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Radiography (2007) 13, 135e141

REVIEW ARTICLE

Observations and reflections of communicationin health care e could Transactional Analysisbe used as an effective approach?

Lisa Booth*

School of Medical Imaging Sciences, St. Martin’s College, Lancaster, LA1 3JD, UK

Received 31 August 2005; accepted 31 January 2006

KEYWORDSTransactional analysis;Communication;Health care;Radiography;Reflective practice

Abstract This paper advocates a model of communication, known as Transactional Analysis(TA), as being highly consonant with communication skills and reflective practice in radiography.The paper reviews the history of TA, from its earliest inception and applications, to its mostrecent use in the observation and discussions of health care communication. Finally it considersthe application of this model to the profession of radiography as an observation/reflection tooland how it might be used to improve the practice of communication with patients.ª 2006 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.

Introduction

The purpose of the present paper is to give an account ofTransactional Analysis (TA) as a means of characterisingstyles of interpersonal communication, to provide evidencethat TA can inform reflection on the practice of communi-cation and to advocate the use of TA within the professionof radiography. Because TA is not widely known in radiog-raphy circles, the paper provides a rationale for itsexploration and elaborates on the history and principlesof TA. This is followed by some evidence for the applicationof TA in health care settings, the development and use ofthe adjective check list (ACL) to operationalise TA and

* Tel.: C01524 384580; fax: C01524 844590.E-mail address: l.booth@ucsm.ac.uk

1078-8174/$ - see front matter ª 2006 The College of Radiographersdoi:10.1016/j.radi.2006.01.010

a discussion of the applicability of TA and the ACL inradiography practice.

Rationale for exploring TA

The act of communicating at an interpersonal level is sonatural that the importance of doing it well is oftenunderestimated. Interpersonal communication serves manyfunctions, a practical function that enables the completionof many of life’s activities, a social function that enables usto achieve social belonging, through the development of ourpersonality, and communication also enables us to achievephysical well being.1 These functions are achieved throughcomplex verbal and non-verbal processes, with much ofthe emotional impact of any message being from a non-verbal source.1 Communications with patients, althoughclinical in nature, take place at this interpersonal level. Assuch they aim to achieve the functions mentioned earlier,

. Published by Elsevier Ltd. All rights reserved.

136 L. Booth

through the same verbal and non-verbal processes. Not with-standing the everyday nature of this communication, statis-tics of NHS complaints show that ‘‘communication’’ and‘‘attitude of staff’’ have consistently been in the top foursubjects of complaint since 1996.2 Dissatisfaction ultimatelyleads to non-adherence to health-care regimes3 and becauseof the importance of communication in engendering adher-ence in health care, a number of methods have been usedto evaluate the effectiveness of communication that occursduring practitionerepatient interactions.

The evaluation of communication can take many forms.For example, surveys or interviews with both staff4 andpatients5 have served a useful purpose in identifying spe-cific problem areas, but these indirect methods are seldomadequate in discerning the actual communication thattakes place. This is because what people say they do andwhat they actually do are often quite different.6 For exam-ple, although patients have reported that practitioners donot tell them what is going to happen to them and why,7

other studies have revealed that patients forget 50% ofwhat has been said to them 5 min after their consultation.8

Therefore, the use of these indirect measuring instrumentsdoes not reveal if patients have been given information andhave simply forgotten it, not understood it,3 or were unableto ask questions due to their passive role in the health carehierarchy.9 It is known, however, that almost 50% ofpatients attending for radiological procedures do notknow which ‘scan’ they are attending for.10 This lack ofunderstanding leads to a number of difficulties within radi-ology, such as non-attendance, for instance as in mammog-raphy,11 or non-adherence with prescribed regimes, suchas following a low-residue diet prior to barium-enemaexaminations.3

