The therapeutic encounter

Chapter 8 The therapeutic encounter



Patient–practitioner relationship145
Role of the practitioner147

Role of the patient148

The holistic intake148

Patterns conveyed through language149
Meaning of words150

Limiting beliefs151

Verbal linking152

Energy of words152

Speech patterns153

Listening154

Non-verbal behavior155

Changes in affect156

Somatic metaphors157

Questioning159
Start with open-ended questions160

Continue with open-ended questions160

Ask clarifying questions160

Lifestyle energy162

Ask awareness questions163

Ask compliance questions164

Willingness to heal165

Questionnaires165

Record keeping168

Assessment outcomes168

Naturopathic diagnosis169

References170

Further reading170

With a holistic approach to health and disease the importance of the therapeutic encounter is paramount. During an assessment a practitioner considers the spiritual, psychological, functional, and structural aspects of a patient. They inquire about the building blocks to health, family, social, environmental, and external factors. A thorough assessment includes the current physiological and pathological state of a patient. The aim is to identify the initiating and aggravating factors that are contributing to the symptoms and illness, and to determine what needs to change or what a patient requires in order to stimulate their innate healing ability and to achieve a desired state of wellness. Subsequent visits assist with understanding how a patient is progressing on their journey to health and in identifying new patterns as they emerge.


It is through the verbal part of the assessment that the initiating and aggravating factors are uncovered. The symptoms reveal ‘what’ is going on, but only by talking to the patient, is the ‘why’ uncovered. It is the ‘why’ that is key to determining what changes are required and what treatment is appropriate and needed. A practitioner then correlates the patterns associated with the subjective symptoms with the patterns that emerge thorough a physical exam. Naturopathic doctors utilize the knowledge gained by blood tests, radiographs, scans, and other objective measurements, but they place a high value on a patient’s subjective experiences and the information that can be obtained from the patient, such as tongue and pulse diagnosis, looking at the alignment of specific aspects of the body, and mapping the manifestation of symptoms to the energetics of particular body parts.


The inquiry into the cause of symptoms and diseases and how to detect illness in the body has always been at the heart of the medical profession. The methods used for assessment have changed substantially over time, and prior to the eighteenth century, history taking and diagnosing was based on the subjective symptoms of patients (Magner 1992). As the conventional medical field introduced more objective means of assessing health and disease, the relationship between the patient and the practitioner became more distant. The information obtained by objective measures was, and often is, taken as more valuable than the subjective information conveyed by a patient. In a naturopathic and holistic assessment a practitioner must value and integrate both the subjective symptoms and the objective signs, and recognize that the patient is more important than the disease. ‘In other words, the subjective should be part of a disease, just as it is part of being ill. If we find a way to include the subjective in our concepts of disease, maybe we will also discover purpose and meaning’ (Duffin 2007).


The naturopathic approach is based on the understanding that health and disease are multi-factorial and that there is a logical pattern that links the patient’s behavior and symptoms with their lifestyle, environment, and external factors (Fig. 8.1). This pattern emerges when we see all aspects of life and nature from the perspective of their qualities and attributes. During the therapeutic encounter a practitioner is looking at putting all the pieces together and determining the overall patterns for each patient. It is by treating the patterns and the patient as an integrated whole that health is achieved and maintained.


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Fig 8.1 Patterns as the common factor. (a) Lifestyle and external factors – all factors can be broken down and understood based on their specific patterns. (b) Patterns – relate to the qualities and attributes, such as internal/external Yin Yang, excess/deficiency, and the five elements. (c) Patient – all aspects of a patient carry and manifest the same patterns.



PATIENT–PRACTITIONER RELATIONSHIP


Communication, both verbal and non-verbal, is the medium through which relationships begin and develop. The quality of communication directly influences the quality of the relationship and it is strongly linked to patient adherence and satisfaction (Bernstein & Bernstein 1985, Barrier et al 2003, Platt & Gordon 2004). The primary purpose of the patient–practitioner relationship is the optimal well-being of the patient. The reason for the initial visit is for the patient to convey to the practitioner their medical history and to provide the practitioner with a window into who they are and how they live their life. The therapeutic encounter is not simply an exchange of information; it is, or can be, therapeutic in and of itself. A detailed and attentive intake often is the first time that many patients have been able to convey ‘their story’ and feel heard. The ability of a practitioner to hear the correlation between a patient’s complaints and their constitution, or situations that have happened in a patient’s life and their symptoms is a valuable skill. Occasionally, a patient might even experience extraordinary ‘spontaneous’ healings of very serious injuries or diseases when there is a strong connection between the patient and practitioner (Murphy 1993).


