil rights movement of 1960's, the feminist movement, and the general rise of consumerism in public life (Light, 1991; Reeder, 1972; Cogswell, 1988). In this model, the basis of the relationship is a collaborative enterprise between physician and patient in which consultation precedes decision-making and information is widely shared.

While there seems to be considerable demand from the public for this more collaborative approach to the doctor-patient-relationship, there is empirical evidence that physicians do not always find it easy to share power and decision making (McKinlay and Stoeckle, 1988). This lack of congruence between patient expectations of the therapeutic relationship and what doctors are actually able to provide often leads to frustration on the part of physicians and dissatisfaction among patients (Taussig, 1980).

The Consumerist Model

In striking contrast to the paternalistic approach and an extension of the shared decision-making pattern is the consumerist model. It places decision-making firmly in the hands of the patient/consumer (Emmanuel and Emmanuel, 1995). Physicians are viewed as service providers in the sense that while the doctor outlines the relevant clinical information to the patient, it is the patient who chooses the type of medical intervention that s/he wants. It is then up to the doctor to execute the chosen option. In the United States, scholars have noted that a new, more business-oriented consumer model had been evolving with the growth of managed care and changes in health care financing (McKinlay and Stoekle, 1988; Kronenfeld, 1997).

A consumerist model, however, is difficult to apply in reality (Lupton et al, 1991). It assumes that patients always have well defined, fixed values and needs that enable them to be certain of what they want and thus all they need are the facts in order to choose a therapy or treatment (Emmanuel and Emmanuel, 1995). Furthermore, this model assumes that patients are always in a position of equal power with their physicians. It presupposes that the patient is a well-educated, assertive consumer who is able to challenge the doctor, to speak as an equal and carry on a sophisticated dialogue about medical options. This fails to take into account the uneducated and those from lower socioeconomic classes or minority groups; the very people who most need help but have the most difficulty in claiming and using medical services (Williams, 1993, Lupton,1996). It also fails to acknowledge that patients who are suffering from pain, distress and illness are usually fearful and anxious and thus unable to clearly calculate the costs and benefits of a particular treatment. Thus, while the consumerist model has value in that it emphasizes the patient's right to self determination, it does not adequately capture the situation for the majority of patients.

The question examined here is which model of the therapeutic relationship best characterizes the needs and desires of health care providers and their patients in today's society. A second, but no less relevant question is what are the key elements of patient satisfaction driving the need to reexamine this relationship? By expanding the kinds of relationships beyond just doctors and their patients, the data presented here can broaden the way we think about these models.

Patient Satisfaction

Analyses of modern medicine often point out that while medicine is at a technological high point in its development, patient satisfaction with medical care seems to be at an all time low (Balint et al, 1993). Research on patient satisfaction with medical care (Lewis, 1994; Greene et al, 1994; Lupton, 1996)) makes it clear that patients today want to have more personal, less distant relationships with their physicians; more sharing of information; more time for consideration of their individual needs, including psycho-social issues, and greater opportunities to participate in decision- making. In other words, patients are showing a preference for a model of care that most closely resembles the shared decision-making one. However, the current economic pressures on industrialized countries have made it difficult for physicians to give patients the amount of time and attention required to deliver care in this way.

It has been demonstrated that lack of satisfaction not only influences the extent of adherence to therapeutic advice (Linn et al, 1982; DiMatteo et al, 1985), but also that it frequently leads to "doctor- shopping" (Kasteler et al, 1976; Haug and Lavin 1983) and to changing doctors (Marquis et al, 1983; Ware and Ross-Davies, 1983). In the present environment, with its constant flow of information about alternative therapies and practitioners, some patients who are dissatisfied with their doctor-patient-relationship are prompted to consider changing from conventional medicine to other forms of health care (Fulder, 1988; Sutherland and Verhoef, 1994). McGuire, (1988, p. 197) describes people who consult alternative practitioners as "contractors" of their own care, making selective choices of therapies based on their values and beliefs about health and illness. Kelner and Wellman (1997a) refer to "smart consumers" who prefer to use their own judgement and the guidance of personal referrals to make decisions about the type of health care they will utilize.

