2.6 The failure of CAM therapeutic relationships
Although therapeutic relationships have the capacity to heal, they can also harm. In reality, the outcome of most therapeutic encounters and relationships lies somewhere on a continuum between good and harm. Few therapeutic relationships are a complete success but, judging by the number of complaints, even fewer are a complete disaster. Studies of therapeutic encounters invariably show high levels of patient satisfaction (see, for example, Sharma, 1992; Kelner et al., 2000). None the less, it is important to consider the ways in which the therapeutic relationship can be unsuccessful or even counter-therapeutic. This can be considered in the following areas.
Clinical failure: the therapy either does not help the user or makes them worse. This may be seen as a failure of the practitioner's ethical duty of beneficence and non-maleficence.
Failure in interaction or communication: sometimes users fail to ‘connect’ with the practitioner, either personally or with the philosophy or ideas involved with their particular CAM. Sometimes a practitioner's style of interaction and questioning is not acceptable to the user. This can also be seen as a failure both of the practitioner's ethical duty of beneficence and non-maleficence and of the practitioner's duty to respect the person's autonomy.
Mismatch of expectations: the user might have different ideas about how soon to expect results from the form of treatment they seek, or what kind of results to expect.
Breach of boundaries: failure by the user, the practitioner or both to manage appropriate boundaries in the therapeutic encounter (for example, the patient or practitioner makes suggestive or judgemental comments, or the practitioner performs an examination that seems unnecessary). This can be seen as a failure of the practitioner's ethical duty of non-maleficence, in that they are actively harming the patient.
Of course, separating relationship failures in this way may be rather artificial. In practice, a therapeutic relationship flounders for several different reasons. As discussed earlier, the components of the therapeutic relationship operate synergistically. Thus, a clinical failure may result from failed communication or an inability to form a supportive, empathetic relationship with a user. A breach of boundaries may be detrimental to healing, even when the practitioner has been technically proficient. The most likely outcome of failure in communication or interaction is that the user will not return to that practitioner. Failed encounters of this sort are detrimental in that they may inhibit the patient from seeking further treatment that may be of benefit. Also, remember that users who pay for their CAM treatment may simply not have the resources to shop around indefinitely. However, it is failures of the final type that cause most concern, since they have the greatest capacity to harm patients directly. Although, stereotypically, people tend to associate breach of boundaries with practitioners acting in a sexually inappropriate way, the scope of failures is considerably broader.