Special Report: ‘Will They See Me?’ How to Rebuild Patient Relationships Frayed by Pandemic

The development of psychiatric medications is surely one of the field’s great advances of the last half-century. When teaching trainees, I often pull up number-needed-to-treat studies, which show that the medications prescribed for many psychiatric conditions are some of the most impressively effective in all of clinical medicine. I love to tell trainees that, say, the number needed to treat for acute mania with lithium is only four and that seeing its remarkable effects in action was one of the experiences that led me to psychiatry.¹

Psychiatric medications are also some of the most widely prescribed. In 2018, researchers found that 380 million prescriptions for psychotropics were prescribed in outpatient retail settings alone.² More than half were medications used to treat people, like the young man I recently cared for, experiencing depression.

According to the National Health and Nutrition Examination Survey, antidepressants are one of the three most commonly prescribed therapeutic classes of medications in the United States. (The other two are lipid-lowering drugs and ACE inhibitors, both of which have less favorable number-needed-to-treat.) Their use has increased over the past 20 years, so that, in its most recent survey, 7.3% of male respondents and 13.9% of female respondents had taken an antidepressant in the previous month. The rates typically increase as people age, so that about a quarter of female respondents over age 65 report having taken an antidepressant in the previous month.³

Most of these antidepressants, and most psychotropics, are not prescribed by psychiatrists.⁴ As any practicing psychiatrist can tell you—and the adverts in this publication attest—psychiatrists are in short supply.

To whom are psychiatric medications being prescribed? A pharmacy student with whom I worked once told me that when she moonlighted at retail drugstores around town, she noticed various prescribing patterns. In impoverished neighborhoods, she filled antipsychotics and opiates. In wealthy neighborhoods, she filled antidepressants and stimulants. Epidemiological statistics bear out her observations and other differences in prescribing. To take just one example, Black patients are more likely to receive first-generation antipsychotics for psychotic disorders and less likely to receive appropriate treatment for depression than White patients.^{5, 6}

Those inequitable prescribing variations are well known, but the young man I met as a patient was asking a further question: how medications would be prescribed. He feared another stilted Zoom visit—You’re on mute!—during which someone worked through a checklist and ended the encounter with a prescription.

In a way, the patient’s concerns are mirrored by what students and trainees have also told me in the past months. They like some aspects of telepsychiatry—the shortened commutes, the casual dress codes—but miss the camaraderie of workrooms and clinics. Many report that they are able to complete more patient encounters, but they are getting less out of the encounters.

Working in medicine during a pandemic has seen the exploitation of preexisting problems. A patchwork public health system allowed a novel infection to spread. A polarized polis enabled social divisions to widen. An inequitable society accelerated income gaps. A burned-out health care workforce overworked itself into new depths of discouragement.

And, for many of my patients and trainees, a frayed physician-patient relationship came undone in remote visits.

What do they all miss these days?

The physical spaces that inaugurate the physician-patient encounter. Remember how you could count on a psychiatrist’s office to stock outdated issues of The New Yorker in waiting rooms?

The outstretched hand that greets you. Remember being able to shake hands with patients and their loved ones?

The tissues when you tear up. Remember the small acts of material comfort that spoke for us?

The closing promise to be seen again. Remember the prescription pads and appointment slips, the little therapeutic souvenirs of care?

Pandemics, like wars, accelerate changes. As we work through the SARS-CoV-2 pandemic, people are asking how we can rebuild public health systems, unify society, increase equity, and reduce burnout. We need to also ask about how we will restitch physician-patient relationships.

With a wise friend of mine, I recently set out to listen to clinicians from around the country who know about these relationships. Some of them were old friends, some were people I admired from their publications. We wrote them all unsolicited invitations. To a person, they were eager to speak with us and to share what they had learned about how to see people: They shared wisdom from their clinical experience, findings from their research, and papers from the past that formed them.

Listening to them, I was introduced to a classic psychoanalytic paper, written about the time I was born, by Edward S. Bordin. Bordin wrote that the therapeutic alliance has three core components: goal, task, bond. At the core of every working alliance, Bordin wrote, is a goal that you work toward together. Some goals are negative. I need to stop using meth. Some are positive. I want to reconcile with my family. Some are material. I need to work enough to get stable housing. You have to understand a patient’s history and current situation to develop a goal you can share. The goal is the “why” of the alliance.

The alliance is forged through working together on tasks, the “what” of the therapy. I can assign thought records, encourage a dream notebook, or prescribe a medication titration schedule. The tasks vary, but their effectiveness depends upon a clinician’s ability to link the task to a patient’s distress and desire to change. The patient has to recognize the tasks as necessary responses to his or her situation.