Comparing Patients of Alternative Practitioners with Patients of Family Physicians

At the outset of this comparison, the therapeutic relationships between CAM practitioners and their patients were expected to closely resemble the model of shared decision-making or the more extreme consumerist model. In comparison, the therapeutic relationships between physicians and their patients were still expected to adhere more closely to the model of paternalism. This supposition is examined by comparing the way patients of family physicians describe and evaluate their relationships with their doctors, with the way that alternative patients talk about their practitioners.

It was possible to make these comparisons on the basis of a research project designed to investigate the health beliefs and practices of a sample of 300 patients in the city of Toronto, Canada during 1994-95. At the time, these patients were consulting either family physicians (general practitioners) or one of four types of alterative practitioners: chiropractors, acupuncturists/traditional Chinese doctors, naturopaths or Reiki healers. These five types of practitioners were selected to represent a broad spectrum of the many types of health care currently available in Canadian society[1]. They ranged from conventional medical care (family physicians) through a popular form of physical manipulation (chiropractors) and mixed holistic care (acupuncture/traditional Chinese medicine and naturopathy) to care characterized mainly by emotional and spiritual healing (Reiki). The choice of alternative practitioners was designed to reflect the spread from the most widely accepted and legitimate (chiropractic) through to one of the least well known and least institutionalized (Reiki). For a description of the methodology used, see Kelner and Wellman, 1997a&b[2].

Comparing the Sample of Patients

Demographic characteristics - A comparison of the demographic characteristics of those who were consulting alternative practitioners with people who were seeing family physicians for their primary health problem, reveals that there are marked differences between the two groups of patients (see Kelner and Wellman 1997a).

The patients consulting alternative practitioners are more likely to be female, young, married, highly educated, in higher level occupations, more likely to be employed full time and to have high incomes. Patients who consult alternative practitioners are also more likely to report their ethnic origin as Canadian, to have no formal religious affiliation but on the other hand, to consider spirituality an important factor in their lives. This demographic profile of patients of alternative practitioners is consistent with other research in Canada, the United States and in the United Kingdom (Wellman, 1995; CTV/Angus Reid Group, 1997; Blais, 1997; Eisenberg et al., 1993; Thomas et al., 1991; Sharma, 1992; Vincent and Furnham, 1997). The key identifying social characteristics in the work of these scholars are gender, level of education, occupational level, social class and age. The fact that patients of family physicians are not as well educated or as affluent as CAM patients implies that they will adopt a more deferential, less independent stance in their therapeutic relationships.

Primary health problems - There are also differences in the type of health problems reported by the two groups of patients. Patients of family physicians most frequently mentioned life threatening problems such as heart problems, high blood pressure and high cholesterol while none of the alternative patients reported cardiovascular conditions as their main reason for seeking care from their practitioners. Patients consulting alternative practitioners were seeing them for chronic conditions like musculoskeletal problems, headaches and for health maintenance. In a national survey of the health conditions of patients of alternative practitioners in the United States, Eisenberg et al. (1993, 1998) confirm that most conditions are minor and chronic, with musculoskeletal problems being the most common presenting problem. Since the health problems of family physician patients are more life threatening and worrisome than the chronic complaints of CAM patients, these health problems may influence patient expectations and their reliance on the expertise and authority of their physicians.

As might be expected, there were also variations between the alternative groups, For example, patients of chiropractors were most likely to seek care for musculoskeletal problems and patients of Reiki practitioners were most apt to be concerned about their emotional health and maintaining and improving their overall well-being. The patients of naturopathic practitioners reported the broadest range of ailments, including colds, flu, allergies, chronic infections and gynaecological troubles

The CAM patients in the study used medical care as a supplement rather than a substitute for their alternative care; 82% of them said they saw their family physician at least once a year for checkups, colds and flu, monitoring of medications and any life-threatening illnesses that might occur. Most of them (88%) said they were happy with their family physicians in general, but that they had been unable to resolve the specific problem for which they were currently seeking help. In the light of these differences of social characteristics and health profiles, this study asks whether there are also differences in the therapeutic relationship that these patients are experiencing with their physicians or CAM practitioners.

