The Value of a Therapeutic Alliance in Patients with Painful Bladder Syndrome

Objectives: Interstitial cystitis/painful bladder syndrome (IC/PBS) is a chronic pain condition with limited effective treatment options and poor patient compliance. The therapeutic alliance (TA), defined as building rapport to enhance patient motivation and sense of ownership with their treatment plan, is well established in psychology. The TA impacts patient satisfaction and pain outcomes in those suffering from chronic pain, a relationship that has not yet been explored in patients with IC/PBS. The objective of this study was to highlight patients’ experiences and identify specific physician behaviors that enhance or hinder the TA. Furthermore, we aim to investigate whether strengthening the TA subjectively impacts patient perception of symptom control.

Methods: After obtaining IRB exemption, an online survey was created using principles of survey design. Components of TA including trust, relationship building, and patient experience were assessed. Responses were measured using Likert scale and open-ended questions. The survey was reviewed by physician and patient experts for content and response process validity. After approval from support group administrators, the online survey was disseminated in four IC/PBS support groups on Facebook. Participation was voluntary and anonymous. The survey was posted weekly from July to October 2023. Respondents were included if they could complete the survey in English and identified as someone with IC/PBS.

Results: Of those who started the survey, 59% (n=115/194) completed. All respondents identified as female (n=115/115). Majority were white (n=106/115) and not diagnosed by urogynecologist (n=111/192).

Respondents felt they had a good (n=79/168) or acceptable (n=50/168) relationship with their provider, while 20% (n=39/168) felt their relationship with their provider was poor. Overall, 77% of respondents reported poor control of their IC/PBS symptoms (n=89/116). Respondents who felt their provider was trustworthy were more likely to feel they had a strong patient-provider relationship (95% CI 0.76 [0.70-0.82]). Respondents who had a better relationship with their provider were more likely to feel their IC/PBS flare symptoms were controlled (95% CI 0.15 [0.01-0.30]).

Provider behaviors associated with gaining trust included: listening, being knowledgeable, and using a collaborative approach. Behaviors attributed to less trustworthy providers left respondents feeling dismissed, not feeling listened to, and being offered limited treatment options. Provider behaviors associated with positive patient experiences included making eye contact, being engaged, and attempting to understand patient complaints. Conversely, lacking compassion, empathy, and being less thorough were provider behaviors associated with negative patient experiences. When asked about the most important aspects of the visit, provider attitude and variety of treatment options discussed were determined to be paramount.

Conclusions: We identified tangible, modifiable provider behaviors that strengthen the TA in patients with IC/PBS. Emphasizing positive behaviors while avoiding behaviors associated with negative patient experience helps to establish patient trust and can positively impact symptom control in patients with IC/PBS.