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Tag Archives: therapeutic relationship

“Because we are worth it!”

01 Tuesday Sep 2015

Posted by Uta Mittelstadt in Food for thought

≈ 2 Comments

Tags

Boundaries, Discount, Friends, Homeopathic practice, Price, Quality, respect, therapeutic relationship

I came across an interesting article on the www the other day, and I wanted to make a point of this topic. It relates to homeopathic practice, and I recommend you read the article if you have the time!

Why friends don’t pay and clients can’t be “friends”

For free… really?

The article title already gives it away, one issue that we all, as practitioners, have or have had sometime in our career. I mean, how often have you given an advice or a recommendation for a prescription to a friend or acquaintance? Be honest! I confess, I did, frequently! I figured for a long time that sharing such ‘tiny tips’ would demonstrate to the other person my competence, my willingness to help, and would as a consequence potentially yield me with a future client. It never did! But, I was often told “Gosh, how can you give your gained knowledge and experience away like this, for free?”. Good question?

I have worked hard to acquire my knowledge, it was a costly time of study, why should I give my information away for free? Especially if there is no gain from it …There is a fundamental problem with this… Agreed?

Stingy is in!

In todays time, with the flooding of the market with cheap goods, and cheap copies of quality products, imported via the Asian economies, our society has changed. We have become ‘stingy’, … but did this pay off? OK, hands up, who has not fallen for the super duper bargain in the ‘cheap-deal’ shops or the ‘SALE’ stores? I have, but in all honesty, I never really made a bargain. Frequently the object purchased at such stores, had only a very narrow life-span, and was of a bad quality. In the end I paid more, to buy a new one, of a better quality. Am I the only one with this experience?… What has this taught us? That what is cheap, is often of a lesser quality, requires earlier replacement, and as a consequence costs us more. Coined to our homeopathic practice, giving advice for free or cheaply, reduces the perceived value and quality of what we do, subconsciously. People expect a lesser quality if the payment for a service is cheap or at no charge. The service we offer is not appreciated as much, and its value not recognized.

Why can we & must we charge our price?

Because we are worth it! Our education was costly, we practice continued professional development, we spend a lot of time in the therapeutic relationship with our patients, therefore our services can be paid for appropriately! But what about those small tips and recommendations to friends? Charge friends? I would say, keep the distance, don’t treat friends, and that for various reasons. This strategy is difficult to maintain, I know, I’ve been there! For the same reasons that clients cannot be our friends. There is a boundary issue! Friends know so much more about us than we should ever be inclined to share with our clients. This is not what you want in the therapeutic relationship! Patients come and see us for their health troubles, they want to share their pains, ills, vulnerabilities. We are the ‘healthy’ practitioner that can ‘handle’ their issues! We do not have these ‘weaknesses’, and if we do, they do not want to know about it! On the other hand, if friends do know, how does it fit in if they ask us, “why did this not work for you?”, or “Great advice, why are you not keeping to it?”. There is also less of a distance between us and our patient within which we, as the practitioner, can be empathic, unprejudiced and nonjudgmental!

To discount or not to discount

Even if it feels awkward to charge friends, we should do so if we cannot decline treating them. Yet, what about a discount? Friends may expect to be treated, at least, at a discount? And for other clients, should we not offer incentives, such as discounts, to attract new clients? From my experience with a different professional hat on, in the tourism industry, I would say: Do never give a discount! Have your pricing scheme and stick to it! Giving a discount makes people think you desperately need their money, and this changes the dynamic. People start disrespecting boundaries, because they think you need them and their money. Giving a discount signals that you want to keep the client, this equates for many, that you are ‘needing‘ them as client. It’s very simple: We are offering a service for which we should get paid our fixed prices. Full-stop!.

Keep it in the treatment room

Finally, what should we do when bumping into a patient on the school run, or at the grocers, and they start talking ‘case’? We gave this patient an appointment and they received their treatment, we got paid. We are not indebted to this patient… just because they paid once. Keep those boundaries! Tell them to call during working hours, or, if need be, to schedule an appointment… and… charge for it!; … maybe not if the question is minor, like “what time to best take the remedy” or another ‘generalized’ question, but certainly for questions that require you to get your notes and consult the books!