Finally, the alliance is formed through the development of effective bonds between the clinician and patient. The bonds are the “how” of treatment. Bonds differ in kind—reciprocal or one-sided, warm or distant, caretaking or consulting—and shape the alliance differently. All bonds depend upon the trust necessary to develop a human relationship.⁷

Goal. Task. Bond. These are the ingredients for working together, and the idea still does work today, as Bordin’s concept forms the foundation for effectiveness studies of the therapeutic alliance. Almost every measure of the therapeutic alliance assesses goal, task, and bond, but these measures—the Working Alliance Inventory, the Therapeutic Alliance Quality Scale—are typically used only in psychotherapy efficacy studies.⁸

I started to wonder what would happen if we used versions of those same measures to understand how psychiatric meds work. Could that help restore physician-patient relationships?

In my clinical setting, adult inpatient psychiatry, the current quality outcomes include hours of seclusion use, use of multiple antipsychotics, influenza immunization, treatment for alcohol and tobacco use, and screening for metabolic disorders.⁹ All of these are necessary, but hardly sufficient. Even more, they measure proxies of good psychiatric care, rather than care itself. They become targets we pursue rather than true measures of care.

What if we measured our work as psychiatrists using measures of therapeutic alliance rather than quality outcomes?

Remember those studies I share with trainees about how effective psychiatric medications can be? David Mintz, M.D., of the Austen Riggs Center recently observed to me that when most empirical researchers assess the efficacy of psychiatric medications, they neglect to measure the contribution of the therapeutic alliance to clinical outcomes. But when studies have looked at this connection, Mintz observed that several possibilities emerge: A therapeutic alliance improves adherence to medications; an alliance leads to better outcomes from medication, even beyond adherence improvements; or strong alliances precede therapeutic gains.

The authors of a recent meta-analysis helped sort through these possibilities. The psychologist Christine Totura, Ph.D., and her colleagues found eight independent studies whose overall effect size was moderate, but statistically significant, and consistent with the effect sizes demonstrated in psychotherapy research studies. For the treatment of serious mental illness—bipolar disorder, major depressive disorder, and schizophrenia—in both inpatient and outpatient settings, the authors found that patients experience better treatment outcomes from medication when the therapeutic alliance is strong.¹⁰ Roughly, the same medication prescribed for the same condition produces about a 10% better outcome if it is prescribed within a strong, rather than weak or conflictual, therapeutic alliance.

Relationship Building for Health Equity

Other experts spoke to us about seeking concordance between physician and patient, making cultural connections, knowing when to deprescribe, how medication affects mentalizing, and more.

Listening to them, I thought of the kind of work they described. It was not like the transactional ads for the “little blue pill,” which promised a quick tour through a symptom list followed by a prescription, the physician as dispenser of an otherwise unattainable substance. What these experts were describing was relational—the physician as collaborator with an ill patient.

One of the experts we spoke to, Kay Redfield Jamison, Ph.D., of Johns Hopkins, told us that a medication achieves its potential only when given in the context of a therapeutic alliance. When you prescribe a medication, she said, it is a kind of investigation in pursuit of understanding the patient.

Doing so, Jamison told us, means that a clinician can offer a patient “the intelligent extension of hope, which is really based on knowing what you’re doing and caring enough about patients to recognize how important that is.”

Clinicians who know what they are doing present a kind of hope for a patient whose condition is incurable. That is the kind of hope many of us, patient and physician alike, seek in the medical encounter.

When we spoke with Sidney Hankerson, M.D., of Columbia University, he said he had entered psychiatry because it depended upon forming authentic human connections with people feeling disconnected. He loved hearing patients’ stories, learning about the communities that sustained them, and reconnecting them to those communities. Now, Hankerson is training the next generation to do the same. He recently started a community-based educational elective for third- and fourth-year medical students, focusing on social determinants of health and community engagement, in which students will advocate for social justice in health. Hankerson will increase the mental health literacy of students and teach them to be advocates.

Teaching medical students in that fashion may help psychiatrists like Hankerson renew the physician-patient relationship by focusing on justice and health simultaneously. After all, injustice is a critical failing of the current medical system, especially the mental health system, as recent books by leading psychiatrists like Waiting for an Echo by Christine Montross, M.D., and Bedlam by Kenneth Rosenberg, M.D., showed general readers. These powerful indictments, and patient-centered narratives like When They Call You A Terrorist by Patrisse Khan-Cullors, are urgent calls for reform.

Many health systems and medical practices are reconsidering how they can pursue health equity in their own practice. Improving the physician-patient relationship for our marginalized patients is a foundational step.

