therapist-patient relationship

therapist-patient relationship 1

Therapist-Patient Relationship

신 정 호YUWMC Dept of Psychiatry


Therapist-Patient Relationship

• initial encounter, the 1st moment of contact

• pt’s personality - primary therapeutic focus

• therapist’s personality- primary therapeutic instrument

• interaction- matrix of psychotherapy


Therapist

• convey an intrinsic genuine interest in pt:- most important than position, appearance, reputation, clinical experience, training, technical and theoretical knowledge

• close, detailed attention needed within professional relationship


Therapist’s Attitude to Patient

• fellow human being

• more complex than can be grasped and described

• Pt offers therapist potential for increasing professional skill, contributing knowledge

• skilled and sensitive therapist - no humility, respect, care,


Initial Encounter

• confidence in his clinical skill• tolerance of perplexity inherent in process • ability to step out of his own needs and conflict• attitude toward sickness • sensitivity to suffering • ability to recognize and confront intense emotion

both in his patient and himself• intrinsic desire to help • awareness of nuance of feeling• ability to relate warmly• respect for himself and others• value for human life, his very philosophy of life


Therapist’s Standard of Conduct

• Practice of shaking hands– personal warmth and respect– ease tension – reassure– make therapist more human

• warm and respectful as in dignitary visit– introduce himself, offer hand, take pain to make

visitor welcome and comfortable, honor visitor’s title, strive to be relaxed, composed, warm, responsive


Therapist Emotional Resources and Standard of Conduct

• Capacity for establishing effective therapist-patient relationship

• same courtesy in social relationship

• more consideration than in ordinary social interaction:pt - stressful, confused, apprehensive, embarrassed, humiliated


Professional vs Social Relationship

Interaction must be solely for the benefit of pt.– constrained though spontaneous– focus solely on need of pt– objectivity– sensitivity– limitation on relationship - frustration – warmth and kindness; friend?


Concept of Resistance and Therapeutic Alliance

• Resistance– overtly & covertly oppose effort to effect relief

• Therapeutic alliance– conscious and unconscious desire to cooperate

with therapist’s effort to help– rational, non-neurotic part


Manifestation of Resistance

clinical manifestation: avoid looking therapist, hide in chair, not move or m

ove incessantly, tell nothing to say, sx disappeared, refuse to discuss, jargon, assume ignorance or stupidity, automatically reject every comment, joke, excessive compliance, hopelessness of help, attempt to talk about therapist, seductive, mute or stutter, overt hostility & uncooperativeness, one- or two- word answer


Resistance

– Tension and anxiety• stress inherent in this relationship• unconscious material• subjective experience

– step to reduce• issue of trust and confidentiality• facilitate communication• initial exchange:

“ 병원 찾기가 힘들지 않았어요 ?”“ 비가 이제 그쳤습니까 ?”


Obstacles in Patient

– Misconception about psychiatric service• pass of information - confidentiality• being ‘brain-washed’ against his will - direct

reassurance, clarification of goals

– secondary gain from illness– displaced motivation

• 1st task - shift motivation from parent to pt himself

– psychological defense• intellectualization to avoid meaningful material


Obstacles in Therapist

• Therapist’s mannerism– alert to his dress and speech– inability to listen sympathetically– insensitive comment– premature reassurance– judgmental tone– patronizing air



• Anxiety within therapist• impede pt’s telling story & therapist’s ability to hear

• blind spot - parallel unresolved conflict in therapist

• professional insecurity, intuitive ability, confidence in clinical skill - difficult to tolerate pt’s hostility and criticism

• handling anxiety• talking excessively

• becoming excessively quiet



– Fatigue • emotionally exhausting, physically immobile

– impatience• over-eagerness rather than waiting calmly

– inattentiveness• attentive level gaze

– restlessness– daydreaming

• more frustrated in his extra-professional life• ‘session-tight compartment’


Effective Listening

– Intensely active emotional and intellectual process though physically inactive

• By effective listening– convey genuine interest – facilitate pt’s communication– establish solid therapeutic alliance

• Keep out of pt’s way– to keep quiet– to keep spotlight focused completely on pt


Elements of Effective Listening

• Awareness and resolution of his own conflicts to avoid reacting to interfere pt’s free expression

• avoid verbal and nonverbal expression of disdain or judgement to pt’s story

• wait patiently through periods of silence or tears

• hear what pt says, trying to say, and what he leaves unsaid

• use both ear and eye to detect messages; tone, posture, other cues


Elements of Effective Listening

• scan his own reaction to pt

• avoid looking away from pt as he speaks

• sitting still

• limit mental excursion s into his own fantasies

• control feelings toward pt interfering with accepting, sympathetic, non-judgmental attitude

• realize that full acceptance of pt is possible without condoning or sanctioning attitude and behavior destructive to him or others


Feelings toward Patient

• Reality– Most patients have some unlikable quality.

• Countertransference– inappropriate intense feeling– unconscious displacement from person in past t

o present patient– more difficult to understand and control them


Jargon as Obstacles

– Pt’s use of psychological jargon– therapist’s use of technical term

• dehumanize

• oversimplify

• express veiled hostility

• less secure - stereotyped concept & more jargon

– ability to describe human behavior with psychodynamic understanding but without psychoanalytic jargon


Humor as Obstacles

– Destructive potential in relationship, though humanizing, easing tension, facilitating communication

– alert to what pt actually feels– joke as a form of resistance– therapist’s humor -

tune with pt’s feelingsmile with, not at pt


Ethical Consideration

• Sexual relation issue– most vulnerable– 5 - 13% of erotic behavior– must reject pt’s physical expression of such

feeling, but be careful never to reject the pt– destructive to pt -

a source of resistanceproblem controlling impulse

– destructive to therapist

therapist-patient relationship

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