Doctor-Patient Communication and Medical Psychology
Main Communication Forms
I- Verbal:
- Direct: The patient says what they think.
- Indirect: The patient implies something; the meaning is covert. The doctor should interpret it.
II- Non-Verbal:
- Body Language <—> Psychology
- Physiology is influenced by psychology.
- Body language:
- (Eye contact, facial expression, gesture)
- Prolonged:
- (Voice tonality, speech style, articulation)
- Self-presentation:
- (Looks, personal space)
III- Disturbance:
(Emotional condition, perception, personality, health, sex, age, stereotype, nationality)
Peculiarities in Doctor-Patient Relationship
Patients expect doctors to provide:
- Communication
- Collaboration
- Time
Factors influencing authority:
(Sex, Age)
| Child | Adult |
6 Months: Non-verbal (facial expressions, crying) 6-18 Months: Non-verbal Some verbal 3-6 Years: More verbal Can make choices 6-12 Years: Like an adult Direct questions 12 Years+: Respect privacy Communicate like an adult Don’t lie | Empathy Listening Collaboration Respect privacy |
Characteristics of an Ideal Doctor
- Self-confident
- Empathetic
- Humane
- Personal
- Straightforward
- Respectful
Stages and Functions of Medical Conversation
MEDICAL CONVERSATION (Stages + Function) | MODELS of Communication |
Orientation Study:
Clarification Stage:
Definition Stage:
Conclusion:
| Parentalistic:
Informational Model:
Interpretation Model:
|
Stress in Medical Occupation and Burnout
Stress in Medicine:
- Physiological: Noises, climate
- Mental: Lack of time, colleagues, family
- Social: Unemployment, financial issues
- Disease + death
- Uncertainty
- Big responsibility
- Fear of mistakes
- Workload
- Lack of staff
Burnout:
- Physiological stress
- Physical, mental, emotional exhaustion
- Work requirement > ability
- Index of dissociation between what is expected and what is done
Influence on Health and Work:
- I- Alarm: (Physiological response —> Neuroendocrine —> Hypothalamic-Pituitary-Adrenal axis —> Cortisol)
- II- Adaptation: (To cope with the stress)
- III- Exhaustion: Autonomic Nervous System symptoms (sweating) —> Immune system (-)
- (Unwillingness to work, fatigue, irritability, conflict, apathy, decreased interest)
Signs of Burnout:
| Physical Occupational | Psychological | Social |
|
|
|
Psychology of Death
Dying: Losing vital signs, a process
Death: Final, irreversible stage of dying
People deal with it differently, but there are stages.
Stages of Dying
I- Denial:
(Natural defense reaction to ignore the news)
(Doctor: Support the patient, verbally don’t argue)
II- Anger:
Individual recognizes denial cannot continue
(Doctor: Help patient understand)
III- Bargaining:
Plea to stop death
(Listen and encourage speaking)
IV- Depression:
Due to sadness
Risk of suicide
Doctor: Alleviation
V- Acceptance:
Ensure that physical and spiritual needs are met
Patients that suffer from lethal diseases often experience anxiety, fear, and stress.
Doctor’s Experience with Death
- Personal threat
- Memories of experience
- Hopelessness
How to Tell a Patient About a Terminal Illness
- Alone in a room
- Eye to eye
- Sit
- Short, clear, direct
- Listen > talk
- Show empathy
- Do not change details
- Self-control and introspection
- Ask about trouble and fears
Manifestation of Grief: Normal and Pathological
Manifestation
| LEVELS | Stages |
I- Physical:
II- Physiological:
III- Social:
IV- Spiritual:
| Grief Crises: 1- Shock Reaction
2- Disorganization:
Coping with Grief: 1- Reorganization:
2- Reconstruction:
|
| Normal Grief | Pathological Grief |
| Change in Psycho State:
Repetitive Behavior
|
Conclusion
- Death is a debated religious, philosophical, and medical topic.
- Doctors aid terminally ill, dying patients.
- Doctors experience the same defense mechanisms.
- Grief is a necessary part of loss unless it becomes pathological.
Working with Unmotivated, Anxious, and Manipulative Patients
Unmotivated Patients
- No motivation for treatment
- No desire
- No emotion
I- Child:
- Decision by parents, if they are motiveless —> court/law
- Team (pediatrician, psychologist, social worker, art therapist, occupational therapist)
II- Adult:
- Doesn’t visit doctor
- No legal capacity, decision to trustee
- Compulsory treatment
- Subscribe to agreement to be treated
- Team: (Physician, psychiatrist, medical psychologist, psychotherapist)
- Treatment is long, doctor-patient relationship is long
Anxious Patients
- Somatic, emotional, cognitive, behavioral components
- Definition: “To vex or trouble”
- In the presence or absence of physiological stress
- Feeling: Uneasy, worry, fear
- Normal in case of stress
- Abnormal in the absence of stress or if excessive
- Symptoms with no biological cause
- (Gastrointestinal problems, headache, chest pain, muscle pain, dizziness, insomnia, tremor)
- General Practitioner called to assist
- Need to develop skills
- 24% of mental disorders
- Number one reason patients seek help from a doctor
- Lack of anxiety awareness is a problem
- Treatment: Benzodiazepines, psychotherapy, doctor-patient relationship
Manipulative Patients
- Seeking control over the interaction
- To have one’s way
- (Social, emotional, material)
- Patient influences doctor
- Lie, fabricate to distort reality
- False sincerity, charm
- Induce guilt
- Avoid responsibility
- Activity to make you stay
Identifying Manipulation
- Guilt, transference
- Refuse to take responsibility
- Anxious, chaos
- Urgent importance
- Self-harm threat
- Lie
- Analgesic use
- Disinformation
“C-E-I-P”
- Collaborate: Remind of power-seeking behavior and retain therapeutic relationship.
