Using Transactional Analysis to Train French Doctors to Improve Their Doctor-Patient Communications Skills: Drawing Parallels with the Language Classroom
Judy Churchill, France
Judy Churchill is a freelance language and communications skills trainer based in the South of France. She is also director of Language Consulting Services Ltd. Her current areas of interest are focused mainly on the pharmaceutical industry where she is training several major companies across Europe in Assertiveness, Presentation skills, EQ and TA. She also runs ESP language courses in Monaco and is a regular contributor to various magazines including HLTmag. Judy is a member of the International Transactional Analysis Association. Her website: www.judychurchill.eu and e-mail: email@example.com
Programme and organisation of evening sessions
The choice of content
The added value of TA
The weekend courses
Transactional Analysis is not only probably one of the most powerful communications tools in existence, it is probably one of the least exploited in contexts where a little can make a big difference. A grandiose name for a simple concept, Eric Berne, its ‘inventor’, sought to make psychoanalysis accessible to the masses by taking out the ‘psycho’ and emphasising the more proactive ‘transactional’ nature of our relationships with each other.
Very basically Berne postulated three "ego states" - the Parent, Adult, and Child states - which were primarily shaped through childhood experiences. Unhealthy childhood experiences could damage any one of the ego states, which would bring discomfort to an individual and/or others in a variety of forms, including many types of unpredictable and unreasonable reactions to simple everyday situations.
Berne considered how individals interact with one another (the transaction) and how the ego states affected each set of transactions. Unproductive or counterproductive transactions are considered to be signs of ego state problems. Analysing these transactions can enable one or both sides to find a solution to communication breakdowns. Berne thought that virtually everyone has something problematic about their ego states and that negative behaviour or reactions would not be adressed by “treating” only the problematic individual.
Although I chose not to go into this aspect of TA in the courses I was running, Berne identified a typology of common counterproductive social interactions, identifying these as "games".
With its focus on transactions, TA examines the dynamics contained in people’s interactions as opposed to their internal psychological dynamics. This is a focus far more useful to those of us involved in teaching or coaching others who in turn interact with others. TA places its focus on the content of people's interactions with each other. Changing these interactions is TA's path to solving emotional problems that affect these very interactions.
In addition Berne believed in making a commitment to ‘curing’ his patients rather than just understanding them. To that end he introduced one of the most important aspects of TA: the contract - an agreement entered into by both client and therapist to pursue specific changes that the client desires. As a trainer this idea is particularly appealing. Surely the idea of the interactive “contract” between learner and facilitator is something that we as teachers strive to achieve in our own learning context.
Not only is TA a theory of inter-personal communication, development, growth and change but it also endorses a philosophy of mutual respect and self-respect and acceptance, without which true learning and progress cannot take place. It is based on the belief in everyone’s ability to learn and potential to change. Its appeal is that it sets out a clear and comprehensible road map for achieving this. It is above all easy to understand and use and as with language learning it can be easily broken down and taught in bite site chunks.
This is a programme that I designed and conducted throughout France along with other trainers in about fifty different locations. The programme was commissioned and run on behalf of two major pharmaceutical companies with the aim of helping doctors improve patient compliance. The two companies were dealing with different therapeutic areas: one gynaecology and the other respiratory diseases. However the problems the doctors were facing in getting their patients to adhere and stick to a therapeutic regime were similar.
The aim of the game was to humanise the encounters the doctors had with their patients, in an environment (the short consultation at the surgery) which was not particularly conducive to warm human exchanges, and to establish a relationship of trust that would lay the right foundations for a constructive long term relationship.
For the gynaecologists, the pathology causing problems of patient compliance to treatment was osteoporosis. Transactional Analysis lends itself perfectly to a context where a person in a position of “authority”, doctor/teacher must quickly be able to size up the person they have in front of them to enable an essential message to be conveyed both fast and effectively. At the same time they must overcome barriers and deep-seated resistance to their explanations and advice; resistance which may have little or nothing to do with the actual pathology being discussed.
For the lung specialists the programme was run over a weekend and the communicative context was that of guiding patients through transition following a change of therapeutic regime. This entailed transition from one asthma treatment to another and ensuring compliance to the new treatment.
For the gynaecologists the sessions were conducted as one-off evening sessions after their working day and lasted ninety minutes. This was followed by a buffet dinner which was designed to include a QA session and further discussion. The actual content of the evening sessions covered was as follows:
- The psychology of change
- A short description of the origins of TA
- The Ego States
- Transactions (complimentary, crossed, hidden)
- Communication techniques (learning to listen and asking the right questions)
The different chapters were interspersed with short video clips (consultation in the doctor’s surgery). These were developed, with the help of a healthcare communications agency. Actors were used and asked to perform their roles in caricature to demonstrate the different ego states and transactions. The result was both poignant and amusing. The doctors were able to laugh while at the same time seeing the TA theory in action.
