Elementary psychotherapy as a method of building and maintaining contact with the patient and the importance of shaping interpersonal competence in health care professions

INTRODUCTION

The basic task of elementary psychotherapy is to provide psychological support for the patient and their strength during the disease and adaptation to changes connected with the disease process and treatment. Elementary psycho-therapy involves several different actions, such as taking care of the quality of the patient’s relationship with the staff and the principles of cooperation, prevention of iatrogenic errors, ad hoc problem solving, the patient’s difficulties and the use of elementary mental hygiene, education, and psychoprophylaxis. The direct goal of elementary psychotherapy is to support the patient during treatment and rehabilitation process or adaptation to changes in the situation of a chronic disease or a disease with an unfavourable prognosis. Restoring emotional balance is considered in the context of health problems; it is also important in supporting the patient in a situation where nothing else can be done from a medical point of view. Elementary psychotherapy, sometimes called bedside psychotherapy, is an action based on good will and the patient’s intuition, where theoretical preparation is secondary [1-3].
Of course, elementary psychotherapy uses all modern trends in psychology and psychotherapy, in practice building a framework for the patient–healthcare worker relationship. It can be said that this type of influence refers to all im-portant and basic psychological influences that may be the domain of various healthcare professionals. Psychological help in terms of elementary psychotherapy should primarily alleviate the emotional effects of the disease, especially reducing the level of fear, helplessness, sorrow, sadness, strengthening the patient’s resources and their inner strength by giving hope, and strengthening the sense of agency or self-esteem. Moreover, its goal is to establish good cooperation with the patient and avoid iatrogenic errors. Long-term goals may also include actions aimed at integrating traumatic, personal experiences of the individual, regaining the human ability to gratify genuine needs, or acquiring new knowledge, skills, or experience. All 3 aspects constitute an integral whole and make up the process of elementary ther-apy. The integration of experiences is supposed to help the patient to accept and experience the painful information that accompanies the disease process [1-3].
This process is particularly difficult in the case of a life-threatening disease or one with an unfavourable prognosis. A large amount of unfavourable information and aggravating emotions, as well as the inability to find a way out of the health situation, are a significant burden for the patient. Disease-related stress triggers various coping strategies and styles, which are not always beneficial for the patient [2, 3].

ELEMENTARY PSYCHOTHERAPY IN BUILDING A THERAPEUTIC RELATIONSHIP

Elementary psychotherapy also refers to such a way of communicating with the patient that is conducive to building a relationship and providing psychological support; in other words, applying the principles of effective interpersonal communication leading to establishing good trust-based contact with the patient.
Building a therapeutic relationship on the basis of a safe and universal space allows for effective implementation of interventions, from basic ones to conducting psychological experiments. Basic therapeutic techniques can be used by all members of the therapeutic team. Their use is aimed at stimulating and strengthening the mental resources of the pa-tient, using them so that they could experience themselves and their situation of struggling with the disease and recov-ering in a constructive way. Elementary psychotherapy is therefore a process aimed at searching for mental forces that are the opposite of helplessness or breakdown. The sense of strength or power is the basis for a positive assessment of oneself, one’s actions and capabilities, including those that are activated in connection with the disease and its treatment process. Within elementary psychotherapy, it is equally important to influence positive mobilization, maintaining a good mood and positive emotions, including being guided by optimism and hope, giving the opportunity to overcome obstacles and difficulties. In this process, self-expression is of particular importance, enabling emotional opening and releasing unpleasant feelings and emotional tensions. Therapeutic communication should not only increase the level of resistance to stress, but also result in the desired changes in general functioning as well as in activating and developing the patient’s resources [3].