As a guide and teacher, the naturopathic doctor is seen to provide a patient with a road map, and a list of changes and options to improve their well-being. The naturopathic medical philosophy, ‘doctor as teacher’ involves providing patients with a framework and understanding for health and disease. This is often done by teaching patients how to become aware of how their lifestyle aggravates or ameliorates their symptoms. The relationship is not about blind obedience or dependancy, but involves the practitioner having the knowledge and skill to teach the patient how to live their life in a more harmonic way based on their unique characteristics. It also involves a practitioner having the skills, tools, and the knowledge of therapeutic substances to assist the body in restoring health and wellness.


The patient–practitioner relationship is influenced by the beliefs of the practitioner, the time and attention that each dedicates to the relationship, by the expectations and openness of the patient, and by the encounter itself. There are many factors that come into play. A practitioner might intimidate the patient or might convey judgment in the way that they speak. A patient might be too frightened or too embarrassed to give an adequate account of symptoms, or they might be defensive about the etiology and causal factors. A patient might be uncertain what a practitioner is looking for and might narrow their responses to the point of leaving out key information, or they might not tell the exact truth about their compliance if they anticipate judgment or disappointment. Being aware of the numerous factors that impact relationships is critical to understand what is really behind what a patient is saying.


There are specific skills that a practitioner can develop to improve their assessment abilities, but assessing is an inherent skill in everyone. When we meet a friend, often we know right away whether or not something is wrong. We avoid some people and gravitate to others based on their energy. We change our mind because things do not feel right. When you need assistance there is a reason why you choose to ask someone for help and not someone else. Interpreting the patterns of symptoms and diseases requires slowing down this inherent assessment process and paying attention to the details. It requires that a practitioner recognize the energetic qualities and attributes of all aspects of life and diseases. As a naturopathic doctor notices, tunes in to the details, and understands what the subtleness of the emerging patterns convey, they understand how an individual shifts in response to stress and trauma, and they can marvel at its ability to shift back.


Most patients are accustomed to having a very short time to convey their symptoms and their story to their general practitioner. When a visit with a patient is short or rushed it can greatly hamper the value of the therapeutic encounter.



From the point of view of the patient, then, the most serious barriers to a good relationship (and consequently better diagnosis and treatment) are the professional’s lack of time, seeming lack of concern, and failure to tell the patient what the patient needs to know and can understand about the illness (Bernstein & Bernstein 1985).


Research also shows that spending time early in patient encounters saves time in the long run (Platt & Gordon 2004).


An initial intake with a naturopathic doctor is usually one to two hours in length, with follow-up visits typically 30 minutes in length. This time is essential for patients not only to convey their symptoms, but to relay their lifestyle patterns, to talk about the significant events that have occurred in their life, and to discuss their goals and intentions, and their beliefs about health and disease. The role of the practitioner is to listen to all the pieces of information and how they are communicated, and then put it all together in a way that makes sense and that gives direction and rationalization to a treatment strategy that accomplishes the patient’s goals. Learning how to achieve and maintain wellness is an ongoing journey. Maintaining a strong therapeutic alliance requires the ongoing attention to the patient’s subjective experiences of their life and their healing journey.


A naturopathic assessment links the symptom patterns to factors that have contributed to their onset. At times, the symbolic meaning of a single symptom ‘jumps out’; when this happens it is important to avoid treating symptomatically or treating individual findings. What a practitioner is looking for is the underlying pattern, what ties all the symptoms together. You are looking for the factor or factors that initiated and contributed to the state of overwhelm and disharmony. For example, a patient might have a swollen left ankle because of collapsed veins, inability to hold her urine, spotting with her period, and rounded shoulders. The common thread, or pattern, is a lack of earth. There isn’t enough earth for the vessels to hold in the blood or the lymphatic fluid, the bladder is lacking the strength to hold in the urine, and her structure is becoming rounded because of a lack of earth. The next step is to find out what has happened in her life to affect her earth; her sense of structure and support. For example, it could be when she lost her job all of a sudden, or when her marriage broke down, or it might be a life-long concern because she has always had a weak sense of confidence.


