The therapeutic nature of the patient-clinician relationship has been described in many ways. Spiro [1] described empathy—the capacity of the clinician to identify with the patient and to feel his pain—as the core dimension. Novack [2] and Irwin [3] called attention to the need for the patient and the clinician to construct a shared meaning of the illness and described specific behaviors that can contribute to the requisite process of exchange and negotiation. Cassell [4] suggested that the clinician lends her strength or wholeness to the patient whose own personhood is disrupted by the illness. Many writers, most notably Peabody [5], view caring—the personal interest that the clinician feels for the patient—as the fundamental quality [5-7].

We have previously proposed that the therapeutic nature of the patient-clinician relationship lies in its capacity to meet the needs of both the patient and the clinician for connection and meaning in their lives [8]. These needs are met through a transpersonal or spiritual dimension of medical care that is most readily recognized in occasional moments of particular closeness during medical encounters. These moments are often marked by a physiologic reaction, such as gooseflesh or a chill; by an immediacy of awareness of the patient's situation (as if experiencing it from inside the patient's world); by a sense of being part of a larger whole; and by a lingering feeling of joy, peacefulness, or awe. Such moments seem to be therapeutic for the patient and the clinician alike [8-10]. We proposed the term "connexional" (from the roots "co" [together] and "nexus" [a drawing together of parts to form a whole]) to describe the powerful and mutual experiences of shared understanding that characterize these moments.

In this article, we describe interviewing techniques that we have found helpful in fostering connexional experiences. The strategies that we present were identified through a process of reflection on our personal experiences, followed by discussion and consensus development. Several of these approaches have been described by others in the more general contexts of patient-doctor relationships and psychiatric interviewing [2, 11]. Their value in promoting connexional experiences has not been systematically studied; we offer our experiences as a point of departure for further explorations by individual clinicians and researchers.

It is important to remember that the techniques we describe are only tools; their use does not in itself constitute a moment of connection. Rather, they help to establish a favorable setting and an attitude of awareness within which such a moment might occur. So, we will not be considering "how to do it" so much as "how to make it possible".

We also present some of the potential risks in using these techniques to deepen the level of dialogue between patients and clinicians. We do this not to discourage the deeper exploration of the patient-clinician relationship but to allow clinicians to proceed in a more informed and prepared manner.

Strategies for Creating a Favorable Climate for Connexion

Establishing Rapport

The most basic element of connection is rapport. Rapport, in turn, depends on mutual respect and interest, expressed in words and behavior, between clinician and patient. This is primarily a personal, not a technical, endeavor; for no matter what techniques are used, the clinician must genuinely care about the patient. Nevertheless, specific interviewing techniques may convey caring and acceptance with particular effectiveness.

Foremost among these communication strategies is the style of questioning. Eliciting the patient's full spectrum of concerns and allowing her to tell her story without unnecessary interruptions conveys the interviewer's interest without adding to the length of the visit [12, 13]. In contrast, an interview composed entirely of highly focused questions about symptoms, without consideration of their context or personal meaning, can easily create the impression that the interviewer is interested in only the disease and not in the patient.

Recognition and explicit acknowledgment of emotional content in the patient's story is particularly important in establishing rapport. Recognition is not difficult when emotions are presented verbally (for example, "I had a bad pain in my chest. I was so frightened".). More often, however, emotions are manifested less directly in the form of "dramatic presentations" (as when a patient states, eyes widened and hands clutching his chest, "It was the worst pain I ever felt in my life. I thought I was going to die!"). The patient's emotion is not mentioned by name, but it is clearly present nonetheless. Once an emotion is expressed, whether directly or indirectly, to continue on without acknowledging it ("Did the pain travel to your neck?") may again make the interviewer seem uncaring. If we respond instead by acknowledging the emotion explicitly ("It sounds like you were quite frightened. Tell me, did the pain travel to your neck?"), the difference is negligible in terms of time but enormous in terms of making the patient feel cared for as a person. Other responses to emotions include support and partnership (for instance, "It's important to me to understand your fears so we can address them together".), legitimation ("Who wouldn't be afraid after something like that?"), and touch [14].

Various nonverbal techniques can promote rapport, such as observing and matching the patient's postures and gestures; respirations; tempo, volume, and pitch of speech; and language patterns [15]. The patient's nonverbal behavior can also call our attention to emotionally charged material (for example, sighs, voice qualities and pitch, posture, brimming of the eyes).

