2 Therapeutic Communication

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Introduction

Health Care Administrators (HCAs) are often the first person that the client speaks to when booking their appointment, upon checking in for their encounter, and they are often the last person the client speaks to at the conclusion of the encounter. HCAs are the person family members speak to for updates on loved ones receiving health care. For these reasons, we propose that it is essential that HCAs continuously improve their therapeutic communication skills. Therapeutic communication is complex and requires a lifetime commitment of reflection, practice, making mistakes, and learning from those mistakes. This chapter focuses on defining therapeutic communication, the Health Care Administrator’s (HCA) scope of practice for communicating therapeutically, and self-awareness for developing effective therapeutic communication.

Assessing What You Already Know

Consider that people seeking health care are often feeling vulnerable. The way a Health Care Administrator communicates with them may impact their ability to access the health care they need. As you reflect upon the following questions and statements, consider the awareness you already have about communicating therapeutically with others.

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Defining Therapeutic Communication

Therapeutic, by its very definition, relates to curative treatments and that benefit both the mind and the body (Merriam Webster).  Effective therapeutic communication requires people to be compassionate. This may seem to be innate in people but that is not always true. In health care settings, effective therapeutic communication is used to care for people so that their health care needs can be met. We propose that effective therapeutic communication skills can be learned through continuous self-reflection, empathy development, and practice.

Scope of Practice

Most health care providers are regulated under the Regulated Health Professions Act (RHPA) and the Medicine Act, 1991 (Ontario Government). Health care administrators (HCAs) are not regulated professionals and, therefore, follow the policy and procedures set by the regulated health care provider (HCP) for which they work. HCAs may be assigned tasks that involve controlled acts under the HCP supervision. It is important that HCAs are aware of their scope of practice, and if there is doubt regarding the performance of a task, or expression of behaviours, then the HCA should check with their immediate supervisor, or HCP for which they work.  You may be wondering how this applies to communicating therapeutically?

Empathy

Empathy is helpful when therapeutically communicating with others because you feel what they are experiencing with the person, and that shared feeling leads to connection and trust with the client. Empathy is an awareness of how someone is experiencing or feeling an emotional event because you have felt the same or similar emotion. Wiseman (2007), suggests that an empathetic episode occurs when the perspective of how someone is feeling is communicated to the person (who is having an emotional event) and then it is confirmed to be true by that person.

For example, a client shares with the HCA that they are extremely sad after the death of their beloved cat Smudgie. The HCA remembers the sadness she felt when her rabbit Hopper died and expresses to the client, “this is a difficult time as pets are like family.” The client then responds, “yes, I was closer to Smudgie than I am to some of my family”. The HCA responds with a caring glance and thanks the client for sharing.

Sympathy

Sympathy is not considered helpful when therapeutically connecting with another person because the sympathetic person feels sorry for the other person and can only imagine how they might be feeling. Often, when sympathizing with someone, people try to solve the person’s problem to assist them in moving outside of their emotional state. This may invalidate the person’s feelings making them feel judged, or as if they do not have a reason to be upset (Brown B., 2018). A person who feels judged or invalidated will shut down communication and it is likely that their needs will not be met.

For example, a client shares with the HCA that they are sad that they will have to quit their job to look after their mother who is in the early stages of dementia. The HCA feels terrible that the client’s mother is suffering from dementia and that the client must now lose income to look after their mother. The HCA responds by suggesting that the client looks into some inexpensive adult daycare centres. The client does not respond and leaves the encounter feeling confused because she interprets the HCA’s response to mean that the HCA doesn’t think that the client can look after their own mother. The HCA doesn’t understand how difficult it will be to have strangers care for their mother. 

Self-Awareness

Wiseman (2007) proposes that empathy can not happen if people are not self-aware. To be self-aware one must examine their behaviours and the perspective from which they view the world, and also from reflecting upon communication interactions with other people. Then they must consider that the people that they communicate with will have different perspectives than they do. If we think back to the Osgood-Schram Model of Communication discussed previously, how often have you gone back and forth in the feedback phase and discovered that the receiver had not grasped the message you had sent? Have you ever reflected upon a conversation days later with someone and been surprised to learn that their interpretation of the conversation was completely different from yours?

Let’s consider where varying perspectives come from.

Interpretation and Perspectives

Interpretation and Perspectives

• What do you see in the following image?
• What do your classmates, friends, or family see in the following image?
• Is it the same or different?

If you read the description below the image, you may have been conditioned to look for a rabbit or a duck. Perhaps, you have experienced similar diagrams in your past; so, you may have known to look deeper into the diagram for further clues to what you should be looking for. Similarly, how one perceives communication with other people includes interpreting clues from the way the other person looks, talks, and behaves and comparing that to what they have been conditioned to expect by previous experiences. This conditioning is part of the development of your perspective.

