CHAPTER 9. Common clinical encounters
• Talking about smoking
• Cardiac rehabilitation: lots to discuss
• Encouraging safer sexual behaviors
• Weight management
• When the problem is mood and not behavior
• Patients who don’t help themselves
• Patients who want more medicine
• Patients who are seeking unlikely explanations or cures
Previous chapters have described our approach to various tasks in a consultation that could involve attention to patient behavior. The aim of this chapter is to illustrate this approach by taking examples from a range of clinical settings. Due to the striking uniformity in talk about behavior change, these strategies should be widely applicable. The same topics of conversation arise again and again. However, there is also remarkable diversity, where each encounter is a unique conversation in which a practitioner must adapt the strategy to suit the situation. The clinical scenarios below are not intended to be models of good practice, but illustrations of how a practitioner can use the toolbox in a range of situations.
Talking about smoking
Typical scenarios
You are a primary care practitioner. A patient has bronchitis and requests antibiotics. You know she is a heavy smoker.
You are a nurse conducting a chronic disease management clinic. A person with hypertension or diabetes attends for review; his condition is not well controlled and he continues to smoke.
Goals
• To make the most of the ‘teachable moment’ when the presenting health problem or an established health problem is directly connected to unhealthy behaviors.
• To provide the structure for patients to identify goals for themselves.
• To ensure that goals are realistic and build on the patient’s resources for change.
• To realize that smoking is a major addiction that is influenced by a complex web of personal and social factors, and which is only very rarely overcome as a result of one brief consultation. Goals for the behavior change aspect of this consultation will vary according to the importance that individual patients place on change, and their confidence in their ability to see it through. Simply planting a seed for change is a worthy achievement.
• To avoid alienating patients by giving them yet another unwelcome lecture that repeats what they have heard many times before.
• To avoid setting impossible goals so that the patient will inevitably harbor a sense of failure and frustration when he or she next consults.
• To avoid being left frustrated by attempting to ‘police’ patients and failing to ‘get people to change’.
• To provide the structure for individual patients to make effective decisions rather than trying to live their lives for them.
Principles and strategies
• Raise the subject in a non-threatening way by affirming your goal of understanding patients’ perspectives and respect for their decisions, even if these run counter to best medical wisdom.
• Explore how important giving up smoking is to patients, and build their confidence in their ability to succeed in giving up.
• If importance is low, focus on that through asking useful scaling questions about the importance score.
• Explore importance further by asking about pros and cons of smoking.
• Offer to share information in a non-judgmental way with those for whom giving up is not important. Keep the door open.
• Where giving up is important to patients but their confidence in succeeding is low, hone in on perceived barriers. Try the useful scaling questions about increasing confidence.
• Ask patients to take you through a typical day in their lives, as this will enhance rapport. Invite patients to make their own judgments about how they view the smoking.
• Brainstorm solutions to overcoming the barriers to successful quitting that are identified by patients themselves.
• Negotiate attainable goals.
• Agree to a follow-up.
Possible practice
Practitioner: Yes, I agree you have bronchitis again. But it would help me get a better picture of your chest and your health more generally if we could take a few minutes to talk about your smoking. I’m certainly not going to give you yet another lecture. I know you have had more than one or two of those! Today, my goal is to really try to understand a bit more about smoking from your viewpoint. OK? Won’t you tell me what sort of smoker you are?
[The patient responds, usually briefly]
Practitioner: I’m going to ask you two questions now that will help me understand things more clearly, and I want you to rate your answers on a scale. First, how important is giving up smoking to you right now? If 1 is ‘not at all important’ and 10 is ‘very important’, what number would you give yourself right now?
[The patient thinks for a moment and gives a number]
Practitioner: OK, great. Now I want to ask you about your confidence in your ability to quit and remain a non-smoker. If you did decide to try and quit, and 1 is ‘not at all confident’ and 10 is ‘very confident’ that you could give up and stay a non-smoker, what number would you give yourself now?
If importance is low, ask a question like You gave yourself a 3 for importance to you of giving up smoking. Why not 1? Whatever basis there is for the patient’s motivation to change will now emerge, such as ‘I can’t afford to smoke so much, I know it’s bad for me’. This has been called change talk (Miller & Rollnick 2002).
If confidence is the main problem, either of these kinds of questions can be asked for confidence. An additional useful question is: What can I, or we in this clinic, do to help you move up from a 3 to a 6 or 7?
When low importance is the main problem, the patient is usually feeling ambivalent; asking about the pros and cons of smoking may bring aspects of the patient’s dilemma into sharp focus. The heightened tension from making the ambivalence so explicit may prompt serious consideration about change.
