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Seminar II: A2 Doctor-Patient Relationship

Part 1: Communication

Tram Ho Dac

on 22 May 2017

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Transcript of Seminar II: A2 Doctor-Patient Relationship

participative model: symmetric, non-directive Rogerian communication --> trustful relation --> anamnesis, compliance
pay attention to (counter-) transference, observation + evaluation errors
different psychotherapeutic methods can be effective dependent on patient + problem
relation + communication are essential for medical success
Seminar II: Physician-Patient Relationship
Models of Doctor-Patient Relation
Paternalistic model
earlier: passive patient
today: autonomy/self-determination of the patient
Consumer model
patient "buys" specific medical services
contractual relationship, containing specific rights, medical services, and obligations
problem: natural asymmetry due to difference in knowledge and competence
Communication is the basis of a physician's work
purpose: anamnesis (orientation + information), compliance, transparency, informed consent
Paul Watzlawick: "You can not not communicate."
Different levels of information exchange
informational content | relation | self-revelation | plea (desires, expectations, demands)
doctor is an own instrument for diagnosis and therapy;
often unconscious and non-verbal communication;
Principles of Communication
Communicative Effects
From psychoanalysis:
Transference: unconscious repetition/activation of patient's behavioral or experiential patterns of earlier formative situations occurs in current situations with the physician
positive: positive pattern is addressed by the physician
negative: negative pattern is addressed by the physician
ambivalent: switching between patterns
Counter-transference: physician unconsciously takes on the role of the earlier formative reference person; e.g. parent
Observation and Evaluation Errors
Distorted perceptions of another person
Halo effect: false conclusion from one feature to another
Contrast error: differences seem larger than they actually are due to a comparison with a reference group
Mildness-/Severity-effect: tendency to evaluate features as too weakly or strongly pronounced
Projection: defense mechanism to project ignored features from oneself to others
Effect of central tendency: tendency to choose average (not extreme) values
Stereotyping: preconceived, general images, esp. of groups
Self-fulfilling prophecy: information selection bias + expectations have an effect on behavior
need to continuously check own perceptions + evaluations
Effects of Communication
Structures of Communication
Styles of communication
symmetric vs. asymmetric
interaction contingency: mutual vs. asymmetric recognition + addressing of patient's needs and questions
directive vs. non-directive
physician- vs. patient-centered interview
quick information vs. open questions and reports
direct (verbal) | indirect (non-verbal) communication
talking about emotional + social aspects of disease can foster trust, satisfaction and be essential for treatment
don't interrupt free speech, mutual understanding
use patients' language code: elaborated vs. restricted
Principles of Communication
3 basic attitudes (Carl Rogers' conversational therapy):
non-judgemental respect ≠ agreement
empathic understanding + self-other distance
personal congruence: authenticity + honesty
Further useful principles:
active listening: bodily signals, inquiring, paraphrasing
search attitude: free report + clarifying questions
we-alliance: offering help + expecting collaboration
Question styles
open vs. closed questions
catalogue questions: e.g. psycho-diagnostic standardized qs
interpretation questions
suggestive questions
different efficacy in gaining relevant information
cooperation of the patient, adherence
only 50%: medication intake + changes of lifestyle
only 10%: stop smoking, reduce weight
intelligent compliance: non-compliance of the patient due to appropriate and reasonable reasons
doctor compliance: adaptation of therapy and strategies to the patients possibilities and needs
Influencing factors:
illness: suffering from symptoms
treatment: effectiveness, duration, side effects
doctor-patient relation: information, inclusion of patient
patient: control conviction, subjective theory of disease; age, income, education, intelligence
organisation: arranging dates, waiting times, time pressure
Somatoform Disorders
Approach: careful + respectful shift of perspective
Carl Roger’s 3 basic attitudes: search for causes together
time: personal history, personality, circumstances
transference: pay attention to own emotions + address them
course of conversation: conflicts? neglected emotions? mental causes?
develop psychosomatic understanding:
body can react to stress with functional disorders or pain
occurs quite often, no personal guilt
can be treated, but not with further somatic methods
Challenge: patient's conviction of an organic disease (10-40%)
Cause: unconscious suppression of emotional/mental conflicts
emotional language disorder
no simulation (real suffering)!
Dying Patients
neglected topic in daily life, medical profession + training
