Winifred Badaiki examines difficult therapeutic relationships in healthcare and explores avenues to managing them.

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The recent global COVID-19 pandemic exposed great distrust of the healthcare system, particularly by racialized communities. Some of this mistrust is not unfounded. Although Canada has not historically collected comprehensive race-related data, Indigenous peoples and visible minorities report a great distrust of the healthcare system, considering that it has either been used as a tool for their oppression or because of the continued macro and micro aggressions meted to them within the healthcare system with dire health outcomes in some cases. Unsurprisingly, members of many racialized groups approach the healthcare system defensively and with limited trust.

Important elements such as mutual trust, compassion, communication and respect are at the core of the therapeutic and fiduciary relationship shared by healthcare providers and patients. These elements are required for the healthcare provider-patient relationship to thrive, and when missing, the human quality of the relationship is lost. Care provision becomes a technicality for the care provider, and patients experience a perceived or real loss of control and increased vulnerability. To maintain the human quality of care relationships, there is an acknowledgement and acceptance that healthcare providers ought to act in good faith and in the best interest of their patients. Yet, regardless of how a healthcare provider approaches care provision and how much of their best foot they put forward, they will inevitably experience difficult encounters with patients or their families.

Photo Credit: stockcake.com. Image Description: A physician in a white coat talking to patients.

There are various reasons why difficult encounters arise. It could be due to patient and family-related issues such as fear, distrust, anxiety, and behavioural or mental conditions. Healthcare providers can also contribute to difficult encounters due to exhaustion, frustration, bias, or other personal issues. Finally, environmental or situational factors such as limited resources, or guiding healthcare policies and legislation might contribute to creating difficult encounters. Wait times to receive care in the emergency department and for many other care services in Canada are abysmal, and patients must wait a long time before healthcare providers are able attend to them. These issues only help compound the distrust of the healthcare system.

When difficult therapeutic situations are not addressed properly or promptly, they evolve into difficult therapeutic relationships, and this is not without consequences. Potential outcomes of difficult therapeutic relationships include reduced quality of care provision, long-lasting distrust of the healthcare system, increased patient suffering, a threat to patient and staff safety, and reduced employee retention. Some of these consequences are palpable today as in addition to poor healthcare outcomes for patients, healthcare providers are experiencing and reporting an increase in abuse, violence, and burnout. Several polls conducted with healthcare providers reveal that abuse and violence are a reality for many healthcare providers, and staff report witnessing and experiencing an increase in violence since the start of the pandemic.

Everyone involved in the care delivery process is responsible for preventing difficult encounters and managing difficult therapeutic relationships. Starting from the very top of the healthcare chain, governments can begin by working to create new or strengthen existing standards, policies, legislation, procedures, programs and training to ensure a safe workplace for healthcare providers. More resources to support healthcare delivery ought to be provided, and governments must continue to work to rebuild trust with disenfranchised communities. Leadership within healthcare organizations has the lion’s share of responsibility for creating a safe environment for patients, families, and staff. Accountability measures and mechanisms for supporting staff and patients in responding to difficult situations and handling reports of abuse, bigotry, and violence must be implemented in a timely and transparent fashion.

Healthcare providers have a great obligation to establish and maintain the therapeutic process. Difficult therapeutic relationships can be salvaged by approaching encounters with respect, empathy, and support. When there is threatening behaviour, it is important to respond proactively by setting boundaries or using resources available at healthcare institutions to address it.

Finally, given the inherent power imbalance that exists between care providers and patients, especially when patients are in vulnerable positions, the onus of maintaining therapeutic relationships lies on the care provider, and patients and their families should be assisted and directed to resources that can guide them in navigating the healthcare system adequately.

Overall, a culture of distrust, fear, abuse and violence in the healthcare environment is unacceptable, and thus, firm and clear actions to provoke a culture change and respond to difficult encounters ought to be implemented. We must remember that healthcare providers are responsible not only to the patient in front of them but to future patients, the community, colleagues and themselves. Therefore, there should be a joint effort to ensure that everyone involved in healthcare delivery is supported.

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Winifred Badaiki is a clinical and organizational ethicist at Hamilton Health Sciences. @WinnieOmoye