Therapeautic Relationship

Dr. D. Dutta Roy, Ph.D.(Psy.)
LECTURE NOTES ON THERAPEUTIC RELATION
PERFORMING ART THERAPY CENTRE
RABINDRABHARATI UNIVERSITY
KOLKATA
To be presented


INTERVIEW
A skillful interviewer is able to gather the data necessary to understand and treat the patient and in the process to increase the patient's understanding of and compliance with the patient's advice.

Factors influencing interview:

1. The patient's personality and characteristics significantly influence transference reactions and the emotional context in which the interview unfolds.

2. Different clinical situations - hospital ward, psychiatric ward, emergency room, or as an outpatient-shape the types of questions asked and recommendations offered.

3. Technical factors - telephone interruptions, use of interpreter, note taking, physical space and room comfort.

4. The timing of interview in the patient's illness, be it in the most acute stage or during remission influences content and the process of interview.

5. The interviewer's style, orientation and experience have a significant influence on interview.

6. The interjections like " uh-buh" can influence what a patient will or will not say and when, as individual tries unconsciously to follow the cues provided by the therapist.

FUNCTIONS OF INTERVIEW

1. Determining nature of the problem
Objective: To establish diagnosis and course of treatment and predict nature of illness.

2. Developing and maintaining a therapeutic relationship
Objective:a) The patient's willingness to provide diagnostic information.
b) Relief of physical and psychological distress.
c) Willingness to accept a treatment plan or a process of negotiation.
d) Patient's satisfaction
e) Physician's satisfaction


3. Communicating information and implementing a treatment plan
Objective:a)Patient's understanding of the nature of illness.
b)Patient's understanding of suggested diagnostic procedure.
c)Patient's understanding of the treatment possibilities.
d)Achievement of consensus between physician and patient over the above items 1-3.
e)Achievement of informed consent.
f)Improved coping mechanisms.
g)Lifestyle changes.



SKILLS:

1. Knowledge base of diseases, disorders, problems, and clinical hypothesis from multiple conceptual domains like biomedical, socio-cultural, psycho-dynamic and behavioral.

2. Ability to encourage the patient to tell his or her story, organizing the flow of interview, the form of questions, the characterization of symptoms and the mental status examination.

3. Ability to perceive data from multiple sources (history, mental status exam, physician's subjective response to patient, non-verbal cues, listening at multiple levels.

4. Hypothesis generation and testing.

5. Developing a therapeutic relationship (Function 1)

6. Hearing, bearing, and tolerating the patient's expression of painful feelings.

7. Appropriate and genuine interest, empathy, support and cognitive understanding.

8. Attending to common patient concerns over embarrassment, shame and humiliation.

9. Elicitation of the patient's perspective.

10. Determining the nature of the problem.

11. Communicating information and recommending treatment.

12. Establishing the differences in perspective between therapist and patient.

13. Educational strategies.

14. Clinical negotiations for conflict resolution.



SPECIFIC INTERVIEW TECHNIQUES:


1. Open-ended vs. Close-ended questions:-

Open ended : Physicians allow the patient to speak as much as possible in his or her own words.For e.g. "Can you tell me more about it?"

Close-ended:Here more directive question is asked or specific information and that does not allow the patient many questions in answering.For e.g. "Tell me more about what your feeling and what you think may be causing it?"


2. Reflection:-

The purpose of reflection is two fold: to assure the therapist that he or she has correctly understood what the patient is trying to say and to let the patient know that the doctor is perceiving what is being said. It is empathic respond meant to allow the patient to know that the therapist is both listening to and understanding the patient's concerns.

3. Facilitations:-

The therapist helps the patient continue in the interview by providing both verbal and non-verbal cues that encourage the patient to keep talking. For e.g. nodding one's head, leaning forward in one's seat, saying "yes, and then....?"

4. Silence:-

Silence may be constructive to allow the patient to cry or just to sit in an accepting, supportive environment where it is made clear that not every moment must be filled with talk.

5. Confrontation:-

Confrontation must be done in a skillful way so that the patient is not forced to become hostile and defensive.

6. Clarifications:-

Here the therapist attempts to get more details from the patient about what the patient has already said: " You are feeling depressed, when is it that you most depressed?"

7. Interpretations:-

This technique is used when the therapist states something about the patient's behavior or thought that the patient may not be aware of.

8. Summation:-

Periodically during the interview, the therapist can take a moment and briefly summarize what the patient has said thus far .

9. Exclamation:-

Therapist explain the treatment plan to the patient in easily understandable language and allows the patient to respond and ask questions.

10. Transition:-

This technique allows the therapist to explore other related information besides already explored information.

11. Self-revelations:

If the physician feels that some piece of information will help the patient be more comfortable, the therapist can decide self-revealing.

12. Positive reinforcement:

This technique allows the patient to feel comfortable telling the doctor anything, even about such things as non-compliance with treatment. For e.g. " I appreciate your telling me that you have stopped taking your medication. Can you tell me wht the problem was with the medication? The more I know, the better I will be able to treat you in way that you will feel comfortable with.

13. Reassurance:

Truthful reassurance can lead to increased trust. False reassurance can badly impair trust and compliance. False reassurance is given to make a patient feel better tactfully.For e.g. "Am I going to be alright doctor?" The doctor response "I am going to do everything I can to make you feel as comfortable as possible".

14. Advice:

Giving advice too quickly can lead the patient to feel that the doctor is not really listening. Therefore, advice is to be given at that time when the patient is ready to accept.