You may be wondering how you came to develop the perspectives that you have and if you can change your perspectives. The first step in becoming self-aware is to reflect upon why you believe what you do? You can do this through examination of  your attitudes, beliefs, and values. eCampus Ontario (2018) proposes that one learns attitudes, beliefs, and values over time and that they are central to the ongoing development of self. Effective therapeutic communication can then be developed by acknowledging and accepting that other people have different perspectives than you do. This does not make their experiences less valid than yours, just different.

Classical Conditioning

Prior experiences play a role in developing attitudes, beliefs, and values by conditioning our responses to situations we have experienced before. You may have heard this referred to as the lens from which we view the world. Consider that Ivan Pavlov, a Russian physiologist, discovered that dogs could be conditioned to salivate even when food was not present and that this discovery led to a field of behavioural study known as classical conditioning (Fields, T., 2020).  Classical conditioning is a learning process in which coupling stimuli produces a response (Fields, T., 2020). In Pavlov’s studies, he paired his dog’s responses of salivation with food to the presence of the researcher bringing the food, noises, or lights (Fields, T., 2020). Once conditioned, the dogs salivated when the researcher entered the room, to specific noises, or lights even if there was no food present (Fields, T., 2020).

Let’s consider areas common to many people where classical conditioning may take place. These are just a few examples, consider what else you might add.

• Culture, ethnicity, religion and/or spirituality
  • Life experiences such as interactions with culture, ethnicity, religion or spirituality are the ways in which people have been conditioned to interpret the world. These experiences work as base knowledge in which to make comparisons of a new experience to what is already known. Communication between people is blocked when one thinks that their way is the only correct way and attempts to impose their views on others.
• Income and social status that includes education, economic, and environmental factors
  • Consider that income and social status are number one on the list of the social determinants of health (Pan-Canadian Health Inequalities Reporting Initiative, 2020). Meaning social determinants that affect the health outcomes for people. Income and social status can be related to the amount of or type of educational experiences a person has had. For example, people who have had opportunities to pursue higher education may have the option to pursue a career in which they receive a lot of satisfaction. A person who could not afford to pursue post-secondary education may have limited options for the type of career they may wish to pursue. Economics determines the type of environment that people live in, the types of nutritional food they eat, the educational supports both at school and at home, and access to social and recreational activities (Pan-Canadian Health Inequalities Reporting Initiative, 2020).

You might be wondering how do these examples relate to self-awareness when communicating in health care settings?

Consider that a child who has grown up in poverty, whose adults had to work multiple jobs to put food on the table, may not have had regular medical appointments and only went to the doctor’s when extremely ill. In this situation, they may not seek out health care for what they perceive as minor symptoms. They may be conditioned to go to work or go to school and tough it out, meaning go while sick because the cost of losing pay to go to a doctor’s appointment or look after an unwell child is not an option. Alternatively, a child growing up in affluence may perceive that everyone goes to the doctor’s when they are running a fever or have a twisted ankle from soccer practice since they have been conditioned to perceive this as a way that everyone lives.

Self-awareness of how you have been conditioned to perceive when to seek health care may impact how you perceive a client’s decision to book an appointment. If you were conditioned to believe to go to the doctors regularly, then you may find yourself judging a client for not bringing their ill child in sooner, and your non-verbal communication may project that belief, whether you intend to or not.

Cognitive Development in Changing Perceptions

Jean Piaget’s Cognitive Development Theory proposes that as people mature, they take what they know and compare it to something new, then develop a new way of thinking about it and that this follows a sequence starting from the time people are born (DeWolfe, T.E., 2019).  Cognitive Development Theory can therefore be considered in answering the question, can you adapt or change your perceptions?

Consider in the Concrete Operations Stage, the person can comprehend other people’s viewpoints and in the Formal Operations Stage, abstract ideas and concepts like justice can be understood, even if not directly experienced (DeWolfe, T.E., 2019). We propose that if people are aware that they might have been conditioned to believe what they do then when they come across someone with a different perspective if they are in the concrete operations stage, they accept that people have different perspectives and if they are in the formal operations stage, they can reason out the two ideas and determine if they will change their thinking.

Check Your Understanding

Summary

In this chapter you have:

• Defined Therapeutic Communication.
• Reviewed scope of practice for health office administrators when communicating therapeutically.
• Explored the importance of self-awareness in developing empathy for effective therapeutic communication.
• Applied common behavioural and cognitive development theories to an example of changing perspectives.

Key Terms

Attitudes: Immediate disposition towards a concept or object.

Beliefs: Ideas based on your previous experiences and convictions often serve as a frame of reference for viewing the world.