A call for equity to be a part of the physician-patient relationship will surely survive the SARS CoV-2 pandemic. So too will the use of telemedicine and, in this instance, psychiatry has taken the lead, setting up telepsychiatry at a scale and scope envied by other aspects of medicine. Telepsychiatry helps redistribute the mental health workforce and reduces some of the inefficiencies endemic in our health care system. The question will be whether we can incorporate it as a tool that serves the physician-patient relationship or whether it becomes another version of the “little blue pill” clinics.

To get it right, many psychiatrists are reaching out to friends who have pioneered telepsychiatry. My own friends tell me it works best for someone with whom you have already established an in-person connection. You can save a patient a trip to an urgent care or emergency department by making a brief check-in about adverse med effects, refills, and other brief encounters that can be quickly addressed by someone who knows a patient. You can also, friends say, glimpse a patient’s lived environment in a way that a lifetime of visits precluded. Home visits have never been easier. Of course, a patient can glimpse the physician’s environment as well, and physicians are circulating tips about how to create the right Zoom background, increase their bandwidth, position ring lights, and otherwise optimize the digital encounter. A handful of researchers have even begun studying how we will build therapeutic alliances in digital encounters. The research is preliminary, but the question is acute.

So I asked my patient whom I introduced at the beginning of this article what it would take for him to be pleased with a telepsychiatry encounter.

On the streets, he struggled to secure a stable signal for a full telepsychiatry visit, but he admitted that he could usually find a wireless signal when necessary. That was not his real misgiving. It was also not his youth. He was young enough to feel like a native in digital encounters, but he was also experienced enough to regard many of them as alienating. He was socially isolated and needed the connection, telling me, “Seeing shrinks can be helpful, but it has never been easy. It is not a dual relationship. We get naked in front of you! And that happens only after we trust you. How can I trust a shrink if they won’t even be in the same room with me?”

Listening to him, I thought of an essay I had read early in the pandemic. The authors, all public health experts, argued that we can do physical distancing with social connection when public health requires it, but never “social distancing.”¹¹ Their rhetoric made this psychiatrist proud. Social distancing is an inhuman phrase. We human beings are social animals, and all the distancing during the subsequent year has surely worn on us all. We need to be back together. We need to come back together in effective physician-patient relationships that improve the health of our patients and reduce the burnout of physicians, so we can prosper together.

When I am looking for a way back, I like to check in on the work being done by a Harvard epidemiologist named Tyler VanderWeele, Ph.D., who runs something he calls the Human Flourishing Program. VanderWeele and his colleagues study ways to reduce social distance and increase social relationships. They have created measures of human flourishing, a sense of prospering, which developed out of Martin Seligman’s work in positive psychology but extend his findings beyond psychology. The first question in one of their surveys is simple: “Overall, how satisfied are you with life as a whole these days?”¹²

I fear most of us, patient and physician alike, would give the last year low marks.

In Great Britain, the psychiatrist Joanna Cannon recently published a memoir about physician burnout, titled Breaking and Mending: A Junior Doctor’s Stories of Compassion and Burnout. Like Hankerson, like me, like many of us, Cannon became a psychiatrist because of the human connections. Cannon wrote that her training taught her that the very act of listening to people can save their lives. “I learned that saving a life often has nothing to do with a scalpel or a defibrillator. I learned that lives are not just saved on the floor or an A&E department or in a surgical theatre. Lives are also saved in quiet corners of a ward. During a conversation in a garden. On a sofa in a TV room, when everyone else has left. Lives can be saved by spotting something lying hidden in a history. Lives can be saved by building up so much trust with a patient, they will still take a medication even if they don’t believe they need it. Lives can be saved by listening to someone who has spent their entire life never being heard.”¹³

Cannon also admitted that she was ultimately worn out by this kind of listening within today’s health systems. Sometimes we imagine burnout as a feature of American medicine, with its inequitable insurance systems, but Cannon’s memoir of burnout within a nationalized health system reminds us that the fraying of the physician-patient relationship is an international sign of the times.

Cannon published her memoir right before the pandemic erupted. There are surely no advantages to a pandemic, but there are surely opportunities. And, for many of us, it has been a reminder that we need social connections—not only with our family and friends, but with our patients as well. We entered psychiatry because we believed, like Cannon, that listening well can save lives.

It is that kind of listening that the young man I recently met as a patient was seeking and that I believe psychiatrists are seeking as well. To be seen. The pandemic has reminded us that we all share a vulnerability to infectious disease, but to social isolation as well. Whatever direction the pandemic takes, rebuilding the physician-patient relationship, both in personal and digital encounters, is the work that lies ahead of us all. ■