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The Johari Window and Improving our Understanding of our Patients

Joseph Luft and Harrington Ingham in 1955 created this ‘Window’ concept to understand how individuals work  within teams and to improve productivity, communication and collaborative working. It is frequently used within counselling to explore self awareness.

It is a metaphor for displaying ourselves, drawing on ideas of visibility and transparency as well as curtaining off areas to keep them protected from on lookers who may mean harm.

I wonder if this tool can also be used to understand the complexity of the patient presenting to their doctor or Health Care Professional (HCP)?

The Open Quadrant

The transparent two way picture.

This is what the patient is willing and able to show to their doctor. But what is it that the doctor believes they are being shown? And what are they willing to see? The picture is quite a simple discrete one, I believe that too often the view for the doctor and HCP is the illness and  treatment for which their patient has been diagnosed. This is not necessarily so for the patient, their presenting picture; what they make visible, may be quite different, not even on the radar of the doctor or HCP. For example they may be showing as an anxious parent unsure of their ability to provide for their children, a highly paid business man who is in denial  ‘not very ill at all’. So  despite this quadrant being ‘open’, and that our patient willing to disclose some of them self, is the same picture being seen by the doctor? Is the doctor, only looking to see a patient with an illness, not a person?

The Blind Quadrant

This area is designed to represent what the other person can see but the patient themselves cannot see. I have  interpreted this slightly differently to emphasise the knowledge the HCP or doctor has about the patient because of their illness.

This area is saturated by the doctor’s knowledge about the patient’s diagnosis, prognosis, and expected complications. So they see, or focus on their own intelligence and ‘dump’ it on the patient. Whether they are able to tune into other aspects of the patient ( not their illness) such as their bravado, courage, or fear,  would provide potential for an improved empathic relationship. Do the blind and open quadrants merge, the patient becoming the illness, detached from the person?

Perhaps the doctor too is being blind?

The Secret Quadrant

This is describing the things the patient is keeping well guarded and hidden from the HCP or doctor who will be completely unaware of them.

An acknowledgement by HCP’s that they in fact are not being presented with the whole of their patient and the patient is concealing aspects of themselves may be useful. It may be relevant to reflect: what is my patient hiding from me?Is this related to their illness?  The situation, environment? Am I being presented with the whole person? How can I facilitate openness? What impact will this have on concordance? Self management?

The Hidden Quadrant

Neither the HCP nor the patient knows what is hidden. But by providing space to explore the potential for understanding how the patient’s illness is impacting on relationships, behaviours and emotions will only serve to increase the potential for our patient to modify their behaviour  to help them reach the potential they hope for themselves. So facilitating the exploration of anxiety, poor sleep patterns, bad dreams and other negative characteristics may prove beneficial for physical health and the relationship between patient and HCP/ doctor,  and patient and their illness.

Johari-Window-Medical-Model

I would just like to conclude that there are missed opportunities within the NHS care settings that deny the patient the opportunity to be truly known by health care professionals such as doctors, who claim to wish to do patients no harm and yet understand very little about the patient they wish to avoid harming.

Is the medical model the right way to support people with long term medical conditions?

I am writing this as a concerned health professional with experience of the NHS for over two decades and also as a psychotherapist, with an appreciation of why individuals may behave contrary, to what might be thought of, as against their best interest. My thoughts are my own. I have used the term ‘patient’ reluctantly; this term, inherent in the medical model is probably the most familiar to my readers.

BLOG003cThe first paradox I encounter is that the medical model extrapolates clinical evidence obtained from Randomized Controlled Trials (RCT) to individuals. Is it appropriate to apply objective data (data aiming to be objective) directly to an individual subject?

Secondly the general assumption of the medical model is that the ‘patient’ wants his illness to progress slowly to maximise life expectancy, and consequently there is an implicit power differential that the health professional has the knowledge to help the patient achieve this outcome.

Thirdly this implicit power differential can be disempowering for the ‘patient’, this can have a variety of consequences:-

  1. He rebels against the health professional and so behaves contrary to advised,BLOG003
  2. He submits to the Health Professional; complies but is not doing so for themselves and so may become angry, frustrated, depressed or rebellious
  3. He becomes dependent on the Health Professional and loses self autonomy
  4. He avoids the situation; begins to fail to attend and aims to manage their illness on their own,
  5. It can prevent a significant number of ‘patients’ from asking personal or challenging questions, resulting in dissatisfaction.
  6. It creates additional barriers to forming healthy, useful relationships, ‘patients’ being labelled as ‘poor attendees’ ‘non-compliant’, ‘troublesome’, ‘time consuming’ and sometimes relatives also being labelled similarly.

Finally (in this blog at least) the NHS does not appear; yet, to add equal weighting to  Patient Reported Outcome Measures (PROMs) compared to mortality rates or length of hospital stay, as a measure of its success.

BLOG003bThe outcome of the medical model, to varying degrees is that individuals with long term conditions have an increased incidence of mental illness, unemployment, and reliance on others for financial support, the latter most likely due to lack of independence but, ironically, on the positive, possibly live longer than had they not had health care input.

Health professionals declare that they should knowingly do no harm. Currently interpreted as insuring the ‘patient’ has been provided with everything they need to know (within their capacity) regarding how to manage their illness appropriately, and which medication to take. Is failure to provide this unasked for information being negligent? I have indicated doing so may in fact cause more harm than not.

What is the alternative?

It is difficult to change a culture. As I see it there are two factors that need addressing. The first is the power and authority that is given to knowledge by health professionals. Knowledge is only valuable to those that seek it. An individual will value knowledge about his illness when he has sought it and that is likely to be when he will find it applicable and appropriate for his own personal needs. As health professionals we need a new set of skills. We need to know how to use our ‘expensive’ time to listen to the person sat facing us, and hear them as a fellow human being who has to deal with what might colloquially be called ‘crap’ and then give them the information they ask for and is relevant for them. This month NICE has introduced a new guidance, on Behaviour Change, which may help http://guidance.nice.org.uk/PHG/55

Secondly, there are many theories regarding the roles we create for ourselves, our need to fit into social norms-conforming; they can be below the surface or in the sub conscious. One of these is the relationship between patient and doctor/ health professional. I described this relationship as one about power earlier. I do wonder whether we used different labels, ‘patients’ became people and doctors or health care providers were ‘advisers’, as any other advisor, available when needed. Not thrust upon us like a PPI sales man.

I am aware, people do not know what they do not know, and this can be where my ideology fails. May I just pose that we, Health Professionals- need to shift our priorities from informing to listening?