Comparing the Nature of the Therapeutic Relationship

Family physicians and their patients

A typical setting for the doctor patient relationship is formal and often institutional. The physician wears a white coat and practices in a professional office with a receptionist or nurse who sees the patients first. When patients are ushered into their physician's office, the doctor usually sits behind a desk and takes control of the interaction, posing a series of questions to the patient allowing little time for response . If a physical examination is required, patients move to another room, usually removing at least some of their clothing, and then return to the doctor’s office to learn their diagnosis and hear the recommended treatment. This kind of setting contributes to social distance and establishes the physician's authority in the healing process.

Despite this portrayal, most of the family physicians’ patients in this study reported that they had a positive relationship with their doctors. Most of their relationships developed over a long period of time (mean number of years=9.7 and the median= 7.0). Close to one fifth (18%) of them had been seeing the same physician for 20 years or more. Over the years, it was quite clear that the patients had built up an association based on shared health experiences and the ease that stems from repeated encounters. These patients did not consult their doctors often, however; as one patient put it: "He wouldn't make a living on how many times we went to him." Forty per cent of the patients of family physicians said that in the past, they had seen them only once or twice a year for routine visits or for emergencies, although they were now seeing them more frequently because their current problem was causing them considerable discomfort and anxiety (almost half of them, 48%, were going as often as once a month or more). The family physicians’ patients reported that they had been suffering with their problem for a while; the mean number of years was 6.6 and the median was 3.0. Thus, the data show that the typical physician-patient relationship is characterized by repeated visits over long periods of time rather than by frequent encounters in a short period of time.

This group of patients reported good working relationships with their family physicians. Almost all of them (90%) said that their physician had fully met their expectations. The vast majority (88%) reported that their family physicians were always willing to answer their questions and over three quarters of them (78%) said they were given clear and complete explanations about treatments. Most (83%) felt that their physician understood their perspective on their health problem.

When it came to explaining the potential side effects of recommended therapies, satisfaction was not as high; only 58 per cent said that their family physician always did this. Under half (48%) of the patients felt that their physicians were willing to involve them in decision-making about their health care. Nevertheless, an overwhelming majority (92%) said they would recommend their doctor to others with similar problems.

When asked why they thought their physician was helping them, these patients gave several reasons. The most frequently cited (43%) was that they had trust in the doctor's diagnostic knowledge, authority and technical skills as well as in the medications he/she had recommended. One patient put it like this: "My doctor is a man I trust; he knows what he's doing and he does it well" . The next most often (38%) mentioned reason was that they had a sense of rapport with their doctor. This rapport, they said, was based on their belief that the physician was supportive and interested in learning the facts about their health problems. As one patient said "My doctor is caring and understanding. He has helped me through my crises ".

Finally, the patients were asked who they thought would be the most helpful with their health problems in general. A majority (70%) of the family physician patients said that they relied primarily on their doctors to help them. These patients can be described as having an external locus of control (Wallston et al., 1976) They feel that their health is beyond their personal control and rely on fate or powerful others, particularly physicians. Just over one quarter (27%) mentioned themselves, or themselves in partnership with their doctors, as the persons they would find most helpful. When asked to explain why they thought their physician was the most helpful person, trust in his/her training and medical expertise was the most frequent response. They also mentioned the fact that doctors can refer patients to the best specialists when they are needed and that their physician has known them for a long time and is thus in a good position to help them.

The surprising finding here is that so many patients of family physicians reported that they had a good sense of rapport with them. In contrast to the studies cited above, where patients complained of a lack of interest and impersonal treatment, this was not the case for the family physicians’ patients in this study.

How do these findings compare to the way the CAM patients describe their relationships with their practitioner?

CAM practitioners and their patients

CAM practitioners are not a homogeneous group; their practice patterns differ according to type of modality and also within each modality. Nevertheless, for purposes of analysis, the four types of CAM practitioners are mainly treated here as one group, although from time to time, the more striking differences between them are identified.