Some of the more reliable and valid direct observationtools that have been used in the observation of health careinteractions include; Conversation Analysis (CA),12 MedicalInteraction Process System (MIPS)13 and Roter’s Interac-tional Analysis System (RIAS).14 There are some fundamen-tal differences between these three tools, but common toall is that they rely on the recording of interactions usingvideo or audio techniques (usually audio). The content ofinteractions is then retrospectively analysed, and in thecase of CA this analysis describes how communicatorsbehave and how they in turn influence the behaviours ofothers. The analysis involves the concentration on ‘turns’within a sequence, with the belief that each turn influenceswhat happens next.15 RIAS and MIPS are used to examineboth the content and the form of interactions.13,14 Againthere is a focus on ‘turns’, but each phrase is placed intomutually exclusive categories such as ‘task-orientated com-munication’ or ‘socio-emotional communication’.14 Usingthese categories the whole interaction is analysed accord-ing to the amount of task-orientated talk and socio-emotional talk. The RIAS in particular is a widely usedquantitative approach to audiotape coding that has demon-strated good reliability in many of the studies in which ithas been used.3,14 However, the categories are not detailedenough to reflect all communication exchanges14 and theuse of audio-coding in CA, MIPS and RIAS also means thatthese tools are largely mechanistic and, as such, not partic-ularly sensitive to the recording of non-verbal behaviours,which are important when establishing the emotional

impact of a message.1 Nor is it possible to use these audio/video recording devices in all areas of medical imaging suchas Magnetic Resonance Imaging (MRI).

It is these shortcomings that form the rationale forexploring the possible applicability of TA to the analysis ofcommunication in radiography. TA can be used as a struc-tured non-participatory observation technique without theneed for either audio or video recording. As with CA, RIASand MIPS content and form can be observed, but para-linguistics (innotations, pitch and intensity) and non-verbalcues (gestures, facial expression and eye contact) are alsoobserved, and these contribute to the interpretation of theverbal meaning.16,17 For example, if a patient is attemptingto sit up whilst the trolley sides are down, a radiographer’sresponse might be:

‘You’ll fall if you try to sit up’.

Although the content and form appears to be a statementthat simply describes ‘what’ is going to happen, it might besaid angrily whilst forcing the patient to lie back down, thuschanging the interpretation of the message. Paralinguisticsand non-verbal communication are therefore used to supportor contradict the content and form of a message.16,17

History and Principles of TA

Psychotherapist Eric Berne first introduced the theory ofTransactional Analysis in the early 1960s.18 Since then it hasgained much approval in the psychotherapy setting. How-ever, TA has succeeded in translating intrapsychic pro-cesses (Structural model) into interpersonal processes(Functional model).19 Although some have argued that theFunctional model lacks the depth of the Structural model,20

it is still useful in helping individuals examine their actionsduring communication, through developing an awareness ofthe positive and negative aspects of their behaviour.

The main idea behind Functional TA is that an individ-ual’s personality is made up of three ego-states. Eric Bernewas, originally, a Freudian psychologist and one area ofsimilarity that can be seen between Berne and Freud is thistripartite system of personality.21 However, the differenceis that Berne’s theories are observable, ‘‘.coherent sys-tems of thought and feelings, manifested by correspondingpatterns of behaviour’’.22 p.11 The three ego-states areknown as Parent (exteriopsychic), Adult (neopsychic) andChild (archaeopsychic).23 The Parent has both Controlling(CP) and Nurturing (NP) functions, the Adult (A) is undividedand the Child has both Free (FC) and Adapted (AC) func-tions.21 A diagram that represents these three ego-statesand their subdivisions can be seen in Fig. 1.

