Psychological Aspects of

Treatment of the Somatic

Patient

PART 2

The doctor – patient relationship and the

selected aspects of psychosomatic

diagnosis

Magdalena Lazarewicz, Dept. of Medical Psychology, Warsaw Medical University

[e-mail]

Last week



The Doctor – Patient Relationship



Barriers of Interpersonal Communication



Models of Doctor - Patient relationship



Principles underlying development of good
doctor-patient relationship



Iatrogenic errors - introduction

Today…



Homework – summary



Communication - exercise



Iatrogenic errors - summary



Appropriate information



Selected aspects of psychosomatic

diagnosis

Communicatio
n

Delay at the polish airport…

Iatrogenic errors 1

An error committed by the doctor or other member of the medical

staff which leads to deterioration of the patient’s state of health.

wrong direct physical
intervention

improper or
tactless behaviour

deterioration of the patient’s
health

psychological
effects

Direct
error

Indirect
error

Iatrogenic errors 2

during the medical

examination

during treatment

disturbed interpersonal

communication

Indirect iatrogenic
errors

Examining the patient
in the presence of
other patients (or
unnecessary medical
stuff)

Some uncontrolled
behaviours (nodding
seriously, gasping)

Useless additional
tests and „taking the
patient by surprise”

Unnecessary
prescription of an
excessive amount of
medication

Frequent issuing of
sick-leave

Unjustified
qualification of
patients for invalid
pension

Lack of any information,
more or less incomplete
information

Unintentionally raising the
patient’s fears in order to
encourage the patient to
comply more diligently with
the doctor’s orders

Highly professional „slang”

Going around one’s own
business when interviewing
the patient

Appropriate information as an
expression of proper doctor-patient
relations



The doctor as a main source of

information



What does „appropriate information”

mean?



Diagnosis and causes of the

disease



Predicted course of the illness

and the prognosis



Planned treatment



Practical instructions (workout,

diet etc)

Empirical studies – S. Miller

• Pulse rate

: prior to the information, after the information, after the

diagnostic procedure.

• Relationship between

compatibility/incompatibility of the information

with the patient’s need for information and emotional tension

Information

seekers

Information

avoiders

Detailed

information

concerning the

diagnostic

procedure

Detailed

information

concerning the

diagnostic

procedure

Minimal

information

concerning the

diagnostic

procedure

Minimal

information

concerning

the diagnostic

procedure

Patients (vaginal endoscopy)

A

B

C

D

Empirical studies – S. Miller

The number of details which the doctor conveys in

his/her information should be adjusted to the

patients individual expectations

Information

seekers

Information

avoiders

Detailed

information

concerning the

diagnostic

procedure

Detailed

information

concerning the

diagnostic

procedure

Minimal

information

concerning the

diagnostic

procedure

Minimal

information

concerning

the diagnostic

procedure

Patients (vaginal endoscopy)

A

B

C

D

Less tension

Less tension

Oral Information –
reccomendations for improving
complience*

*compliance – „the extent to which the patient’s

behaviour

(in terms of taking medication, following diets or

other lifestyle changes)

coincides with medical or health

advice”

(Haynes et al., 1979)



Primacy Effect – patients have a tendency to

remember the first thing they are told



Stress the importance of compliance



Simplify the information



Use repetition



Be specific



Follow-up the consultation with additional

interviews

Objective and range of
psychosomatic interview



To extend the information concerning the patient



Description of the psychosocial determinants of the disease

and its consequences and also the psychosocial aspects of

the treatment process



The meaning which the particular patient ascribes to his/her

disease



type of disease



moment of onset



the need hierarchy



Attitude Towards Illness



attitudes of the nearest environment towards patient

Psychosomatic diagnosis layout



General information: age, sex, occupation



Medical diagnosis



Observational data



appearance



Indices of emotional tension



Patient’s behaviour during examination



Psychological risk factors and factors affecting the course of

illness



Attitude Towards Illness



Cognitive components



Motivational components



Emotional components



Basic problems



Assessment of relationship with the patient



Indications for doctor in charge, the patient, the patient’s

family and psychologist (if necessary) resulting from the

psychosomatic diagnosis

The psychosomatic
interview



AIM: to collect information* on the
interviewee, from the interviewee and
from other people who know the
interviewee.