COMPONENTS OF THERAPEUTIC COMMUNICATION

Among the many elements that constitute the process of therapeutic communication, a generalized sense of power is mentioned, which can be internal or external. This dimension may be connected with a sense of contact with others, an existing bond, belonging to a specific group, the awareness that “I am not alone”, that I can experience support. This ap-peal to the patient’s awareness is also to draw their attention to the fact that they are also part of a group of people who are in a similar situation, in other words that they are not alone in trouble, which in turn may result in lowering the sense of injustice, inferiority, jealousy, etc. Sometimes downward comparison allows you to see your situation in a better light. In the dimension of a generalized sense of power, the basic issue is to create such conditions that the patient has the feeling of being accepted, understood, received with kindness and with the feeling that there is someone who wants to help them. The generalized sense of power is also self-confidence, a sense of efficiency or resourcefulness, an internal sense of control, which can function autonomously to some extent, but is also connected with the possessed knowledge and interpersonal skills. Important factors that increase the sense of power also include identification, a sense of under-standing or confrontation with reality. The identification process consists of the patient’s unconscious identification with people who arouse admiration (these can be, for example, people who have overcome the disease). Drawing on the desired and possessed identification patterns extends the scope of the patient’s remedial competence. The sense of understanding is considered as “expanding awareness” and refers to the patient’s knowledge and understanding of their current situation, resulting from the disease and treatment. It also includes one’s own reactions to the disease, emerging fear or lack of control of the situation, it helps to reduce unrealistic fears and increases the level of optimism. In turn, confrontation with reality should lead not only to the recognition of the current situation, especially when it is unfavourable or hopeless, but above all to facing its emotional aspect, which is its acceptance in the positive sense of the word. Acceptance on an emotional level is often a very difficult process, especially when the level of suffering is high and the chances of recovery are impossible. Building a sense of power is also a reference to the sense of meaning and the concept of altruism. The sense of meaning plays an extremely important role, especially when the disease is serious, requiring numerous changes, limiting the ability to function. Giving meaning to these experiences and efforts to make critical experiences positive; in other words, to make sense of what is happening, however difficult and sometimes bor-derline. The sense of meaning in such situations is often connected with the implementation of worthy values constituting the fulfilment of some important mission. Regardless of the patient’s situation, the factor bringing satisfac-tion is altruism understood as helping others, meaning that self-esteem and a sense of usefulness are associated with kindness and offering help to others who are in a worse situation [2, 3].
On the other hand, in the dimension of emotional mobilization, important factors are hope, humour, and positive motivation. Hope as a therapeutic factor is understood as a positive expectation of experiencing effective help, recovery, or some compensation for suffering, as well as maintaining the belief that the patient’s situation will improve. The ther-apeutic function of humour is connected with both the power of positive emotions and the safe discharge of tension, as well as obtaining a new perspective on problems from a distance, which weakens the sense of seriousness and signifi-cance of problems. Humour can also be used by the patient to understate and downplay the disease, which should be considered as an unfavourable factor. Positive motivation to live, defined as “the will to live”, together with emotional mobilization and hope, are conducive to positive motivation for treatment and making the patient aware of their tasks connected with following the recommendations regarding the interface between life, treatment, and how much de-pends on their commitment and activity [2].
The last dimension describing the possibilities of influencing the patient in the process of elementary psychotherapy should include abreaction and openness understood as self-disclosure. Abreaction, or releasing accumulated negative emotions, can be expressed through crying, screaming, and naming the experienced feelings. The response to this type of behaviour should be active listening as well as paraphrasing and reflecting feelings, also maintaining a safe therapeu-tic relationship that provides a safe space for expressing grief, fear, and worry. Openness, on the other hand, is a form of self-expression, revealing information about oneself, talking, or crying one’s heart out. Talking about one’s experiences, often connected with fear and shame, eliminates tensions, and gives a sense of understanding and being accepted [2, 3].

THERAPEUTIC INTERVENTIONS

The discussed factors constituting elementary psychotherapy and the process of interpersonal communication show, on the one hand, various types of nuances characteristic of such interaction, and on the other hand, the ease of using very basic techniques that are available not only to people professionally dealing with psychological support.
It is worth emphasizing that often single interventions, undertaken on the basis of attentiveness and caring interest, may be extremely helpful and mobilize the patient to recover.
In the available source literature, the authors propose various divisions of therapeutic interventions. These activities may include the following:
1. Advice and recommendation interventions (directing or guiding the patient’s behaviour).
2. Informational and explanatory interventions, the purpose of which is to provide knowledge or missing information, highlighting what the patient was not aware of.
3. Confronting interventions showing some significant, limiting attitudes or behaviours, often of negative character.
4. Interventions supporting the orientation to the patient’s strengthening, improving their self-esteem, and maintaining their active attitude.
5. Catalytic interventions aimed at expanding awareness, gaining insight and a better understanding of oneself, enhanc-ing autonomy, self-learning, and problem solving.
In another classification, therapeutic interventions are viewed from a different perspective. The following categories of activities are listed in it:
1. Direct actions for the benefit of the other person.
2. Giving advice, including saying what is best in the therapist’s opinion.
3. Providing missing and necessary information.
4. Learning on the level of knowledge and skills.
5. Counselling (help in identifying the problem, revealing conflicts, alternative ways of coping).
6. Influencing the system to which the person requiring assistance belongs.
7. Practitioners specializing in training for medical staff point to some basic skills that include:
• Listening (including collecting information about the patient);
• Providing information, including clarification;
• Making suggestions, through words or behaviour;
• Helping in externalizing thoughts and feelings;
• Confrontation, including drawing attention to the contradictions between what the patients say and what they do;
• Support (strengthening and care).
Some researchers complement this type of division additionally by:
1. Facilitation, i.e. activities aiming at improving and maintaining communication.
2. Directive actions (telling the patient what to do and taking direct control).
3. Open questions.
4. Interpretation [2, 3].
The above-mentioned elementary skills constituting therapeutic interventions should be shaped and developed both in academic and postgraduate education.