Finally, rapport is established by a willingness to involve patients as equal partners throughout the interview, from negotiating an agenda at the beginning to negotiating a treatment plan and follow-up at the end [12, 16].

Silencing Internal Talk

As we listen to the patient's story and as rapport deepens, we may experience a transition from hearing a description of his experiences to entering his life world—the story changes from being abstract and distant to being immediate and felt, as if we were inside it. This is the essence of a connexional experience. Various techniques help us make this transition. First, as the patient begins to relate his story, it is necessary to silence our own internal talk [17]—that part of consciousness that is already forming the next comment, question, or criticism, even as the patient is still speaking, distracting our attention away from his experience and from our own spontaneous responses. The diagnostic reasoning process, too, is a kind of internal talk that can interfere with our ability to listen; it can safely be deferred for a few moments until the patient's story is completed. Once we have listened carefully to the story, we can proceed with clarification and hypothesis testing.

With internal talk silenced, we find more freedom in our awareness; we may shift attention frequently and continuously across various levels: the literal content of the patient's words; recurring themes; the use of metaphors and imagery; facial and body expressions; our own physical, mental, and emotional sensations; and so forth [18]. In this state of freely floating attention, we can have greater access to our own hunches, associations, and imagination, effectively harnessing our unconscious mind in the exploration of the patient's situation [19]. All of these observations are rich sources of hypotheses about what the patient is experiencing and the meaning that it holds.

Accessing Unconscious Process

The patient's unconscious process is our most important resource, provided we are alert to its methods of expression. Unconscious process will persistently urge the patient toward healing and growth and attempt to bring underlying problems to light, within the bounds of what the patient can accept consciously [20]. This principle, which is also the basis for "free association" in psychoanalysis, can lead both patient and doctor to discover connections between symptoms, feelings, and life events that may not have been consciously apparent to either of them at the start of the interview.

To make use of unconscious process, we must begin with the assumption that no aspect of the patient's behavior is random—that there is information to be gained from noticing how things are said, what is said, and what remains unsaid. Thus, by continually asking ourselves such questions as, "Why is he telling me this?" or "Why did she use that particular phrase?" we can identify clues pertaining to the deeper levels of the patient's story.

I (DAM) was seeing a 56-year-old man in routine follow-up for hypertension and lingering depression that had responded poorly to medication. As usual, the patient was angry and belligerent about his treatment from his employer; his hostile comments about the company were peppered with references to being "shot in the back," "stabbed in the back," and "raped from behind". I felt a sudden eerie, almost uncanny, feeling. When the patient subsequently described himself as a veteran, I encouraged him to describe his war experiences.

The patient said, "I don't know whether I should tell you about this," then paused. I asked him whether he had killed anyone. His belligerent tone turned remorseful, and he spoke of deliberately shooting a teenage civilian in the back for no particular reason, other than that he had just downed a few drinks and had been dared to do it by one of his comrades.

By noticing his own emotional response to the patient's repeated references to violent acts committed from behind and associating these in his own imagination with the patient's war experiences, the physician developed a hunch about the nature of the patient's distress. He then tested this hypothesis by asking the patient directly whether he had killed anyone, which broke the standstill in the communication process and gave the patient an unexpected and needed opportunity to free himself of a long-held, painful secret. In this case, the doctor's hunch was correct. Had it been incorrect, his tentative and tactful presentation of his hunch would have enabled him to back off easily and resume the patient's train of thought with little or no harm resulting.

The story of the war veteran exemplifies the way in which how something is said—in this case, the patient's choice of metaphors—can point directly to a source of ongoing suffering. Following the lead embedded in the patient's language, the physician helped the patient and himself to discover the true nature and meaning of the illness.

An example of the patient's unconscious process expressing itself through what is said is the "aside," a seemingly gratuitous comment that appears to be unrelated to the topic immediately at hand but that may point to an important, associated issue (for example, the patient "happens" to mention his boss while talking about chest pain). An open-ended statement ("You mentioned your boss".) permits further exploration of this potential clue.

A 45-year-old school teacher who was very well liked and respected by his pupils visited me (DAM) for evaluation of diarrhea, which only occurred on days that he was teaching. In the course of the story, the patient also mentioned that he had recently joined an evangelical church. When asked why he had joined the church at this time, he appeared agitated and avoided eye contact with me. I asked him if he was feeling guilty. After a pause, he resumed eye contact and disclosed a problem with compulsive gambling, which had threatened his marriage and had adversely affected his self-image. He felt that he was a hypocrite and could not in good conscience continue to advise his students about their lives and behavior.

