The Patient’s Perception of the Doctor    Fearful patients require a specific kind of behavior from doctors. Janis constructed a blueprint of such behavior based on his results obtained from a five year study of the psychological stress endured by patients preparing for and undergoing major and minor surgery, including operative dentistry. He explored, in great depth, the emotions, needs and responses of these patients relative to the doctors who were caring for them. The behavior of the doctors was determined to have a powerful influence on the patients’ fear and stress levels. What they needed from their doctors became apparent. To begin with, Janis concluded that the patient perceives his doctor in 2 important ways as: A Danger Control Authority, and A Protective Authority. Surrounding the perception of the doctor in these roles were strong feelings and needs. Janis summarized them as follows: The doctor controls what the patient perceives as threatening or dangerous and is the only one able to protect him from that danger. The patient facing a threatening situation becomes anxious and looks for emotional support. The Danger-Control Authority, able to protect him from that danger, becomes invested with strong emotional significance. His behavior and communications assume greater importance than would ordinarily be expected. The patient’s ability to tolerate stress and learn to cope with this fear depends upon his being able to develop a sense of trust and maintain high confidence in the Protective Authority figure. In order to do this and develop a feeling of safety, there must be a "working through" before the patient is exposed to what he considers dangerous. This "working through" is the iatrosedative interview, the first interaction between the fearful patient and his doctor. Skillfully performed from a base of knowledge, it ordinarily should not exceed five to ten minutes. Janis’ findings suggest 2 questions that must be answered in order to solve the problem. They are: What does the patient perceive as threatening or dangerous? What can the doctor do to make the patient feel safe, that he will be protected from the danger? The answers to these questions are the heart of the iatrosedative process. The Iatrosedative Interview   The iatrosedative interview has been fashioned after the traditional open-end interview. It begins with a question such as, "Are you having any difficulties?" The question provides the patient maximum opportunity to reveal what is uppermost in his/her mind; it permits the patient to establish his/her priority of "difficulties." If the patient elects to begin with a statement about sensitive teeth or bleeding gingiva or a need for examination because he suspects caries, the doctor responds to each particular cue. He will go on to get information about the problem or need until he is satisfied that he has all that is required to help make a diagnosis and treatment plan. Most patients are not inordinately fearful and manage their anxieties well, hence the iatrosedative interview is not needed. However, should the patient respond with any of the many statements of anxiety such as, "I am a coward about teeth" or "I’m the worst patient you’ll ever have" or "I’m scared to death, " the interview should be put on an iatrosedative course imediately. Strategies of the Interview  Two strategies are involved: A verbal, fact-finding, interpretative strategy, and A non-verbal, empathic strategy The verbal fact-finding strategy is divided into 2 major categories: gathering information giving information Gathering information has a Sherlock Holmes quality about it. The objective is to ferret out pertinent information quickly and concisely. The first question, as suggested from Janis’ findings, the doctor (Danger Control Authority) must have answered is, "What is it that the patient perceives as threatening or dangerous?"  Once the patient’s fear is determined, the second step is to determine how the fear was learned. Knowledge of the learning paradigms mentioned above can be helpful at this point. Again, this information can be elicited quickly and concisely in a matter of four or five minutes, or less. This is not meant to be an in-depth, prolonged inquiry. Good information gathering requires an adroit questioning technique, the ability to listen and "hear" what is central in the patient’s communication and to respond in a way that will facilitate the unfolding of the story. After gathering information, the doctor switches to giving information. It is his turn to talk and the patient’s turn to listen.  In giving information, the doctor (Protective Authority) answers Janis second question, "What can the doctor do to make the patient feel safe, protected from danger?" The gathered information is valueless unless it is sorted out and interpreted. It is then fed back to the patient in a way that will give him insight into the specifics of the fear, how is/was this learned and how it can be unlearned. The doctor then states his commitment as to how he will behave and what effect he expects his behavior to have on the patient’s ability to relearn. This verbal communication, coupled with empathic non-verbal communication will initiate a feeling of trust. If the trust is maintained and subsequently deepened by the Iatrosedative clinical encounters, the fear may be eliminated because fear is soluble in trust. Model of the Iatrosedative Interview   A simple four step model of the above strategy is: Gathering Information 1. Recognizing and acknowledging the problem 2. Exploring and identifying the problem Giving Information 3. Explaining (your interpretation of) the problem 4. Offering a solution to the problem (commitment) The following is a brief explanation of each of these steps: 1.   Recognizing and acknowledging the problem: To respond both non-verbally and verbally to the expression of fear. In a way as to communicate understanding and acceptance of the fear and the intent to explore the problem in order to help. The dentist may say, "I’m sorry, this must be difficult for you. Let’s look at this first because we can do something about it." This is a crucial point – a sort of "moment of truth". Fearful patients are very perceptive and sensitive to a dentist’s behavior. If the doctor feels threatened by the fear either because he does not know how to deal with it or does not want to, he is apt to communicate the message [nonverbally]. This will either intensify the fear or terminate the relationship. 2.  Exploring and identifying the problem: To gather information through the use of questioning and facilitation skills in order to determine: The specific fear and its intensity The origin of the fear The behavior of the doctor(s) or authoritative figure(s) that may have been involved if traumatic conditioning had occurred. This usually is revealed with the origin. Determining the specific fear and its origin enables the doctor to offer a specific solution and aids in formulating a plan of effective behavior. The goals of giving information are: 3.  