Building on the notion that it is better for patients to make their own evaluations about how their behavior affects them and how they should respond, the practitioner invites the patient to say what he or she likes and dislikes about the behavior in question. After the patient has listed the positive sides, the practitioner, without interrupting or interpreting, asks the patient to list the negative side of the coin as he or she sees it. The practitioner attempts to summarize both the pros and cons of the dilemma, keeping as close as possible to the words used by the patient, and then asks the patient to say how the summary leaves him or her feeling and thinking. Practitioners should fight hard to avoid capitulating to inevitable urges to push their own healthcare agenda.
Practitioner: Tell me what you like about smoking.
Patient: You really want to know what I like about smoking? Most people I’ve seen just give me the hell and damnation bit. Well now, let’s see, smoking definitely helps me relax, and in my job with all the uncertainty, I need that. I live a very stressful life you know. Funnily enough, smoking also gives me a feeling of giving something to myself, like it’s my time for me. And I enjoy having a smoke when I have a drink with my friends.
Patient: Well, my wife nags me to hell and back, that’s for certain. It does stink a bit, my kids hate it, and sometimes I do worry about what it’s doing to my lungs…
Practitioner: OK. So, on the one hand, you’ve got a stressful job and smoking gives you time for yourself, it helps you to relax and socialize. On the other hand, it stinks, your family gives you a hard time about it, and sometimes you get worried about what it’s doing to your health. Have I got it more or less about right? OK. Now, where does that leave you feeling right now about your smoking?
Patient: Well, it certainly is a problem. I guess I’ve got to sit down and do some hard thinking.
Another useful strategy is the Typical Day strategy, where the practitioner asks the patient to think of a recent, typical day in his or her life and talk the practitioner through it, mentioning where the smoking fits in and how they felt about it. Again, the practitioner avoids the temptation to interrupt and extract lessons; the process of self-articulation is often a much more powerful teacher than external proselytizing. It also helps to build rapport and engenders an understanding of the patient as a person. This interpersonal understanding and consequent sense of mutual respect can be a very powerful therapeutic tool.
For those patients for whom giving up smoking is not important right now, avoid nihilism. Sometimes exploring ambivalence among patients who seem really set against change brings startling success. This is precisely the group that is least likely to receive opportunistic health promotion (Sesney et al 1997).
Offer to share information in a non-judgmental way:
Sure, it sounds like you are not ready to really stop right now. That’s fine. It’s your decision and after all, no one else can make decisions for you. But I was just wondering whether some up-to-date medical information about the effects of smoking and perhaps some of the new treatments might help you in your decision-making.
Endeavor to couch information in general terms and then ask the patient to provide interpretations about his or her own specific circumstances:
The research clearly shows that smoking does more damage among people with diabetes than those who do not have diabetes. On average, a 50-year-old smoker with diabetes will live an extra 3 years if he or she were to give up smoking. I wonder what you make of that?
Many patients will say that they already know all they want to know about the ill effects of smoking. As a rule, smokers are well informed about the negative health consequences of smoking, and a qualitative interview study we conducted shows that established smokers feel that they have already been saturated with anti-smoking information (Butler et al 1998). The practitioner may respond to this:
Fine, OK, you know as much about the good and the bad sides of smoking as you feel you need to know. But can we agree to keep the door open on this one? Things often change and if you want to discuss the issue at any time, feel free to get in touch. By the way, did you hear about that woman in France who suddenly decided to give up smoking at the age of 112?
For patients who feel that it is important to give up but who are low in confidence to succeed, brainstorming solutions can identify practical ways forward which are meaningful to the patient’s unique situation. Say a patient identifies fear of weight gain as the main barrier to giving up smoking. The practitioner may ask her to identify broad approaches to tackling this particular stumbling block. For example, one might ask, What things do you know that people can do to lose weight? Again, the practitioner encourages the patient to provide solutions and interpretations before offering suggestions of his or her own. Various general topic areas are identified: for example, exercise, diet, drugs, eating less, eating differently, weight loss programs, and so on. The practitioner then asks, Does any of these approaches appeal to you at the present time? Again, patients can be encouraged to choose the approach that suits them best. They might say, Yes well, I could try eating differently. The practitioner again avoids jumping in with suggestions like, Stop eating fast food meals or Don’t fry your food, and instead asks the patient to identify possibilities. Creative and surprising suggestions frequently emerge that practitioners might never have thought of in a thousand years but which patients come up with immediately.