The function of each ego-state can be expressed quitesimply. The Controlling Parent (CP) is the part of thepersonality that criticises, controls or finds fault, theNurturing Parent (NP) nurtures and promotes growth,the Adult (A) expresses logic and reasoning, the Free Child(FC) expresses fun and frivolity, whilst the Adapted Child (AC)conforms and compromises. 21 When individuals communi-cate using any one of these ego-states they are ‘expecting’a particular response from the other communicator. Forexample, if an individual is shouting, controlling, or arguingusing their Controlling Parent state, it is likely that they

Transactional Analysis: An effective approach 137

are expecting a response from either the other personsControlling Parent ego-state, or from the other personsAdapted Child ego-state. In the CPeCP example an argu-ment would ensue (see Fig. 2) e.g.

CP NP

FC AC

A

Figure 1 A Parent, Adult, Child (PAC) diagram, demonstrat-ing the three ego-states and their subdivisions.

Patient (angrily): Do you know how long I have beenwaiting to be seen? (CPeCP).

Radiographer (also angrily): do you know how long it issince I’ve had a break? (CPeCP).

In the second example the Controlling Parent ego-stateexpects a submissive, apologising and compromising re-sponse from the other persons Adapted Child (see Fig. 2) e.g.

Patient (angrily): Do you know how long I have beenwaiting to be seen? (CPeAC).

Radiographer (upset and anxious): Oh I’m so sorry. Thisis terrible. I can’t think how it has happened. I will go andsort it out straight away. (ACeCP).

The examples given above are of complementary in-teractions (transactions). These are where a stimulus istargeted toward a particular ego-state and responses aregiven from that ego-state24 i.e. the response is one that isanticipated. Of course both are extreme representationsand are unlikely to be observed in actual practice, butthey serve to demonstrate that complementary transactionsare not necessarily mediators of a positive interaction.

It can be seen in the examples given above that ego-states do not have to be the same to be complementary,what is important is that the vectors on the diagram areparallel.24 Examples of possible complementary transac-tions can be seen in Fig. 3. (There are four other possiblecomplementary transactions known as ‘psychologicallyunequal’ transactions that are not represented in Fig. 3as their use is beyond the scope of this paper.)

While an individual is engaged in a complementarytransaction, the interaction will continue quite naturallyin this way until one of the communicators creates a changein the interaction by shifting ego-states. This is known asa crossed transaction and is where a stimulus attracts an

Key

= Vector

S = Stimulus

R = ResponseCP NP

FC AC

A

CP NP

FC AC

A

S

R

S

R

Figure 2 Diagram representing CPeCP and CPeAC interactions.

138 L. Booth

A A

CP CP NPNP

FC AC AC FC

Figure 3 Possible Complementary transactions adapted from Ref. 18 p. 32.

unexpected response. Crossed transactions feel less naturalthan complementary ones as one, or both, communicatorsare receiving an unexpected response from the othercommunicator. In these instances there is a desire on thepart of the communicator to engage in a more complemen-tary transaction.21,24 If we use the example given earlier,where an individual is interacting using their ControllingParent ego-state, an unexpected response would be onethat is elicited from the Adult ego-state e.g.

Patient (angrily): Do you know how long I have beenwaiting to be seen? (CPeAC).

Radiographer: Can I ask what examination it is you arewaiting to have done? (AeA).

Patient (annoyed): I’ve given my card in, do you notknow anything (CPeAC).

Radiographer: OK if you can give me your name. (AeA).Patient (interrupting, still annoyed): what for the 10th

time today? (CPeAC).Radiographer: If you give me your name I can find out

what the hold up is (AeA).Patient: It’s Paul Smith (AeA).Radiographer: OK Mr Smith you just wait there and I’ll

find out what is going on (AeA).In the example given above, the communication is

forced to change. This change would either be to a morenatural AeA complementary transaction, as in the exam-ple, or the communication would be forced to end.21,24 Adiagrammatic representation of this interaction is given inFig. 4.

