When you need to change tack…


There are some times when things just don’t go the way you plan…Therapists don’t very often publicise when things don’t work out, but I think we can learn a lot from these situations – and the reflection process models one of the ways that we can help patients learn from every situation too. As one saying goes ‘it is not a failure, it’s a learning experience’!

So, with this particular client, I found myself in a ‘yes, but’ situation…this situation occurs when I’m asking the person to take action before they’re ready.
This man is a Very Busy Man – a ‘type A’ if you like. He’s a professional, in a senior position in a medium-sized organisation, and very, very busy. He works 10 hour days, rarely takes breaks (even lunch), and takes work home. He has had an exemplary work record, very few ‘sick’ days – but when he has abdominal pain, he can end up in Emergency Department. His admissions have increased in frequency over the past 12 months, and he is now asking for ‘something’ to help so he doesn’t have to be admitted to hospital, but can carry on at home.

As I assessed him, I thought the most important areas of concern were these:

  • when he experienced discomfort he tended to not notice it until it became overwhelming
  • when he became aware of his pain, he became very fearful and immediately used pain medication or sought medical care
  • he rarely communicated his pain concerns to anyone, and had been careful not to tell anyone at work
  • he had few friends and his relationships at work were somewhat distant
  • he and his wife were very worried about his health and were very keen to have his pain completely abolished
  • he was very capable of focusing and becoming completely immersed in his work
  • he had a limited range of relaxation or leisure activities

I started with offering him the menu of options, and mentioned that I had observed from the assessment he had completed with our service that he was finding it difficult to relax, and I wondered whether he would like to see how relaxation might help him.

His response?

‘Yes, but…’

And what came next was a long list of reasons why he couldn’t relax – his job was too busy, he enjoyed the ‘buzz’ of pushing himself to achieve, he was aiming for promotion, he was ‘carrying the load’ for other people at work….

I tried another tack, and reflected to him that he must find the thought of relaxing quite strange and perhaps that it felt unnecessary and a ‘time-waster’ – to which he said ‘yes’ and that what he thought he needed was to have his pain ‘properly managed’ and that ‘doctors must be able to find the cause of my pain and fix it’.

hmmmm… time for a moment of quiet reflection!

Once again I used reflective listening to let him know that I ‘heard’ what he was saying, and suggested that perhaps it might be a good idea to see if we could have a joint consultation with one of our doctors to review the medical situation, to ensure that he had the best advice available on whether a ‘fix’ was available. If there was a medical area for follow-up, that’s great, if not – the door was always open for him to come back.

Using the review process, I spent a bit of time thinking about what had happened – why had CBT and my suggestions fallen flat? What could I do differently?

I use a semi-standard set of questions (well, some of them are the same every time!):

  1. What did I do well? I think I went well with rolling with his resistance – using listening skills to demonstrate empathy and respect.
  2. What was not so good about that session? I misjudged his readiness to begin making changes and to see his pain as ongoing.
  3. What was particularly frustrating? For me it was that he wasn’t ready to move on from finding a ‘cure’ or ‘fix’.
  4. What was the most satisfying aspect about this session? That I recognised this and rolled with it instead of getting into a ‘yes, but’ situation.
  5. What skills did I use? Listening skills and a range of ‘motivational’ approaches including the menu and listening skills.
  6. What skills could I have used? Asking him what he wanted or thought was his ‘next best step’. Perhaps asked him what went through his mind when he experienced his pain at work, or started to feel pain and ‘knew’ he needed to go into hospital, or even asking him about what was important about maintaining his pace at work and establish the discrepancy between this value and what happened when he went into hospital.
  7. If I could wave a magic wand, what would I change about the situation? Spend more time listening to what he wanted before starting on a menu that assumed he was ready to make any changes at all.
  8. What extra resources could I draw on? Going through his medical file and working with his medical doctor to establish his readiness and what the options were – helping him come to a point of ‘creative helplessness’
  9. What would I do differently next time? Listen first, talk less, assume nothing.

Now I don’t use all these questions all the time, and some of them I don’t use often at all (particularly the magic wand one!! that would be too tempting…)
Is CBT the right approach? Yes – but with a tweak or two to make sure this person is at the right point of readiness before starting to introduce change.

I hope this post has helped you see some of my thinking style and that we never stop learning! By drawing on a range of different therapeutic styles that hold to a similar value base, we are able to respond with flexibility to people at different points in the change cycle.

If you want to continue reading about how I apply CBT and other therapies in chronic pain management – don’t forget you can subscribe using the RSS feed above (just click!), bookmark this blog, and comment!

2 comments

  1. Thanks for a thoughtful post. I am impressed that you took the time to analyze your own performance so deeply — and then share it with your readers.

    I focus on resistance to change in organizations and all that you say about the importance of listening fits there as well. In fact, every step of your debrief could have been referring to the challenges we face working on change in organizations.

    Rick Maurer
    http://www.beyondresistance.com
    http://www.changemanagementnews.com (blog)

  2. Thanks Rick, it’s always great for me to have someone make a comment!! I think resistance is a sign that I have moved too fast – misjudged the readiness of the person. Because I’m relatively ‘in control’ of the clinical situation it’s up to me to change and listen more effectively, not up to the client to do the work! I’ve been working on this since I came across Motivational Interviewing, and finding it makes my work so much easier and more rewarding – and I can see how it would fit really well in an organisational situation too. That’s something I want to work on as well.

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