Giving lectures that set impossible goals for patients condemns both practitioners and patients to inevitable failure: I’ve told you before, and I am going to tell you again. By the time I next see you, you simply must have given up smoking, be eating only salads, have stopped drinking so much, and have started an exercise and relaxation program. Not likely! It is incumbent on the practitioner to ensure that the goals that patients select to work on are short term and attainable; most patients with unhealthy behaviors have taken years to get into their present predicament, have been told many times to change, and have become accustomed to returning to the practitioner with an inbuilt sense of failure and sometimes resentment. Many see their visits to the practitioner as a ritual in which they have to endure some admonishment before they can begin to express their own agenda. They are reminded of their failures. This harms their sense of self-efficacy and undermines their sense of themselves as people who can make things happen, as opposed to being at the mercy of urges and stresses. However, just as failure often begets failure, nothing breeds success like success; success more or less ensures that the patient will be able to come back next time with good news, and this may be the first step in a new way of viewing themselves and the practitioner–patient relationship. Goals like agreeing not to increase the number of cigarettes smoked or taking the dog for a walk around the block twice a week can be the first small steps down a long road to healthier living.
Resistance will often rear its head:
Well, I would love to give up smoking, I really would, but each time I try, I just about bite the kids’ heads off. Even my husband says, For God’s sake, go and have a cigarette if this is what giving up does to you.
The thoughtless response is to say:
I’m not going to collude with that. Of course giving up is tough. But after biting on the bullet for a week or two, you’ll get over it. Sometimes in life, you’ve just got to stop making excuses and get down to business.
Such an approach is likely to damage the practitioner–patient relationship, and may even result in the patient changing practitioners or not consulting when it would be appropriate to do so. An alternative approach is agreeing with those aspects of the patient’s comments that are accurate, and then to shift focus:
I know. For some people, giving up smoking can play havoc with their nerves. It really can be tough. I’ve seen people climb the walls, and I’m sorry that nicotine withdrawal affects you that way. But these days, there are treatments for that craving. They don’t take it away, but they help take the edge off it. What do you know about nicotine replacement therapy, for example, you know, the gum or the patches? And there’s other stuff too now.
This may also be met with further resistance:
Well, I’ve tried the patches and they don’t work for me.
It’s too expensive.
My friend had terrible mouth ulcers when he started on the gum. I don’t fancy that.
Sometimes it seems that whatever the practitioner says will be countered by Yes, but in one form or another. This is a signal to avoid entering into a head-banging interaction where the smoker and practitioner Yes, but each other in a series of sterile encounters. Rather, move to closure, summarize and emphasize personal choice or control as a good way of ending:
Sure. You get serious withdrawal symptoms and you have problems with nicotine replacement therapy. And at the same time, giving up smoking remains the single most important thing you could do to improve your health now and to live a longer life. As you said earlier, that’s important for you and your family. I agree 100% that there are no easy ways to give up smoking. At the end of the day, it’s your life, and you have got to make some tough decisions for yourself. Nicotine replacement was just one suggestion. Maybe you could come up with a few of your own that might be better suited to your needs. After all, you are expert in what you want from life and what will or will not work for you when it comes to quitting smoking. I’ll be around if you want to talk about ideas that you come up with at any time.
Cardiac rehabilitation: lots to discuss
Typical scenario
You are a cardiac rehabilitation specialist nurse. A patient attends after a diagnosis of stable angina. She drinks 35 units a week, is overweight, does very little exercise, smokes, and regularly eats fast or fried foods.
Goals
• To establish and maintain rapport with the patient. Change and its maintenance are likely to make up a lifelong process and the patient will benefit from a trusting, supportive, and understanding relationship with a practitioner.
• For the practitioner to accept that small shifts in attitude or taking a new look at an old problem is a worthy beginning.
• To promote an appropriate level of concern about risk (the patient should ideally be neither blasé nor so worried as to be incapacitated by anxiety).
• To promote self-efficacy and responsibility.
• To view lifestyle holistically in that each aspect usually affects another; changing one unhealthy behavior may lead to change with another. However, keep the focus on practicalities rather than making global exhortations for dramatic sea changes in personality and behavior.
• To avoid increasing resistance.
Principles and strategies
• Do not give the same talk to everyone. Target your information to the needs of the patient. Each one is a unique human being with unique challenges, fears, and hopes, and each deserves your full attention and understanding. Establish what the patient already knows about the causes and course of his or her condition.
• Share information in language appropriate to the patient in a non-judgmental and non-threatening way.
• Sensitively raise the issue of lifestyle change.
• Assess importance and confidence for change when focusing on a single behavior.
• Typical Day strategy.
• Pros and cons.
• Brainstorming solutions.
• Negotiate attainable goals.