* information on the various spheres of the patient’s life and
functioning which are important for the diagnosis

The interviewer has to …



develop sufficient motivation in the

interviewee so that he/she will be encouraged

to share significant information



weaken motivation which is counter-productive

to communication



Fear of the interviewer’s moral evaluation and

criticism



Fear that the information will be used to harm the

interviewee



Fear of bringing to daylight certain facts from the

interviewee’s life



Fear that the interviewer will „look him/her through”

The psychosomatic
interview



Observation



Verbal contact

Observational data



Objective – a thorough description of
the observed facts (no premature
interpretations)



It is a source of hypothesis which may
modify the course of the interview



It allows the interviewer to monitor the
emotional state of the interviewee



In is a source of diagnostic information

What shell we pay attention
to?



Appearance:



Height, weight, build, skin, nails



General hygiene, dress, hair-style, make-up



Emotional tension:



Tears, shiny eyes, paling and reddening of the face,

quickened breathing, sweating, trembling of the hands and

feet, shaky fingers



Excessive self-composure, rigidity (lack of spontaneity,

gesticulation, facial expression, shifting of the body position)



General mood:



Facial expression, gesticulation, eye expression



Adequacy of emotional behaviour to situation



Formal characteristics of speech:



Speech intensity, dynamics, tone, articulation, logic,

adequacy of response to questions, level of abstraction,

speech fluency etc

Halo-effect



The importance of the first impression



source of hypothesis



source of negative feelings or prejudice



source of positive feelings

„The only way to avoid one’s errors is to

analyze and correct one’s behaviour.”

(Wallen)

Developing a REAL
relationship



Have an „open” attitude: whatever is going on

between us in interaction is important and

intimate, no matter what is being discussed.



Develop in the interviewee a feeling that he/she is

accepted



Concentrate all your attention on the interviewee



Help the interviewee to express those contents

which are important for the diagnosis



Create a calm and unhurried atmosphere



Listen kindly with empathy



Do not express surprise

First minutes…



Try not to be late…



Concentrate fully and only at the
patient



Take care of the patients comfort



Organize the environment



Pay attention to the physical
distance



Introduce yourself…

The Art of asking questions



The first question: general, open, refer
to the interviewee’s general life
situation or the presenting problem



What brings you here?



What can I do for you?



What is your problem?



Why are you here? (in the hospital)



Could you tell me a bit more about …

The Art of asking questions



Narrowing down the questions (general to
specific)



Progression (relatively benign to personal)



Embedded Questions (hidden among
others)



Leading questions (indirect)



Postponed questions (change of context,
better moment)



Projective questions („some people…”,
description of interpersonal situation)

Language…



The language must be matched to:



interviewee’s intelectual level



verbal skills



personal experience



Avoid the proffesional language and

shortenings

How to maintain the rapport?



Verbal signals:



„Yes”, „I understand”, „Yhym”



„Could you tell me more about this?”



Paraphrasing



Silence



Nonverbal signals:



Body posture



Tilt of the head



Facial expression



Gestures



Eye expression



Smiling



Synchronisation

When the interview comes to
a close…



Check whether all problems have been discussed and leave

some time for their discussion



When time is up – communicate it directly instead of

constantly checking the time or „suggesting” that you have

to go (e.g.. By gathering the notes impatiently)



Try to summarize the interview



Finish the conversation stressing your interest in the

interviewee and in what has been said



You can ask the patient to evaluate the conversation



Say good-bye, get up and thank the interviewee for coming.

Psychosomatic diagnosis is
based on:



Information collected in an interview +
observational data + case history



What the patient said and what he
didn’t want to talk about (!)



It’s better to formulate questions than
premature statements.

Indications



For the doctor in charge, family, patient
and psychologist



General or/and specific



Realistic and constructive

Literature

This week reading:



Basic textbook, pages 81-92.

For the next week:



Prepare for your case role-playing

search the Internet for necessary information; imagine
what kind of person you will role-play; think of the first
question; think of your goals; try to imagine your patients
needs and problems etc.