Introduction to RelationalDynamics in Practice:Managing difficult situations

Tsafi Lederman & Jenny Stacey

www.cpdo.net

Aims

1.To increase the practitioner’sawareness of psychologicalprocesses during treatment

2.To increase understanding about howpsychological processes can lead todifficult situations

3.Consideration of how to managedifficult situations

Topics• Therapeutic Encounter• Working Alliance

– Frame and Boundaries• Relational Dynamics

– Power– Projections– Transference– Counter transference– Empowerment

• Communication– Verbal– Non-verbal– Touch

Therapeutic encounter

TreatmentBackgroundHistoryBeliefsAttitudesEtc.

BackgroundHistoryBeliefsAttitudesEtc.Practitioner Patient

Relationship

Physical/contractualboundaries

Fox S (2008) Relating to clients. Jessica Kingsley Publishing. London

Therapeutic Relationship

Studies show:

Cooper, M. (2008) Essential Research Findings in Counselling and Psychotherapy Sage

Positive outcome is dependent on therelationship created with the patient, morethan the psychotherapeutic approach used

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)

Past therapeutic experiences

Failure or success of past treatments

What the Therapist brings to theTherapeutic Relationship

• Expertise• Skill and Knowledge• In charge• Is expected to be helpful• Presence• Personal Process• Self awareness• Power Differential• Clothes on

SchedulingFrequency, time, duration,length, number of sessions,dates, etc..

ConfidentialityRespect private emotional andphysical space

AdministrativeFees, who pays, who collectspayment, cancellation, reports andcorrespondence to other healthprofessionals

The Therapeutic Frame

ProceduresHistory taking, examination, type oftreatment, How oftenPatient involvement / participation inmanagement

Possible issues around the framePositive:

Secure baseGood authorityBeing cared forAppropriate boundariesEasing anxietyProviding containment for feelingsBuilds Trust

Negative:

ResentfulnessCheatedRageHelplessnessRebellionLoses trust

Awareness level of relational dynamics

Conscious

Out of awareness/unconscious

Personal/cultural history and relational patternsFeelings 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’

Relational Dynamics

• Projections• Transference• Power dynamics

Personalexperiences

Therapeuticexperiences

The session

Past Present

Projections

A defence mechanism where your own emotions andtraits are attributed to someone else

You areangry with

me!?

Transference

You are angrywith me

because I didn’tdo my exercise,

just like myfather

The process whereby emotions are passed on or displaced fromone person to another (usually the parents) onto the therapist

Counter-transference

You are angrywith me

because I didn’tdo my exercise,

just like myfather

Yes, I am angrywith you

because youdidn’t do your

exercise.Why am I feeling

so angry?

The feelings, thoughts, behaviours evoked and experienced by thetherapist in the therapeutic relationship

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?

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?

Internal Supervisor

“what’s going on here”

**!!!?? ??!!”**”?

Power Dynamic

Power with

Powerless

Power Over

Relational dynamic: Transactional Analysis Ego States

Parent - Taughtconcept of life

Adult - Thoughtconcept of life

Child - Felt concept oflife

Parent

Adult

Child

Parent

Adult

Child

Transactional analysis model

Parent

Adult

Child

Therapist Patient

Transactional analysis model

Therapist Patient

Parent

Critical Nurturing

Adult

Rebellious Free

Child

Parent

Critical Nurturing

Adult

Rebellious Free

Child

Co-created Relationship

Collaboration

What does the patient want?

Therapeutic encounter /relational dynamics

Working alliance(framework)

Communication

Practitioner caring, listeningand empathicTreated with respectFeel at easeSame practitionerthroughout treatment

Information about thetreatmentReferral when necessaryEnvironment hygienic andprofessionalUse appropriate examinationand procedures expectedfrom the disciplineMinimum 30 minutesconsultationValue for moneyPatient involved in decisionmakingConfidentiality

Advice on self-careExplanation of conditionTo be able to ask questionsSufficient and easy tounderstand explanationInformed of risks and sideeffects

Leach J, Cross V, Mandy A et al 2011 What patients expect from their osteopath. The Osteopath

How to Empower?

ListeningUse of wordsMatch language to patients levelAwareness of non-verbalInformed judgmentUse positive statementsUse inclusive speech (we can..)Give choiceAllow contribution from patientAgreement is negotiableShared responsibility

How do you listen?

Verbal CommunicationListen to words

Non-verbal CommunicationObserve the bodyListen to the underlying expressionTouch Communication

Communication: Blocks to Listening

JudgingMindreadingEvaluatingBeing rightAdvisingArguingDeflectingNot being present

What stops you..?What helps youlisten?

Empathy

Empathy is standing in the shoes of theother person and seeing the world throughher eyes

Communicate your empathicunderstanding

The Therapeutic Relationship depend on the communication betweenpatient and therapist.

Non- verbalVerbal

30-40% 60-70%

Forms of communication

Body language is particularly important at the initialmeeting.

Liking 7% Verbal + 93% Non Verbal

Albert Mehrabian, 'Silent Messages' (2009)

Touch Communication

What would you like to communicate in atherapeutic situation (with touch)?

What would you like to communicate?

Re-assuranceComfortSafetyAcceptanceTrustA Calming PresenceCompassionEmpathy

Patient’s perceptionof touch

• Psychological, socialand cultural attitudes

• Previous tactileexperiences

Touchevent

Response

Touch Dialogue

Lederman E 2005 The science and practice of manual therapy. Elsevier

Must be appropriate to the therapeutic situation

The objectives and intentions are clear

Does not impose greater intimacy than the patientdesires

Does not communicate a negative message

What we need to be aware of in the Touch Dialogue

Lederman E (2005) The Science and Practice of Manual Therapy. Elsevier

Relationship to the body

Most woman have difficult relationship totheir bodies. They expect to be criticisedor attacked

97% woman have daily negative thoughtsabout their bodies Ann Kearney-Cooke

Dissatisfaction with body shape continuesthroughout the life

Touch Communication Dialogue

Therapistintention

Patient(receiver &

respondent)

Breakdown in Communication

Therapist(giver & receiver)

Patient(receiver &

respondent)

Lederman E (2005) The Science and Practice of Manual Therapy. Elsevier

Characteristics of Instrumental & Expressive Touch

ExpressiveInstrumental Touch intent

Local / Focal Broad, integrative

Brief Maintain contact

Force dependent Force irrelevant

May be painful Pleasurable

Investigative, prodding Touching the ‘whole person’

Mechanistic Attentive & responsive

Uninvolved Expressive

Corrective communicative

Lederman E (2005) The Science and Practice of Manual Therapy. Elsevier

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