SOFT SKILLS IN BUILDING A THERAPEUTIC RELATIONSHIP

Building contact on the basis of elementary psychotherapy is largely about developing soft skills. In helping profes-sions, they are all the more necessary not only to establish satisfying relationships with the patient and their family, members of the therapeutic team, or superiors, but also their high level reduces the risk of professional burnout and enables coping with everyday professional stress. Therefore, it is worth noting that developing skills in this area is, on the one hand, a great support for the patient and can strengthen them in their fight against the disease, and on the other hand, it translates into building their own professional path, in which interpersonal relationships matter and are a value.
Attention to the development of soft skills and learning to build relationships based on the basics of psychotherapy are in line with the requirements of modern employers. People starting work consider soft skills to be the least im-portant, while employers are most interested in the following competences:
• self-organization – responsibility, time management and punctuality, independent organization of work, ability to cope with stressful situations,
• interpersonal skills – being communicative and ability to convey one’s thoughts clearly and making contact with peo-ple easily, working in a group, fluency in Polish,
• cognitive skills – learning new things, resourcefulness, creativity, analysing information, and drawing conclusions [4].
For many graduates the very situation of starting work is difficult, and the additional expectations of demonstrating soft skills arouse anxiety and often result in moving away from the patient, due to the sense of helplessness and lack of competence [5]. Currently, the emphasis in university education is still on acquiring specialist knowledge and shaping skills connected with the profession, and the development of interpersonal competences is often a margin of interest in some humanities, which provide knowledge of the basics of psychology or sociology without much reference to prac-tice.
Although in the current standard of education in medical studies attention is paid to social competences, e.g. in the area of health promotion and health education, the level of preparation of students to use these competences is, in their opinion, low, and they see the need for development in this area. Without soft skills, it is difficult to build even basic therapeutic contact with the patient. My own long-term experience shows that the introduction of new examination rules based on the OSCE method also indicates the need to work in this area and demonstrates situations in which stu-dents cope much better with instrumental tasks than stations assessing soft skills.
Developing interpersonal competences and using elementary psychotherapy interventions is not an easy task, alt-hough what is indicated nowadays is the growing importance of self-education and regular practice of using them. In the ranking of requirements for job candidates, high values are preferred in the area of communication, honesty and reliability, interpersonal skills, work ethics and initiative, as well as adaptation to changes [6-9]. That is why striving to shape and develop them is so important.
Soft competences, which are the basis of therapeutic contact with the patient, often referred to as psychosocial or in-terpersonal skills, are an element of social knowledge, and they mean awareness of what is important in a given situa-tion, which rules and behaviours are expected and effective, and which are ineffective and inappropriate. These compe-tencies include 3 components, namely cognitive, motivational, and behavioural. The list of interpersonal competences is extensive, but when it comes directly to the performance of helping professions, including the profession of nurse, life-guard, or physiotherapist, the following competencies undoubtedly come to the fore: building relationships, assertive-ness, communicativeness and making contact, readiness to learn, emotional control, organization of one’s own work, coping with stress, and cooperation within a team. Each of these competencies allows functioning in numerous profes-sional relationships, creating comfort for both the employee and the people interacting with them.
The development of interpersonal competences and the principles of elementary psychotherapy can be based on the principles of teaching adults, which emphasize the value and importance of one’s own experience, self-reflection (experience analysis), formulating abstract concepts, and drawing conclusions, as well as testing new knowledge in practice [10, 11]. The numerous methods of developing social competences include the following: courses and training, internships and apprenticeships, volunteering, handbooks, e-learning, coaching, mentoring, and self-improvement [10].
On the basis of interpersonal competences, it is possible to shape the attitudes of future members of the therapeutic team in a way that aims to make them aware that in a relationship with another person, especially one experiencing illness and suffering, it is possible to bring mental relief and elementary support, which are among the essential ele-ments of treatment, as well as encouraging the patient to become involved in the process of therapy. Using the basics of elementary psychotherapy in interpersonal relations with the patient also frees them from the sense of being lost, fear, helplessness, and lack of the ability to get involved. The use of even basic therapeutic interventions provides a wide range of possibilities and makes it possible to build a relationship based on trust, understanding, attentiveness, and re-spect for the rights and dignity of the patient.