An understanding of the initiating and aggravating factors can seldom be made on one symptom. And not all things that you notice about a patient indicate a heterogenic or disease state. For example, there is a difference between a person who naturally has a broader right side, indicating a more naturally Yang disposition, and someone whose right side has expanded due to a life that is too Yang. In the first example, you will not find other symptoms of overwhelm due to Yang excess. In the second example, there will be other shifts, such as increased aggression, a red tongue with a thick yellow coat, arms that are held further from the body, or a red rash that is worse on the right arm.



Role of the practitioner


A practitioner is a guide and a facilitator of health. Their role is to listen and observe from a neutral place, without judgment or preconceived ideas. They use their skills and knowledge to identify the root cause of disease, and to provide the education and support that is needed for healing. To recognize the uniqueness of patients, to identify and remove obstacles to cure, to support the inherent healing ability of each patient, to recognize the stages of disease, and to prioritize treatment recommendations to ensure optimal wellness and a logical healing process. It is to be curious about health and to remember that health and disease have a logical pattern, to continually search for the truth and the factors that are at play for each individual patient. The aim of a practitioner is to translate the patterns back to the patient in a way that provides them with the knowledge to change what needs to be changed in order to restore wellness and a homeodynamic state. ‘The most important treatment any doctor can give is to hope for the health and well being of his or her patients’ (McTaggart 2002).


Another role of naturopathic practitioners is to recognize the difference in healing intentions and to understand and communicate to patients the difference between short-term treatment relief and long-term health strategies. There are many different windows that a practitioner can use for assessments and each practitioner has specific skills and attributes that increase their tendency to utilize one or more of the windows. For example, some practitioners are gifted at picking up information by listening to patients, other practitioners can tell a lot about a patient by pulse and tongue assessment, and others are skilled at reading the alignment of tissues and structures.


The specific energetic constitution and beliefs of a practitioner also impacts their approach and style with patients. It is valuable for practitioners to understand their own constitution, to recognize how they process information, and what their strengths and weaknesses are. For example, if a practitioner has a lot of ‘earth’ qualities, that is they are good at details and like order and continuity, they are more likely to get impatient with patients that are more scattered or that tend to go and on and on when speaking.


It is valuable for practitioners to continually clarify their own personal intentions and to ensure that they recognize that their role is to provide patients with choices and knowledge, not to ‘fix them’. Sometimes the expectations of the practitioner and their need to help people can cloud their perspective on what is best for a patient. The challenge of transference and counter-transference comes into play. Recognizing the complexity of the therapeutic encounter, continually assessing intentions, and reviewing challenging situations with peers and professionals is continually needed as a medical practitioner.



Role of the patient


The role of the patient is integral to a successful therapeutic relationship. In order for a practitioner to utilize their skill, a patient needs to be forthcoming with key information. The more that a patient is aware of the nature of their symptoms, of what aggravates and what ameliorates them, the better a practitioner can understand the energetic patterns that are currently manifesting.


Assessment is not a guessing game, it is like a puzzle, and a practitioner needs as many pieces of the puzzle as possible. This involves recording a complete list of medications, supplements, and homeopathic remedies; other treatments, including dental, cosmetic, and energetic; an understanding of external factors, which might include the type of cooking utensils, how a patient’s house is heated, the use of microwave ovens, cell phones, etc. What often is surprising to a patient is the breadth and depth of inquiry in a naturopathic assessment. As practitioners and patients recognize the growing number of factors that impact health, the role of the patient becomes more extensive, as they are the ones that can confirm the exposure to individual factors and the impact that key factors have had.



THE HOLISTIC INTAKE


I have chosen to use the term ‘holistic intake’ instead of history taking due to the breadth of the intake. A holistic intake includes the medical history of the patient, their family history, an overview of their lifestyle, social history, a review of environmental factors and other external factors that impact the patient’s life. It also includes understanding the patient’s goals and beliefs about their illness, their health and their potential to heal.



The importance of the history cannot be overestimated. Studies performed with hospital out-patients show that diagnoses are made from the history in the vast majority of patients. Examinations only provide significant unexpected findings in a minority (Welsby 2002).


