COMMUNICATION

Dr Alex Hunt &Dr Helen Brotherton

7th Dec 2012

Session Outline

• Patient Centred Communication • Conscious communications

– Interviewing skills• Attending skills• Open & closed questions• Responding skills

• Unconscious communications• Subtext- process vs content• Transference & counter-transference• Noticing feelings

Communication

• Patients assess the quality of their care largely through experience of talking to their clinician

• No matter how much knowledge you have, no use to you unless you can communicate it to others effectively and elicit information effectively from others.

• Good communication skills and patient centred care are associated with better health outcomes especially in chronic diseases.

Communication

• ‘Skills’– Behavioural actions (non verbal

communication)– Goals or function (elicit information)– Techniques

• ‘Process’– Negotiation – dance – Creative – intuitive

Tasks of communication

• Doctor

• Patient

Patient centred communication

• Eliciting, understanding and validating the patients perspective (concerns, emotions and expectations)

• Understanding the patient within his or her own psychological and social context

• Reaching a shared understanding of the patients problem and it’s treatment

• Helping share power by involving the patient in meaningful choices about their health care

Factors influencing patient-centred communication (Epstein, 2005).

Interviewing Skills

• In threes 5 minutes in each role– 1 interviewer– 1 interviewee– 1 observer

– Focus of interview - Why did you choose to become a psychiatrist?

– 1 minute feedback by interviewer about their interviewee.

Interviewing Skills

• Note that clients will always ‘hold back’ on important information during interviews/assessments

• This may be a conscious process on their part, or they may not be aware of what they’re holding back

• All interviews therefore reflect ‘Tip of the Iceberg’ conscious communications and ‘Beneath the Iceberg’ unconscious communications

Interviewing Skills

• Freud (1901):- “They [clients] can, indeed, give the physician plenty of coherent information about this or that period of their lives; but it is sure to be followed by another period as to which their communications run dry, leaving gaps unfulfilled, and riddles unanswered; and then again will come yet another period which will remain totally obscure”

Interviewing Skills

• Freud considered that interviews will always consist of:-– 1) Patients deliberately and consciously

holding back what they should tell;– 2) Unconscious memory lapses- parts of

the story disappear from the patient’s knowledge during its telling; and

– 3) ‘True amnesias’- gaps in the memory into which past and current attempts to recall information can fall

Interviewing Skills

• These reflections show how the psychiatric interview can be such a complex and difficult process

• The patient may be quite understandably guarded & protective about what information they reveal

• The interviewer will need to process the ‘tip of the iceberg’ content and will be influenced by the wealth of information ‘beneath the iceberg’

Interviewing Skills

As part of the psychiatric interview, the doctor may need to:-

• Help the client to understand the rationale of their mental health treatment

• Provide the client with sufficient information about their therapies, treatments to make consent meaningful (ie risks, benefits etc)

• Encourage the client to reflect on their reactions to the proposed therapies and treatments

• Share a tentative account of how you, as clinician, understands the client’s problems early on, to provide the client with opportunity to ask for clarity

Attending Skills

Dynamic engagement is achieved by:-• Listening attentively• Responding non-judgementally to the

client’s conscious and unconscious experience

• Clinician maintaining a consistent attitude

Attending Skills

Dynamic engagement is achieved by:-– responding to presenting problems in a concerned,

non-judgemental manner– asking clarifying questions, to understand the client,

without making assumptions– communicating empathic understanding in response

to conscious and unconscious communications– respecting the client’s need for defences and

defensiveness

Examples of Attending skills

• Handout

Open & Closed Questions

• A closed question can be answered with either a single word or a short phrase

• They give you facts. • They are easy to answer.• They are quick to answer.• They keep control of the conversation with the

interviewer.

Open and closed questions

• An open question is likely to receive a long answer.

• They ask the respondent to think and reflect.• They will elicit opinions and feelings.• They hand control of the conversation to the

respondent.

– Balance between the two types and styles– Closed questions helpful for clarification and

to provide frame and containment

Responding Skills

Developing a therapeutic alliance & good working relationship needs:- – The ability to foster development of a working relationship

of trust and rapport through…– containing anxiety, by engaging with the client’s anxieties

(conscious & unconscious) about their treatment– tolerating feelings and distress, and remaining emotionally

in tune with them– adjusting technique for clients who are presenting in a

disturbed way– providing brief guidance of expectations– communicating the frame and boundaries very clearly

Responses to patient communication

• Acceptance responses• To indicate understanding and Non-judgemental

listening•  Reflection responses• To reflect the feelings which underlie what the

person is saying to indicate understanding and accurate listening

•  Clarification / summarisation• Attempting to simplify what the client is trying to

say; tentative and therefore often phrased as a question

• •  

Responding to patient communication

• Specificity– To help the client to become more specific

and accurate, to move from vagueness to clarity

•  Paraphrasing – Restating the meaning of what the client is

saying in other words. Reflects understanding• Summarising

– Bring together what the client is saying in the form of a brief statement

Examples of types of responses

• See sheets

Unconscious Communication

Unconscious Communications

Small Group Exercise• What do we mean by unconscious

communications? • What may these actually look like in

clinical practice?• Why may attending to these

communications be particularly important to clinicians?