PERSONALITY VARIABLES AND THE THERAPEUTIC RELATIONSHIP

A review of the analysis of the source literature confirms that some personality traits are conducive to creating satis-fying social relationships, and so, for example, emotional stability, internal locus of control, or a high level of empathy are important components of building relationships with patients. A high level of empathy combined with a sense of emotional balance makes it easier to achieve realistic goals and create stable interpersonal relationships.
Negative emotionality described in the source literature is indicated as unfavourable in dealing with difficult and stressful situations. People characterized by a high degree of negative emotionality show fear and anger when faced with everyday experiences. In the context of permanent stress, emotional processes of this kind are conducive to expe-riencing events as strongly threatening and harmful, thus they do not favour building positive social relationships [12, 13]. According to Kępiński, fixed anxiety traits manifested in a permanent tendency of personality result in a constant disposition to perceive objectively harmless situations as threatening and to react to them with disproportionately strong anxiety. The destructive effect of fear leads to the impairment of abstract thinking and to the inability to detach from a specific situation, lower self-esteem, the impression of having control over one’s life, loss of self-confidence, and narrowing the boundaries of oneself [14]. Researchers notice that traits such as aggression and hostility are inherent in anxiety. Both of these features counterbalance the low self-esteem. People revealing personality traits such as neuroti-cism use defence mechanisms which, on the one hand, are supposed to reduce the level of anxiety, and on the other hand, are conducive to aggressive behaviour [15].
The concept of emotional control is close to emotional maturity, which makes it easier for an individual to express their own emotions in a controlled manner [16]. Human beings have the ability to influence their emotional state pro-vided that they become aware of their own emotions, respond to them, and try to control them before strong emotional agitation occurs [17].
Numerous studies report that the dimension of locus of control is essential in the sphere of professional activity, while the locus of reinforcement control is important for the sense of human subjectivity in a work situation [18]. In the sphere of human professional life, achieving success is attributed to the internal control of reinforcements, which de-pends on individual experiences. Awareness of the locus of control is extremely important in a work situation because it affects motivation and performance. In addition, in a work situation, success is greatly influenced by mental balance, which is maintained thanks to the sense of exercised internal control [19]. At work, it is important to remain fully pre-pared in the event of various threats, and this feature is ensured by a sense of internal control, and it also determines a lesser tendency to make hasty decisions, which is of fundamental importance in the case of medical professions.
An extremely valued interpersonal competence is empathy. It is understood as “the ability to perceive, understand, and empathize with the state of another person, (...) it is co-feeling, but not compassion, (...) making the other person convinced that they and their problems are understandable by us. It is conducive to the creation of a climate of trust and closeness” [20]. The term empathy was introduced to psychology in the early 20th century by Titchener. He talked about the process of “empathizing with the mental states of other people, consciously going beyond one’s own self, into the space of other people’s experiences” [21]. Empathy plays a huge role in the process of getting to know oneself and the other person, it is perceived as an attribute of professionals who occupationally deal with helping other people.
In medical professions, where contact with another person, in this case the patient, plays a fundamental role, and the possessed ability to empathize is an essential tool in the work of the staff, Kuduk in her work points out that “just like professionalism in a job, from the first contact with the patient their empathy should be noticeable” [21].
The ability to perceive the patient’s problems, especially the emotional ones, and to react to them in a correct way is considered one of the components of the professional response of the medical staff [22]. Possessing the ability to empa-thize gives one a chance to initiate and maintain proper therapeutic contact. It helps to see the problems/needs of the patient entrusted to care, make a diagnosis, plan goals, implement appropriate nursing actions, and fully understand the patient.
The ability of mature sympathizing in helping professions allows, on the one hand, to give the patient a sense of se-curity connected with understanding their concerns and fears, and on the other hand, to maintain one’s own identity, full professionalism, and objectivity about a given situation [22].

SUMMARY

In light of the presented analysis concerning the importance of using elementary psychotherapy in building contact with the patient and improving soft and interpersonal skills, it would be important to conduct practical, cyclical work-shops, which, on the one hand, would be focused on getting to know the trainees’ own resources, modifying faulty communication patterns and eliminating mistakes in communication, and on the other hand, learning to recognize the patient’s emotional states and adequately respond to them as well as the ability to assess the patient’s level of motiva-tion to introduce changes in their life in connection with the disease. Another postulate that could be implemented would be to introduce content and skills concerning the discussed area as part of didactic classes (e.g. health promotion, optional classes), and not only within the subject of psychology, so that it could be developed and enriched with modern methods of working with a patient whose personal resources are limited due to their illness, treatment burden, rehabil-itation, or the need for significant changes in the current lifestyle.
The proposed additional classes raising the level of competences and techniques in the basics of psychotherapy should be implemented in all medical faculties to a similar extent, especially interactive forms conducted as part of low- and high-fidelity simulations. They would create conditions not only for developing these skills in the relationship with the patient, but also for more effective communication between members of the therapeutic team. The author’s own experience shows that students experience particular deficits in contact with patients from older age groups, people whose prognosis is unfavourable, and patients in the process of passing away and experiencing various emotional states related to death [23-25].

Disclosure

The authors declare no conflict of interest.

References