We ended the session with a doctor/patient role play where trainees were able to try out the various techniques, observe their colleagues and give and receive feedback.
Given the obvious limitations of a ninety minute session, the results were astounding. Presenting the different TA concepts in bite sized manageable chunks, meant that the doctors were able to grasp the concepts quickly and see them immediately reinforced by the video clips, after which they put the newly acquired tools into action. Thus they left the session with an ‘I’m taking something away with me that I can I use in my surgery tomorrow morning’ attitude.
The content was by no means an arbitrary selection. The intent was to enable the doctors to understand the ‘problem behind the problem’, the patient’s hidden agenda as it were, when refusing to accept or comply to treatment.
By way of introduction to improving general communication skills for the gynaecologists with their female patients and more particularly where doctors were complaining of their patients’ lack of compliance to treatment; it was important for them to understand that the lack of compliance to treatment was directly related in most cases to a flat denial of the ‘change of life’ status their patients had reached and the psychological difficulties attached to this acceptance. This needed to be ‘treated’ before medication could be discussed. It was important to help the doctors identify the psychological state the patient was in when she arrived at the surgery, understanding that menopause is a difficult period to negotiate for a woman and how any change in our lives (above all physical change) will be perceived by the brain as a threat, an upset and a major destabilising factor. TA would be the tool that would help the doctors to better understand their patients and what mechanisms were at work when faced with a seemingly stubborn, uncooperative patient or even an overenthusiastic ‘nothing wrong with me’ type patient attitude.
I took the doctors through a series of images of traditional societies where people placed more emphasis on the gradual transitions of life, taking different generations through life’s milestones and marking the important moments with different rituals and ceremonies to aid the psyche to fully embrace the different stages of life. Traditionally we likened our life cycle to nature with its gradual progression through the seasons, with visible changes in temperature, trees losing their leaves, animals going into hibernation. Each stage was gradual, progressive, recognizable, familiar, and somewhat similar to the well structured, supportive language course, which although rather predictable in its format still empathetically takes students’ different learning styles and multiple intelligences into account.
The doctors were then awakened to the fact that ‘change’ often has to be assimilated within the confines of a fifteen minute consultation. Again this is similar to the time-restricted language lesson where the teacher may ‘prescribe’ the ‘present perfect’ with a ‘now go forth and be presently perfect with the rest of humanity and make no mistakes’ attitude. The doctor who prescribes a hormonal or similar treatment to his patient with a matter-of-fact attitude, is blissfully ignorant of the fact that in her head, the patient hears: “right well now let’s face it you are no longer a young, fertile woman so leave my surgery and age gracefully. These pills are the proof that you are now old and have lost your womanly charms”. Fifteen minutes later the female patient steps back out into the cold light of day, her self-image and esteem in tatters.
The language student finds himself in a similar situation when not allowed the time to repeat, make mistakes, recycle etc
William Bridges in his book “Transitions” explains how change of any kind is a process comprising three major stages:
- Acceptance of an end of what was before
- A neutral zone where you no longer know whether you want to go back to what or where you were before (familiarity factor) or forward into the new and unknown situation
- The new start, where choices have been made and full acceptance of the new situation is registered. The no going back factor kicks in.
Bridges explains that change is a natural process in our development as human beings and that clinging to the past although extremely hard for human nature to resist, should be avoided. Doctors can help patients navigate these difficult waters towards a positive ‘renewal’. In the same way the language teacher guides his student through the pitfalls of the new language to enable him to be reborn into the new linguistic context and environment.
The key message throughout the training is that the patient who is listened to will listen. This should strike a cord with language teachers. I have recently started “checking myself out” in my own language lessons practising the same principles I teach the doctors. LISTENING to what my students tell me they would prefer to do, HOW they want to learn, HOW I can, interest them and this is generating surprisingly rewarding results. I remind the doctors that they will have to listen to a certain amount of their patients’ conversation that is seemingly unrelated to the pathology, but this will be the ground work for the trust that must be built and that will allow the doctor to open up the communication channels with the patient at the moment of the explanation of the prescription.