responsibility as medical caretaker
patient's helplessness, despair, fear, anger
Special Communicative Requirements
Suicidal Patients
Challenge: (suspected) suicidal intention
maybe due to a psychic disorder, e.g. depression, schizophrenia, personality disorder
Approach: overcome awe of addressing the suspicion
each hunch of a suicidal intention must be taken seriously
address as a matter of course
transfer to a psychiatrist or psychic clinic
Anamnesis Groups
Training of doctor-patient conversation
in many German cities with medical universities
8-10 medical students + 2 psychologists
collectively do a complete patient anamnesis: medical, biographical, family and psycho-social circumstances
Double Bind Messages
contradiction between informational content (verbal message) and relational (non-verbal) message
Approach: empathic + authentic support of remaining life
current conversation goals: What is important now?
own handling: emotional distance? therapeutic Actionism?
accept own and patient’s feelings
be attentive to patient’s development + needs (e.g. advices, consolation, condolence)
be normal: humor, liveliness, or silence may help
don’t push the patient to process + confront his situation
conversation must end in a concrete agreement on the further procedure
Participative model
currently applied best synthesis
information on alternatives + collective decision-making
Communication techniques
mirroring: show understanding
directing attention: towards important statements
clarification: deepen understanding
establishing links: connections, e.g. reasons
conclusion: address open questions
physician needs to understand reactions and patterns of the patient
Sigmund Freud (1856-1939): first "
talking cure
behavioral therapy
integrative approaches: non-directive conversational therapy, systemic family therapy, somatic psychotherapy, relaxation techniques… (psychosomatic clinics)
Psychotherapy Act
: state-regulated training —> license
= super-concept for a variety of methods for
the treatment of psychic disorders
Parson describes ideal rights, obligations, and expectations towards a patient;
In reality stigmatization and prejudices influence how society judges and what they expect;
psychotherapy: need to access mental causes of suffering
get a holistic picture
Roger’s 3 basic attitudes: respect, empathy, authenticity
no perfectionism: respect own + patient’s limits
hope for a
change in perspective
empathic + caring doctor-patient relation
develop qualities: sensibility, openness, personal responsibility
Differences: adequate therapy depends on patient’s problem, personality, and needs
Sigmund Freud
(1856-1939); conflicts due to
unresolved desires
(sex drive), natural needs
internalized experiences
in relationships —> experience of
own value
+ inner and outside world
Key assumptions
Dynamic unconscious
: influences conscious experience + behavior (neuroscience)
Structure model of personality
Psychoanalytic theory of development
Psychoanalytic theory of disease
: unconscious, neglected conflicts that originate during mental development —> psychic + somatic symptoms:
2-3 times/week; over several years
trustful and safe relation enable the patient to become aware of conflicts
find more adequate solutions
correct emotional experience
": maturation/change of personality structure
Psychoanalysis-Based Therapy
once/week; 1-1.5 years
: reduction or elimination of current symptoms, conflicts, developmental deficits
Psycho-dynamically oriented therapy
Therapeutic Procedure
basic rule:
Free association
: access to earlier developmental states, conflicts, memories, and feelings
Floating attention
+ pointed questions
: unconscious topics, transference (of earlier relational patterns) —> explanation
thorough understanding + new handling
relation as diagnostic + therapeutic tool
requires time, motivation, introspection, handling of negative emotions
+ unsuccessful attempt to solve conflict (
conflict model
experience-based deficits (
deficit model
continuous traumatic damages (
trauma model
cooperative interpretation
: against unconscious contents
Working through
: insights into relations between problems and unconscious desires/needs; integrate to self-image
: use as diagnostic tool
Rule of abstinence
: no non-professional contact
Behavioural Therapy
1950s: treatment of
problematic behavior
+ causing and maintaining conditions
intrapsychic processes
, e.g. perception, thinking, evaluation, emotional reaction
today: behavioral + cognitive therapeutic approaches
uses principles of
learning psychology
for therapy
Key assumptions
psychic disturbances are
learned, dysfunctional strategies
to cope with mental stress
learning processes are
: behaviors can be replaced
explanations should be parsimonious, short, comprehensible, close to reality
Therapeutic Process: 7 Stage Model
therapeutic alliance
: cooperation, responsibility
: analysis, increase —> desirable change
behavior analysis
functional model
: conditions of cause + maintenance
therapy planning
of interventions
: problem-solving, self-management
horizontal behavior analysis
: description of current behavior + conditions of maintenance —>

