Relationships Will Drive Primary Care’s Future Success

A profound change occurs in primary care when psychotherapists arrive. Powerful new relationships are created. Relationships are the context in which healthcare services are delivered. They are also a key therapeutic ingredient. PCPs and psychotherapists have patient relationships that are unique in healthcare. When they align forces, the foundation is set for unprecedented levels of patient change.

An essential element of primary care is the longitudinal relationship between doctor and patient. It helps foster connection and trust, and it offers a perspective on health issues over time. Clinicians can witness the progression of an illness. Patients can ruminate over treatment discussions and recommendations during the long intervals between visits.

The power of longitudinal relationships cannot be overstated. They can increase the likelihood of success for every clinical intervention—a genuine secret sauce. PCPs encounter problems at all stages of development, while specialists are more likely to see severe or chronic cases. This is a big issue in the behavioral field. For example, care for substance use disorders (SUDs) has been compared to starting with stage 4 cancer.

The longitudinal relationship also permits some interventions to have less pressure or urgency attached to them. Episodic treatment relationships focus on taking action during a brief window of opportunity. A longitudinal relationship means that it is possible to make comments and suggestions in the spirit of “planting seeds,” with the intention of checking later to see what has taken root.

While this relationship is associated with primary care, it should be viewed as archetypal. A longitudinal relationship has unique qualities that could benefit other healthcare disciplines. For example, behavioral healthcare might easily take advantage of this extended relationship. Whether the focus is a behavioral disorder, a health behavior, or a bad habit, change is usually a protracted process.

A longitudinal connection may have even greater power as a framework for behavioral than medical care. The passage of time between visits can be an opportunity for patients to consider behavioral recommendations and wrestle with early steps toward behavior change. A therapist might suggest self-reflective or action-oriented tasks to start a clinical process.

We also realize the importance of readiness to change. Some clients are not ready for therapeutic input, and others need time to work through immobilizing ambivalence.

Effective therapists learn patience. Patients must be ready to disclose painful events or hear certain feedback. We can only hope that therapy is available when patients are ready to use it. Longitudinal relationships maximize opportunities for well-timed interventions. Episodic, specialty care may occur at the right time, but we know this is often not the case. It can be too early or too late for optimal results.

PCPs cherish the longitudinal relationship not simply because it has specific benefits (e.g., facilitating early detection of problems), but also because it has general benefits. The PCP knows patient history first-hand. It is a reliable relationship offering long-term support. This is captured in the concept of the health home. It inspires confidence and collaboration whatever the recommended treatment.

The behavioral healthcare field has discovered its own secret sauce in terms of professional relationships. Research on psychotherapy has identified the power of common factors across therapies. The therapeutic relationship accounts for much of the success of therapy. This unique connection is termed a “therapeutic alliance” and it is a general driver of change across all therapies.

People benefit from therapy because they interact with a caring, empathic therapist. They agree on their tasks and goals for getting together. These factors account for much of the value of therapy, apart from however much specific therapeutic techniques contribute to clinical outcomes. Imagine combining a longitudinal relationship with the relational power behind therapy, the therapeutic alliance.

This is what happens when therapists are included as core providers within the primary care setting. PCPs are typically warm and welcoming, but few understand the nature of the therapeutic alliance. Imagine the power of a therapeutic alliance maintained over years. Psychotherapy has been found to be remarkably efficacious. How might effectiveness grow when more people get care at the right time?

This is the hope for therapists in primary care. Behavioral interventions will be spaced over time in small doses for people ready to receive them. A therapeutic alliance will be framed in a longitudinal relationship. Visits will be marked by empathic, non-judgmental listening. Is this a longitudinal therapeutic alliance? Such a framework can nurture valuable services beyond the confines of therapy.

Let us set therapy aside. People are often primed for change, and they need a caring professional to give a push in the right direction at the right moment. While not therapy, such simple interactions can be transformative. They will become more common as our clinicians enter primary care. Therapists will expose more people to longitudinal therapeutic alliances. Behavior change will flourish in primary care.

Ed Jones, PhD, is currently with ERJ Consulting, LLC and previously served as President at ValueOptions and Chief Clinical Officer at PacifiCare Behavioral Health.

The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.