CHAPTER 11. Calls from the consulting room
• Listening a little, helping a lot
• Your emotions
• Some patients like to be told what to do
• Some patients will never change
• They know all the facts but they never listen, they never change
• A little bit of knowledge can be dangerous
• Why so much talk about behavior? What about feelings?
• How do habits and addictions fit in?
• Can I use this in the groups that I run?
Listening a little, helping a lot
This book has described quite a few things you can do with patients when talking about behavior change, all based on the idea that your skillfulness can make a big difference to outcome. The most fundamental perhaps is listening. Here is a slightly unusual true story we heard on a hospital ward where the behavior change involved agreeing to undergo surgery. A little listening transformed a seemingly desperate situation:
She completely refuses to have surgery. The patient refused to agree to cardiac surgery despite a warning that she could die soon after returning home if she did not. Two surgeons and a nurse tried to persuade her. Their approach was based on rational persuasion; two of them tried a soft and kind approach to information-giving, while the third, perhaps feeling a little desperate, tried to induce fear by pointing out how grim the prognosis was if she didn’t agree.
Then a nurse decided to wait until the patient had had an afternoon nap to ‘have a quiet word’. She came alongside the patient and did not try to persuade her. The episode of listening took 5–7 minutes. It turned out that the patient wanted to be discharged because she wanted to be with her partner. The nurse offered to call her partner and ask him to come in and talk things through. His increased presence and support over the following 24 hours led to a joint decision to undergo surgery.
Can listening do harm?
The successful resolution to the surgery example above started with a simple question: How are you feeling? Listening led to the solution. Yet calls do come from the consulting room that are not so straightforward. One of the most common is a concern that listening can place both the practitioner and patient in a difficult position. Here is an example.
The patient
He was 35 years old, had type I diabetes, and worked as a barman, smoking and drinking, and leading a ‘work hard, play hard’ kind of existence. He did worry about his control of his diabetes, particularly when he would have what he called a hypo, get irritable, and throw people out of the bar. His daily routine was seldom predictable, and he often went out to parties after work.
The setting
Like many patients with long-term conditions, this man went to his routine outpatient consultation with an air of resignation. He expected what he called, the usual lecture about my bad behavior.
The consultation
The nurse asked him how he was getting on, making a genuine attempt to listen, because she had 25 minutes set aside for him; she had met him once before. He started responding to her genuine interest in his everyday life. He said the structure of his life was all messed up, and his diabetes often got neglected. Hypos caused trouble. His smoking was something he clung to; it made him feel in control, and helped in all kinds of moods. The nicest thing was that the first puff was a time to take a break from it all, a moment to rest. They were 8 minutes into the consultation when she offered a listening statement, a summary of her understanding of what he was saying.
Nurse: In all these busy times, it’s like you’re in the fast lane and you find it hard to slow down.
Patient: Exactly right. I can’t and it’s a darned mess.
Nurse: And your smoking, you say it’s just part of this life.
Patient: Completely. I can’t imagine doing without it.
Nurse: It’s like your best friend.
Patient: [Puts his head in both hands, looks up] This is a ridiculous mess. [Bursts into sobbing and puts his head down again]
What’s going on here? Has this high-quality listening been harmful? What should she do now? This real case example was discussed with a multidisciplinary team, and their conclusions were as follows:
• They often came across people like this, felt very concerned about them, and usually did not know how to deal with them. One tendency was for them to pass this kind of case from one professional to another, in the hope that someone else might do better than they could.
• Some staff felt that it was not part of their role to do this kind of counseling, while the majority felt that it was an inevitable part of their work. One nurse put it this way: You never know which patient is teetering on the edge of despair until it’s too late. You can’t avoid it.
• Listening is part of quality health care. Practitioners should not shy away from this.
• The experience of being listened to could be the turning point for many patients. If handled well, they will feel cared for and appreciative.
• A distressed patient does not necessarily need to have a problem solved. The nurse need not feel that anything needs to be fixed. Her genuineness is key.
• Among the potentially useful possibilities in a case like this were to comfort him and then summarize the situation, to offer affirmation in a genuine manner, to see if he wanted to talk about any changes to his lifestyle, and to offer support and a commitment to seeing him again.
The enormous potential value of listening in a case like this, and so many others, cannot be underestimated. It is only with considerable insensitivity in response to an upset patient that harm can be done. The most important thing that patients need in this kind of situation is a sense of being contained and supported. They don’t necessarily want practical advice, and it’s usually quite straightforward to round up an episode of listening by summarizing what has been said, offering a few supportive observations, and asking permission to change direction.
Most practitioners know the experience of listening to a patient and wondering where it will end. When patients feel listened to, they can sometimes experience a hunger for more, leaving you concerned about time and how to bring matters to a constructive close. The few simple guidelines noted above are usually sufficient to deal with most situations.
Your emotions
Talking about behavior change is no neutral matter, where one can sit in a comfortable and detached bubble and just get on with the job. Emotions can run high. Frustration is common because you can’t make people change, yet you often feel strongly that if only the patient would change, their health would improve.
Those shoes she wears are a big problem; yet she refuses to change them, even though she knows that surgery might be necessary if she doesn’t. (Podiatrist)
When I ask them about using condoms I get this shrug, even though we both know that HIV/AIDS is a problem around here. (Nurse, South Africa)
If frustration is the outcome, other emotions often provide the starting point; concern for the patient’s well-being, optimism about making a difference, or sometimes even desperation about helping someone to avoid trouble looming in the future. Patients, for their part, often resist openly or ‘close down’ in response to strong urging from the practitioner. They have their own views about their lives, and can be left feeling guilty, threatened, or even angry about your good intentions. This is because they probably sometimes feel that your best efforts threaten their autonomy to make decisions for themselves. Yet you can’t deny your feelings! Is there anything you can do that is constructive about this dilemma?
Take a step back
• How are you feeling, before, during, and after the consultation? Just knowing this can help. It settles you down. Self-awareness of this kind is an indication of professional and personal maturity. If you are in the middle of a consultation, it’s often also the signal to change tack, to try something different.
• Are you falling into the trap of trying too hard to persuade the patient to change, or of overloading them with information?
• Are you falling into the trap of just following the patient and getting nowhere? Are you losing control of the direction of the consultation?
• Remember, if you feel things are not going well, the chances are good that the patient will share that feeling.
Adjust your approach
• Summarize what’s been covered thus far. This is a good prelude to changing direction. See if you can capture how the patient is feeling and what he or she has said thus far about behavior change. Use you rather than I when doing this. Most patients will appreciate an effort to summarize in this way, and won’t mind you changing direction.
• Consider being open with the patient about what will be most helpful. Does the patient want you to provide advice, or does he or she just want to talk it through; in other words, have some space to consider the why and how of change (as outlined in this book)? The effect of this brief conversation will be to reinforce patients’ sense of autonomy over decisions in their lives.
• Consider the menu of strategies outlined in this book. Their purpose is to allow you to stand back in a relatively more neutral position, while you guide the patient through the process of considering the why and how of change.
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