In comparison to the settings of the physician-patient encounter, CAM practitioners meet their patients in a less formal and structured environment. The practitioner may practice in an office or at home (chiropractors are more likely than homeopaths or Reiki healers to work in offices), but even in offices, the ambience is informal, with personal touches provided by signs and childrens' drawings on the walls. Most CAM practitioners eschew white coats and present themselves in a more informal manner. Some do not even use a desk, but prefer to sit close to their patients without any barriers between them. History taking, diagnosis and treatment often take place in the same room and the whole interaction seems more like a visit than a consultation.

The CAM patients in the study had been seeing their practitioners for a much shorter length of time than was the case for patients of family physicians (mean=3.2 and median=1.0). This difference can be attributed, at least in part, to the recent growth of interest in using alternative health care. A recent Canadian poll ( CTV/Angus Reid Group, 1997) reveals that of the 42% of Canadians now using alternatives, just under one half (49%) had started using them within the last five years. Another factor that may explain the shorter duration of the relationship between the CAM patients and their practitioners is that the patients had been trying various kinds of treatments to resolve their chronic problems without receiving much respite and had only recently decided to try this particular type of practitioner. As an acupuncture patient told us "This whole sequence of events, going from one doctor to another has been going on for about ten years. I've only recently been seeing the acupuncturist, but I've always believed my problem was solvable". The pattern for CAM patients seems to be that most had suffered with their primary health problems for a considerably longer period of time than the patients of family physicians (mean=9.2 and median=5.0). This suggests that they had already tried a number of other kinds of practitioners without finding relief.

What the relationships between CAM patients and their practitioners lacked in duration, they made up for in frequency of contact. CAM patients had not been consulting their practitioners for as long a period of time, but the frequency of their visits was much greater than it is for the patients of family physicians. When CAM patients began their treatments, the frequency of visits tended to be much higher at the beginning, compared to later in the treatment process. The data reflect this pattern by showing that in the past, more than half ( 52%) of the group of CAM patients in the study saw their practitioners at least once a week. Currently, only 29% were visiting them that frequently, while another quarter (25%) were seeing them a few times a month. The frequency of these visits is related to the type of problem as well as the type of treatment. For example, patients of chiropractors and acupuncture/traditional Chinese doctors see them more often than do patients of naturopaths and Reiki healers, and they typically suffer more from chronic pain. The fact that most kinds of CAM treatments require repeated visits, creates a situation that fosters the development of personal relationships quickly.

The data make it clear that the relationships between doctors and their patients and CAM patients and their practitioners evolve over different time periods and entail different degrees of frequency.

Like the family physician patients, the CAM patients expressed high levels of satisfaction with their current practitioners; 86% of the total group felt that their practitioner was fully meeting their expectations. There were, however, some variations between the CAM groups; more of the patients of chiropractors (90%) and Reiki practitioners (98%) reported that they were fully satisfied than did the other CAM patients.

Most CAM patients (85%) said that their practitioner always was willing to answer their questions; close to three quarters of them (71%) reported that their practitioners always gave them clear explanations about their health problems; just under half of them (47%) found that their practitioner always explained the side effects of their treatments; most (82%) felt that their practitioner understood their perspective very well and 60 per cent reported that their practitioner always involved them in the decisions about their treatment. Almost all (94%) agreed that they would recommend their practitioner to others with similar problems.

Variations between the different groups of CAM patients were evident in these assessments of practitioners. The clients of Reiki healers were most likely to report that their practitioner fully met their expectations and in most cases it was the Reiki practitioners who ranked highest on issues such as answering questions, understanding the patient's perspective and involving patients in decision making. At the other end of the spectrum were the acupuncturists/traditional Chinese doctors who ranked lower on these questions than the rest of the CAM practitioners.

When asked why they thought their practitioner was helping them, the responses of the CAM patients were much more pragmatic than the patients of family physicians. Over half (53%) said it was because they were seeing positive results. As a chiropractic patient said: "Now I can finally turn my head. He's getting to the root of the problem and not just treating symptoms". A Reiki client put it this way: "After the treatment I feel better, looser---as if I have just had a lubrication job in my joints".

