Therapeutic alliance refers to the “nature and strength of an affective bond between patient or family and the clinician in collaboration toward shared goals.”1 It is about the quality of clinician-patient relationships, including the mutual affect and respect necessary for trusting, constructive, compassionate, and goal-concordant care. In other words, therapeutic alliance is something all clinicians should strive to achieve. However, there are few empirical descriptions of how to do so, and none explicitly focused on pediatric populations.2 In a secondary analysis of qualitative data from a prospective cohort study of 141 recorded conversations between 6 pediatric oncologists and 17 families of children with advanced cancer, Kaye and colleagues1 begin to bridge that gap. Specifically, they identify 28 concepts from 7 core themes supporting a framework for clinicians to approach building therapeutic alliance: human connection, empathy, presence, partnering, inclusivity, humor, and honesty.
That this investigation1 focuses on pediatric end of life is critical. This period of a child’s care is when therapeutic alliance is most necessary and most threatened; not only are patients and families navigating complicated decisions about how to align their values and goals of care, parents’ confidence and trust in clinicians can wane with advancing disease. An additional strength of this analysis1 is its longitudinal approach. Most of what we know about pediatric (and adult) relationship building is based on cross-sectional studies. To my knowledge, the study by Kaye et al1 is the first to record serial conversations between clinicians and families during the last few years of a child’s life. As a result, the findings reflect the evolution of relationships and suggest broadly applicable strategies to strengthen them over time.
What are those strategies? Essentially, Kaye et al1 suggest that we follow evidence-based guidelines for communication. Every one of the proposed concepts and themes is corroborated by rigorous communication science. For example, the themes of empathy, presence, and partnering all encompass constructs of compassionate, sympathetic, and empathetic communication. These themes include elements of the broadly used NURSES pneumonic for responding to patient and family emotions, albeit with alternative titles. Specifically, the NURSES pneumonic encourages clinicians to name the emotion they see; express that a family’s reaction is understandable and valid; respect and praise the patient’s or family’s role, effort, and expertise in managing the illness; support patients and families by affirming a commitment to them; explore their perspectives from a place of curiosity; and, finally, to actively listen and stay silent while patients and families process. These tactics work because they enable people to manage intense or overwhelming emotions and then listen and retain the information that follows.3
Similarly, the themes of honesty and inclusivity endorse clear, transparent delivery of information. This is important not only because understandable information makes a difficult situation more navigable but also because truth telling, even when the news is difficult, promotes trust.4 The themes of human connection and humor are about building rapport, something that is necessary for any successful relationship.
None of these communication strategies is unique to children with cancer; they may be useful in any other pediatric or adult setting. Some of the other strategies, however, may be less generalizable. As Kaye et al1 point out, this study included predominantly White mothers at a single institution. What was successful in this population may not succeed in other, more diverse settings. For example, the concepts (ie, subthemes) of sharing personal information and demonstrating affection toward patients and families may breach cultural and/or professional boundaries and, in turn, undermine therapeutic alliance.5 Second, using analogies or metaphor to communicate may be lost in translation for families who are not native English speakers (as well as among some who are), thus hindering patient and family understanding. Third, even transparency and truth telling are culturally nuanced; pediatric patients and their families have discrete preferences about what, when, and how information is delivered, and to whom it is relayed.6 Fourth, there are well-documented race-based disparities in patient-reported perception of therapeutic alliance; bereaved Black parents report significantly lower therapeutic alliance than White parents.7 Finally, this analysis1 included only the perceptions of clinicians, not the perceptions of families. Until racially diverse patients and families share their own opinions about what creates a strong therapeutic alliance, the work remains incomplete.
Nevertheless, Kaye and colleagues1 should be commended for taking the necessary first step. They provide a framework on which clinicians and researchers may build and practice. Those wanting to promote therapeutic alliance can begin by developing skills to respond to patient and family emotions with compassion and empathy, delivering information clearly and completely, and making efforts to create rapport. In summary, Kaye and colleagues1 provide evidence to affirm what previously seemed intuitive: skillful communication is the cornerstone of therapeutic alliance.
Published: August 20, 2021. doi:10.1001/jamanetworkopen.2021.22536
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Rosenberg AR. JAMA Network Open.
Corresponding Author: Abby R. Rosenberg, MD, MS, MA, Palliative Care and Resilience Lab, Seattle Children’s Research Institute, 1920 Terry Ave, CURE-4, Seattle, WA 98101 (firstname.lastname@example.org).
Conflict of Interest Disclosures: Dr Rosenberg reported receiving grants from the National Institutes of Health, American Cancer Society, Arthur Vining Davis Foundations, Cambia Health Solutions, Conquer Cancer Foundation of ASCO, CureSearch for Children’s Cancer, St Baldrick’s Foundation, and Seattle Children’s Research Institute outside the submitted work. No other disclosures were reported.
Disclaimer: The opinions herein represent those of the author and not necessarily those of her institutions or funders.
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Rosenberg AR. How to Make Communication Among Oncologists, Children With Cancer, and Their Caregivers Therapeutic. JAMA Netw Open. 2021;4(8):e2122536. doi:10.1001/jamanetworkopen.2021.22536
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