None of the ego-states or transactions previously men-tioned is inherently good or bad, since they can all be usedin a positive or negative way. Despite this, it is the AdulteAdult response that is desirable in most healthcare

situations.25 The Adult transactions are open and confirm-ing26 and encourage patients to become active participantsin their care, as a complementary AeA communicationstyles discourage sick-role behaviour,26 which is more oftenassociated with Parental-Adapted Child styles of communi-cation. By becoming more self-aware health practitionerscan utilise their use of Adult communication to encouragepositive effects in their patients.25

Evidence of applying TA inHealth Care Settings

One of the first applications of functional TA to improveself-awareness in the commercial sector was made byAmerican Airlines to improve communication between staffand clients. The programme was quickly modified andadopted by British Airways in 1973 and other commercialbodies such as the GPO have also developed such pro-grammes.27 More recently, because TA provides a means ofidentifying communication and avoiding unproductive con-frontations, the benefits of using TA to improve communi-cation in health care settings was recognised.28 It hasbeen used for example in: understanding the mentorshipprocess29 and in the pre-registration training of nurses.30

Chue and Slater31 have used Functional TA as a reflectivetool in a programme aimed at giving confidence and copingskills to midwives and students, which was achievedthrough encouraging the use of AdulteAdult transactions.Although it was acknowledged that the TA training did nothelp during the actual event, the process of slowing downa situation and using TA for reflection enabled a better

Transactional Analysis: An effective approach 139

CP NP

FC AC

A

CP NP

FC AC

A

S

R

Figure 4 Example of a crossed CPeA Transaction (Ref. 18 p. 31).

understanding of what had happened and how strategiescould be used to prevent such events from happening again.On this basis Chue and Slater suggested the use of TA in theempowerment of health care staff. Parissopoulos andKotzabassaki presented a complementary discussion thatcentred on using the same TA techniques for the empower-ment of patients.25 They argued that this reflective tech-nique can be used by all health care staff to categorise,understand, predict and, most importantly, alter the be-haviour of both sick and well individuals. The premise ofthis case was that individuals who use their Adult ego-stateare more likely to engage in responsible health behaviours,such as improved attendance for appointments and adher-ence to therapies such as dietary regimes.

Using the TA Sub-Sales of the AdjectiveCheck List to operationalise reflectivePractice

A number of methods have been proposed for the objectiveand reliable identification of ego-states that can aidpractitioners in this reflective process. One of the earliestexamples demonstrated that even inexperienced subjectscould be taught the basic concepts within a few hours.These subjects could then reliably identify ego-states fromaudio-tapes of interactions.32 Later the concept of ego-grams was put forward, a method where each ego-state isawarded a percentage score,33 but recently both methodshave been criticised, as discernment of the ego-statestend to be impressionistic and intuitive.20 A more reliableand valid measure was explored in Williams and Williams

study of ego-states and the Adjective Check List (ACL).The ACL is a standard personality assessment tool, origi-nally put forward by Gough and Heilbrun in 1965, that con-sists of 300 adjectives. These adjectives are treated in sucha way that ‘.key notions pertaining to any particular per-son can almost always be formulated, and shades of differ-ences and nuances between similar persons delineated’.34

These 300 adjectives were rated according to 15 expert(TA) judges, who were asked to assign a score of 1e4 besidethose adjectives that best described a particular ego-state,with 4 indicating a strong agreement. It was found that nojudge was distinctly different from another in the rating ofthese adjectives. Each adjective that had a mean score of3.5 or more was assigned to the relevant ego-state (seeFig. 5) and subsequent testeretest scores demonstratedan acceptable degree of reliability for all five of the ego-state lists.34

An observer/rater uses the ACL by ‘ticking’ or ‘circling’those adjectives that best describes a communicator’sbehaviour. The ego-state is then determined by thecolumn that contains the most ‘ticks’.

