Refining the Therapeutic Relationship - Essay Example

Refining the therapeutic relationship Fcmt623 Reflective Study Module Leader: Liz Hawkins Achara Chavanakunakorn number: 11525033 Total number of pages including cover sheet: Word counts: 2697 Introduction The reflection examines my consultations as an observer held with a patient who was in her late forties and undergoing treatment for depression. Reflective learning is a vital tool that considerably contributes in personal and professional development because it enables one to critically evaluate one’s actions to improve and develop skills and competencies for higher work performance. Most importantly, when one critically reflects over past experiences, it helps to widen the understanding of self and explore unexamined thoughts, memories and tasks which can be improved upon. It therefore served as hugely pertinent mechanism for self-realization and self-improvement in order to gain critical competencies for greater productive outcome. The reflective report aims to investigate my performance and explore myriad facets of myself and my work competencies, including therapeutic relationships with patients, within the wider scope of the clinical practice in the polyclinic. Looking back on my notes and diaries, I have been able to explore deeper understanding of nursing paradigms and become more articulate in using the theoretical framework to tackle challenging situations. Through personal experience as well as by observing my mentors, colleagues and patients, I have identified several aspects of my relationship and workplace technicalities which need to be addressed for improved work outcome. My reflection uses Gibbs’ reflective cycle and encompasses key elements like experience; feelings; evaluation; analysis using theory into practice; and action plan to improve. Gibb’s cycle of reflection was chosen primarily because it focused on reflective journey as effective tool to the development of therapeutic relationships (1988). It allowed introspection on incidents and processes to identify issues that are detrimental to personal and professional development, especially development of therapeutic relationship that thrives on better understanding of human psychology and professional competencies. The reflection on myriad aspect of personal and professional paradigm help to investigative known and unexamined arenas that provoke not only critical thinking but greatly facilitate change in behaviour and application of theoretical knowledge into practice (Burnard, 1997; Boud et al., 1985). Reflection on my workplace performance has considerably enhanced my learning graph. Narrative based enquiry tends to unfold complex situations and provide new perspective to it (Hendry, 2010). I have identified and analysed my perceptions and feelings about the patients, situation and myself as practitioner/observer. I have realised that one of the most challenging situation is when I start to relate the patient’s story/experiences to my own. I realise that it is essential for a practitioner to feel empathy but not sympathy toward their patient, in order to maintain patient/practitioner dynamic and boundaries. Using the theoretical framework of Transactional Analysis, empathy vs sympathy, wounded healer and drama triangle (being a ‘rescuer’), identifying my major role has emerged as key workplace challenge (Lapworth & Sills, 2011). ‘Am I a rescuer? It seems like I am a wounded healer and in order to develop a good therapeutic relationship with patient. Deciphering and distinguishing across the various roles is essential as I need to maintain the boundaries with the patients and ethically deliver healthcare services. Experience As a student practitioner, I still feel slightly nervous every time I take new case. Initially, I felt extremely nervous and struggled with performance anxiety. However this fear has lessened as the years progress, and I persevered. I tried to overcome my fear by taking new cases and met the challenges with stoical aptitude and belief in my competencies. I find that the best approach is to be honest with myself and know that each case and each experience are lessons to learn. As a student practitioner, it’s okay to not knowing everything. Now I feel much less anxious and take every opportunity to take the case rather than sit in the consultation room as an observer. Each consultation has been a revelation about myself, the patient and the way we tend to unconsciously communicate with others, especially the patient. Analysis of the varying communication paradigms and development of subsequent relationship using transactional analysis become important facilitators in the therapeutic relationships (Stewart & Joines, 2012; Berne, 1968; Freud, 1912). I have learnt from the many cases that I have handled independently or been associated with. Gaining trust is inherently linked to nursing practice but how to identify ways as not to get too absorbed into the patients’ world is also hugely important (Chitty, 2007). It helps to gain their trust or seek their approval for developing effective therapeutic relations when pain is shared. As such, though there were several occasions where I felt sympathy toward the patient but one case was specially very pertinent as it allowed me to delve deeper into the therapeutic relationships and understand the boundaries and constraint that are crucial issues within the clinical practice. The case involved a patient who was suffering from depression. I was one of the observers and prior to the consultation, the student practitioner who was handling the case gave a brief summary of the patient’s case. The main points gleaned from short briefing of the case summary revealed that patient was suffering from