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Educating medical practitioners through IFS

The following three scenarios are composites of experiences that patients seeking medical care have experienced. You or people you know, may have had similar experiences.

A thoracic surgeon comes into his office, walks by his brand-new patient while looking at the chest x-rays and says, matter-of-factly, “You have a lung A-V fistula; we need to get that out of there; are you free next week?” A primary care doctor looks at a newly diagnosed breast cancer patient and cheerfully suggests “Let’s make a list of the pro’s and con’s about each treatment choice, so we can come up with a good decision for you.” A sympathetic medical consultant says, “I know just how you feel…”, interrupting the patient’s narrative, before the patient has told the consultant what she wants the consultant to hear about her.

Doctors have Parts. Patients have Parts. The unconscious dynamic of these Parts of both the doctor and the patient, in relationship to each other, can influence the outcome of medical care. In the first scenario, confusion and fear blocked the patient from hearing and recalling any additional information that the doctor offered, no matter how valid the clinical data was. In the second scenario, research evidence shows that if decision-making comes from cognitive Parts, it blocks emotional and informational processing which significantly raises risks of decision remorse, poor pain tolerance, and family conflict. In the third scenario, mis-attuned empathic-sounding words from the doctor’s Part, failed to notice the patient speaking about something deeply important to her. This impacted the patient’s ability to trust what the consultant had to offer.

Awareness of the power of unconscious subpersonality Parts activated in the doctor/patient relationship, within both the doctor and the patient, is what is missing in all these cases. These cases are like so many other, similar, scenarios around the world in hospitals, clinics, and consulting rooms. The personal connection within a doctor-patient relationship enables emotion processing. Emotion processing impacts pain intensity, speed of tissue healing, information intake, and adherence to post-op recommendations.

Illness activates Parts carrying the vulnerability within a patient and also those Parts which protect that vulnerability. Doctors need to possess specific skills to identify and relate to both and also to those activated by the doctor/patient relationship. These skills are in addition to the many important clinical skills of diagnosis and treatment. They are an important component of effective medical care. They determine whether the information and treatments the doctor offers are fully taken in and understood by the patient. All doctors and health-care professionals would benefit from learning these skills.

Doctors/health-care professionals also need to be aware of their own Parts that are present in the provider/patient relationship, before they can be aware of their patients’ Parts. Most health-care professionals are identified with their “professional Parts.” It is essential that they maintain connection to their own vulnerability as well.

Current teaching in medicine does not include understanding the differences in the brain networks activated and the impact on patients and clinicians between empathy, compassion and cognitive perspective-taking that the neurobiologist Tania Singer and others discovered. Premature “empathic sounding” statements are not received as empathy or compassion by the listener. On the other hand, a strongly personal empathic response coming from clinicians is not experienced by patients as connected, and it exhausts clinicians.

Staying calmly present, however, and holding the space for the patient to take in the information and find specific words for their emotions allows their nervous system to regulate their emotions and process their beliefs. This supports them to work with the health-care professional to manage difficult health situations.

Both of us have witnessed many instances, caused by us as well, of derailed alliance-building. These derailments happened with patients and their family members during our clinical years at medical, nursing, and social work schools, during clinical experiences in surgery, child psychiatry, social work, and the ICU, and during the years that John trained med students and post-docs in pediatrics, neurology, and child/adolescent psychiatry.

We, as well as most health-care providers, have each experienced our own stress when childhood experiences and their emotions, body sensations and beliefs, were re-activated during adult health-care training.

For example, John had an experience at age six of being wheeled, without a comforting adult, to an operating room, in a cold, confused, and terrified state of mind and body. These latent body sensations, emotions and images were triggered many times during his surgical training. Most medical students and health care providers have their own set of past experiences that get triggered. It is how, and if, they consciously process them, or not, that matters.

Vulnerability fills the daily life of all health-care trainees and health-care providers, whose only choice, without specific training, is to “manage” their activated emotional system (emergent body sensations, inner imagery, and beliefs) – activated repeatedly during their working time. Those managements include disconnection from feelings. Whatever the trainee’s internal psychological “managers” are, although they allow trainees to continue providing the technical aspects of diagnosis and treatment, these internal managers can block the affective connection required for crucial aspects of patient care, including treatment decision making, pain management and patient follow-through. Patients suffer at the hands of this situation. Health-care providers are also suffering. Tania Singer demonstrated that basic skills that combine compassion, empathy, and cognitive perspective-taking reduce this suffering and can be learned by all health-care providers.

