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Linus Geisler: Doctor and patient - a partnership through dialogue   © Pharma Verlag Frankfurt
Conflict and overcoming it in discussion
Approaches to a solution
Conflict and overcoming it in discussion
There are many internal and external irritating areas that can lead to conflict between a doctor and his patient. If they are not resolved, they can lead to a stressful doctor-patient relationship and usually hinder successful communication because anxieties and aggression are released. Resolving these sorts of conflict is usually difficult, less often because the parties in conflict are not prepared to find a solution, but because the situation of conflict makes them helpless. Discussion is the best way of overcoming the conflict. This chapter attempts to show how to best solve interpersonal conflicts rather than "interpersonal" conflicts.
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All definitions of "conflict" include irreconcilability of ways of acting, motives or ways of behaviour as the general but essential characteristics. Mack and Snyder described interpersonal conflict as being characterized by values which were non-complementary, irreconcilable or opposed. Rüttinger's definition includes the qualification of "apparently or actually incompatible plans for therapy". Birkenbihl called conflict "every tension which can be characterized by hidden or open antagonism". It is then the irreconcilability between two tendencies to behaviour which, by definition, is the distinctive feature of conflict (Seibt). In itself, because of its very nature, conflict is not solvable. The only possibility of solution rests in transforming conflict into a framework of problems, as problems are potentially solvable, whereas conflict is not (Seibt).
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Approaches to a solution
The transformation of conflict into the theoretically solvable structure of a problem involves metacommunication in discussion. By referring to the conflict in the sense of metacommunication, both parties should be made aware of the irreconcilability of the way in which they are dealing with one another or tend to behave. Only then is it possible to find a common explanation and/or change the situation. At that point there is no longer conflict, but a problem. The result of this metacommunication is that "both have agreed to disagree".

If this situation can be attained, not only is the path smoothed towards the solution of the conflict, but productive or creative forces can be released. 

This principle has been used by the church in canonization procedures in which the devil's advocate was expected to take a contrary position, in order that men should not make incorrect decisions. Certain techniques depend on somebody deliberately creating an opposing position, a procedure which is said to be used in meetings of the American cabinet.

Every attempt to change a situation of conflict depends on two conditions:
1. awareness of the conflict situation and
2. the attempt to attain a conflict-free situation.

Attempts at solution consist in trying to overcome the initial situation (conflict, which is characterized by an irreconcilable behaviour pattern) and to attain the objective (problem which is characterized by patterns of behaviour which can be reconciled). Attempts for resolution are of the first and second order.

In the first order attempt, both parties remain at the level of the conflict. It is not possible to attain a real solution. This can be shown by a common example of inability to escape from this level of conflict:
A says to B: "I have to nag all the time, because you are always smoking."
B says to A: "I have to smoke all the time, because you are always nagging."
or another:
A says: "I only carry on talking, since nobody listens to me." 
B says: "I can't listen to you any more, because you talk so much." 
If these people continue to insist on their positions at this level, no solution is possible.

Second order attempts to solve the situation reside in moves to change the system from the "conflict" structure into the "problem" metastructure. This is only possible when there is an awareness of the conflict and when those involved in the conflict have a high degree of flexibility and discernment of "the relative and unique construction of actual internal drives" (Berkel). Put another way, accepting the relativity of one's own reality is the first step in the second order of conflict management.

It also has to be recognized that many apparently content-related conflicts are in fact conflicts on the level of relationship. If in fact polarization is purely a matter of facts or content, both are usually aware of the differences. If the relationship is intact there is a good chance of reconciliation. However conflicts in relationships are often hidden under other differences. "These points of argument change from situation to situation, and rather than being objects of conflict, they are only symptoms of conflict" (Seibt). Both parties are surprised to find themselves conflicting again and again, and do not realize that behind these more superficial conflicts, conflicts are present in the relationship itself. Watzlawick says: "Both parties experience each of these controversies as a completely new event, a crisis that they have never had before as the substance of the conflict is always different, but neither recognizes the persistent unresolved structure of the relationship."

