CHAPTER 10. Learning to practice this approach
• Introduction
• How do adults learn to adapt their working practices?
• What impedes your learning of this approach?
• What helps your learning of this approach?
• Teaching yourself through practice
• What to expect from a training workshop
• Other structured learning opportunities
Introduction
This book focuses on helping people to consider making changes in their daily lives. One of the key messages has been that people change when it is important to them to do so and they feel confident about being able to achieve it. There are probably some parallel processes at work for practitioners learning to apply this approach to their work. If you have gotten as far as reading this chapter, you are probably interested in this way of working and wondering if it is important enough to you to apply it to your own practice. How confident you feel may depend on how different this approach is to the way you already work, and how far you feel you have transferable skills.
How do adults learn to adapt their working practices?
As a reader of this book, you are probably someone who absorbs information and ideas well through reading. How else do you learn well?
• Reading is accessible and flexible in terms of how much you do and when.
• Some people find it more helpful to have someone else explain ideas to them through lectures and talks. Making notes and having supporting material provided can reinforce this and help with retention of the information.
• ‘Sitting next to Nellie’ is a traditional way of learning related to the apprenticeship model where we learn by observing others. Medical professionals will recall the old adage of ‘see one, do one, teach one’, with observation being the first stage. This, of course, only works when there is a competent colleague to observe, and some practitioners are luckier than others in this respect.
• Use of audio-visual examples (on DVD, CD-ROM etc.) can be an alternative to watching someone do it live, and has the advantage that parts of the consultation can be watched again.
• Practicing (either in vivo or in a simulated situation) under the supervision of a more experienced colleague is one way in which most of us have honed our skills, especially in the early days of professional development. Such supervisors can help us with both positive and negative reinforcement.
• Reflective practice is an increasingly popular way to learn. Journals and face-to-face discussion sessions with peers can help us to observe more clearly what we are doing and to what effect. We deliver our own reinforcements through this process, and then do more of the things that work or feel good and less of the things that do not. Reflective practice encourages a greater mindfulness in the way we work.
• New ways of working are often developed through experimentation, which clearly needs to be supported by reflective practice.
People all learn differently and usually respond well to the use of more than one method: for example, hearing a lecture, then seeing a demonstration, then trying to do it with someone else coaching. Ultimately, we learn to do by doing.
What impedes your learning of this approach?
Over a few years of teaching this approach, we have come across various obstacles to people’s learning. Some people are reasonably satisfied with the way they are working at present, so there is just not enough motivation to try something different. When some of their patients do not take advice to change health behaviors, they attribute this to characteristics of the patients or their circumstances rather than to the style of the consultation. If you have been interested enough to read so far, this probably does not apply to you. You are wondering if you might be able to do something differently with better results.
Some people are just too busy to be able to ‘see the forest for the trees’ in their jobs. They attend a lecture or workshop or read an article, are interested and engaged with the ideas, but then get overwhelmed with the volume of their workload. Even though a new style of working might ease their workload in the long term by enabling patients to take more responsibility for their own health and well-being, in the short term, it is quicker to conduct ‘business as usual’ so the ideas get forgotten.
Increasingly, health practitioners are set targets to meet. For example, a smoking cessation service might be given targets of seeing X people in a year, getting X% of them to set a quit date and X% of these to abstain from smoking for at least a month. Such practitioners feel under pressure and find it more difficult to maintain a patient-centered approach. They start thinking:
We can’t spend [waste?] time asking people how they feel about their smoking. We have to get them to quit and if they don’t want to quit now, we need to stop working with them and find some more people who do want to quit.
Being in such a situation makes it very difficult for practitioners to embrace the spirit of this approach, and to value the time they spend with patients who are still contemplating change.
Linked to this is what William Miller calls the righting reflex. This is the ‘powerful desire to set things right, to heal, to prevent harm and promote well being’ (Rollnick et al 2008). The righting reflex can seriously get in the way of rolling with resistance, and can lead to a firm advice-giving stance. Even practitioners experienced in using this approach struggle to keep their righting reflex at bay! Where it is very strong, it can make it difficult to believe that an approach such as this is appropriate, and this gets in the way of learning how to do it.
The learning environment can hinder the process. A certain level of stress or arousal is useful in keeping the brain active and focused, but too much anxiety gets in the way of learning. Practicing new skills (or new ways of using old skills) is best done in a non-judgmental and safe environment. Good coaches or mentors are supportive rather than critical, and use a mix of positive and negative reinforcements.
Sometimes, health professionals say things to themselves or their colleagues that make learning less likely:
• I’ll learn this in a 1-day workshop. It would be great if it were true. A workshop will certainly familiarize you with the ideas and set you on the path to learning the skills. Real proficiency with any skill comes over time, practicing in a range of different situations, being mindful all the time of what works well and learning from mistakes. The feedback you get from your patients’ responses will be your best teacher if you pay attention to it. If you do not have access to a workshop that you can attend in person, you can learn through distance learning, practice, and peer support.
• Role-play is artificial. Yes of course it is! Some people don’t like it for this reason. They feel that they perform less well in a role-play situation than they would in real life. This may be true but it may not matter if it still teaches you something about what works well and what works badly. One of the most common comments we have had as trainers, running workshops, is, I hate role-play but I must admit it was the most useful part of the course. Playing the part of the patient is particularly instructive in developing a ‘feel’ for resistance and readiness to change. It may sometimes be appropriate to use ‘real play’ instead. In real play, rather than role-playing a patient and health professional, the participants use a real issue that one of them presents, and work as colleagues addressing this issue using the techniques described in that section of the workshop.
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