vertical behavior analysis
: conditions of origin
Therapeutic Procedure
anxiety, compulsory behaviours, phobias
Repeated confrontation with weak to severe fear-inducing stimuli/ situations —>
Systematic desensitization
: according to
fear hierarchy
+ relaxation techniques
in sensu
": counter conditioning, unlearn fear reaction
in vivo
": deletion of fear reaction
: direct exposition to maximally fear-inducing situation —> extreme fear —>
physiological exhaustion
Key assumption
dysfunctional cognitive processes contribute to maintenance of psychic disorder, e.g. negative thoughts, expectations, attitudes, evaluations —> emotional reactions —> behaviors
Cognitive Procedures
Operant Methods
use learning principles of
operant conditioning
Positive + negative reinforcement
; e.g. anorexia
Stimulus control
of external factors —> new behaviors
: removal of all positive reinforcers
: removal of all reinforcers
S =
O =
organismic variables
: somatic + cognitive influences
R =
: psychological, cognitive, emotional,
K =
: reinforcement, punishment
C =
: correlation between reaction and
structured, problem- and patient-oriented process
explain development, maintenance of disrupted behavior
example: fear of exam
patient has to stay in the situation until fear is clearly reduced (relaxation or exhaustion) <—> else: negative reinforcement
Albert Ellis: Rational-Emotive Therapy
replace irrational with realistic cognitions
Cognitive-Behavioral Therapy
mix: cognitive techniques + change of deficit behaviors
Problem-solving training
: analyze + handle complex daily problems
Group training
of social competencies; e.g. role plays
Aaron T. Beck:
Cognitive Therapy
originally for depression
restructure typical thought patterns +
systematic thinking errors
notice selective perceptions, emotional arguments, should-/must-statements
example: exam
making, maintaining, stopping contact
distinguish emotional statements from opinions
express own + others’ desires and needs
distinguish aggressive from confident appearance
+ safe atmosphere
+ social learning: by observation of others + therapist
+ effect of an exposition therapy
+ direct, constructive feedback
Socratic Dialogue
+ check with facts (reference to reality)
Self-verbalization training
(Maichenbaum): positive,
constructive inner monologue
Other Forms of Therapy
Carl Rogers
inborn tendency for
of self-image with ideal self + experiences
—> growth, happiness, creativity, self-determination
—> neglect of undesired parts of self
—> problematic behaviors and experiences
support self-realization tendencies +
no concrete interpretation of causes
no concrete advices or behavior changes
deepen emotional experiences, clarification, insights
: enable reflection of (unconscious, nonverbal) thoughts, feelings, experiences, values in conversation
of emotional contents of experience
Key assumptions
Non-Directive Conversation Therapy
partner-like encounter
3 inner attitudes
+ active listening, paraphrasing, acceptance
consider family as a
self-regulating system
dynamic mutual relations
—> experience + behavior
"identified" patients: "
symptom carriers
" are the manifestation of dysfunctional interactions
of the system —> unblock development processes
Circular questioning
: interview family members about relations + behaviors of others
: alternative explanations of family patterns
Paradox intervention
: more intensive + regular dysfunctional behavior
Key assumptions
Systemic Family Therapy
reduce mental pressures, prevent psycho-somatic diseases
Progressive Muscle Relaxation (PMR)
Edmund Jacobson
: 1920s
tension + relaxation
of muscle groups
systematic + regular training reduces elevated
muscle tone
improved bodily perception + conscious relaxation
can lead to bodily + mental relaxation, reduce negative emotions
esp. anxiety symptoms, week depressive disorders, sleeping disorders, somatoform disorders, chronic pain syndromes
Relaxation Techniques
Wilhelm Reich
(1897 -1957): unsatisfactory results of psyhoanalytical approach
neglected + unconscious contents of earlier developmental stages show themselves in bodily signals,
movement patterns
, emotional expressions
training of
bodily exercises and expressions
emotional reaction, relief of tension
insight into unconscious
strengthening of healthy parts of personality
importance of relation + collective movements
Somatic mirroring
, „
“, verbal company of therapy
Key assumptions
Somatic Psychotherapy
Autogenic Training
Johannes Heinrich Schultz
: 1920s
auto-suggestive relaxation technique
focused imagination
of bodily sensations of the vegetative nervous system (parasympathicus: „rest & digest“)
verbal repetition
of relaxing formulas + training of a relaxed state
esp. examination stress

Medical Action

Physician-Patient Relationship


Life Span and Development


Theoretical Principles



Disease and Society


Special Medical Situations

Conducting Conversations
Special Communicative Situations

Full transcript