Every encounter with a patient, whether the first time or follow up, involves conversation. The conversation is an integral part of the ongoing assessment process and it requires time and attention. It is through conversation that a patient can tell their story, that they can indicate the impact that their life has had on them, and their desire for change. Conducting a thorough history is not unique to naturopathic medicine. The difference is that a naturopathic practitioner typically asks a broader range of questions and asks for more details on each component of the intake. A holistic intake explores the following:


• the essence of who the patient is

• how the patient perceives health and disease

• what a patient thinks about their life

• what the patient wants or expects from the practitioner

• how the patient experiences their symptoms and illness and what impact it has on their life

• what aggravates or ameliorates the symptoms and the specifics on the nature of the symptoms

• the associated symptoms and their timing of onset

• the patient’s ideas and feelings about their illness and their ability to heal

• to what degree a patient sees the correlation between their lifestyle and their symptoms

• their family and medical history

• the situations or events in a patient’s life that are have impacted them

• the external and environmental factors that impact a patient’s life

Conversation is important to build rapport between the patient and the practitioner, and it keeps the patient actively involved in the therapeutic encounter. Determining what the body is expressing is not the difficult or critical aspect of an assessment, it is determining why the body is expressing and holding a specific pattern that is important. The answers lie within the patient and come from the conversation. Through this conversation, a practitioner is able to assist their patient in hearing and seeing how their symptoms relate to their life, and to situations that have happened. When a patient comes in to see a practitioner inquiring about a specific symptom or disease state, the role of the practitioner is to recognize that the map differs from the territory. For example, when a patient comes in with a flare up of psoriasis (the territory) a practitioner would ask about the history (the map) that got them there.


History taking includes listening, questioning and observation. It recognizes the impact and significance of words and realizes that patients reveal how their life and their symptoms relate; if a practitioner just takes the time and learns how to truly listen. There are many good books written on history taking skills. The purpose of this book is to introduce the concepts of energetic patterns, as they are conveyed in a history taking.



PATTERNS CONVEYED THROUGH LANGUAGE


Words and language are powerful. They can stimulate the healing process or block it. The words that patients use, and the words that practitioners use, have a direct and dramatic impact on the therapeutic encounter. Words trigger memories and they are used as a way of tracking, labeling, and categorizing our experiences.



It is of inestimable importance that we are able to listen deeply to our patient’s words and to be aware of our own. The quality of our ability to think deeply and consistently about the unconscious experience of our patient is intimately related to our ability to hear what is being said. The effect of our own words upon the patient likewise cannot be overstated (Proner 2006).


The words that a patient uses describe the qualities and the subjective experience of symptoms. Patients use words such as, wet, dry, hot, cold, rough, smooth, constricted, heavy, stiff, blocked, weak, etc. These terms can also be used to describe the qualities of foods, behaviors, and situations. The words often mirror the patterns or behaviors that caused the symptoms. By listening to a patient’s words a practitioner will be guided to the underlying patterns that are causing the disruption to health.


The structure of language reflects a patient’s mental organization, their unconscious perceptions, and their beliefs. The conscious and unconscious create expectations and boundaries and convey a patient’s perceived limitations, not actual limitations. How a patient speaks and what they say, both outwardly and internally, provides a road map that explains how they have interpreted events in their past, how they see the present, and their outlook on the future.


If a patient cannot envision being well it is unlikely they will achieve wellness; as their mind is capable of overriding the healing process. There are also times when a patient conveys that they ‘feel better than they thought possible’. When this happens it is important to recognize the significance of these words and to assist patients in increasing their expectations and in recognizing that they might have more healing potential than they initially realized.



Meaning of words


The meaning of each word is complex and unique to that patient. Words are symbolic triggers that have energy and that bring into consciousness aspects of a patient’s experience (Bandler & Grinder 1979). Speech is a form of symbolic behavior and it holds meaning.



Thought processes suppose context and meaning. One cannot simply think; one has to think something. One does not simply ‘behave,’ but behavior is directed toward a conscious or unconscious goal (Thass-Theinemann 1968).


A patient’s choice of language is unconscious to a large degree and reflects the energy within. It reflects the depth of the shift in the body, the willingness and vitality of a patient to heal, and a patient’s expectations and beliefs. For example, patients use phrases such as:


• ‘It can’t be cured.’

• ‘It is a progressive disease.’

• ‘I guess I’m just getting old.’

• ‘I know I’ll always be on medication.’

• ‘I am just looking for the pain to decrease so that it is more bearable.’

• ‘I could get by even if I had a couple of good nights of sleep a week.’

• ‘I would like better control of my blood pressure.’

There is a difference between a patient looking to manage their pain better and having the expectation and belief that they can be pain free; or a patient expecting that it is normal to have a good night’s sleep every night, instead of just once in awhile; or a patient believing that once they have hypertension they will have it for ever. In order for a patient to change their perception and way that they interpret events in their life, they need to bring their unconscious beliefs and expectations to their consciousness (Murphy 1993). If a patient has a limiting belief about their symptoms or state of disease, it limits the degree of health that they achieve.