Working with unconscious communications

• The first level of communication (the conscious level) needs to be attended to during interviews

• But there is another level of communication -the unconscious level- which also needs to be attended to

• An over-emphasis on what is not explicitly said can undermine the development of a good therapeutic alliance, as much as not attending to it at all

• Balance is therefore needed between attending to conscious and unconscious communications

Working with unconscious communications

• Listening and responding to unconscious communications:-– By noting and reflecting on latent meanings in the

client’s nonverbal communications• By helping the client to elaborate on the idiosyncratic

use of language/imagery/dreams, to facilitate expression of feelings

• By considering the potential latent content by:-• Being curious to anxieties behind questions• Helping the client to reflect on un-verbalized

feelings

Listening to the Subtext

Lemma (2003)– When engaging in therapeutic encounters with

distressed clients, we need to always be asking ourselves:-

“is there a subtext to the story”? [p.181]– Listening to the subtext means listening to the

latent/unconscious content of a narrative– This process is the starting point for eventually

working with unconscious communications

Listening to the Subtext

How to listen to the subtext [Lemma, 03]– 1) Don’t be tied to the narrative’s apparent content - listen

to the relationship patterns, ie ‘who is doing what to whom?’

– 2) Observe the language, eg rhythm, tone– 3) Whatever the client tells you, resist the temptation to

jump in- instead ask for associations • ie ‘What do you make of this…?’

– 4) Explore the dominating affective experiences in the narrative with the client, • ie In telling you about someone else, is the client

feeling fearful, envious, hostile etc?– 5) Make a note of how you feel (your C-T)– 6) Consider the possible implications in what is being

recounted, esp if something is told awhile after it happened • ie ‘why is this particular story being brought now?’

Transference & Counter-Transference

• Hughes & Kerr Responses to the article– Transference and counter-transference in the

doctor patient relationships

What is the Transference?

Strong feelings for both the client and the clinician exist within an ‘emotionally live’ therapeutic relationship (Lemma, 2003)

‘Natural transference’ is “a very ubiquitous phenomena” (Krause & Merten, 1999)

Essentially, the transference refers to the transfer of strong feelings from both past and current situations/ relationships into an immediate interaction (ie the ‘here and now’ therapeutic encounter)

What is the Counter-Transference?

• Essentially, counter-transference is the clinician’s own emotional reactions within the therapeutic encounter

• However, definitions of counter-transference are varied & include:-– a) affective resonance and empathy (Stern, Winnicott)– b) feelings resulting from projective identification

(Klein, Bion etc)– c) the clinician’s response to the client’s ie the client

representing important people from the therapist’s past (Freud)

– d) the clinician’s blind spots or resistances (Freud)

Counter transference

• Being aware of our responses and feelings;

• DVD

Guidelines for working with Counter-transference (Lemma 2003)

1) Learn to note your own emotional responses to the client’s verbal/ nonverbal communications

2) Are feelings you are experiencing (or not) linked to issues in your own life?

3) Even if the feelings produced seem to reflect personally relevant issues, they may also still be projections

4) Try to stay with the feelings evoked in you - note how they’re making you feel or pressing you to do, but repress the urge to act on these

5) This internal reflection will enable you to gain an emotional perspective, which will be helpful in your communications and how you respond to the client

Responding to difficulties in the clinician-client relationship

• The therapeutic relationship can be used as the main vehicle for change for the client

• But, the relationship can suffer misunderstandings and misattunements all the time

• The clinician needs to be open to these difficulties, using interest and openness to make sense of them

• The therapeutic relationship can actually be strengthened by the exploration of these difficulties

Responding to difficulties in the clinician-client relationship

• In the therapeutic relationship, there will be the difficulties brought by the client, the clinician, and sometimes the organization

• A clinician needs to reflect on their part in any difficulties in a therapeutic interaction by:-– a) engaging in self-reflection on this;– b) considering contributions from both client and

clinician– c) distinguishing between when difficult reactions to

the therapeutic encounters are actual client difficulties, or an accurate perception of differences, or reflect difficulties in the relationship

Difficult Clinician-Client Encounters

Role Play/ Group Exercise:-•Read through the information you have on your card•Observe the clinician-client encounter being role-played•Ask yourself…..

– Where do the communication difficulties in this encounter seem to lie?

– Who did your sympathies lie with?– How could the clinician have communicated

differently to the client?

Difficult Clinician-Client Encounters

• Letters exercise– Think about this referral letter from a

psychiatrist to a team colleague– What do you think could have been occurring

for both the client and the clinician in this encounter?

– What may it have felt like for the client to receive this communication?

Noticing Feelings

• DVD clip ‘Paul Whitehouse’

Reflections on feelings in therapeutic encounters

Small Group exercise• Think about a client encounter that you’ve had

your strongest feelings/ reaction about:-– either positive or negative feelings– why this may have been the case with this particular

client?– was it something about the client? what they did/said?

how they presented in the session? Etc– was it something about you at the time of the

encounter? did something about the client possibly resonate with something in your life?

– or does it now still seem inexplicable & confusing?