Explaining (your interpretation of) the problem: To provide feedback of the information gathered in order to validate it and to explain: How the fear is learned. Some fears, although on a conscious level, are not apparent to the patient and require explanation and interpretation. An example will follow. The specific fear and associated fears of helplessness, dependency and the unknown leading to some discussion of control. Patients have the ability to unlearn the sense of danger and relearn a sense of safety. With supportive statements that other patients with similar problems have relearned. 4.  Offering a solution to the problem: commitment: To provide a commitment through explaining: How the doctor will perform the procedure that is feared. The kind of behavior the patient can expect from the doctor, for example: Offer of control so that the treatment will be stopped if the patient feels threatened. Being kept informed as to what to expect as treatment progresses (Preparatory communications) Keeping a two-way line of communication open in the event the patient needs to discuss feelings or emotions. Technique of the Iatrosedative Interview   Although the verbal, fact-finding interpretative aspect of the technique is discussed and exemplified below, I wish to emphasize that the separation of the verbal and non-verbal aspects is artificial.  Obviously the verbal and non-verbal communication are, in reality, united and inseparable. However, looking at the techniques separately simplifies the presentation. Once a patient responds to the opening question with a statement of anxiety or fear such as, "I'm petrified of dentists, " a simple but precise tactical design should be operative.  The doctor must progress from the general statement of fear to the determination of what the patient specifically fears.  Eliminating or reducing the fear level is thereby made much easier;  it is virtually impossible to make a commitment of behavior if the specific fear is unknown.  Once the specific fear is known, the next step is to learn the circumstances of its origin. Graphically stated:      General statement --> specific statement--> origin of fear The most economical and expeditious technique of moving from the general to the specific to the origin is by the use of brief, highly specialized questions in responding to the patient's statements.  We will label these questions as: 1.  "What" questions 2.  "Can you tell me" questions These "on target" questions are succinct.  The doctor at this stage of the interview does a minimum of talking and a maximum of listening and responding.  This will be reversed when the time comes for him to give information.  Examples of these "what" and "can you tell me" questions can be illustrated briefly as follows: Patient: "I'm petrified of dentists." (general statement) Doctor: "What is it that you are petrified about?" Patient: "The drill" Doctor: "What is it about the drill that bothers you?"   The patient may respond to this question with the specific aspect of the "drill" by stating it is the pain; that the patient had always had painful experiences.  An appropriate response would be, "Can you tell me more about it?"  The objective is to have the patient elaborate on the history of her experiences.  Another such question is:  "Can you tell me what happened?" Example and Analysis of an Iatrosedative Interview    The doctor initiates an open-ended interview, unaware that the patient is fearful. Doctor: "Are you having any difficulties?"  The usual open-ended question; the doctor knows nothing of the patient's feelings.  This question permits the patient to establish the priority of "difficulties." Patient: "Doctor, I'm terribly afraid of anything to do with my teeth."  With this general statement of fear, the doctor signals his recognition and acceptance of the problem by responding with the first of the "what" questions.  This also sets him on course to determine the specific fear. Doctor: "What is it that you are afraid of?"  The first of the basic "what" questions. Patient: "I hate needles."  This is more specific but not specific enough.  There are many reasons people fear injections, i.e. deep penetration, pain, sense of body damage, etc. Doctor: "What is it about injections that bothers you?"   Another "what" question designed to pinpoint the specifics of the fear. Patient: "It's the pain of the shot that bothers me."  This is the specific threat.  Now the questions should be directed toward revealing the origin of the fear and the behavior of the past doctors which may be responsible for this learning. Doctor: "Have you had painful injections in the past?"  This is a precise question repeating the word "pain" (painful) is to get to the origin. Patient: "Yes, I have ... many times and I'm really afraid of them."  Sometimes the patient will continue the story, particularly if facilitation [by the doctor] is used by nodding the head.  If not, then ... Doctor: "Can you tell me what happened?"  This brings the patient closer to the origin. Patient: "As a child I had shots for fillings and the needle hurt a lot ... they were awful..."  This pairing of pain with injections may be traumatic enough to set up a conditioned response.  But if the doctor's behavior is traumatic as well the threat increases. Patient continues: "I cried and squirmed and they got angry which frightened me even more..."  The sense of helplessness is magnified here, the danger is intensified by the doctor; he offers this girl no protection ... the distrust is compounded by his anger... in all creating a traumatic experience of considerable power. Patient continues: "It got worse because sometimes the shots didn't take, but he drilled anyway, it was terrible."  The fear of the unknown is added to the other fears .. she did not know if she would have protection from the pain or not ... again compounded by the doctor's not caring. At this point the strategy shifts from gathering information to giving information.  The elements of the conditioning are painfully clear: the pain, the distress, the fear of helplessness and the unknown coupled with a nonprotective, angry authority figure.  the counter-conditioning process begins with an emphatic statement of support followed by your interpretation of the effects of the experience on the patient and an explanation of why you believe she can relearn.  Suggestion is used in conjunction with a commitment of how you will behave when both of you face the first injection together.  This commitment will state: How you will behave What you will do How you will do it Click here to view part 3 of this paper Suzanne Boswell Presentations -  12108 Amoretto Way, Raleigh, NC  27613  USA Phone: 919-845-4189   -    Fax: 919-845-4188  Email : Suzanne@BoswellPresentations.com Website: www.BoswellPresentations.com