Caveat: A caution, warning, qualification, or forewarning.

Classical Conditioning: Classical conditioning is a learning process in which coupling stimuli produce a response (Fields, T., 2020).

Cognitive Development Theory: Jean Piaget’s Cognitive Development Theory proposed that people develop their thinking by comparing new experiences to what they already know. This theory proposed that cognitive development follows a sequence.

Concrete Operations Stage: This is a stage in Jean Piaget’s theory where a child can comprehend other people’s viewpoints (DeWolfe, T.E., 2019).

Controlled Acts: May only be performed by authorized regulated health professionals (CPSO, 2021).

Empathy: Awareness of how someone is experiencing or feeling an emotional event because you have felt the same or similar emotion.

Formal Operations Stage: This is a stage in Jean Piaget’s theory where abstract ideas and concepts like justice can be understood even if not directly experienced (DeWolfe, T.E., 2019)

Innate: inherent or born with.

Invalidate: To view the person’s issues as if there is no merit or foundation.

Judged: A formed negative opinion.

Scope of Practice: Work within the limits of what you have been educated or trained to do.

Self Awareness: Examination of a person’s own behaviours and perspective of themselves.

Social Determinants of Health: Social determinants like income and social status that affect the health outcomes for people.

Stimuli: An agent that produces a response

Sympathy: To feel sorry for someone else.

Therapeutic Communication: Relates to treatments that are curative and benefit mind and body (Merriam Webster, n.d).

Values: Core concepts and ideas that you categorize as good or bad, right or wrong, or what might be worth making a sacrifice for.

References

Brown, B. (2018). Dare to lead : brave work, tough conversations, whole hearts. Random House.

Cleveland Clinic (2013, February 27). Empathy the human connection to patient care [Video]. YouTube. https://www.youtube.com/watch?v=cDDWvj_q-o8&t=7s

DeWolfe, T. E. (2019). Jean Piaget’s theory of cognitive development. Salem Press Encyclopedia of Health.

Fields, T. (2020). Ivan Pavlov. In Salem Press Biographical Encyclopedia.

Merriam-Webster. (n.d.). Therapeutic. In Merriam-Webster.com dictionary. Retrieved July 14, 2020, from https://www.merriam-webster.com/dictionary/therapeutic

Ontario Ministry of Health Workforce Planning Branch. (2018). Regulated health professions. Ontario Ministry of Health Ministry of Long-Term Care. https://www.health.gov.on.ca/en/pro/programs/hhrsd/about/regulated_professions.aspx

Pan-Canadian Health Inequalities Reporting Initiative. (2020) Inequalities in children in low income families in Canada. Government of Canada. https://www.canada.ca/en/public-health/services/publications/science-research-data/inequalities-children-low-income-families-infographic.html

RSA. (2013, December 10). Brené Brown on empathy [Video]. YouTube. https://www.youtube.com/watch?v=1Evwgu369Jw

Wiseman, T. (2007). Toward a holistic conceptualization of empathy for nursing practice. Advances in Nursing Science, 30(3), E61–E72. https://doi-org.conestoga.idm.oclc.org/10.1097/01.ANS.0000286630.00011.e3

Image Descriptions

 Figure 2.1: Illusion image in which a person may interpret as a rabbit or as a duck. [Return to Figure]

Assessing What You Already Know (Text-based Activity)

Question 1

Consider the following examples and choose the statement that best reflects how you would respond to this situation.

Statement one: Juan, your friend has just found out that they did not pass their AP midterm exam. Juan is visibly upset and tells you that if they have to take this course again they will not graduate with his peers. You respond therapeutically by:

1. Telling Juan that you had that same AP teacher and that this is going to be a challenging semester for them and you wish them good luck.
2. Telling Juan that this is a challenging situation and asking Juan what you could do that would be helpful.
3. Telling Juan about a time that you failed a midterm and how it motivated you to study harder and you ended up with 80% as your final grade.

Solution: The correct response is option two.  This is an example of therapeutic communication you have acknowledged Juan’s feelings and asked how you could help.

Statement two: A client completing registration for an upcoming surgery mentions to you (the health care administrator) that they are extremely worried about the upcoming surgery so much that they have not been sleeping. You respond therapeutically by saying:

1. That is a fairly common before surgery but you don’t need to worry the surgeon is very good.
2. Yes, waiting for surgery can be worrisome. I will make a not for the surgeon to prescribe something to help you sleep.
3. Yes, waiting for surgery can be worrisome. When you speak to the surgeon mention that you are having trouble sleeping.

Solution: The correct response is: Option 3. You have validated the way the client is feeling and you have stayed within your scope of practice by asking the client to speak to the surgeon about this concern. Return to the Activity