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UBC Theses and Dissertations

Examining how medical practitioners establish therapeutic alliance : a dynamic systems approach Baxter, Kristy


Background: Patient-centred care is a key and understudied concept in modern health care. One notable influence on patient-centred care and patient outcomes, is therapeutic alliance. State space grids (SSGs) are an observational, dynamic systems methodology that allow for the trajectory of dyadic interactions to be mapped in real-time. By examining interactions between medical practitioners and patients, SSGs have the potential to characterize how therapeutic alliance is established in real-time. Objective: To use SSGs to examine how practitioners’ real-time use of verbal behaviours is associated with the perception of therapeutic alliance between a practitioner and a patient. Methods: This exploratory study involved video-recording practitioners having a simulated appointment (session) with a standardized patient. Following the sessions, therapeutic alliance was assessed using the Working Alliance Inventory (WAI). Analyses were conducted in three steps. In Step 1, WAI scores were calculated. In Step 2, a coding manual was developed to reliably code for verbal behaviours within the sessions. In Step 3, the coding manual was applied and SSG analyses were used to understand how practitioners and patients used verbal behaviours during the session, and if these behaviours were associated with WAI scores. Results: 11 practitioners participated in the study (55% men). The number of practitioner support statements were positively correlated with the patients’ WAI scores (p < .01). In contrast, the number of times the practitioner gave information was negatively correlated with the practitioners’ WAI scores (p < .05). The relationship between the number of transitions and WAI scores was negative (p > .05). Whereas, the average duration per visit was positively correlated with WAI scores (p > .05). Conclusions: Our findings highlight the importance of using a dynamic systems approach to understand how conversations between practitioners and patients unfold over time to influence therapeutic alliance. Preliminary data from this thesis indicate that practitioners should be cautioned about giving ample information or advice. Instead practitioners should consider spending more time creating a relational bond with the patient by offering supportive statements.

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