Since 1980 further studies have also tested the reliabilityand validity of Williams and Williams tool, through the useof the alternative measures technique. These studies haveused comparative measures such as the Brief SystemInventory20,35 to demonstrate positive correlations withthe ACL. However, Controlling Parent correlations havebeen found to be slightly lower when compared to the otherfour ego-states.20,35 It is argued that because the Control-ling Parent is viewed pejoratively, this can create difficul-ties when asking individuals to rate themselves.20

140 L. Booth

ControllingParent

NurturingParent

Adult Free Child Adapted Child

Autocratic Affectionate Alert Adventurous Anxious

Bossy Considerate Capable Affectionate Apathetic

Demanding Forgiving Clear thinking Artistic Argumentative

Dominant Generous Efficient Energetic Arrogant

Fault Finding Gentle Fair Minded Enthusiastic Awkward

Forceful Helpful Logical Excitable Complaining

Intolerant Kind Methodical Humorous Confused

Nagging Praising Organised Imaginative Defensive

Opinionated Sympathetic Precise Natural Dependent

Prejudiced Tolerant Rational Pleasure-Seeking Hurried

Rigid Understanding Realistic Sexy Inhibited

Severe Unselfish Reasonable Spontaneous Moody

Stern Warm Unemotional Uninhibited Nervous

Figure 5 Williams and Williams Transactional Analysis Sub-scales of the Adjective Check list (Ref. 34).

The applicability of TA and the ACLin radiography

To determine the applicability of TA and the TA sub-scalesof the ACL in radiography, a number of studies serve tosupport its use. For example, inter-observer reliabilityscores of 41 radiographerepatient interactions demon-strate excellent reliability when using the ACL to observethese interactions.37,39 Furthermore, the use of the ACL toobserve 173 interactions in diagnostic radiography estab-lished that diagnostic radiographer interactions fall intothe five ego-state categories and that the ACL was effectivein categorising these interactions accordingly.38,39

Through the use of the ACL it is possible for radiographersto re-analyse the qualities of their communication withpatients or colleagues. Exchanges that merit re-analysis andreflection are often (but not always) those where a crossedtransaction has occurred. These can generally be identifiedby the uncomfortable feeling that arises from being involvedin these transactions.26,36 On revisiting the situation, the indi-vidualneeds to identify their ownego-stateaswell as theego-state of the other person. This part of the analysis requireshonesty on the part of the individual, and they need to askthemselves ‘what was I trying to achieve, how did I feel,why did I behave in this way’, and ‘what do I think the otherperson was trying to achieve, how do I think they felt, whywere they behaving in that way’. However, it is possible atthis stage that the negative adjectives associated with theControlling Parent might affect the radiographer’s view ofhis/her ego-state and it is important that radiographers areaware of this prior to using this method. Once the ego-states

havebeen identified it becomespossible todrawupa series ofPAC diagrams (see Fig. 1), which enables the individual to de-termine the point at which the crossed transaction occurredand, therefore, why it occurred. Through this identificationthe individual can then consider alternatives that mighthave prevented the negative interaction from occurring.Nonetheless complementary transactions can also be nega-tive. It has, for example, been said that the majority ofhealthcare interactions are ParenteChild in nature, withthe practitioner the Parent and the patient the Child. Theseare negative complementary interactions that are said to beillness maintaining, disconfirming and actually prevent pa-tients from being empowered.26 It is only through practi-tioners using Adult communication styles, that patients canbecome involved in their own care and improved adherenceachieved.25 The purpose of using TA as a reflective tool istherefore to develop self-awareness and self-regulationthatallows theconscioususeofpositive transactions, throughidentifying, challenging and modifying behaviour, whichshould be aimed at encouraging more Adult communicationstyles in future interactions.28

Conclusion

This paper has described and evidenced the use of TA inhealth care and other settings. It has demonstrated thatfunctional Transactional Analysis, supported by the use ofthe Adjective Check List, is a valid method for the analysisof communication styles. It can provide a means forradiographers to reflect on and improve their communica-tion with patients and others.

Transactional Analysis: An effective approach 141

Acknowledgements

The author would like to thank Professor Helen Leathard forall her help with this article.

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