depression as she had recently lost her job and home, got separated from her boyfriend and had sleep related problems. Most importantly, the patient did not want any drugs treatments. I did not get the patient’s date of birth but gathered that she was in her forties (late) or early fifties and she was also suffering from some premenopausal symptoms. The patient spoke very softly and despite sitting right opposite to her, I could not hear all of what she said! She had come to herbal clinic for her depression, sleep disturbances, and to manage the symptoms that wake her up at night (e.g. night sweat, hot flushes, cold feet). At the beginning of the consultation, the patient seemed rather well and cheerful as she was satisfied with the herbal treatment as it was effective and supported her emotionally. But later on, she started showing signs of slight distress as if she was trying to put a brave face and ‘holding it together’. She mentioned how the herbal treatment improved her ability to cope better with day-to-day tasks and abilities to deal with paperwork. I was not too sure which paperwork she referred to as she did not share all the information with us apart from telling us that she lost everything including her home, her job and her boyfriend and had to move out to a new accommodation. She had also informed the student practitioner that she was seeing a counsellor and mentioned that she was still in shock about all the things that had happened to her. She got teary and shook up as she muttered ‘I have hit rock bottom!’ As she was narrating her story, I could connect with her easily as I had also gone through difficult times when I was overwhelmed by unexpected events through life. Though much time has passed, I can still feel the pain, helplessness and the trauma of the time. Therefore I knew exactly what she had referred to, even though her circumstances and mine were different. Observing the patient, I found myself deeply involved into the patient’s story and felt her pain. As she got emotional, I was also emotional and closed to tears. But luckily, supervisor distracted her attention by asking her about her night sweat and if the treatment given helped. As she responded, I took that opportunity to pull myself out of that sympathetic feeling and focus on her case rather than her story. Though my first meeting was not actually a success, it did teach me to control my feelings and become more proactive in the treatment rather than with the problems and issues of the patients Feelings Initially I was empathetic towards the patient and admired her for the courage that she was showing against the adversities. Putting on a brave face and having the nerve to accept her state of depression and seek treatment required indomitable will power and inner strength, especially when drug treatment is not taken. I know that depression is a very difficult condition to treat and to get through, especially without drugs treatment as I have experienced it myself. There were times when I did not want to get better and was least bothered about my welfare. Later on in the consultation I got sucked into the patient’s story and felt more and more sympathetic towards her. I literally relived her experience and felt her pain and feeling of utter helplessness as I visualized all the pain she might have gone through and was trying to suppress. I again became a victim rather than a rescuer which was serious concern because it could undermine the professional goals and objectives and compromise the basic tenets of healthcare delivery (Early & Weiss, 2010; Heron, 2001). I found myself wishing that I was her practitioner so I could help her more. Luckily, at the nick of time, I was able to pull myself back and realised that it would be unprofessional of me and could cause considerable distress to the patient. Evaluation It was not the first case where listening to the patient’s story had made me emotional. I had noticed on several occasions that listening to the patients helped create special connection based on emotional distress that was common. I would feel the urge of being agreeable with the patient and share their experiences. The incessant desire to repeat past experience was reflected in the unconscious communication that empathized with the patient (Freud, 1912). The Freudian transference of my feeling onto the patient was critical factor that interfered with the treatment of the patient because patient’s feelings and personal dogmas became secondary (Kahn, 1997). This was a major faux pas that had prevented me in deciphering the finer points in her narrative that revealed her anxiety, insecurities and appeal for constructive help. The need to maintain the role of nurturing parent was strong influence that led to the overzealous response and empathy with the patient. While the issue would be discussed later, I realise that it is one of my weaknesses as I want to make them feel that they are not alone and I want to help them in any way I could, which is not professional. Even as an observer, I always have to remind myself I need to focus on the case and patient’s experience and not relate them with my past experiences. It was important to understand the situation/patient of how they might feel not how I would feel. I should stop thinking from my own perspective but focus on what the patient feels and how can we help her. Analysis I sometimes feel that my past trauma have inculcated a sense of abandonment creating unresolved issues with my past which still have the capacity to influence my feelings and my reactions with other people. I think that the personal trauma and depression that I had undergone had brought forth strong sense of guilt and feeling of inadequacy that had instinctively been brought out