Less than one quarter (22%) of the CAM patients in the study cited trust in the practitioner's skills and knowledge as the principal reason they believed they were being helped; next most often mentioned was rapport (16%), followed by a natural/holistic approach. Differences between the various alternatives were again evident; over three quarters (78%) of the patients of chiropractors mentioned positive results, compared to about one third of the patients of naturopaths (37%) and Reiki healers (30%). The lower ranking of Reiki on the dimension of positive results is particularly interesting in view of the high levels of satisfaction with Reiki practitioners reported above. Clearly, there were other, perhaps more personal reasons for this satisfaction.

The patients of CAM practitioners had more independent and self reliant views than the family physician patients concerning who they believed would be the most helpful with their health problems. Only one fifth (20%) of CAM patients specifically mentioned a physician and only 6 per cent mentioned a practitioner with a natural or holistic approach. The majority (65%) said they would rely most on themselves, or on themselves plus a health care provider of one kind or another. A Reiki patient explained that: " I left my doctor and went to an alternative because he didn't like the fact that I was a thinker. Most of these doctors don't like people who think and want to take care of themselves. It's that sort of feeling that drove me to find an alternative ".

This belief of patients in their own ability to influence their health has been described as an internal health locus of control (Roter, 1977; Wallston et al., 1976). People who have this kind of orientation perceive their health status as largely under their own personal control. CAM patients reported more confidence in their own ability to influence their health. It was patients of Reiki practitioners who most often expressed this trust in themselves as healer (58% self, and 22% self plus a practitioner), and they also reported the least faith in doctors as healers (only 8%). Patients of chiropractors showed the least faith in themselves (25%) or themselves plus the practitioner (25%) as resolvers of their health problems.

The CAM patients explained their reliance on themselves in several ways. They believed the primary responsibility for decisions about their own care rested with themselves and that they were the ones who could best practice prevention. They argued that each kind of practitioner has distinctive skills and expertise and that they wanted to select different healing options, depending on their particular situation. They claimed that self-knowledge assists healing and declared that because they knew their own bodies best, they trusted their own judgement more than the judgement of anyone else. This faith in their own instincts and knowledge of their bodies was largely responsible for the tendency to demphasize the place of trust in their relationships with their CAM practitioners.

CAM patients reported that they typically worked as partners with their practitioners in the healing process. Most CAM practitioners employ a holistic approach to treatment which focuses on the emotional and spiritual well-being of their patients, as well as their physical health. They also see each patient as unique, requiring individual assessment and treatment. They rely on input from their patients to keep them informed about changes in lifestyles, moods and attitudes. The CAM patients said their practitioners knew their situations intimately and tried to tailor their advice to fit the patient's life, rather than expecting him/her to adapt to a standard set of recommendations. In turn, CAM patients played their part in the healing process by accepting responsibility for their own care; they were more likely than physician patients to pay attention to their diet, posture, sleep patterns and exercise regimens.

Although both groups of patients expressed satisfaction with their current practitioners, they frequently had negative comments about the relationships they had with the health care providers they had seen in the past (mainly specialist physicians but also some CAM practitioners).

Past Experience

Reasons for dissatisfaction with past therapeutic relations related both to patients' expectations about receiving help and also to the way they were treated. They complained that their previous physicians or CAM practitioners were unable to give them relief from their health problems, or that the help they received was only short-lived. Other complaints, directed primarily at medical specialists, included inadequate or mistaken diagnoses, not being listened to or treated with respect, being rushed, lack of interest in their specific situation and too great a reliance on drugs and surgery instead of trying to get to the root of the problem.

For example, a woman who was currently consulting a Reiki practitioner told us "I went to see this neurologist; he was supposed to be so good, and I wrote down a list of the symptoms I had and everything.-----He didn't even look at it. I was there all of five minutes.----he just handed the list back to me and was writing out a prescription for me, for nerves or something. I tore out of there and I tore up his prescription. He didn't even listen to my problem, you know ”.

