1. therapist-patient relationship1 Therapist-Patient Relationship 신 정 호 YUWMC Dept of Psychiatry

2. therapist-patient relationship2 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

3. therapist-patient relationship3 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

4. therapist-patient relationship4 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,

5. therapist-patient relationship5 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

6. therapist-patient relationship6 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

7. therapist-patient relationship7 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

8. therapist-patient relationship8 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?

9. therapist-patient relationship9 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

10. therapist-patient relationship10 Manifestation of Resistance clinical manifestation: avoid looking therapist, hide in chair, not move or move 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

11. therapist-patient relationship11 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 ?”

12. therapist-patient relationship12 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

13. therapist-patient relationship13 Obstacles in Therapist Therapist’s mannerism –alert to his dress and speech –inability to listen sympathetically –insensitive comment –premature reassurance –judgmental tone –patronizing air

14. therapist-patient relationship14 Obstacles in Therapist 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

15. therapist-patient relationship15 Obstacles in Therapist –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’

16. therapist-patient relationship16 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

17. therapist-patient relationship17 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

18. therapist-patient relationship18 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

19. therapist-patient relationship19 Feelings toward Patient Reality –Most patients have some unlikable quality. Countertransference –inappropriate intense feeling –unconscious displacement from person in past to present patient –more difficult to understand and control them

20. therapist-patient relationship20 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

21. therapist-patient relationship21 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 feeling smile with, not at pt

22. therapist-patient relationship22 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 resistance problem controlling impulse –destructive to therapist