Patient-physician relationships form the basis of a therapeutic alliance that promotes healing, especially in mental healthcare.

But how can a doctor tell whether a patient is the “right fit”? And what happens if you need to end a relationship with a patient?

Components of a good fit

As with all relationships, developing a positive patient-clinician relationship can take time and effort. However, while working toward this goal is admirable, there may be occasions where the patient would be best served seeking help elsewhere.

According to the American Psychological Association, several factors could promote an effective, professional relationship fostered on mutuality, collaboration, and trust.

DeAngelis T. Better relationships with patients lead to better outcomes. American Psychological Association. November 1, 2019.

• Collaboration: You should be “on the same page” with your patient throughout the entire treatment process. In recent years, mental health professionals have begun viewing their patients as equal partners, helping them identify issues and explore possible therapies and treatment goals together as a team.

• Empathy: The ability to view issues from the patient’s point of view is extremely helpful for developing positive connections. If you feel judgment arising towards the patient, the relationship may not be a good fit.

  DeAngelis T. What the evidence shows. American Psychological Association. 2019;50(10):42.

   

• Flexibility: No two patients are alike, and psychiatrists should tailor each treatment session to their unique needs. Flexibility in the relationship helps clinicians better respond to each patient’s needs.

• Genuineness: Each person in the treatment session should be themselves; hiding behind personal or professional facades are not therapeutic for any patient. Being genuine in your interactions fosters trust and encourages closer connection.

• Mutuality: Mental health professionals may consider disclosing their own perspectives when and if appropriate to the patient’s treatment session. Actively listening to patient feedback also helps you determine how treatment is progressing from the patient’s perspective, allowing you to change behaviors or treatments as needed.

• Positive affirmations: Supporting your patient regardless of their attitudes, emotions, or behaviors helps create a safe space optimized for personal development.

• Willingness to repair: If any breakdown in the therapeutic relationship occurs, providers can opt to use tools like empathy and mutual discussion in order to repair minor disagreements.

Common issues preventing therapeutic alliances

The following signs may necessitate finding another psychiatrist to help.

• Dual relationship issues: Boundary issues can sabotage therapeutic relationships. Occasionally, a patient may come to you for help without realizing you know or are already treating another party involved in their mental health issue. This could create a complex situation in which you cannot be completely unbiased.

  Kolmes K. Couch surfing: when a therapist says it isn’t a good fit. Psych Central. March 8, 2010.

   

• Countertransference: Emotional responses to patients are normal. You may have a strong dislike for, or even a sexual attraction, toward a patient. Any emotion that may interfere with the professional relationship should be appropriately managed, otherwise it may be best to refer them to an alternate provider.

• Issues are outside your scope: Some mental health patients may present with challenges outside the scope of your practice. In such cases, opt to refer them to another doctor who can fully address the concerns at hand.

• Safety is at risk: Some patients are prone to abuse or outright violence. If you feel threatened, intimidated, or otherwise unsafe in your interactions, you should help the patient find another psychiatrist.

Ending a relationship with a patient

When ending any professional relationship with a patient, review your state’s regulations or laws for terminating patient-doctor relationships. Your state may have certain laws which must be followed; not doing so could expose your practice to significant risk.

Wertheimer M. What happens when the patient ‘fires’ the psychiatrist? American Psychiatric Association Psychiatric News. October 27, 2017.

Documentation is a critical part of ending such relationships. Be sure to document notice of intent to end the relationship, regardless of who initiates the process. Additionally, it is important to document any recommendations for continued treatment elsewhere, including information concerning the importance of continuing prescribed medications and the provision of such medications (including refills) in the duration of time until the next provider will assume care.

For some psychiatrists, consulting with a risk management professional or lawyer is advisable.