Possible practice
Practitioner: I’m pleased you’re feeling a bit better, and getting on OK with the tablets. But before we go on any further, I just want to say that the most important factor in your recovery, even more than taking the pills, will be how well you look after yourself, your lifestyle. This depends on what you know about [your condition]. So I’d like to begin by checking what your information needs are, I want to check with you on your understanding of your condition.
Patient: Well, from what I gather, I’ve got a touch of angina. Stable angina. Nothing too serious, or so I have been told, so long as I continue with the tablets and don’t push myself too hard.
Practitioner: Do you know what causes angina? What is happening inside your body, do you think?
Patient: It’s a shortage of blood to the heart, or so they say. The heart is starved of oxygen a bit. Furring up of the arteries that take the blood to the heart muscle, or something, by cholesterol. But the tablets will lower the cholesterol so…needn’t be too bad.
Notice the resistance emerging already (the patient is minimizing), and notice too that the patient’s level of anxiety about her condition, on the surface at any rate, is perhaps inappropriately low. Try a simple reflective listening statement; these are statements (not questions) which reflect the meaning of what the patient has just said. The practitioner’s tone goes down at the end of the sentence. Such statements invite an explanatory response from the patient.
Practitioner: Your angina, it’s not too serious then.
Patient: Well, lots of people have it, and I guess some do go on to have heart attacks. But mine is mild and the tablets will remove the cause.
Another reflective listening statement could be used at this point: You might or might not have a heart attack yourself. Or the practitioner could move to a direct question.
Practitioner: What do you understand of the causes of the problem? What could turn your mild angina into a very serious heart attack even if you are taking tablets?
Patient: Well, they blame everything on smoking and they told me in the hospital that the smoking and the cholesterol brought this on and could make it worse. But I don’t smoke any more than most of my friends.
Avoid this invitation to get into a resistance-enhancing argument by responding in a challenging way to this tantalizing but dangerous bait. Roll with the resistance. Try agreement and a shift in focus to increase this patient’s anxiety to an appropriate level.
Practitioner: You are 100% right! Angina is caused by the heart muscle being starved of oxygen by narrowed blood vessels, and smoking and cholesterol make it worse. Smoking is by far the most important thing that affects your condition right now. But it can also be made worse by being overweight, drinking too much, stress, and not exercising. You are also right that your angina is mild at the moment. But there is nevertheless damage to your arteries, and it could get a lot more serious quite quickly. Changing some of the aspects of your life that lead to narrowing of the arteries could help you live a much longer, pain-free, and active life.
Patient: Yeah. But right now it’s mild and under control.
This patient continues to deny the seriousness of her problem. Amplified reflection is a strategy that could be tried here. The goal is to reflect back to the patient in an amplified or exaggerated form. This should be done very carefully, avoiding sarcasm or hostility.
Practitioner: So, you should be able to get away without changing your lifestyle.
Patient: No, of course not! I really do want to stay healthy. I’ve got my job and family to think about. [A bit of change talk has at last emerged]
Practitioner: [Emphasizing personal control] Well, you’re the one in the driving seat here. It’s your life. My job is to give you the information you need to help you make decisions which you feel are best for you, and to provide support and help when you decide to change. I’m also concerned about you as one of my patients and as a human being with a condition that could become even more serious quite quickly.
Patient: Yeah, I know you’re only trying to help, but I don’t want anyone to nag me. The doctor who was in charge of my case when I was admitted in the hospital treated me like I was a naughty schoolgirl.
Practitioner: No nagging, I promise. I know it’s useless me trying to make decisions for you and unfortunately neither of us is a schoolgirl anymore! So, I’m going to try something different now. Here is a chart [practitioner produces agenda-setting chart] that may help you in the process of thinking about aspects of your life that have a bad effect on your heart and which can improve your outlook if you change them. But notice here and here are some blank circles for you to put your own concerns into. Concerns that you may feel affect your health or which you just want to talk about. Which of these things, if any, do you feel ready to explore a bit further today?
Practitioner: OK, regarding the food issue, I’m going to ask you two specific questions that involve you rating yourself on a scale of 1–10. How important do you feel healthier eating is to you right now? If 1 is ‘not at all important’ and 10 is ‘very important’, what number would you give yourself right now?
Patient: 9 or 10. Not only for my heart, but also for my figure. Sometimes I feel I look like a slob. I deal with the public at work. I don’t think looking like a slob helps me professionally.
Practitioner: How confident are you, again on a scale of 1–10, that you could make lasting changes to the way you eat? If 1 is ‘not at all confident’ and 10 is ‘very confident’, what would you give yourself right now?
