Communication with patient in terms of elementary psychotherapy versus Gestalt psychotherapy. Experience from a workshop devoted to developing a relationship with the patient and using selected methods of therapeutic work

INTRODUCTION

Learning to communicate with the patient on the basis of elementary psychotherapy in the classical approach is largely about developing soft skills. This contact is crucial, especially in health care professions, but also, what is important, it might be difficult, both due to skills deficits and difficulties experienced in the relationship, resulting from one’s limitations. In the theoretical approach it is emphasised that reaching for the tools of elementary psychotherapy not only facilitates building satisfying relationships with the patient and their family or members of the therapeutic team, but also enables good quality of these relationships and reduces the chances of occupational burnout. Developing communication skills, on the one hand, constitutes great support for the patient and may be helpful in strengthening them in the fight against the disease, while on the other hand, it translates into shaping one’s professional path, in which interpersonal relationships are important and valuable [1, 2]. However, learning communication skills and basic techniques of elementary psychotherapy as part of a medical study program often turns out to be insufficient. Being in a relationship with the patient is very often connected with the resources of the person who initiates this relationship, and their awareness of their own mental processes is of great importance for shaping a relationship that will be supportive for the patient, but also safe being in a relationship for the person coming into contact with the patient [3].

ELEMENTARY PSYCHOTHERAPY VERSUS GESTALT THERAPY IN COMMUNICATION WITH THE PATIENT

A review of the source literature indicates that the most important thing in the relationship between a health care professional and a patient is providing psychological support for the person and their strength during the disease and adaptation to changes connected with the disease process and treatment. The situation of developing a disease, experiencing unpleasant symptoms, uncertainty about the diagnosis, and further prospects for treatment are the time of greatest stress, confusion, or increased anxiety. At this time, the patient expects support, presence, and listening, ex-pressing unpleasant emotions, and these expectations often cannot be met, not only due to the lack of staff time, but often because of their own fears, confusion, and the feeling that it is difficult to be in a relationship into which the patient brings their own effort, sadness, or fear. In such a situation, the patient or their family are often offered a conversation with a psychologist, but the question arises whether delegating the patient to another professional is what they really expect [4]. Elementary psychotherapy, which is taught as part of the medical study program, concerns a number of different activities, e.g. the quality of the patient/client relationship with the staff and the principles of co-operation, the prevention of iatrogenic errors, ad hoc response to problems, and the use of elementary psychohygiene, education, and psychoprophylaxis. The assumption is that including in the communication the support for the patient/client during the treatment, the rehabilitation process, adaptation to changes connected with the disease or in the event of an unfavourable prognosis is sufficient. This support is supposed to restore emotional balance, especially when nothing more can be done from the medical point of view. Elementary psychotherapy techniques used in the communication process are based on good will and intuition, where theoretical preparation is secondary [1, 2, 5]. It turns out, however, that the very lack of specific knowledge, and thus skills, is a serious limitation of such an approach. The question also arises whether such basic tools are sufficient for the patient, and to what extent they allow the health care worker to feel good and safe in such a relationship. Is it then possible to change this situation, but what areas should one reach for, on the one hand, to respond to the patient’s needs and, on the other hand, to feel confident in such contact and also take oneself into account? A proposal that can be implemented is to use the basic resources of Gestalt psycho-therapy, which is assumed to be more holistic in nature and refers to emphasising the awareness of a person’s current experience “here and now”. On the one hand, Gestalt, through its simplicity, assuming the healing nature of being in a relationship, rehabilitates emotional and bodily feeling, enabling the expression of various emotions; anger, resentment, sadness, anxiety, but also love, joy, or tenderness. In other words, it allows not only what appears on the rational level, but connects this area with the world of emotions and bodily sensations. This contact is very specific and takes into account the creative adaptation of the body to the environment and the awareness of internal mechanisms, repetitive behaviours, which do not allow the satisfaction of needs and interrupt the normal cycle, escalating fears, inhibitions, illusions, etc. What is important, this type of contact very often does not require a lot of time, and specific attention and simple questions can quickly bring relief to the patient, especially when the disease situation escalates unpleasant emotional states [6].