I tried out my listening techniques on a twelve year old student who was ‘subjected’ to a French lesson with me by his well-meaning father. The boy was lying on the sofa staring at the ceiling holding the remote control for two small helicopters daring me with his eyes to tell him to put them down. So I did the opposite and asked him to show me how they flew and landed, to tell me why he had bought them, when, where, how and finally what they were made of. Having gained his trust in an area of interest to him, I then proceeded to ask him to tell me how he learnt French at school, how he felt about it, what he thought he could say and finally what he wanted to do in his French lesson with me. He replied unsurprisingly that he would like to play games, which is exactly what I had anticipated. But as opposed to imposing this as my idea, my game, he had the impression that he had been listened to and willingly accepted to play both cards and another French game that is a cross between scrabble and crosswords, enabling us to revise numbers colours, learn card suits, revise both passive vocabulary and be introduced to some new words. He willingly accepted the challenges and was genuinely disappointed when we finished. His father was amazed that I had managed to engage his son’s attention stating that: “He never normally listens to anyone.” The moral of the tale: people will only listen if they are listened to first. LISTENING = EMPATHY
To be able to convey any kind of message you must show empathy. Listening is the first step towards showing the other person that you understand them. For doctors and teachers who are used to being prescriptive and operating out of their ‘Critical Parent’ ego state, this is particularly challenging.
I present TA as a tool the doctors can use for deciphering their patients. In fact it is a proven system made up of knowledge and skills, which can be put to effective use in any situation where human communication takes place, so it is something they can use in and out of the work place. Although there is a certain amount of terminology associated with TA, this vocabulary is limited and the terms are easy to understand. The value they offer to the doctors in improved future doctor/patient relationships far outweighs any effort involved in learning them. It enables the doctors to identify and break up repetitive and often harmful patterns of ulterior behaviour that their patients and they themselves bring to the consultation.
By exploring the different ego states and watching the video clips the doctors are able to see quite clearly that the most common configuration or pattern of communication that they find themselves locked into with their patients is the unhelpful complimentary transaction of Parent/-Child. They may also find themselves stuck in symbiosis. Symbiosis is the term used to describe a situation where two or more people together use just three ego states instead of the six available. Where doctors etc are involved usually one will be using Parent and Adult and one only Child. This situation is often paralleled in the language classroom where the teacher - pupil relationship automatically leads to no other possibilities being explored, with all the responsibility for learning being shouldered by the teacher who over operates out of his Nurturing Parent ego state allowing the pupil to remain in his Free or Adapted Child ego state. Symbiosis differs from other Parent-Child transactions in that the other ego-states are not available; they are discounted. So where are the origins of this particular problem? Symbiosis originates in childhood, when the mother is the ‘care-taker’ (Parent) and ‘thinker’ (Adult) and the infant has only the Child available, so together they have a complete set of three ego-states.
If we not encouraged to become independent by wise parents, as grown-ups we may still crave some symbiotic relationships. We may want to be looked-after or, where we have crossed over to the ‘grown-up’ side, to look after others - to be led by others or to tell them what to do.
According to Napper and Newton, in an educational context, this is most apparent when students depend on teachers to ‘learn it for them’, for example by acting ‘stupid’, discounting their ability to work out a problem and relying on teachers to give the answers. Teachers similar to doctors, collude by doing just that, and discounting their own Child creativity in enabling students or patients, maybe also excluding painful childhood feelings of inadequacy and failure.
Whenever a teacher or doctor Rescues a student/patient by giving an answer, or Persecutes them by telling them off for not understanding, a symbiotic invitation is being extended. If the other responds as required, symbiosis is maintained and strengthened.
I show the doctors the basic tools for ‘reading’ their patients and themselves helping them to see that the most fruitful transactions (communication) in the consultation setting, will take place in a complimentary Adult-Adult ego state transaction. Again this can be paralleled in the adult language classroom where optimum language learning will take place where the teacher is considered the facilitator as opposed to the ultimate Authority.
My task involves showing the doctors how to use questions to break the Parent-Child deadlock and help ease the patient out of the over Adapted Child response which includes both rebelliousness and passive acceptance and into the objective, rational Adult capable of making “here and now” decisions. Doctors like teachers who over use their Critical Parent ego state can be guilty of heightening the patient/student’s latent insecurities and self-critical mode (increasing the intensity of the inner critical voice). The same goes for excessive use of the Nurturing Parent where over use of this part of the personality can also have unimagined negative effects. To be over nurturing is to smother people, to block off their potential for growth and above all to deny them some of their personal autonomy. In the doctors’ case it means not allowing patients to take responsibility for their own health regimes and in the teacher’s case not helping students become responsible autonomous learners.
The doctors gain insight into the benefits of making their patients at least partly responsible for their choice of treatment and entirely responsible for compliance. Both doctor and teacher can be shown how to help the patient/student to leave their Parent (where judgements are made on the basis of taught patterns of behaviour) and the Child (who makes emotional decisions based on feelings or avoids decision making altogether) behind once rational , clear thought patterns are acquired.