The language that is spoken everyday which is more subtle and repetitive affects health at a deeper level. Most people are unaware of how they reinforce internal patterns solely based on their language. Words carry an energetic pattern, a message to the rest of the body. If that message continually is that a person needs to be ‘on guard’ or that they ‘aren’t safe’ the functional and structural aspects of the body respond accordingly, by constricting components of the body or blocking the flow of energy to an area.



Limiting beliefs


When practitioners have limited beliefs about the healing power of the body, and the logic of health and disease, they ‘train’ patients to believe certain things. For example, it is common for a conventionally trained medical practitioner to belief that once a patient has hypertension and is put on medication they will be on it for the rest of their life. But what if the hypertension is primarily due to a separation or a loss of job? From a naturopathic perspective, when the stress of the situation is resolved, the blood pressure might return to normal, especially if the aggravating or contributing factors were also addressed. It is important for the patient to recognize how their body responded and to understand why. For example, if the patient was aware that the rise in blood pressure was due to how they handled the stressful situation, a more appropriate treatment strategy might be for the patient to learn new coping strategies. It is important for patients to continue to have their blood pressure monitored, but it might not be needed, or desirable, for them to continually take medication for a condition that they have resolved, especially if in the process they have learned new coping strategies. If, on the other hand, the blood pressure does not return to normal, a naturopathic doctor would look for other aggravating factors, such as diet or lifestyle and would assess if the situation was completely resolved, i.e. is the patient still angry about the separation, do they still fear that they will lose their job again, are they apprehensive about getting into another relationship, did they settle for a job with less pay or status?


Not all disease states can be resolved completely, but I would contend that there are many more than the current medical system acknowledges. The mind, that is a patient’s intentions, beliefs and expectations, dictates the degree of change that is possible. I expect that practitioners of the future will spend more time with patients addressing the limitations that they impose on themselves. Making the unconscious conscious, and modifying intentions and beliefs can be done many ways, such as mindfulness exercises, meditation, yoga, journaling, ‘talk therapy’, etc. Also, changing language changes experiences and the impact of those experiences on health. Learning to reframe situations and to re-write the internal mental map is a valuable treatment strategy.



Verbal linking


When patients are conveying information to a practitioner they do so in a specific sequence. They link events and symptoms often unconsciously. This linking and sequencing of language is an important piece of the puzzle. It provides a guide to the factors that have contributed to the state of overwhelm and it indicates the factors that need to shift in order for healing to begin. For example, when a patient says, ‘Ever since university I have had digestive problems’, the practitioner then ask further questions to determine what changed in university, was it because of late nights, changes in dietary habits, increase in alcohol, stress because of grades, relationship issues, or something else.



Energy of words


For some people there is an upside to illness or disease. There is some benefit or result that they desire. For example, a patient who is in a car accident and finds that since the accident her family is helping out more around the house. If the patient is concerned that when she gets well she will have to go back to doing most of the work on her own she may consciously, or unconsciously, block the healing process. Addressing the impact of any disease or injury, both the positives and negatives, provides a practitioner, and often a patient, with insight into any factors that might be contributing to the healing process being inhibited.


The impact of words is especially relevant when it comes to the labeling of diseases and the conveying of the relationship between symptoms, disease, and a patient’s life. Words have energy, and there are symbolic meanings to many diseases that have an impact on a patient’s perception of their ability to heal (Benor 2006). For example, the fear associated with the diagnosis of cancer, the chronic debility associated with arthritis, the anticipation of ongoing pain associated with the diagnosis of fibromyalgia. Words either create boundaries or opportunities. The words that a patient associates with their symptoms and disease convey not only the nature and characteristics of the symptoms, but the symbolic meaning.


A patient’s language reveals a contracted or supportive state. When the body is contracted, healing and health are restricted. In a supportive state, a patient has more choice, more movement, and more ‘space’. By bringing a patient’s awareness to their language, and assisting them in reframing it, you can stimulate the healing process. The following is a list of contracted language:


• ‘not good enough’

• ‘have no control’

• ‘not safe’

• ‘stuck’

• ‘not strong enough’

Related posts:

  1. The changing perspectives of health and medicine from the ancient era to the postmodern era
  2. Causes of symptoms and diseases
  3. Health and disease
  4. Symptom patterns

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Mar 24, 2017 | Posted by in NURSING | Comments Off on The therapeutic encounter

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