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  • Dental Health Magazine

Transactional analysis: A useful tool to ensure highly effective communication

Source: Dental Health Magazine, Vol 58, March 2019

At every appointment there is a complex interplay of expectations from both the dental hygienist or dental therapist (DHT) and the patient. Mismatches of expectation can start from the very outset. The DHT’s role is often greatly misunderstood by patients. Many, especially those who have never been treated by a DHT before, simply do not see DHTs as a highly trained health care professional. Some patients are even surprised to learn that a hygienist is tasked with treating, and therefore touching, the gums (and not just the teeth). An understanding, therefore, of the nuances of communication and the psychology behind it can help promote effective communication and manage any misunderstandings that might occur.

Of course, effective communication is at the heart of a DHT’s role. It is the DHT’s role and responsibility to motivate and educate patients to practise optimum oral self-care. To this end, much time during training is spent on fine-tuning the art of communication, both overt and covert.

The 7-38-55 concept of communication1 is highly relevant to those wanting to communicate effectively. Devised by Dr Albert Mehrabian, the concept quantitatively proved the importance of non-verbal cues in communication.2 Dr. Mehrabian’s research highlighted that when someone talks, the listener focuses on three main things: Figure 1.

As DHTs, some of our covert communication is self-evident, for instance making sure we have a friendly and welcoming manner when we meet our patients. But often, covert communication is far more complex. Unwittingly, on occasion, we invite our patients (as they do us) into modes of communication that we need to be able to recognise and disentangle ourselves from.

This article focuses on Transactional Analysis and how it can be used to ensure positive outcomes on patient rapport. Transactional Analysis is a branch of psychology devised by Eric Berne (3) based on the idea that one's behaviour and social relationships reflect an interchange between different aspects of personality. Berne argued that when we communicate we adopt, both consciously and unconsciously, the Parent, Adult or Child. The terms Parent, Adult and Child do not correspond to their common definitions but are used as terms for the behaviour they represent:

1. Parent. This state is further split into:

  • Controlling Parent

  • Nurturing Parent

2. Adult: rational and balanced

3. Child. This state is further split into:

  • Adapted Child: anxious and submissive

  • Natural Child: spontaneous and emotive

Figure 2:Transactional analysis diagram services/transactional-analysis/

Further, Berne outlined three types of communication (Fig. 3):

1. Complementary transactions.

These lead to effective communication. In complementary transactions, what is said engenders the expected response (4).


DHT (speaking from Adult): Mr Jones, it looks like you haven’t maintained your flossing habit.

Patient (replying from Adult): You are right. I wanted to talk to you about that. I found it hard whilst I was on holiday to stay in my routine.

2. Crossed transactions.

These occur when what is said engenders a different response from what was expected. The communication is ineffective. This could lead to an argument. One or both parties will need to try to shift states to re-establish effective communication. Ideally both parties should aim to switch to Adult to Adult communication.


DHT (speaking from Adult): Mr Jones, it looks like you haven’t maintained your flossing habit.

Patient (replying from Adaptive Child): Who are you to judge me?

In this example the patient might feel like the DHT has spoken to them from Controlling Parent.

A possible solution might be for the DHT to reply from Adult: ‘Mr Jones, there is no judgement here. I am here to help you and take care of you’

Example 2:

DHT (speaking from Adult): Mr Jones, are there any change in your medications list since I last saw you?

Patient (replying from Adaptive Child): Why do I need to answer these questions all the time? You’re just cleaning my teeth.

Whilst it might be easy for the DHT to feel upset at such a reply, staying in Adult to reply is likely to provide a positive outcome:

DHT replying from Adult: That is a good question. It is best practice for me to update your medical history at every appointment, in case something has changed or you forgot something on the form. A great many medications can affect what I see in your mouth’

3. Ulterior transactions.

These involve two or more states in parallel. Often one part of the transaction is verbal and the other psychological. The outcome of the communication is psychological. Such communication is manipulative and often based in game playing. (5) Interestingly, patients can assume that the DHT is employing this technique when they are not.


DHT speaking to Patient from Adult (but whilst giving out a long audible sigh – from Controlling Parent): Mr, Jones, it looks like you haven’t maintained your flossing habit.