Sharing information is not enough

In the mid-1990’s, while those of us in IFS therapy training were re-framing these psychological issues and re-noticing them in medical care, main-stream medicine was focused on medical decision making. Research by the Foundation for Shared Medial Decision Making (FSMDM) was noticing “unwarranted variations” in medical care that appeared to be inappropriate in the face of medical data and the treatments available. To remedy this clinically unwise and costly variation, a health coaching company was formed in 1997 to enhance the validity of and access to information about specific illness and treatment choices.

Dozens of nurses were hired (supported by insurers) to supply valid information by telephone and print to patients about their conditions and treatment choices. When simply increasing access to valid information did not remedy the unwarranted variations in treatment, nor lower the costs of care, they focused on enhancing the patient’s assimilation of the information. They called it “information transfer.” Decision making in those days was still thought to be based mainly upon providing sufficient and valid information to patients. The company began to train nurses in Motivational Interviewing (MI) to improve information assimilation and behavior change. Not based upon multiplicity of mind, it was a model from 1980, found effective for addictions.

In 2005, when the results of using MI had not decreased the number of unwarranted variations in treatment, they hired the authors of this article (Joanne and John) as consultants to review their coaching program. We were able to review more than a hundred recorded telephone calls. What the nurses summarized they were doing with their patients was not what the recordings revealed to us. We classified the many causes for derailments in alliance-building, like those mentioned in the stories above. We then enhanced their training program using the multiplicity of mind paradigm of Voice Dialogue (in which we were trained) and Internal Family Systems (in which we were training). The research that we and the company designed to test efficacy, showed such valid and significant improvement in both training and patient care, that they hired us to train nurses to be trainers of several thousand nurses across the country. We have a summary and a training manual from 2007 that we can share (please get in touch via our author profile info). The approach is akin to the nurses taking an IFS direct access approach.

What our work had uncovered was that many of the nurses had been employing a mixture of Parts managers- professional nurse Parts, as well as caretaking Parts. What we did not anticipate was that the experienced nurses in the pilot program, working full time, volunteered their time to be part of this program and reported back a sense of decreased stress, increased job satisfaction, confidence, and gratitude for this training. In IFS language, this training helped them unblend from their primary Parts.

After 14 years of experience with IFS, you can imagine that we have enhanced our IFS application to health care. Our 2016 textbook Relationship Power in Health Care contains links to three audiovisual recordings of medical health coaching (by Joanne, now co-lead trainer in IFIO) that demonstrate our version of health coaching at that time.

The need

Shouldn’t all health-care students, their faculty instructors, and post-doc trainees have opportunities to learn the concepts of effective, health-providing alliance building with patients? Shouldn’t they be trained in relationship and self-care skills informed by IFS? The understandable burnout of clinicians from the Covid pandemic has piqued interest in self-care.

Potentially, face-to-face encounters and Zoom calls between health-care providers and their patients carry more relational impact than telephone conversations.

And there still is a need, seen from many angles, for more understanding of the role of unconscious dynamics in derailing potentially successful health-care/patient relationships. There is a need for more specific skills outside of psychotherapy to work with the relational dynamics of health care. This includes the need to increase awareness of what is emotionally present both inside the health-care provider and within the patient when they are meeting together.

It seems important to us to help remedy this situation for three reasons:

1) The well-being of health-care students and faculty is vastly improved by being trained in the internal emotional skills needed to build interpersonal alliances.

2) The quality of relationship between patients and their providers are proven to impact the success of diagnosis, treatment, and cost of care.

3) It supports the truth of the human experience, as being more than one part or one role, whether it is about health-care providers or patients.

We have initiated projects to engage mainstream medical and health-care training programs. A few experienced IFS trainers have already agreed to help. We urge anyone reading this who is interested in improving relational aspects of health care and practitioner self-care to contact us.

Note: Clarification

The authors would like to communicate that although they possess their original 2012 training manual of “Enhanced Nurse Health Coaching”, the model has been significantly modified and strengthened. Information from the outdated original manual, not the entire manual itself, can be shared with others in the context of their engagement with the authors on current projects.

The authors, John Livingstone and Joanne Gaffney, invite readers to become engaged by sharing their experiences and questions on this topic. It is possible to post comments below or email the authors – contact details in the author box.

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Author´s Bio

Authors

  • John Livingstone

    John Livingstone is a Level 2 IFS therapist, Child and Adult Psychiatrist, Health Coach, member of the Harvard Medical School Academy of Medical Education, and a founding member (2013) of the IFS Research Program.

  • Joanne Gaffney

    Joanne Gaffney, RN, LICSW is a level II IFS therapist in private practice and co-lead trainer in IFIO. jgaffneyliving@gmail.com