When closing in on a diagnostic hypothesis, it is easy to dismiss asides as irrelevant when in fact they often mark the path to a fuller understanding. In this case, the seemingly gratuitous comment about changing churches was the critical clue. Had the clinician passed this by and continued to focus exclusively on the patient's diarrhea, the generative cause of his illness would not have been appreciated. Treatment would have been directed only at the most superficial level of his problem, and he probably would have remained ill in one way or another. Recognizing the core of the problem as addiction and guilt made it possible to pursue a more appropriate (and ultimately successful) form of treatment directed at a deeper level of the problem.

What the patient leaves unsaid is harder to notice but equally revealing.

On rounds with a group of third-year students, I (ALS) was introduced to a 64-year-old woman with long-standing rheumatoid arthritis who had been admitted to the hospital for severe thrombocytopenia, possibly resulting from gold therapy. Her skin was covered with petechiae. To learn about the context of her illness, I inquired about her work and her home. She described some minor stress at her job but nothing out of the ordinary, and she told me in some detail about her grown children. When I said to her, "You haven't mentioned the children's father," she began to weep.

She paused to gather her thoughts, and then related the horrifying story of her husband's death. Her daughter had decided to break off her relationship with a drug-addicted boyfriend. Enraged, the boyfriend returned to the family's home, carrying a gun and threatening to kill her. The father jumped in front of his daughter to protect her and, in full view of his wife and daughter, was shot and killed.

We all sat in stunned silence, an air of sadness but also profound intimacy filling the room. She finished her story, saying that the experience had left her and her daughter "badly bruised" and that it had been helpful to her to talk about it.

Unconscious process offers the most direct and effective access to deeper levels of patients' experiences. It requires rapport between the patient and the interviewer, and it requires flexibility within the agenda of the interview and in the mind of the interviewer for unexpected topics and associations to arise. Direct, focused questioning, such as that used to solve a differential diagnosis, does not allow adequate room for this process. The goal of such questioning is narrowly defined and, consequently, so is the range of topics deemed relevant for the interview. Therefore, the diagnostic reasoning component of the interview is better left until after the story of the illness has unfolded and the clinician has been invited in.

Communicating Understanding

As we develop a fuller understanding, we are then in a position to let the patient know that we understand. This may take various forms: a simple empathic statement ("You've really been through a lot".); legitimation ("I can see why you would have found that difficult".); self-disclosure ("I went through a situation like that once; I felt the same way".); a rephrasing or summarization of the patient's situation ("Let me make sure I understand what you've been telling me".); or a comment about one's own immediate responses to the patient's story ("It makes me sad to hear that".) [14]. By our explicit indication that we comprehend their story, patients get the feeling of being understood. This feeling is the culmination of effective empathy and is frequently the initiating factor in moments of profound connection [8-10].

Walking towards R's room, I (ALS) felt angry, frustrated, and totally at a loss about what to do. She was a 42-year-old former nurse with a history of asthma (requiring intermittent hospitalizations) and borderline personality disorder. This was her second emergency admission in as many months for extreme dyspnea, which was not accompanied by wheezing, hypoxemia, or airway obstruction. During her last admission, she appeared to be in such respiratory distress at presentation that she was immediately intubated, only to have her preintubation blood gas analysis come back normal. I greeted her and sat down to listen to the story of this latest episode. I encouraged her particularly to talk about what she had been experiencing as her breathing first got tight. As she spoke, I began to get a sense of what her "borderline personality" really meant, that she could not be sure of who she was or of what was consistent about herself from one day to the next. Her asthma seemed to be the only stable element that she could count on day in and day out, the only reliable feature of herself that she could hold onto to keep her from the annihilating void of nonbeing. This void was palpably present to me as we spoke, and it was terrifying.

I said, "I'm beginning to understand how hard it is to be you". Her eyes welled up, and she nodded slowly. Seeing how much it meant to her to have someone grasp even momentarily the private hell she had to endure, I found my eyes welling up, too, and I felt a chill in my neck and spine. For a moment, it felt like we were joined, both parts of some larger whole; it was very peaceful and reassuring, even loving. A feeling of calm and joy was with me for the rest of the day. R seemed peaceful, too. She went home the next day, and although she is certainly not "cured" of her personality disorder, she has not been admitted again in the 5 years since.

Beyond feeling understood, patients may often need to feel accepted. After personal feelings come to light, they may feel surprised, embarrassed, and vulnerable to judgment, mockery, or rejection on the part of the listener. Having encouraged patients to explore these deeper levels of meaning, it becomes our responsibility to show them compassion and unconditional acceptance [21].