- Empathize: If behavior interferes with therapy, pause and try to understand the reason behind the need to act this way.
- Instruct: Teach alternative ways to get their needs met.
- Problem-solving: If they accept the fact that they are behaving inappropriately, help them think through pitfalls and alternative behaviors.
Coping with Manipulation
- Proactive
- Listen
- Stick to the agenda
- Assert
- Negotiate
- Share responsibility
- Someone who is manipulating has a problem distinguishing reality from their own perception of the situation and distortion.
- Try to maintain the upper hand in the relationship.
Conflict Resolution
- Avoidance: (Physical or emotional withdrawal from conflict situation)
- Acceptance: (When a person refuses their own interest and accepts the opponent’s position)
- Competition: (When a person puts their needs over the opponent’s)
- Compromise: (A middle agreement, each gets something, gives something)
- Cooperation: (People work together for a common goal or conflict resolution)
- Let your opponent speak
- Recognize your emotions, don’t follow them
- Name the reason for dissatisfaction
- Don’t argue
- Tell your position
- Find the solution to the conflict
Psychology of Disease: Detection Stages
Abnormal condition of the body of an organism
- External —> Infection
- Internal —> Autoimmune
- (Isolated symptoms, deviant behaviors are considered diseases too)
- Death by disease is death by natural causes
- (Types: Pathogenic, deficiency, hereditary, physiological)
- (Communicable vs. non-communicable)
Disease Detection
- Visible symptoms: More likely patients will ask for help
- Threatening symptoms: Symptoms that lead to severe illness
- Degree of life disruption
- Frequency
Stages of Disease
- Premedical: The patient thinks, “Am I ill?”
- Clinical: Patient goes to the doctor
- Outcome: Result is treatment or no result
Disease and Patient
- Identity: Symptoms, disease (catching a cold)
- Reason for disease is achieved: (Biological, psychological)
- Duration of disease: (Acute, chronic)
- Consequences: Physical, emotional, mixed
- Cured, controlled
Stages of Acceptance
- Interpretation: Society accepts them
- Coping: Accepting diagnosis and adaptation, somatic, systemic
- Evaluation: Somatic disease may change the patient
Inner View of Disease
Autoplastic Adaptation
- Attempt to change oneself when faced with a difficult situation
- Developed by Freud, Ferenczi, Alexander
- Hypothesized when a person is faced with a hard choice, they will do two things:
- Autoplastic adaptation: Tries to change themselves
- Alloplastic adaptation: Subject tries to change the environment
- Debate over which is better therapeutically, autoplastic or alloplastic
- Most Western modalities focus on autoplastic
Identity (beliefs) —> Action —> Outcome
Alloplastic View
- Adaptation where the subject tries to change the environment
- Example: Criminal, mental illness
- Is part of human “cultural evolution” via alloplastic experimentation outside their own body
- Unlike autoplastic, alloplastic are both replicable and reversible
- Any advance in human civilization (technology and otherwise) is considered alloplastic
Conclusion
- Disease is a natural part of life
- Treatment is the overall process
- The endpoint of disease depends on the patient and doctor team
Psychotherapy Essentials, Basic Schools, and Treatment
Essence
- Psychotherapy is a scientific and practical area for mental and personality disorder treatment.
- Goal: Improve biological, physiological function
Principles and Basic Schools
- Combination of factors
- Reduce and cure the patient’s disability
- Patients without coercion accept it
- Sympathy + empathy
Indication
- Professional competence and education
- Psychotherapist must know what they are doing
- Follow ethics
- Patients must be willing to participate
Psychodynamic and Humanistic Approaches
Psychodynamic
I- Psychoanalytic Psychotherapy:
- Traumatic experience in childhood
- Hidden between internal conflict of Id, Ego, and Superego
- Aim: To reach the conflict and subconscious to make it conscious
- Method: Dream interpretation + free association
II- Behavioristic Psychotherapy:
- Change behavior to change emotion
- Psychological difficulties are viewed as behavioral problems
- Aim: Isolate the problem and change the behavior
- Method:
- Decrease systematic sensitivity
- Decline in behavior after removing the causing element
- Encouragement of appropriate behavior
- Punish inappropriate behavior
III- Cognitive Psychotherapy:
- Key component of psycho disorders
- Focus on real-time and failure
- Believe in changing irrational thoughts
- Deals with distorted thoughts, belief systems
- How a person interprets events (frames them) and attempts to reframe them in the opposite way
- “All or nothing thinking” meaning something is either good 100% or bad 100%
- Focus on real-time and future instead of former events
Humanistic
I- Existential:
Give patients the opportunity to get familiar with and accept themselves —> Authentic self-realization
II- Gestalt:
“Here and Now”
Asking questions not “Why” but “Who” and “How,” “What this means to me”
III- Interpersonal Psychotherapy:
Rather than internal intra-psychic conflicts, current interpersonal relationships are interpreted and analyzed; personal factors are indicated but not analyzed.
IV- Relaxation Method:
- Autogenic training (relax for complacency, muscle tension reduction, regulation of the autonomic nervous system)
- Increase muscle relaxation for psychosomatic illness
- Hypnosis is desired to treat psychosomatic disorders
V- Body Acting Ways:
Concentrated movement therapy —> Body movement + breathing exercises help feel the body and improve health status