Introduction to Relational Dynamics in Practice: Managing difficult situations

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Miles Cooper
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1 Introduction to Relational Dynamics in Practice: Managing difficult situations Tsafi Lederman & Jenny Stacey

2 Aims 1. To increase the practitioner s awareness of psychological processes during treatment 2. To increase understanding about how psychological processes can lead to difficult situations 3. Consideration of how to manage difficult situations

3 Topics Therapeutic Encounter Working Alliance Frame and Boundaries Relational Dynamics Power Projections Transference Counter transference Empowerment Communication Verbal Non-verbal Touch

4 Therapeutic encounter Relationship Background History Beliefs Attitudes Etc. Practitioner Treatment Patient Background History Beliefs Attitudes Etc. Physical/contractual boundaries Fox S (2008) Relating to clients. Jessica Kingsley Publishing. London

5 Therapeutic Relationship Studies show: Positive outcome is dependent on the relationship created with the patient, more than the psychotherapeutic approach used Cooper, M. (2008) Essential Research Findings in Counselling and Psychotherapy Sage

6 What the Patient may bring to the Therapeutic Relationship Vulnerability Pain Not in control of body & emotions Frustration May be regressed Expects the therapist to be helpful May be in crisis Wants to trust you Power Differential (may have clothes off; lying down)

7 Past therapeutic experiences Failure or success of past treatments

8 What the Therapist brings to the Therapeutic Relationship Expertise Skill and Knowledge In charge Is expected to be helpful Presence Personal Process Self awareness Power Differential Clothes on

9 The Therapeutic Frame Scheduling Frequency, time, duration, length, number of sessions, dates, etc.. Administrative Fees, who pays, who collects payment, cancellation, reports and correspondence to other health professionals Procedures History taking, examination, type of treatment, How often Patient involvement / participation in management Confidentiality Respect private emotional and physical space

10 Possible issues around the frame Positive: Secure base Good authority Being cared for Appropriate boundaries Easing anxiety Providing containment for feelings Builds Trust Negative: Resentfulness Cheated Rage Helplessness Rebellion Loses trust

11 Awareness level of relational dynamics Conscious Out of awareness/ unconscious Personal/cultural history and relational patterns Feelings expressed in relation to the frame (e.g. by coming late; changing times, payment, etc.) Directly to the therapist my other osteopath got me better in one treatment

12 Relational Dynamics Past Present Personal experiences Therapeutic experiences Projections Transference Power dynamics The session

13 Projections You are angry with me!? A defence mechanism where your own emotions and traits are attributed to someone else

14 Transference You are angry with me because I didn t do my exercise, just like my father The process whereby emotions are passed on or displaced from one person to another (usually the parents) onto the therapist

15 Counter-transference You are angry with me because I didn t do my exercise, just like my father Yes, I am angry with you because you didn t do your exercise. Why am I feeling so angry? The feelings, thoughts, behaviours evoked and experienced by the therapist in the therapeutic relationship

16 Counter-transference: mine or theirs? Consider: Is this a familiar? Does it make sense? Is it related to my own process? Do I feel like these with other patients?

17 Exercise Think about a difficult client. Imagine they are about to arrive What sensations do you have in your body. What thoughts are you aware of? How do you feel?

18 Internal Supervisor what s going on here **!!!????!! **?

19 Power Dynamic Power with Power Over Powerless

20 Relational dynamic: Transactional Analysis Ego States Parent Parent - Taught concept of life Adult Adult - Thought concept of life Child Child - Felt concept of life

21 Therapist Patient Parent Parent Adult Adult Child Child Transactional analysis model

22 Therapist Parent Patient Parent Critical Nurturing Critical Nurturing Adult Adult Child Child Rebellious Free Rebellious Free Transactional analysis model

23 Co-created Relationship Collaboration

24 What does the patient want? Therapeutic encounter / relational dynamics Practitioner caring, listening and empathic Treated with respect Feel at ease Same practitioner throughout treatment Working alliance (framework) Information about the treatment Referral when necessary Environment hygienic and professional Use appropriate examination and procedures expected from the discipline Minimum 30 minutes consultation Value for money Patient involved in decision making Confidentiality Communication Advice on self-care Explanation of condition To be able to ask questions Sufficient and easy to understand explanation Informed of risks and side effects Leach J, Cross V, Mandy A et al 2011 What patients expect from their osteopath. The Osteopath

25 How to Empower? Listening Use of words Match language to patients level Awareness of non-verbal Informed judgment Use positive statements Use inclusive speech (we can..) Give choice Allow contribution from patient Agreement is negotiable Shared responsibility

26 How do you listen? Verbal Communication Listen to words Non-verbal Communication Observe the body Listen to the underlying expression Touch Communication

27 Communication: Blocks to Listening Judging Mindreading Evaluating Being right Advising Arguing Deflecting Not being present What stops you..? What helps you listen?

28 Empathy Empathy is standing in the shoes of the other person and seeing the world through her eyes Communicate your empathic understanding

29 Forms of communication Verbal Non- verbal 30-40% 60-70% The Therapeutic Relationship depend on the communication between patient and therapist.

30 Body language is particularly important at the initial meeting. Liking 7% Verbal + 93% Non Verbal Albert Mehrabian, 'Silent Messages' (2009)

31 Touch Communication What would you like to communicate in a therapeutic situation (with touch)?

32 What would you like to communicate? Re-assurance Comfort Safety Acceptance Trust A Calming Presence Compassion Empathy

33 Touch Dialogue Patient s perception of touch Touch event Psychological, social and cultural attitudes Previous tactile experiences Response Lederman E 2005 The science and practice of manual therapy. Elsevier

34 What we need to be aware of in the Touch Dialogue Must be appropriate to the therapeutic situation The objectives and intentions are clear Does not impose greater intimacy than the patient desires Does not communicate a negative message Lederman E (2005) The Science and Practice of Manual Therapy. Elsevier

35 Relationship to the body Most woman have difficult relationship to their bodies. They expect to be criticised or attacked 97% woman have daily negative thoughts about their bodies Ann Kearney-Cooke Dissatisfaction with body shape continues throughout the life

36 Touch Communication Dialogue Therapist intention Patient (receiver & respondent)

37 Breakdown in Communication Therapist (giver & receiver) Patient (receiver & respondent) Lederman E (2005) The Science and Practice of Manual Therapy. Elsevier

38 Characteristics of Instrumental & Expressive Touch Instrumental Touch intent Expressive Local / Focal Brief Force dependent May be painful Investigative, prodding Mechanistic Uninvolved Corrective Broad, integrative Maintain contact Force irrelevant Pleasurable Touching the whole person Attentive & responsive Expressive communicative Lederman E (2005) The Science and Practice of Manual Therapy. Elsevier

39 Considerations Communicate clearly: use empathic listening Explain what you are doing Ask permission before any procedure Ask permission before you touch any part of the body Be aware of the relational dynamic Engage with the Adult part Check out what s going on for patient Write up notes of session

Habits & Goals Discovery & Assessment. What kind of person do I want my child to grow up to be? How do I react to my child most often?

Habits & Goals Discovery & Assessment How do I react to my child most often? What kind of person do I want my child to grow up to be? Focus on the Relationship Conscious Communication Practice Use these