On another note

‘Boundaries’ is also why I am not too keen to be working in my home! That environment is not neutral. I have in the past found this to disturb the patient/practitioner dynamic. The patients see how I live, question things they may see, and ‘know’ things about my environment and consequently about me. At one time, before my homeopathic career, a person being round to the house had seen a foreign bank-note pinned to a board in the entrance. I had at the time received this for a friends currency collector son, from a far travelled friend. Not worth more than a few pennies… but the ‘talk across town‘, by the next morning, was that I must be rich as ****, because in my place the walls were ‘wallpapered’ with bank-notes. What shall I say… I’d like to avoid situations that potentially could arouse misunderstandings with patients, and definitely such misapprehensions that have nothing to do with my work!

I agree with the above mentioned article Why friends don’t pay and clients can’t be “friends” We are service providers! There is a distance, has to be a distance, between us and our clients! I know that in practice this is at times very difficult to exercise. Maintaining a distance while being in a therapeutic relationship is not easy, and boundaries can occasionally get blurred. Yet, cases need to be managed, and patients need to get managed! Successful management keeps us and our practice healthy! Mutual respect and boundaries are key elements, and the maintenance of a payment scheme, and sticking to it, can help build a clientele, and a striving homeopathic practice! It is our quality that attracts clients, not the discount! Stick to it!

Embracing the differences – we are at an advantage

01 Monday Sep 2014

Posted by Uta Mittelstadt in Experience in Practice

≈ Leave a comment

Tags

consultation, Conventional medicine, homeopathy, support, therapeutic relationship, time

The average time spent by the general practitioner in the consultation with his patients is approximately 9 Minutes per patient [1, 2]. During this time a GP has to appraise a patients state of health, must diagnose or examine the presenting situation, has to decide on prescription or referral, and must supplement the patient records on file [2]. Can this be enough to understand a patient case, the cause, the treatment and prospective development under medication? How much is likely to be missed in only 9 Minutes of face-to-face interaction with the GP? In times where “not only the diagnosis, but also the treatment of patients has become more complex” [3, (n.p.)] such a short engagement with a patient must ultimately be seen as a “risk-factor” [4, (p. S35)]. Reduced time spent with the patient in the patient-practitioner encounter, may be the cause of reduction in patient compliance and satisfaction, and may promote negative impact on outcomes due to improper prescribing and subsequent potential adverse effects [2].

Albeit the fact that research has shown that physicians that devote more time to their patients, arouse increased confidence in the patients, for the targeted treatment regime, and subsequently promote better treatment outcomes [1, 3], an average of 10 Minutes spent with the patient in the consultation is considered as indicative of quality of a routine appointment [3].

Therefore, as homeopaths, we are clearly at an advantage where the time spent with the patient in the therapeutic union is concerned. In homeopathy we facilitate, to a much greater extent, a space for the patient where he or she can feel confident, and supported. This is a major factor where homeopathy and conventional medicine differ.

Yet, time is not the sole factor that renders the homeopathic therapeutic union especially valuable for the patient-practitioner interaction in the consultation. It is however an indispensable basis for other supportive aspects of the therapeutic alliance, to evolve. These elements, if brought into the consultation, may be essential for the successful appraisal of a patients case-history, and as a consequence may ultimately support patients in their recovery.

 

Continue reading about the therapeutic relationship at:….http://cleverhthemag.com/

 

References:

[1] Ogden, J., Bavalia, K., Bull, M., Frankum, S., Goldie, C., Gosslau, M., Jones, A., Kumar, S. & Vasant, K. (2004) “I want more time with my doctor”: a quantitative study of time and the consultation Family Practice Vol. 21, No.5, pp. 479-483 [online] last accessed August 2014, available at: DOI: 10.1093/fampra/cmh502

[2] Chen, P. (2013) For new doctors, 8 Minutes per Patient The New York Times [online] last accessed August 2014, available at URL: http://well.blogs.nytimes.com/2013/05/30/for-new-doctors-8-minutes-per-patient/?_php=true&_type=blogs&_r=0

[3] Oxtoby, K. (2010) Consultation times BMJ Careers [online] last accessed August 2014, available at URL: http://careers.bmj.com/careers/advice/view-article.html?id=20001044

[4] Dugdale, D. , Epstein, R. & Panilat, S. (1999) Time and the patient-practitioner relationship JGIM Vol. 14, pp. S34- S40

Hahnemann and the Therapeutic Relationship

01 Tuesday Jul 2014

Posted by Uta Mittelstadt in Lectures of the Organon

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Tags

care, caution, confiding, Hahnemann, Organon, person-centred, therapeutic relationship, trusting, unprejudiced

Hahnemann in his Organon [1] makes little to no reference to the therapeutic relationship. The few indications for the patient-practitioner encounter that he does make, in particularly when treating mentally impaired persons, were revolutionary in his time.