when I hear the story of the patient. Berne (1964) believes that it is the reaction of inner critic that wants to respond to the current needs because need/ actions could not be carried out previously. This might be due to the fact I would feel better by helping others who had gone through bad times. Consequently, helping others is cathartic and was akin to helping myself when I had felt like there was nothing that could be done or changed. I had bonded with the patients because of the common past traumatic experience. But the unsettling feeling of inadequacy remains as my empathy had nurtured unconscious negative consequences for the patience because despite being physically presented, I was feeling quite disconnected and I had traversed time distance where I was back with my trauma and pain. Fox (2008) asserts that practitioner should attentively listen to the patients and respond to the issues that are raised within the case. Though I was engaged with the patient but I was distracted by personal issues that corroborated with the problems of the patient which had significantly lowered my prowess of active listening that could discern patient’s concern. I believe that I need to explore the implications of my disconnected being. I had not broken any rule or code of conduct but my deep involvement with the problems of the patient was highly troubling. I needed to investigate why acted the way I did and confront the inner self and get answer as to why I was not able to overcome my past experience or why it was constantly interfering in my work. Scholars affirm that some traumatic experiences are compartmentalized so that one can cope with the trauma to live normally (Kurtz, 2007) while others emphasize that body and soul tend to separate when people are faced with trauma (Levine & Frederick, 1997). Moreover, the role of victim and rescuer become relevant within the wider context of treatment and developing wider perspective of issues. I had become a victim because my past experience was overpowering and I was unable to challenge the role or the circumstances. I was bringing my personal problems in my workplace that adversely impacted my response to the patient. The Freudian transference was evident where feelings from patients were transferred and I unable to respond. Crawley and Grant, (2002) assert that counter-transference is natural process that is experienced from practitioner to the patient. But this was not happening in my case and it worried me. One of the more interesting facts that came out was that I tend to fall into a ‘rescuer’ category by being the nurturing parent. I often activate my ‘wounded healer’ state without realising it. In my private life, I am seen as the wise, strong, kind and joyful friend who is always there for everyone. But I know that I am not strong and most of the time, I put a brave face on to make others happy which in turn makes me happy and less miserable. However in practice this aspect of myself is a big challenge that I would have to deal with and suppress in order to be professional and maintain good practice. Action plans for improvement 1. Regular meditation to improve my concentration and focus so as to heal my spirit and soul as a measure to overcome personal traumatic experiences. 2. I make efforts not to pre-empt patient’s response and patiently listen to them and constantly monitoring of self helps to re-shape the wandering thoughts into concrete response (Johns, 2006; Schon, 1983). 3. My client-relationship suffers from inbuilt distrust in my abilities to overcome my weaknesses regarding frequent disconnections that I tend to face when confronted with the traumas of the patient. It manifests in many ways that adversely influences my clinical practice. I have therefore decided to become more positive and develop trust in my core competencies and skills. I therefore, like to get involved in cases where personal distressing experiences have resulted in depression and other mental problems. I take the cases and apply evidence-based theories which proactively involve patients in their treatment and critically evaluate their symptoms for right treatment. Conclusion I realised that I can be my worst enemy if I don’t control how I feel and maintain boundaries of what I should and should not do. I would feel that if I don’t act or do something I would be seen as cold, and if I was in need I would not want to ask for help but for someone to realise it and come to my rescue. That is what I would do for others. I observe them and would offer my help without them asking me, even when it would put myself into trouble. I need to remind myself that I cannot help everyone and that sometimes it is important and more helpful to keep a safe distance. I need develop a non-biased approach and rather than thinking ‘what if it was me?’ I should focus on the patient’s case and his/her personal experiences so that effective treatment could be given keeping within the constraints of defined professional boundaries and promoting best ethical practices for optimal outcome. Reference Berne, E., (1968) Games People Play, London: Penguin Boud, D., Keogh, R., & Walker, D., (1985) Reflection: Turning Experience Into Learning, NY: Nichols Publishing Company. Burnard, P., (1997) Effective Communication Skills for Health Professionals, 2nd edition, Cheltenum: Stanley Thornes Publishers Ltd. Chitty, K Kittrell. (2007) Conceptual and Philosophical Bases of Nursing, Phoenix: Elsevier Inc. Crawley, J., and Grant, J., (2002) Transference and projection, Maidenhead: Open University Press. Earley, J., and Weiss, B., (2010) Self-Therapy for Your Inner Critic, Larkspur: Pattern System Books. Fox, S. (2008). Relating to Clients. 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