The Therapeutic Relationship
By Alex Owen - BSc. (Hons) TCM, Bachelor Medicine (Beijing), MATCM
The Therapeutic Relationship
BSc. (Hons) TCM, Bachelor of Medicine (Beijing), MATCM
26th April 2004
The therapeutic relationship is central to the patient oriented approach to health care that stands complementary medicines apart from their western counterpart. But what are the skills required by the practitioner to instate a strong therapeutic relationship that can beget great benefit for patient?
This thesis will investigate some of the skills that must be developed, by the practitioner, to enhance the healing relationship with their patients. It will also explain the benefits of each of the different skills and look at the consequences of over using them.
The therapeutic skills looked at will be:
This thesis aims to explain the skills that a practitioner must develop, in order to build a strong therapeutic relationship with his/her patients.
When a patient encounters illness, it seems that their body is no longer under their control. In modern western medicine, this phenomenon is due to the encroachment of disease, if the disease can be controlled, then health will return. The patient must visit a doctor, who will ask them a series of questions about their symptoms in order to categorise the disease. A treatment can then be prescribed and the disease fought. As western medicine has moved toward a scientification approach to medicine, it has been found to be far less appropriate for chronic and stress related complaints. These complaints make up a huge proportion of cases that now encumber the National Health Service in this country and Millenson puts forward that this is due to the movement away from the patient centred approach and toward a more practitioner oriented one (1995, p236).
Complementary therapies often implement the patient oriented treatments in order to fully understand the patient as a whole, not simply their disease. This type of treatment is in contrast to practitioner centred treatment where the practitioner is seen as the expert and upon whom the patient relies to overcome their illness. The patient oriented approach aims to empower the patient with the knowledge and ability in order to recover from their illness.
Although complementary therapists must know when to use each of these approaches, most of the work with the patient is from the patient centred approach. At the centre of the patient oriented treatment is the therapeutic relationship between the practitioner and patient. If the practitioner has the ability to nurture a strong therapeutic relationship with his patients, they will be more willing to open up to him, strengthening his capacity to treat them. The extra trust alone that comes with a strong therapeutic relationship has been shown to significantly improve the therapeutic outcomes of treatments.
Mitchel & Cormack summarise the concept by saying that “patients themselves value therapeutic relationships which offer respect, trust and care and it seems that such relationships may in themselves prove to be healing in the broadest sense.” (1998, p50).
The increased level of trust between patient and practitioner will also aid treatment by making the patient more willing to follow the practitioners advice and treatment strategy. Therefore, if a practitioner really desires to help his patients, he must become adept in the skills required to forge and maintain a strong therapeutic relationship.
In practice, the relationship enables the sharing of knowledge, which gives the patient a sense of control over their situation. A further sense of control is gained by the apparent ‘sharing of power’ within the therapeutic relationship. The relationship not only offers knowledge but also the ability to take an active role in the management of the illness.
The practitioner must be able to accept every patient who comes to see him, regardless of their background, social standing, ethnicity or presenting illness. This acceptance must be unconditional and the patient must not be made to feel that it has to be earned. The practitioner must also remember that this acceptance might not always be reciprocated. If this skill can be practiced, the patient will feel less inhibited when talking to the practitioner, as they do not have to fight against preconceptions.
Empathy is another important skill that is vital to building a therapeutic relationship. Burnard sites Kalisch as defining empathy as ‘the ability to perceive accurately the feelings of another person and to communicate this understanding to him’. This means that the practitioner must be able to view the patient’s illness and situation from their position and not look down upon them from an exalted stance.
It is underpinned by the notion, central to patient centred treatment, that the patient has the ability to find the answers and changes needed in order to overcome their illness and difficulties in life. By being empathic the practitioner is able to support the patient as they find these answers and make the changes. Empathy must not be confused with sympathy, which often has the effect of reinforcing powerless felt by the patient.
Empathy does not always have to rely on the ability of the practitioner to enter the perceptual world of the patient but he can, at times, draw on his own experiences of life and illness. Throughout history the notion of ‘the wounded healer’ has been associated to the ability of the practitioner. Mitchel & Cormak site Carl Jung saying ‘In the end, only the wounded physician heals’.
This form of empathy appears to be able to work in several ways. The first works on the understanding that being a patient or a healer is not mutually exclusive. If the practitioner is able to convey the awareness of his own potential for being a patient, then this may activate the intrinsic potential in the patient to be a healer. Which could contribute to their own self-healing.