The first mention of details pertaining to the patient-practitioner relation is made by Hahnemann in Aphorism 83, where he not only stresses the individualized analysis of a patient case, but also emphasizes the need of the practitioner to be unprejudiced toward his patient. In Aphorism 84 he notes, that a practitioner should register with all his senses what is altered or peculiar in a patients case.

Hahnemann recommends aspects a practitioner should be attentive to and be sensitized for in the patient in Aphorism 90, and stresses in Aphorism 96 to be aware of the fact that all patients have differing dispositions. He goes on to mention in Aphorism 98 that the treatment of disease requires care, precariousness, knowledge of the human nature, caution, and much patience.

Sharp and persevering observation, and diligence of the same, Hahnemann repeatedly stresses throughout the Organon (Aph. 211, 216, 217). He emphasizes in cases of mental illness, to be understanding (Aph. 224) and trusting (Aph. 226). He continues that the practitioner needs to be without reproach towards his disabled patients, must show confidingness, and must abstain from all corporal punishment and torture (Aph.226). Hahnemann further mentions, with these patients, the need to avoid allegation (Aph.228), contradiction, reprehension and taunt (Aph.229).

Interestingly Hahnemann recommends, in the treatment of mentally impaired patients, the employment of concealed deceit to induce an emotional sense of comfort, which in turn may evoke physical well-being in the patient (Aph.226). This is an approach that is considered ethically disputable. He further suggests another form of deceit, where he recommends that in avoidance of the need of force, a patient may be given a homeopathic remedy without his knowledge, in a beverage, for example (Aph. 228). This too may be considered ethically questionable.

In Hahnemanns’ time there was little emphasis on a ‘relationship’ of patient to practitioner. It was largely the practitioner who was considered the expert and a patient case was frequently only subtly taken. Hahnemann strongly opposed this practitioner-focused approach that was common in conventional medical therapy, and openly criticized his contemporaries for not taking more rigid case histories of their patients, and for generally not focusing more on the patient. He mentions this in the footnote to Aphorism 104 (p.200).

Leaving aside the considerations of ethicality of deceit in the treatment of mentally impaired persons (Aph. 226 & 228), which until today is considered ethically disputable, and in spite of the little information given in the Organon on the therapeutic relationship, the few aspects mentioned by Hahnemann accentuate first elements of a patient-centred therapeutic relationship.

 
Reference:
[1] Hahnemann, S. (1974). Organon der Heilkunst (2.Auflage) 6B Heidelberg:Karl F. Haug Verlag.

 

The homeopathic therapeutic relationship – a patient-centered union ?!

11 Sunday Nov 2012

Posted by Uta Mittelstadt in Experience in Practice

≈ Leave a comment

Tags

comfort zone, congruence, homeopathic consultation, patient-centred, person centred approach, therapeutic relationship, trust, unconditional positive regard

The alliance between homeopath and patient is a critical one. The homeopath, by way of the homeopathic principles, requires of the patient to share, reveal, and convey in explicit detail the nature of what ails him [5]. The patient needs of the homeopath, in order to feel secure and prepared to share such intimate information, that he provide a trusting and comfortable space in the consultation.

The homeopathic consultation is one that differs to that exercised in conventional medical practice. It is dominated by the patient and not by the practitioner. The contrary is customary in the encounter between general practitioner and patient. Here the patient assumes a passive role while the GP identifies what ails the patient and proposes a medicinal intervention [1]. The homeopathic patient-practitioner union is reliant on what the patient perceives as symptoms of the disease in his totality, and as such is therefore patient-led. This fact alone does not suffice to provide a patient with trust and ease in the consultation. Such sensitive union requires other elements or ‘tools’ in order to ascertain to the patient that his encounter with the practitioner is a safe and comfortable space. Person-centered qualities may facilitate what is necessary to establish such features in this union.