By showing doctors how to operate appropriately from their own different ego states and how to help their patients access their Adult ego state at the right moment, they can help their patients rationally assess their options and estimate the probable outcome of their decisions (treatment/no treatment, compliance/non-compliance). In this way both doctors and patients together working in partnership can go a long way towards minimising failure and increasing the possibility for success. Of course healthy, helpful behaviour involves not only the Adult ego-state but also the positive aspects of the Controlling and Nurturing Parent and of the Adapted and Free child ego states. Here we are concerned with helping doctors to empower their patients and themselves at the appropriate times.
On the weekend courses where we have two half days at our disposal, we are really able to exploit the practical exercises I have developed for the lung specialists. We also engage in a series of clinical role plays based on real case studies. I ask the doctors to do the first role play in caricature, forcing them to act from their Critical or Nurturing Parent ego state as doctors and from their Free or Adapted Child ego state as patients. This allows them to ‘feel, see and hear’ what they very often do unconsciously and by observing their peers, they are able to understand how this pattern often ends in deadlock or unsatisfactory compliance or abandonment of treatment.
In the second role play I ask the patients to continue to act from their Child ego state but instruct the doctors to act from their Adult ego state using the techniques I have shown them to try to elicit the Adult ego state from their patients. The feedback stage is invaluable as we are able to discuss the challenging moments, the failures, breakthroughs, and glimpses of success. The doctors are able to ‘try things out’ while being challenged by ‘difficult’ patients (their peers) and can seek my advice and that of their peers for suggestions and help in crossing their transactions.
In the third role play, the doctors and ‘patients’ choose the ego states they wish to operate from. We then return to the first and second role plays where I present the doctors with the ‘what happened next….’ results of their first role play. They see the situation after the patient returned home and the unsatisfactory results of misinterpreted prescriptions and non compliance.
We then re-enact role plays one and two, with one pair volunteering to do a demonstration before their peers. This is run as a stop-start exercise. With our finger on the proverbial ‘pause button’ we improve the Transactions and communication techniques as a group exercise.
As with the evening sessions where video is the medium for enlightenment, it is the demonstration and practical exercise phase where the ‘learning takes place’. I liken this to the language lesson where the grammatical, lexical or functional highlight of the day is explained, and yet it is only the practice and production stages that will “anchor” the new point in the student’s mind. A maximum of senses should be exploited: seeing, hearing, feeling, doing, to enable each person’s emotional intelligence to register in the way that means the most to them. My training is based on the following presupposition: “To learn anything fast and effectively, you need to see it, hear it and feel it.” (Tony Stockwell – Educational Psychologist)
Both the short evening and the longer weekend courses have proved successful with the doctors observing that they can use these TA insights and techniques in other areas of their lives, outside of the work place to enhance their all round communication skills.
TA provides a solid basis for understanding where we all go wrong in communication with others; because all of us, no matter how perfectly we communicate, never reach total perfection. We find ourselves probably daily, in situations (including classrooms), where our communication does not go quite the way we want it to. It breaks down. Sometimes the breakdown is only superficial and the situation/student/patient is easily retrieved; sometimes it is deep, leading to more serious consequences and that is where TA can help us out of the mire without placing the ‘blame’ on any one side. TA seeks not to blame but to explain. Experience shows that the occasions where we have real difficulties in communication always seem to be those times when it is most important to us to be effective.
It would not be possible to claim that TA can guarantee 100% effective communication in every situation of difficulty or conflict all the time. However, as far as my doctors were concerned, a basic knowledge of TA, appropriately applied, will enable them to analyse and better understand what dynamics are operating, what games are being played when communications breaks down. They will then be in a better position to avoid or redress the balance in these situations.
TA gave the doctors new insights into their relationships with their patients but also with others both in and out of the work place. The knowledge and skills needed to gain those insights were easily assimilated. However, and this is probably the most important point and the one that teachers and trainers should take to heart: TA skills will be useless without some element of self-examination and a willingness to change even slightly, some of our own ingrained , hardwired patterns of behaviour. We will need to practise what we preach!
Eric Berne: Games people Play (Penguin books 1975)
A. Cardon,V. Lenhardt, P. Nicolas: Mieux Vivre avec l’Analyse Transactionnelle (EYROLLES 2006)
Ron Clements : A Guide to Transactional Analysis(Insight Training Ltd 1980)
Rosemary Napper & Trudi Newton : Tactics (transactional analysis concepts for all trainers, teachers and tutors + insight into collaborative learning strategies)(TA RESOURCES 2003)
Merlevede, Bridoux, Vadamme: 7 steps to Emotional Intelligence (Crown House Publishing Ltd 2003)
William Bridges: Transitions-Making sense of life’s changes (Lifelong books 2004)
Please check the CLIL - Teaching Other Subject Through English course at Pilgrims website.
Please check the Teaching Advanced Students course at Pilgrims website.