The fact that the patients expressed considerable dissatisfaction with their previous health care providers is not surprising. If they had received the help they sought and had been able to develop a positive therapeutic relationship they would not have decided to look elsewhere. What we do not know is how the patients will feel in the future about their current physicians or CAM practitioners if they fail to meet their expectations. This research captures patients at only one point in their search for improved health and thus can not reveal the whole story.

Discussion

Physicians and their patients relate to one another within the framework of the biomedical model, whereas CAM practitioners relate to their patients within a more holistic framework. Yet this study shows that in some ways, the relationships between CAM patients and their practitioners do not differ much from the relationships between family physician patients and their doctors. Both groups reported overall satisfaction with their health care providers and said they would recommend them to others. Both groups found care givers who will usually answer their questions, give them explanations, understand their perspective and to a lesser extent, involve them in decisions concerning their health care. It is important to remember that the respondents for this study were recruited in the offices of their health care providers and are thus likely to be satisfied consumers. Unfortunately, we do not know how those who have departed due to dissatisfaction would feel about their caregivers.

Where the two groups of respondents differed most was in the basis for their satisfaction. While only a small percentage of the physician patients were getting positive results from their current treatment, most of them nevertheless expressed trust in the skills and expertise of their doctors and some also mentioned rapport with them as an important element in the healing process. The CAM patients, on the other hand, placed most emphasis on positive results such as less pain and discomfort. Their relationships with their practitioners were largely pragmatic; if the practitioners could help them, they would continue to see them; if not, they would move on to try another practitioner or another kind of therapy.

The other major difference between the groups of patients was the role they saw for themselves in the healing relationship. While almost all respondents expected to have input into decisions about their care, there were differences in emphasis. Most family physician patients believed that their doctors should play the key role. CAM patients, on the other hand, typically believed each patient should have the main responsibility for their own health and decisions about which kind of treatment to pursue. Whereas physicians’ patients favoured provider-control and placed their trust in their doctors, CAM patients more often favoured self-control and placed their confidence in themselves, or in themselves in partnership with their practitioners.

These findings indicate that the popularity of CAM practitioners can be attributed in large part to the search for relief from persisting chronic conditions. These patients want a practitioner who can help them cope with their ongoing problems. While physicians have had extraordinary successes with many acute illnesses such as polio, pneumonia and heart conditions, they have not been able to offer much assistance to their patients who suffer with chronic problems. Medicine continues to rely on its existing armamentarium of solutions such as drugs and surgery for conditions which require different and less drastic approaches. Physicians often discourage patients from presenting painful chronic conditions as their primary problems because there is little they can do to help.

The explanation presented at the beginning of this chapter that it is the more intimate and sympathetic style of interaction employed by CAM practitioners that explains their popularity was not upheld by the findings. Instead, they emphasize the continuing search for relief from chronic problems. This finding throws doubt on the claim that it is the response of CAM patients to their practitioners' holistic interest in them that is the chief reason for the ability of CAM to help chronic illness. While there is no question that patients' perceptions of the nature of the therapeutic relationship can have a significant influence on the outcome of their treatments, all kinds of interventions--medical and alternative, have a degree of placebo effect on the healing process (Lewith and Aldridge, 1993; Goldstein, 1999).

When we look at the continuum of care delineated by the three models of the doctor-patient- relationship: (1) paternalistic, (2) shared decision-making and (3) consumerist, we see that each model directs attention to different aspects of how the therapeutic relationship is structured. The paternalistic model was only minimally evident in the reports of the current experiences of all the patients, although one key element of the paternalistic model was still apparent in the relationship between most family physicians and their patients. It was the physicians who made the decisions about treatments and the patients who trusted in these decisions.

Paternalism was clearly evident, however, when it came to the stories that both groups of patients recounted about their past experiences with medical specialists. In many instances they reported evasion of their questions, limited communication, and complete physician control of decision-making. A distinction was thus apparent in the type of relationship the patients experienced with family physicians, as compared to the more authoritarian and remote medical specialists they had consulted.