Patient: Well, 1 while my partner does all the shopping and cooking. My partner is as thin as a beanpole regardless of what he eats, and he loves his food fried. Don’t you just hate the type?
Practitioner: OK, so let’s consider ways in which you could tackle this problem and get to eat more of what you would like to. What ideas have you got?
Patient: Well, I could kick him out. No, seriously, perhaps you could talk to him.
Practitioner: Sure, having a meeting with the three of us is one excellent way forward. Any other specific changes you could think of?
Patient: Well, I guess I could do the shopping and cooking if he could pick the kids up from school; that way, I would be more in control of what we eat. But he would have to agree with that.
Practitioner: And how would you eat differently if you could get control of the shopping and cooking?
Patient: I could grill more; go for things like baked potatoes every now and then, more fish. My friend is a vegetarian and she comes up with some pretty good dishes without any meat at all. I quite enjoy being with her when she cooks.
Practitioner: Great. I can see you have some excellent ideas. So why don’t we leave it there for now, and you can talk to your partner about the question of what you eat and how it could seriously affect what happens to your health. I’d be happy to meet with the two of you, if he feels that would help. I agree that serious change probably involves getting his help. And you will talk about him picking up the kids in exchange for you doing the shopping and cooking. How does that sound?
The ongoing process of monitoring resistance and readiness is crucial in such consultations; patients are coming to terms with the loss of aspects of their health, and adjustment is a complex and dynamic process. Different people will use varying strategies to deal with it, and the same person may change quite quickly in terms of how he or she reacts to bad news. In the foregoing scenario, the patient’s defense was to minimize the problem. However, some patients will feel like they have received a death sentence and are frightened to embark on certain changes (e.g. exercising or having sex after a heart attack). Other patients will argue that there is no point in change since their condition is beyond palliation. So, while the goal was to raise the level of anxiety in the above scenario, sharing information will be important to reduce anxiety in other patients who are too anxious to take practical steps for change.
Encouraging safer sexual behaviors
Typical scenarios
You are a nurse working in a family planning clinic. Your next patient says, I’ve got a regular partner now and I’d like to be on the pill.
You are a doctor in a genitourinary medicine clinic. A patient asks you about a rash on his penis. He tells you he is gay.
Goals
• To develop a trusting relationship where frank discussion about sensitive issues is comfortable.
• To maintain reasonable boundaries and avoid excessive intimacy.
• To enhance knowledge of safe sex and promote low-risk sexual behavior.
• To enhance the patient’s sense of being in control and of being able to say ‘no’ in an uncomfortable situation.
Principles and strategies
• Establish good enough rapport to be able to raise health promotion issues sensitively.
• Establish the patient’s information needs.
• Avoid giving a hurried, uncomfortable lecture.
• Assess importance and enhance confidence to practice safe sex.
• Use scaling questions.
• Try eliciting the pros and cons of an aspect of the practice of safe sex.
Possible practice
Practitioner: Sure, I’m happy to help find the best contraception for you and also be a resource for you on sexual health more generally. I appreciate the fact that you have taken this responsible step to come and talk about it all. We’ll go through the more medical aspects of your choices, including the pill, in a minute, but would you mind if we first discussed some of the wider implications of being sexually active first? To save me gabbling on about things you already know, can I ask you to tell me a bit about what being sexually active means to you as a person?
Patient: It’s kind of a bit awkward talking to you about how I feel. But I guess I do feel I’m ready for it now, and it’s something I want to be able to do. But I do get a bit worried. Well, Mark wanted me to go on the pill …he doesn’t always like using condoms and sometimes we just don’t. I get worried …and they are such a hassle.
Practitioner: Could we spend a moment talking a bit about condoms? Using condoms is crucial to the practice of safe sex, especially if you are not in a long-established relationship. How important is using condoms to you right now? I’m going to be quite specific and ask you to rate its importance to you on a scale of 1–10. If 1 is ‘not at all important’ and 10 is ‘very important’, what number would you give yourself right now?
Patient: Well, I don’t want to catch anything bad. I’m young and want to stay healthy, so I’d give myself a 9.
Practitioner: OK. Now how confident are you that you could practice safe sex every time you make love? Again, if 1 is ‘not at all confident’ and 10 is ‘very confident’, what number would you give yourself right now?
Patient: Perhaps a 5 or 6. Mark doesn’t like to use them, and I’m not wild about them either. Mark sometimes seems to think I don’t trust him if I ask him to put on a condom. Nothing bad has happened yet.
Practitioner: So, you would like to use condoms all the time but it’s not always easy to do. What would help you to move from a 5 to a 10, and practice safe sex every time you made love?
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