The Risks of Connexion

Establishing closer relationships with patients has several potential risks. The sharing of personal thoughts and feelings creates a profound sense of intimacy between patients and clinicians, which can often give rise to three potentially problematic reactions: complementary wishes for dependence on the part of the patient and for power on the part of the clinician; sexual attraction; and increased susceptibility to pain on the part of the clinician. Although these reactions are common and usually normal, they can cause difficulties for both the patient and the clinician if they are not handled skillfully and with appropriate supports and safeguards in place.

Dependence and power frequently emerge as issues in medical relationships. Patients tend to attribute all the accomplishments of the patient-clinician relationship to the wisdom and skill of the clinician, reserving little of the credit for themselves. Perhaps this is an expression of the sublimated but never extinguished wish to be thoroughly cared for by an omnipotent parent. The more powerful the experience or the clinical result, the more powerful is the potential projection. Clinicians may be tempted to accept the resulting idealization. It gratifies our wish for power and bolsters our self-esteem. However, this projection of power can encourage the patient to regress into a less powerful role and to assume less responsibility for his or her own growth and health. Also, as our own estimation of our power becomes inflated, we can become either less accountable to our patients, creating the potential for an exploitative relationship, or overly accountable, assuming an unrealistic degree of responsibility for the patient's health and risking a profound sense of failure.

To guard against the complementary risks of dependency and excess power, we must remember that the patient is a collaborator and that any accomplishments of the patient-clinician dyad are cocreations of both the patient and the clinician, not the achievement of either party alone. Also, we can be attuned to the phenomenon of idealization as a predictable stage in the clinician-patient relationship. When it occurs, we can remember not to take it too literally and to insist that our patients accept their share of the power and the credit.

Feelings of sexual attraction are a common part of intimacy. Suppressing these feelings is not possible, nor even desirable: We would make ourselves less human and more detached in the attempt, and we would lose valuable information about the status of our relationship with the patient. However, acting on these feelings is equally wrong, even when the patient appears to consent. The asymmetry of power in the patient-clinician dyad and the phenomenon of projection described above make it virtually impossible to accept at face value a patient's apparent consent to sexual relations. Without credible mutual consent, sexual contact is by definition exploitative, and the potential for patients subsequently to feel abused is enormous [22].

We cannot suppress sexual feelings, but neither should we act on them in a sexual fashion. Rather, we can acknowledge our feelings, talk about them with others, or sublimate them into other activities. In the thrall of particularly strong feelings, our judgment can become temporarily distorted; "letting the steam out" by confiding in trusted colleagues can protect our patients and ourselves from the harmful actions we might otherwise undertake on our own. The need to maintain and use a network of trusted colleagues cannot be overemphasized.

Fostering greater intimacy with patients brings us more deeply into their experiences. We cannot listen empathically to their descriptions of pain without feeling it ourselves. Moreover, the issues that they bring to us often resonate with our own unresolved griefs or remind us of our own unhealed wounds. Without some source of strong grounding and support, we could easily become engulfed in or overwhelmed by the suffering we encounter and our inability to fix it.

Once again, having a group of colleagues with whom we can share our feelings is helpful [23]. It is also important to have other sources of connection and meaning in our lives outside of medicine [24, 25] and a personal philosophy that gives meaning to suffering and allows us to accept the intrinsic limitations of our ability to "control" disease [10]. Fortunately, the connection with patients that exposes us to their pain also allows us to share in their joys; the sharing of all the experiences—happy and sad—can itself be a source of profound meaning [9, 26].

Conclusions

Connexional experiences arise frequently in the context of suffering and healing; they address the needs of both patients and clinicians for connection and meaning. Looking back at the history of medicine, the relationship between healer and patient has always been of central importance. We are fortunate to have the marvelous advances of our modern technology, but they cannot supplant the particularly human contact that clinicians and patients share. Because our collective knowledge of technology is not currently coupled with an equally systematic knowledge of relationships, we clinicians have much to learn, individually and as a group.

Exploring issues of connection and meaning in medical care, like venturing onto any other unfamiliar terrain, requires both curiosity and caution. We have examined some of the interviewing techniques that might be helpful in this exploration and pointed out some potential hazards and their remedies. Now it is up to each of us to engage in our own personal exploration and to compare our results. Through a scientific process of consensual validation, we can help each other learn how to integrate the connexional dimension more fully into modern medicine. A great richness of experience awaits us.