Patient replying from Adaptive Child: I have, I can’t even sleep at night because I have to floss every 5 minutes.

In this example, both parties are using an ulterior transaction. The DHT’s sigh belies the fact that they are not happy with the patient even though what is being stated is a fact. The patient picks up on this and replies with sarcasm. Sarcasm in particular is a tool used in ulterior transactions in order to show that what is being said is not what is meant. (5, 6)

To understand why crossed transactions and ulterior transactions occur, it is useful to examine both the patient’s and the DHT’s perspective.

The mouth is an intimate area. Indeed, the lips are the body’s most exposed erogenous zone. It is hardly surprising that two emotions are key here from a patient perspective: Fear and shame.

New patients in particular are walking into the unknown, which in itself is frightening enough. They also might well have had a bad previous dental experience (or heard about someone else’s).

Possible fears might include:

  • Lack of rapport with clinician

  • Pain

  • Damage to teeth or fillings

  • Other issues being discovered e.g. lumps and bumps, further cavities

  • Additional costs

  • Being ‘told off’

Possible shame might be centred around:

  • Being judged (found ‘dirty’)

  • Lack of oral self care

  • Not having ‘perfect’ teeth

Fear and shame are two key emotions that place the patient in the Child and therefore more likely to react emotionally (rather than rationally from Adult). More importantly, emotional reactions are often based in a fight or flight response, where any advice from the DHT is more likely to be perceived as criticism.

The dice are loaded in this regard against the DHT. The DHT is tasked with discussing and educating patients about highly emotive subjects such as self-care, smoking and diet. This educatory role can caste the DHT in the Parent role (and thus invite the patient into the Child). The DHT’s challenge therefore is to stay in Adult at all times, further remembering that according to Mehrabian, ‘delivery of what is said’ represents 38% importance vs. 7% importance given to ‘actual words’. (2) Of course it seems obvious that it is important for the DHT always to communicate without the slightest hint of emotional involvement. But this is not always easy.

Now to examine the DHT’s perspective; The DHT can be likened to a swan. To an observer, a swan gracefully glides across the water, but what the observer cannot see is the swan’s legs kicking furiously to keep it moving forward. To the observer, the DHT might appear simply to be scaling but he or she is often under considerable stress.

Patient centric stress can be centred around:

  • Ensuring pain free treatment

  • Managing patient fear

  • Managing patients who move whilst being treated

  • Meeting the expectations of hard to please patients

DHT centric stress:

  • Perfectionism (often associated with ensuring best practise)

  1. Effective note taking and charting

  2. Ensuring all deposits are removed

  • Working alone

  • Time pressures e.g. patient runs late, linked appointments, 20 min appointments, performing own instrument decontamination.

This stress, no matter what the cause, needs to be kept internalised as far as possible to ensure a high degree of professionalism. It should not however be forgotten that those under stress can subconsciously display body language that belies their stress. This in turn can lead to communication breakdowns. Patients in fear can often pick up on the clinician’s stress and assume they are the sole cause of it. Often clinician stress will be perceived as displeasure or even anger by that patient. A simple frown, for instance, at the wrong time can unconsciously invite the patient into thinking they are involved in an ulterior transaction.

In conclusion it has been shown that, expressing oneself from, remaining in and responding from Adult is key to harmonious communication and patient management. It has also been seen how difficult this can be given the stresses of the DHT’s role and the fine nuances of covert communication.

Patients who are nervous or in shame are likely to pick up on subtleties that the DHT might not even be aware of (e.g. frowning or sighing). Such a patient is likely adopt an adaptive Child role and thus invite the DHT into a chiding Parent role, causing a breakdown in effective communication.

Further, the DHT's educative function can trigger some patients' shame or sense of being judged, especially those who are not aware of the DHT's remit to assist patients in attaining gold standard oral self- care.

Where communication breaks down, a recommendable strategy for regaining positive exchange is to ensure to speak from Adult. Subsequent communication will only appear authentic if all covert communication such as body language and facial expressions do not belie any emotional involvement (7). Another useful tool to redress any communication breakdowns is for the DHT to switch to the Nurturing Parent. Here again it is extremely important to ensure that the role is adopted authentically. If the patient thinks that the DHT is simply playing a part, rapport can be damaged still further.


Transactional analysis:A useful tool to
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