Alternatively the practitioner could inspire the patient by sharing knowledge, based on direct personal experience, of overcoming specific afflictions that relate to the patient. This authority may bolster the patient’s confidence and inspire them to take action against their current situation. The understanding the practitioner has gained by personally experiencing suffering can also give him a great insight into the needs of the patient.
However, one very important aspect that must be maintained, is the patient must always remain at the centre of treatment and must in no way feel that the practitioner is more interested in imparting wisdom and personal experience than actually listening to them. Millenson roundups by stating: “accurate empathy is always empowering, since it represents an understanding and acceptance of the speaker’s feelings” (1995, p256).
Attending & Listening
Listening and paying full attention to the patient is possibly the single most important skill that must be honed by the practitioner. It is a prerequisite of many of the other skills, for without listening and actually hearing what the patient has to say, there is no base on which to build a relationship with the patient. Burnard describes the art of ‘attending’ as “the act of truly focusing on the other person, consciously making ourselves aware of what they are saying and what they are trying to communicate”. By fully concentrating on the patient, the practitioner will not be distracted by their own thoughts or by getting caught up in trying to interpret what the patient is saying.
Listening refers to more than simply hearing what the patient says. The practitioner must be aware of three aspects; linguistic, paralinguistic & non-verbal. The linguistic aspect refers to what the patient says and the ways in which they choose to express it. Paralinguistic refers to the aspects of speech such as timing, volume and fluency. Non-verbal aspects mainly refer to the patient’s body language and facial expressions that occur during the dialogue. The three aspects will not necessarily support each other and can relay information to the practitioner that the patient may be unaware of. However, it is very important for the practitioner not to jump to conclusions as to the meaning of specific aspects. Instead they should be used as a way of directing the practitioners questioning in a direction that may not have been taken.
The practitioner must refrain from ‘over-talking’ and asking too many questions. Instead open-ended questions should be used. This reaffirms the patient at the centre of the treatment, encouraging them to talk openly and unrestricted. This may have the benefit of revealing a deeper understanding of the patient and new levels to their personality.
Reflection can also be used to this end. This is when the practitioner picks up on the last few words spoken by the patient in order to encourage them to expand on the point. However, closed questions are sometimes necessary when looking into specific manifestations of illness but in general open-ended questions will go further to empowering the patient.
Silence can also be an important tool to the practitioner and they should not feel that there must always be someone talking. Silence can give the patient time to think about what they want to say and the best way to express themselves. At the same time it gives the practitioner time to collect his thoughts and assimilate what the patient has been expressing. It must be remembered not to allow the silence to last too long, as it may become uncomfortable and if silences occurs too often, it could cause the patient to question the practitioner’s ability.
Physical and Behavioural Techniques
To encourage the patient to continue their elucidations, the practitioner must maintain concentration on what they are saying while at the same time clearly conveying this fact. Several skills can be employed by the practitioner to indicate to the patient that he is following what they are saying. Minimal prompts such as head nods, ‘yes’s’ and ‘mm’s’ can be used to this end. Although useful, if used excessively they can actually have the opposite effect, making the practitioner simply appear to be using a detached, automated response.
The practitioner can use certain behavioural techniques to show that they are interested in what the patient has to say. Different seating arrangements can lead to subtle changes in the communication process. Sitting directly across a desk from the patient, the practitioner creates an authoritative / dependant setting. However, if the patient only sits across the corner of the desk from the practitioner this authoritative barrier is reduced, allowing up to six times more interaction to be obtained. If the practitioner sits next to the patient there is a further reduction in the sense of authority and interaction will fall. This lack of authority can be compensated for in other ways, such as wearing a white coat.
In all seating scenarios, the practitioner should always sit squarely to the patient so as to be in a position to clearly observe all aspects of the patient’s communication. It is helpful if the practitioner adopts an open posture so as to ‘physically embody’ receptiveness to what the patient is saying. If the practitioner leans toward the patient slightly, it can again ‘physically embody’ interest. Reasonable eye contact is an important tool to convey that the practitioner is listening and understanding the patient. However, these techniques can be overused, making the patient feel uncomfortable.
Finally the practitioner should be relaxed when listening to the patient and fully devote themselves to the tasks of listening and attending. If the practitioner appears nervous this will not inspire trust in the patient and the practitioner may begin to ‘over talk’ and forget about listening.
