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Relational Frames...

Updated: Mar 6, 2022

As the CHCW trainees can attest, there has been a topic of late that has permeated my mind and I cannot seem to shake, what my mind says, is the profoundness of it. Recently, the CHCW interns completed the Relational Frame Theory course through FoxyLearning (shout out to Hilary Richardson who told me about this training). Pretty informative training that goes through basics, and, at times, more nuances of RFT and the impact it has on humans (would highly recommend it to anyone interested in behaviorism, ACT, and RFT). Going through this training and the simultaneously working with patients, assisting some transitions in our health center, and completing consulting work, my mind has been thinking non-stop about this question, “what relational frames are ignited when I interact with someone?”

Okay, so, briefly, what is a relational frame? Essentially and in a very elementary definition, it is the automatic cognitive processes that occur within our minds when we are presented in a specific context. One of the best ways I have found to explain this to people is through the “Peanut Butter and Jelly” exercise. The idea of the exercise, which I have done numerous times with patients and at trainings, is to show how automatic our minds are. I usually start the exercise out by saying, “is it okay to show you how our mind works? I am going to say a word or a phrase and I want you to just say the first thing that pops in your mind. There isn’t a right or wrong to this, or some Freudian association, but just say the first thing your mind says after I say the phrase or word.”

Mary had a little…

Twinkle, twinkle, little…



Now, even as you were reading this, my mind predicts that most likely it automatically responded with “Lamb; Star; Down; Bad.” Pretty neat, right? And, pretty obvious why this works, right? We have been in contexts that have reinforced the relational frames of these words/phrase to go together. What is also cool, is that even if your mind didn’t say those words, it said something; thus, even showing more that there are relational frames for everything we experience. Every time we hear a word, every time we hear a song or a joke, our mind ignites relational frames that are automatic. No matter how hard someone would try to stop their mind from saying “lamb” after “Mary had a little…” it couldn’t. It was going to say lamb because of the reinforcement of that relational frame.

Now, your mind might be sitting there and thinking (i.e., having the next relational frame) of “ah, cool Dave, what’s the point?” Well, let’s do this exercise again, as I will often with patients, and instead, this time, notice what your mind says after reading, “I love myself.”

What was the automatic PB&J moment? What came next? Maybe it was affirmation, “you’re god damn right, I love myself.” Maybe it was a memory of something you are proud of. Maybe, though, it was a relational frame of “no, I don’t love myself, never have.”

Which, makes my mind explode and really think about the interventions we do with patients. When we tell patients to “not worry, be kind, love yourself,” does it actually produce the responsive relational frame we are hoping? Or, does it ignite the very frames we are striving to avoid? Think about the word “weight.” What relational frames are associated with that word? When we enter a room and begin to talk about “diet,” “exercise” in the service of “losing weight,” do we have an idea of what the PB&J moment that is concurrently happening with the patient?

You know what is interesting about relational frames? Anything can ignite them; literally, any contextual change will ignite and ripple with frames. Someone entering a building ignites a chain of relational frames that helps the mind predict what is coming down the road. Often, obviously, these are completely out of our awareness. White-coat high blood pressure is a great example of what relational frame happens, even at the biological level, when a patient enters a medical building.

This, then, in a very exciting and scary way, makes me think, “what relational frames are prompted when I enter a room with a patient? How does the way I introduce myself, ask my questions, interact with the patient, what does that ignite within them?” What if we ask it in a different way by including the concept of reverse engineering; what if the question was, “what relational frames do I HOPE to ignite within the patient?” You all know me, my mind hopes to ignite the relational frames of love and compassion, as it automatically produces flexibility, which will ripple out and prompt the patient to be more connected with their values and loved ones. Side note, my mind is becoming more aware of why Steven Hayes says, “love isn’t everything, it is the only thing,” as, much like the research coming out with physics, there are transcendent, parsimonious factors that prompt growth within the human experience. If you think about what context will allow our patients to do some of the interventions that we ask of them, having a context and relational frames ignited of love and compassion will most likely prompt a higher probability of flexibility, resulting in a higher probability of engagement with the treatment we are offering. The reason why love is everything is because it ripples out to every thing we hope for humans to be and do.

Okay, my mind says to get back to the point here, the point is this is another reason, and honestly, the main reason I do the Contextual Interview with patients. For sure, the CI allows us to understand the internal, external, and relational contexts the patient is carrying, which will ripple out to us understanding and being able to predict with better precision what evidence-informed interventions are germane to their experience. And, think about what may be ignited, as far as relational frames, for an individual when you have someone genuinely come in and strive to get to know their situation? Think about what relational frames that evokes in a healthcare system? That last question really baffles and astounds me when I meditate on it. We are taught, largely, that when you go see the doctor that they are there to find something “wrong with you.” They will find a “diagnosis, a disorder” and intervene… And, my mind wonders, “damn, what is the PB&J moment there?” Then, think about your own relational frames that are ignited by asking the CI questions? As I progress through “love, work, play” my mind is also thinking, “how does this person see themselves? Is there love present? What would be realistic of this individual to do?” Simply, doing the CI, provides a stimulus controlled context that ignites frames in my mind “be curious, be kind, be love.”

I have noticed something of late, the more I am doing the CI intentionally to create a context of love and kindness, the more I notice and am intentional with my body language, the words I use, the way I ask questions, the moments that I strive to time a reflection and contextual statement, simple pauses, all of the above that are in service of creating a context of love and compassion, the more the patient’s mind, at least in my prediction, says, “this is different.” There is more flexibility, on both my end and the patient’s, to discuss radical ideas that permeate the spirit and our experience. There appears, again, purely on my mind’s belief of what is happening (as I often tell patients, ‘who the hell knows what is actually occurring’), that love is present, which as we know based on human’s biology and evolution, ripples out in profound/healing ways.

So, going back to that original question, “what relational frames are ignited when I interact with someone?” My request (to myself, to the trainees, to healthcare), think about that question. Think about what are the relational frames when we goal-set indiscriminately, when we ask someone to make a change, when we ask a PCP to give us a handoff; what are we unknowingly igniting? And, maybe phrased in a more positive way, “what behaviors, questions, statements, etc., can we do to ignite the relational frames we hope to?” What can we, without ever doing an overt intervention, do to promote kindness, compassion, and, above all, love with those we come in contact. And, maybe on a more macro scale, what can we do within our clinics to make the relational frames associated with them ones of “curiosity, grace, excitement, and, again, love?”

And, as always, gratitude for the community and to be able to share such writings... it is healing for my spirit and I appreciate you all doing the work of primary care...

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