Communication based on the fundamentals of Gestalt psychotherapy creates specific conditions for teaching a person to recognise observations and feelings or current emotions caused by experiencing an old situation that was unfavourably resolved or is unfinished. Hence, in a new and difficult health situation, this type of contact may allow us to see automatic reactions and behaviours that are reflected in the present and have their roots in the past. All available means of communication are used: speech, posture, gestures, emotions. It is assumed that the dialogue with the patient consists not only of “saying everything” but also of “expressing everything” through various channels: body movement, body contact (touch), and emotional expression (tears, screaming, laughter, anger), freely and in accordance with individual preferences of a person at a given moment [6]. This approach seems to be liberating for the patient, because the moment of stress connected with the disease may trigger old mechanisms, and understanding and experiencing them will be conducive to regaining blocked energy and integrating the current experience. Expanding the field of conscious-ness and the freedom of choice as well as overcoming past conditions will be conducive to taking responsibility for one’s choices, and it enables better self-knowledge and acceptance of oneself as one is [4].
Looking at the possibilities emerging in elementary psychotherapy, in its classic approach it is worth noting that it is primarily intended to alleviate the emotional effects of the disease, especially to reduce the level of anxiety, helplessness, and sadness, and to strengthen the patient’s resources and their internal strength by giving hope, a sense of agency, or self-esteem. The intention is to integrate a person’s traumatic personal experiences, as well as to regain their ability to gratify authentic needs or acquire new knowledge, skills, or experience, i.e. to prepare the patient/client to accept difficult emotions connected with the disease and the treatment process [5].
In communication and contact based on the assumptions of Gestalt therapy, it is assumed that people in need of mental help are the greatest authorities in the area of their own observations and have enough strength and skills to cope. Hence, they should be provided with the conditions for learning about themselves and the mechanisms of behaviours as well as experiencing them through contact with emotions and their own body. Therefore, initiating contact is based on partnership, and it is intended to support strengthening human awareness, striving for their autonomy, through the process of learning, searching for subjective truth related to the context, and emphasising the importance of self-responsibility [6]. In other words, the patient may experience various states, becoming more and more independent in dealing with their mental processes, and this is possible by experiencing and releasing them as well as going be-yond the known pattern of previous reactions.
The values of elementary psychotherapy in the classical approach are seen in a process aimed at searching for such mental strengths that are the opposite of helplessness or breakdown. It is assumed that the sense of strength or power is the basis of a positive assessment of oneself, and one’s actions and possibilities, including those activated in connection with the disease and its treatment process. As part of elementary psychotherapy, it is therefore important to influence positive mobilisation, maintaining good mood and positive emotions, including optimism and hope, which gives the opportunity to overcome obstacles and difficulties [2]. In the approach based on Gestalt psychotherapy, instead of this type of assumptions discussed above, a relationship filled with emotions and based on trust is considered healing. This is a place where there is space for revealing emotional and sensual reactions, emerging ideas and suggestions that determine the quality of this relationship. In this type of dialogue, a person has a chance to participate in corrective emotional experiences, and it may be the first situation in their life in which they have a sense of being heard, appreciated, and noticed [6]. This approach seems to be crucial in the situation when the patient experiences strong emotions, requires immediate support and a sense that they are not alone in this particular situation, and may experience the feeling of being an important person in the relationship.
Both approaches focus on expanding consciousness. In elementary psychotherapy, the sense of understanding is considered as “expanding consciousness” and refers to the patient’s/client’s knowledge and acceptance of their current situation, resulting from the disease and treatment. It also includes one’s own reactions to the disease, emerging anxiety, or lack of control over the situation; it helps to reduce unrealistic concerns and increases the level of optimism. In the emotional dimension, the importance of hope, humour, and positive motivation is emphasised. Together with emotional mobilisation and hope, they are intended to promote involvement in the treatment and to make the patient aware of their tasks connected with following the recommendations concerning lifestyle, treatment, and how much depends on their involvement and activity [7]. The patient is therefore expected to take considerable responsibility for their health, treatment, etc.
Although the principles of Gestalt psychotherapy are aimed at seemingly similar premises (i.e. strengthening the client), and these are to awaken a person or mobilise them to such an extent that they can cope with life better, find the right shape of the relationship with their environment, and increase their potential and self-sufficiency, they are not treated as an ideology, but as something that manifests itself in experience. Expanding consciousness is supposed to make a person aware of what they do and what they experience, what they are and what their responsibility is, as well as their experience of being in the present [8]. In the context of disease, it may be liberating to admit to feeling helpless, lost, or terrified, precisely not to repress these states from consciousness, but to experience them and bring them to the surface of consciousness.