Concreteness refers to clarity, both in the practitioner’s dealings with the patient and also in helping the patient to express themselves. This is very important when dealing with patients who are suffering from an illness. It often entails the use of closed questions to help clarify vague statements made by the patients. An example would be when enquiring about diet and the patient responds that they have a ‘healthy diet’. The practitioner’s idea of healthy might be far removed from the patient’s idea and it will be beneficial if the practitioner enquires more specifically as to the composition of the diet.
The practitioner can greatly empower the therapeutic relationship by clearly explaining how he views the patient’s illness, what steps he will take and what steps he would like the patient to take. When these explanations are given, technical language should be avoided. The practitioner must also try to make sure they are understanding what the patient is explaining and can occasionally summarise in order to clarify what has been said.
The practitioner must also take measures himself in order to remain professional and in a position to help the patient. They must find an optimum position at which to stand in regard to the patient. The practitioner must avoid throwing himself into each case, as he will lose objectivity and allow personal feelings and emotions affect his professional position. However, stand too far back and he will lose the empathic viewpoint.
Another aspect of remaining professional is that the practitioner must know his limits. The practitioner should never be too proud to know when something is beyond his capabilities. By referring a patient to another more experienced or specialised practitioner, not only will patient benefit by receiving the best care available but the practitioner will be able to learn from the experience and improve their own skills.
This ability to make boundaries and stay within them, is very important for the practitioner. It can even be extended to not overexerting himself in the work place, for example taking on too many patients or not following prearranged treatment times. This will apply extra stresses on the practitioner, reducing his ability to apply himself to each patient.
Warmth & Being Genuine
The final two skills looked at here are more to do with personality of the practitioner rather than skills that can be learned. However, they are very important in achieving a close therapeutic relationship in which the patient feels they can fully trust the practitioner.
Warmth refers to how approachable the practitioner appears to the patient. The practitioner, in order for him to express warmth, must embody certain aspects. Burnard quotes Schulman as naming these as equal worth, absence of blame, non defensiveness and closeness.
Warmth is difficult to perceive and one person’s warmth may be another’s patronage or sentimentality. Be this as it may, the practitioner should always strive to be warm and welcoming and gauge this depending on his individual patients.
Genuineness is another facet of the practitioner’s personality that cannot really be learned The practitioner really must have a genuine desire to help if a therapeutic relationship is to ever develop. If other factors motivate the practitioner, i.e. money or personal gain, then this will always act as a barrier between himself and the patient. Genuineness is based on the ability of the practitioner to be open with his patient and not to over emphasising his professional role. It will help to reassert the patient as the centre of the treatment and promote the patients trust in the practitioner and his treatments.
It can be seen that the skills above can go along way to building a good therapeutic relationship but it must be remembered that they can be overused. The practitioner must also learn when to use a more practitioner centred approach but must remember that in order to truly develop the therapeutic relationship, he must return the patient to their rightful place at the centre of the treatment. This knowledge will come with experience and a genuine interest in helping patients.
With the holistic idealism of complementary therapies, the practitioner must aim to build a strong therapeutic relationship so that the patient will engage their own spiritual and personal resources – strength, courage, determination, the will to live, the ability to see and find meaning in crisis, the grit to convert problems into challenges. Healing is seen as a result of a natural force that resides in us all and when combined with an effective therapy and a good therapeutic relationship this healing power can be greatly enhanced.
Placebo treatments have proved to be up to seventy percent effective when three important factors were present: i) the patient believed in the method, ii) the practitioner believed in the method, iii) the patient and practitioner believed in each other (i.e. strength of their relationship). This shows that a strong therapeutic relationship has a enormous effect on the patients perceived ability to recover and must be seen as an indispensable tool for any healthcare professional interested in helping those in need.
Burnard P. (1992). Effective Communication Skills For Health Professionals. London: Chapman and Hall
Burnard P. (1995). Counselling Skills For Health Professionals. (2nd ed). London: Chapman and Hall
Kaptchuk T. (2000). The Web That Has No Weaver : Understanding Chinese Medicine (2nd edition). Lincolnwood (Chicago): Contemporary
Maciocia G (1989). The Foundations of Chinese Medicine. Edinburgh: Churchill Livingstone
Millenson J.R. (1995). Mind Matters: Psychological Medicine In Holistic Practice. Seattle: Eastland Press
Mitchell A & Cormack M. (1998). The Therapeutic Relationship in Complementary Health Care. London: Churchill Livingstone
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