It was the mid-point on the continuum, the shared decision-making model, that best reflected the relationships of most patients with their health care providers. Both groups reported that they typically shared clinical information with them, communicated well and proffered emotional support. The model fitted therapeutic relationships with CAM practitioners more closely, however, due to the partnership role they took with patients, particularly around psychosocial issues and recommended lifestyle changes.

At the far end of the continuum, the consumerist model was reflected in the desire of both kinds of patients to find a successful resolution to their chronic problems. This was particularly apparent when patients spoke of their past health care experiences. The pattern was that if the practitioner was found to be unable to help them, or failed to respect them and their opinions about treatment, most decided to act as "smart consumers" and search for another physician or CAM practitioner who would listen more attentively and make more appropriate, individualized recommendations.

To reiterate, most of the relationships experienced by patients in this study fall somewhere in the middle of the continuum. Paternalism appears to be disappearing for family physicians, who are relating to their patients in more open ways. The authority of the physician over health care decisions is no longer as influential. They are not, however, assuming partnership roles with their patients to the same extent that characterizes therapeutic relationships with CAM practitioners and their patients. An interesting question for the future is whether patients of family physicians will come to expect the same kind of consultative and egalitarian relationship from their doctors that they have been experiencing with their CAM practitioners.

This study demonstrates that models of the practitioner-patient-relationship that were developed solely on the basis of doctors and their patients can be expanded to apply to relationships with patients and CAM practitioners as well. While the models do not fit the realties of health care perfectly, they do direct our attention to salient points concerning the ways in which both physicians and CAM practitioners relate to their patients, and they also enable us to see interesting differences between various types of CAM practitioners.

Conclusion

The key finding here is that while there are overarching differences in the nature of the therapeutic relationship that exists in medicine and in alternative care, both kinds of relationships are nevertheless positive and valuable, and not mutually exclusive. The physician relationship is based primarily on trust in expertise, while the CAM relationship is based principally on partnership in healing. The opportunity to take an active role may well be part of the attraction of CAM for patients. The research reported here, however, indicates that their primary motivation is the continuing search for relief from chronic problems. This motivation is not restricted to Canadians who use CAM, but also applies to patients in Britain, the United States and other countries where CAM is currently popular.

Further research on the nature and significance of the therapeutic relationship in CAM is needed to flesh out the picture portrayed here. Rather than rely on patients’ accounts of past and present health care experiences, scholars can pursue this topic in depth through use of tape recorders and video cameras during the actual encounters, as Mishler and his colleagues have done for the doctor-patient- relationship (Mishler, 1984). Analysis of the content, the tone and the timing of the consultation between CAM practitioners and their patients can reveal the nuances of the dynamics involved in the healing encounter. Some questions that could be answered using these research methods include: (1) Do different types of CAM practitioners have different kinds of therapeutic relationships with their patients?, (2) Do age, gender, and cultural differences generate different kinds of therapeutic relationships with a CAM practitioner?, (3) At what point in the treatment process do CAM patients show an interest in the healing philosophy of their practitioners?, (4) Do the characteristics of the therapeutic relationship vary according to different societal conditions and contexts? and (5) Will the increasing professionalization of CAM practitioners change the dynamics of the therapeutic encounter in the future? The nature of the relationship between patients and their CAM practitioners has yet to be fully identified.

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ENDNOTE

[1] In the Canadian national health insurance scheme, all medical services are covered by government insurance. Alternative care, on the other hand, is paid for by patients out of their own pockets, with the partial exception of chiropractic.

[2] It is important to recognize that there is some overlap between the groups being analysed here. Several investigators have shown that individuals do not abandon conventional medicine when they use alternative therapies (Lewith et al, 1996; Kelner and Wellman, 1997a; Eisenberg et al, 1993, 1998; Vincent and Furnham, 1997). Many use both, either sequentially or at the same time. Moreover, some patients may simultaneously consult more than one alternative practitioner for their current complaint. It is also true that many alternative practitioners and even some family physicians are qualified in more than one discipline and may utilize a mixture of therapeutic practices in treating an individual patient. In spite of these complications, for purposes of analysis the patient groups in this study have been defined according to the type of practitioner in whose office they were first contacted.