The understanding of man in terms of Gestalt, understood in all its fullness, i.e. in the physical, affective, rational, social, and spiritual dimensions, as part of an interaction encompassing the entire human being in the entirety of their environment, creates a new type of relationship and creates a broader framework in communicative exchange. Taking into account the search for the basic meaning, in the process from association, through the body, emotions, verbal language, to social interaction, and vice versa, provides a holistic and process view of a person in a relationship and creates a richer context for understanding their situation, needs, deficits, and possibilities [9].
The process of understanding is also the ability to solve problems connected with communication barriers. Reaching for elementary psychotherapy techniques in overcoming these barriers is also of limited importance, for example due to the intuitive nature and deficit of specific skills. Common problems in the communication process between a health care professional and a patient include, for example, withholding information, inability to listen, inability to convey information directly or lack of feedback, and finally, conveying too much information. Without taking into account the patient’s limitations, what is happening in the relationship at the moment and what defence mechanisms the patient uses to avoid, for example, confronting something that is too difficult for them, there is no chance of being in a satisfying relationship. However, learning even the basic mechanisms of avoiding contact by the patient (through the use of contact modification mechanisms such as: confluence, introjection, projection, retroflection, reflection) helps to understand the causes of specific behaviours and often prevents the unpleasant labelling of patients as “difficult”, “demanding”, etc. [10].
An important element of being in a relationship is showing support. Support in elementary psychotherapy is combined with informational, explanatory, supportive, and catalytic interventions. The first 2 refer to transferring knowledge and supplementing its deficits. Supportive interventions are aimed at strengthening the patient, reinforcing their self-esteem, and influencing their active attitude. In turn, catalytic interventions strive to expand consciousness, gain insight, better understand oneself, strengthen autonomy, and solve problems independently [11].
In a relationship based on Gestalt therapy, support is an indispensable and primary function of contact. However, its meaning has much deeper references and is understood as the search for everything that is assimilated and integrated with the entire human functioning. The most important and basic support function is breathing. Focusing on one’s breathing, in which a person disturbs their natural breathing rhythm, provides various information, e.g. when the body does not support itself with breathing, anxiety appears, and a lack of oxygen (as a prototype of anxiety) may be experienced as a complete lack of support. At the same time, strengthening and expanding the support function may lead to becoming aware of previously suppressed emotions. What is crucial in the area of support understood in this way is to notice what the patient uses in their own support (even in such basic reflexes as breathing) and what they do not use in support in the therapeutic contact. Working with support is answering the questions: What does the person do? What does this person’s support do to me? (What do I feel?) What does this person do in the situation between us? What does it matter what this person does? What does the person not do? (What support do they not use?) What experiments with new support are possible for them? [12]
The use of elements of elementary psychotherapy and the basic principles of contact with the patient taken from Gestalt psychotherapy allows people caring for the patient to be equipped with tools and techniques that, on the one hand, respond to the patient’s needs, and on the other hand, increase awareness of one’s resources but also of limitations in relationships with other people [13] (Table 1).
An attempt to translate theoretical concepts into specific skills of people having their first experience in contact with a patient became possible thanks to the proposal of an acting workshop conducted for bachelor’s degree students of Nursing. The idea of teaching selected skills and principles of contact with patients based on the resources of both therapies and one’s experience in working with patients was a response to the expectations expressed by the students during exercises preparing them to conduct educational actions.
The workshop program focused, on the one hand, on recollecting the most important rules of being in a relationship, and on the other hand, on implementing specific exercises in the field of mindfulness, active listening, developing non-verbal contact, non-judgment, and providing support, as well as experiencing oneself in a relationship with another person.
The first part of the workshop was devoted to the issue of co-creating relationships, especially building trust and a sense of security. Attention was paid here to one’s experience of the workshop participants and their families, as well as the expectations that arise when they themselves are the recipients of medical services or accompany their families in contact with health care professionals. Such a view enables a change of perspective and an answer to the question of how one wants to be perceived in such a relationship, but also what one does not want to experience, and thus what one does not want to be like in contact with a patient when one is in the role of a professional. A safe relationship is based on clear rules, respect for the patient’s beliefs, their way of being, and their ability to learn new behaviours. Trust in a relationship may appear when the patient experiences genuine care