The only chance which promises success to resolve conflicts in relationships is to make the structure of their relationship clear to both, regardless of the actual substance of the conflict. This is most likely to succeed through the intervention of an external uninvolved person. It must however be emphasized once again that the first and decisive step towards resolving conflict is to make it known to both of those involved that there is really a disorder in the relationship rather than just a divergence of opinions. Seibt explains: "The major handicap in relational conflicts resides in the fact that the people involved are not aware of their disturbed relationship or of their part in it, but tend to unconsciously transfer their conflict onto any old subject with the illusion that the discussion is objective and "serving the cause". For example, in the case of marked conflict at the relationship level, those involved in it can take part in conferences or discussions which appear to be based on "completely factual" arguments about the budget or introduction of permanent posts, but which are in fact marked by power struggles, fawning or attempts to conceal incompetence.

Most possible solutions fall at the first gate, as the aggression which is released by the conflict (usually as an expression of anxiety) leads to a more or less complete hardening of the positions. This means that the first step in a conflict situation is to accept the aggression (Salewski). Accepting aggression avoids the danger of blocking conflict management from the very beginning. A further step is required, which attempts to reveal the problem at the base of the conflict. This is done by considering whether there is a conflict of substance or if the conflict is really due to a disordered relationship. A basic requisite here again is the ability to grasp the reality of the other, and to strive towards a common reality, within and through awareness of the conflict, to make a solution as likely as possible as it comes to be seen as a problem. Salewski called this form of overcoming conflict the APO method:
1. Accept Aggression
2. Bring the Problem to a conscious level
3. Be Open to hear the arguments of the other.

It is usually useless to argue in a conflict situation. This leads to continual escalation with new arguments and counterarguments, which bring no new facts to light. It is more promising when one person is prepared to take a step: for example if B were to say to A: "If you think that you only nag because I smoke all the time, I won't smoke for 24 hours" (if A carries on nagging, that proves that this behaviour does not depend on the fact that B smokes). This first step should not be interpreted as simply "giving in", as its actual objective is to attempt to leave the closed system of conflict in which there is only unreconcilable behaviour or ways of acting.

The solution is most difficult when the conflict is really not based on the facts, but rather due to conflicts in the relationship. The possibility of resolution is usually afforded in these cases by the intervention of a person external to the situation.

It is particularly important to listen actively to the other person in a conflict situation, and to let him "have his say", even when he is critical. It is also particularly difficult to leave time for the pauses which are necessary. However it is only by doing this that there is a chance of determining what are the real motives, expectations and points of view of the other.

There are three reactions, commonly used by conflicting parties, which should be avoided, because they do not serve the objective of resolving the conflict: appeasement, evasion and confrontation. These techniques either put conflict material "back under the carpet", "off until another day" or increase the conflict. It also does not solve conflict to strive for harmony "at all cost".

Putting a name on the contents of the conflict can have a clarifying function, as it defines the positions and possibly achieves the first step in the direction of transforming conflict into a problem. In addition everything should be avoided that would unnecessarily extend the conflict further or lead it to go on endlessly. Even when disordered relationships are at the bottom of a conflict, it would be wrong to question the whole of the relationship ("... you probably don't think much of my whole treatment"). It is much more important to define the limits of the conflict, and to go into only that which relates to the actual conflict material. A compromise (that those involved in the conflict come together and each concedes something) is always better than an unresolved conflict. It is also legitimate to mutually agree that the conflict cannot be solved immediately, and that both should have time to think about it.

Guide-lines for overcoming a conflict situation
1. Accept aggression
2. Create awareness of the divergence (content) - ("We have agreed to disagree")
3. Decide on the level of the conflict (content, relationship)
4. Only second, order solutions have a chance of success - (transformation of the insolvable conflict into a theoretically solvable problem)
5. Attempt to define the contents
6. Attempt to define the disorder of the relationship - (perhaps with the help of a third party)
7. Take the first step
8. Solve the problem
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Linus Geisler: Doctor and patient - a partnership through dialogue
© Pharma Verlag Frankfurt/Germany, 1991
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