The ‘person-centered approach’ was first described and explained as such by Carl Rogers, one of the initiators of the humanist approach to psychology [2]. In the field of psychology and counselling, the focus of the practitioner is on activating the patients most inert resources in order for growth to be achieved. The believe underlying this concept is that the patient knows best of his own needs. The practitioners sole role is to aid the patient in accessing or recognizing these resources [3] [4]. Homeopaths can, following the principles underlying homeopathic practice, as is outlined in the Organon [5], borrow aspects from this approach in order to facilitate a comfort-zone to the patient, in the consultation. Yet, ‘patient-centered’ does not only mean that the focus is on the patient, his descriptions and narrations, but actually emphasizes much more on the practitioners presence within the therapeutic encounter [6] [7] [8] .

Of the 6 core conditions that inform the person-centered approach, in application to a homeopathic context, the following descriptions are useful to the development of a functioning therapeutic relationship:

The practitioner has to be there, qualitatively, with the patient   in the consultation. [6] [7] [8]. This he may express by being empathic and understanding towards the patient [7]. A form of mutual trust [4] of practitioner and patient aids in abolishing discomfort and may provide security in the therapeutic union. This trust may be further deepened by the practitioners expression of acceptance and non-judgement towards the patient and his case. Termed the ‘unconditional positive regard’, this requisite is an acknowledgement of the fact that every individuals actions are grounded on his very own personal reasons [9]. A practitioner may further deepen this trust if he is genuine toward the patient and if this is conveyed by the practitioners own authentic expressions arising from the patients descriptions in the consultation. The patient is then believed to be congruent towards the patient [10].

These attributes of the homeopathic practitioner may serve to create the ‘trusted zone’ for the patient, where he feels comfortable enough to disclose his ailing state in such detail as is relevant for the case-taking. Only if the idiosyncrasies, the most individual characteristics of the disease in the patient, by way of the patients own expressions, are reported, can the practitioner select the best matching remedy to suit the patients case [5]. A relationship that lacks trust and comfort may suffer of misinterpretation of the case-taking as the reported descriptions and expressions may have failed to inform the case sufficiently. The elements, native to the person-centered approach, are to an extent natural to the homeopathic patient-practitioner encounter, but the awareness of a patient-centered attitude that is expressed toward a patient, may facilitate its use as a tool to promote the creation of a trusted and comfortable union in the consultation.

References:

[1] Hartog, C. (2009) Elements of effective communication-Rediscoveries from homeopathy [online] Patient education and counseling Vol.77, pp.172-178, article from Elsevier, last accessed 02 October 2010

[2] Casemore, R. (2006) Person-centered Counseling in a Nutshell London: Sage publications Ltd.

[3] Pörtner, M. (2000) Trust & Understanding: The person-centered approach to everyday care for people with special needs Ross-on-Wye: PCCS Books.

[4] Wilkins, P. (1999) The relationship in person-centered counseling. Chapter 3 IN Feltham, C. (Ed.) (1999) Understanding the counseling relationship London: Sage Publications Ltd.

[5] Hahnemann, S. (1974) Organon der Heilkunst (2.Auflage) 6B Heidelberg: Karl F. Haug Verlag.

[6] Lane, R., Koetting, M. & Bishop, J. (2002) Silence as communication in psychodynamic psychotherapy [online] Clinical psychology review Vol.22, pp.1091-1104, article from sciencedirect, last accessed 23 September 2010

[7] Nacht, S. (1963) The non-verbal relationship in psycho-analytic treatment [online] The international journal of psychoanalysis Vol.44, pp.334-339, article from PEP Web, last accessed 04 October 2010

[8] Freshwater, D. & Stickley, T. (2006) The art of listening in the therapeutic relationship [online] Mental health practice Vol.9, No.5, pp.13-18, article from Ebscohost, last accessed 04 October 2010

[9] Tolan, J. (2003) Skills in person-centered counseling and psychotherapy London: Sage publications Ltd.

[10] Merry, T. (1999) Learning & Being in Person-Centered Counseling Ross-on-Wye: PCCS Books, pp.85-117.

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