and feels that we care about their well-being. Co-creating a relationship is also learning to be present in the relationship – in other words, aware of what is happening between the sender and the recipient, what, for example, was not expressed verbally, but by observing communication from the body (changes in the expression of face, eyes, movement, changes in the way of breathing) may be revealed in the relationship and brought into it. Awareness of what is happening in the relationship also allows one to take into ac-count and work with strong emotions so that they are not overwhelming or causing helplessness. In this part, the work-shop participants had the opportunity to express in writing their greatest concerns in a relationship with a patient. As part of experiencing themselves in contact with another person, the students had the opportunity to feel what emotions and thoughts appeared in them when the contact was non-verbal. The exercise involved communicating only through eyesight and body language. In the discussion, the participants pointed out the difficulty of being in such a relationship and some behaviours that appeared and that were inappropriate in their opinion (the desire to escape from contact, laughter, a sense of shame, fear). At the same time, they noticed more details, allowing them to see what a person reveals not entirely consciously, and that non-verbal message may be more true than through the spoken content.
One of the most important parts of the workshop was discussing with the participants the situations that cause the greatest level of stress, a sense of helplessness, and even the desire to escape from the relationship with the patient. The participants pointed to the situations when the patient learns about an incurable disease with an unfavourable prognosis, makes decisions about a procedure associated with a high risk of health loss or the need to undertake treatment with side effects, or receives information about their terminal condition and short life prospects. With reference to this type of problem, learning to transmit information from various levels and direct communication was suggested.
The participants had the opportunity to learn and then test in practice how to introduce 3 levels of descriptions into contact, namely: “what do I see?”, “what do I feel?”, and “what do I imagine?”. The safety of this method of communication consists, on the one hand, on focusing on the person speaking in such a way that they can be seen in their entirety, while on the other hand, it allows us to deal with our own difficult emotions when we convey difficult information. In the message “what I see” it is possible to convey information about what we read non-verbally (body language), in de-scribing “what I feel” we refer to the emotional layer connected with the situation, while for “in imagination” we present a hypothesis about what the patient may be experiencing at a given moment. This way of talking creates the opportunity to experience support and empathy, instead of an assessment and procedural approach often based on medical language. This way of maintaining a relationship creates conditions for emotional closeness and involvement in it.
What is equally important, in limit situations it is important to use the “I” message in such contact, i.e. not to use generalisations and not to say things like “we” (which is common practice). It is also useful to pay attention to the forms of direct and indirect communication, and to limit the indirect form, which is impersonal. The participants also had the opportunity to practise these skills by assessing various messages and assigning them to direct and indirect forms.
The last part of the workshop was about finding one’s potential and strengthening one’s self-image. Access to one’s own resources, awareness of them, and the ability to search for support in them in a relationship creates not only psychological comfort but also reduces the feeling of being helpless or insufficient in a relationship. People taking part in the classes learned this skill, among others, by talking about their successes and listening to feedback from other work-shop participants. Drawing attention to one’s potential and important past successes in various areas of life enabled access to experiences and emotions connected with them that had been forgotten or diminished. However, receiving feedback from other participants often made us realise that we can share not only difficult situations, which are usually remembered longer, but also that our success told by others makes us more aware of it and able to assimilate it.

CONCLUSIONS

The analysis of the available source literature presented above together with the proposal of specific exercises/tasks to be performed by the workshop participants is an attempt to implement solutions aimed at using simple and accessible methods of working with the patient based on both elements of elementary psychotherapy and Gestalt therapy. This proposal is mainly aimed at changing one’s self-awareness and acquiring communication skills that create a new framework for the relationship, where there is space not only for a meeting in the sphere of thoughts, but also emotions, bodily sensations, and, to some extent, self-disclosure, thus becoming a contribution to the possibility for the patient to experience true and sincere care and interest, even when the framework of such a meeting is limited. This new quality of the relationship was noticed by people taking part in the classes, who found them to be a valuable experience, helpful in working with patients.
The presented work is also an invitation to other communication practitioners to express their opinions and experience in this area. Perhaps it will become a contribution to further research and encourage the development of this type of competences in medical students [14].

Disclosure

The authors declare no conflict of interest.

References