motivational interviewing

Dealing with distress


From time to time anyone who works with people trying to help them make changes in their lives will encounter someone who is overwhelmed, distressed and generally not willing to (or able to) take even a tiny step forward. It’s hard for us as therapists because, after all, we want to help people – but hey! This person in front of us just isn’t up to it!

I think many of us who weren’t trained in psychology can find it really hard to know what to do, and like all humans, we deal with feeling helpless by hoping to avoid it.

Some of us will tell people what to do – this is the way most of us were trained, so it’s what we do when under threat. We might couch this advice in fancy words, but essentially we try to get the person to make a change on the basis of our expertise and superior position. After all, the person came to us for help, right?

Some of us will feel stuck ourselves. Perhaps we’ll give up, or blame the person we’re sitting in front of. They’re not motivated/willing/ready so we stop trying and back off.

In both of these situations, the person’s actual needs at the time can be inadvertently ignored. They’re distressed and we either ignore and advise, or back off – when perhaps what they’re really wanting is someone to be present with them and offer them time to work together on the next best step they can take.

Here’s one way I’ve used to help people who are stuck, distressed and not certain.

  1. Be fully present and let them express what’s going on. This means listening, perhaps asking “can you tell me more about that?” or “it’s tough but are you willing to talk me through what’s going on for you right now?” or “what’s your theory on why you are feeling what you’re feeling?”
  2. Listen with an open and enquiring mind and heart. That means absorbing what they’re saying without trying to respond to it. At the most, you can reflect what you hear, perhaps saying things like “I think I understand that you’re feeling [sad, afraid, overwhelmed], do I have this right?”, or “From what you’re saying, you’re not sure [what’s going on with your rehab] and this is incredibly hard”, “if I’ve heard what you’re saying… is that what you mean?”
  3. Breathe and be mindful of your own response before charging on with the session. It’s OK to tear up if someone is saying something that would make you feel sad. It’s OK to feel aghast that this terrible thing is happening. It’s OK to notice your own body tighten up, your breathing change, not to know what to say. Just notice this in yourself BEFORE you respond. If you do feel something, respond naturally – normalise the experience described by the person as being something anyone in their shoes would feel, and reflect your own response to it. You can say things like “Oh that sounds like such a tough situation” or “I feel a bit tearful myself when I listen to what you’ve been through”, or “I really don’t know how to respond to what you’ve said, I’m lost for words, it’s really hard”.  The purpose behind doing this is to acknowledge that we’re human too, and get affected by what we hear. To be transparent and real so that the person is aware of your own readiness to “show up” and be fully present alongside them.  If you need a moment to catch your breath after they’ve told you something emotionally charged, say so.
  4. When you do respond, summarise what you’ve heard and ask them if that’s what they intended to mean. In motivational interviewing terms this can be called “giving a bouquet” – collecting together a summary of what the person has said, then offering it back to them to check you’ve understood (and it also shows them you’ve been listening).
  5. Before doing anything else, ask them “where does this leave you?” or “what do you think you should do right now?” or “what’s the next step for you now?” People have ideas about what to do next, most times, and we work more effectively with those ideas than if we try to bolt on some piece of advice without recognising their thoughts.

A couple of nice tools to use at this point are the choice point  , and the matrix by Dr Kevin Polk.

The hardest part of responding this way is often our own response. Because we feel uncomfortable, and we’re aware of timeframes, expectations, and because we probably don’t enjoy people crying or being angry in our sessions, we often don’t want to take the few moments needed to be present with someone who is in the middle of it all. Being present is about being there and not trying to change the situation, or rush away from it, or fix the problem – it’s about being willing to bear witness and honour the vulnerability that person has shown us. What a privilege!

It can be emotionally tough after a day of seeing people who are feeling distressed. I think this is where using mindfulness as I’ve described above can be really worthwhile. Noticing what our body is doing when someone is distressed can help us notice the work we do (and help explain why some of us don’t want to talk to anyone at the end of a hard day!). The odd thing is, that when we honour someone by being present and not trying to change their situation at the time, we often find the person is ready to move on and engage in therapy far more quickly than if we’d tried to “make” it happen. At least, that’s my experience!

A good clinician once told me “never be afraid of allowing someone to have a crisis, because after a crisis, shift happens”. I’ve found that to be true.

I’d love to know your thoughts on this post – I don’t have loads of references for it, but a couple that come to mind are:

Beach, Mary Catherine, Roter, Debra, Korthuis, P. Todd, Epstein, Ronald M., Sharp, Victoria, Ratanawongsa, Neda, . . . Saha, Somnath. (2013). A Multicenter Study of Physician Mindfulness and Health Care Quality. The Annals of Family Medicine, 11(5), 421-428. doi: 10.1370/afm.1507

Goubert, Liesbet, Craig, K., Vervoort, Tine, Morley, S., Sullivan, M., Williams, A., . . . Crombez, G. (2005). Facing others in pain: The effects of empathy. Pain, 118(3), 285-288. doi: dx.doi.org/10.1016/j.pain.2005.10.025

How to talk about ‘psychosocial’ issues with people experiencing chronic pain


If you’ve been following the discussion on my last post about selecting the right person to receive spinal injections (see here), you’ll see a doctor challenged with how to begin to talk about psychosocial issues with patients without the patient thinking ‘she thinks it’s all in my head’!

It’s a really common problem, IMHO. How to communicate to a person who feels anxious, somewhat disbelieved, and definitely fearful that someone, somewhere is going to suggest that if they ‘pull themselves together’ they’ll be all right!

The problem is that I haven’t found a lot of very good evidence to provide direction as to the best way to actually DO this, so I’m going to rely on a few years of experience – and invite you to have a go.
The underlying principles that guide me in this are drawn from motivational interviewing, especially the role of reflective listening, and being aware of the suspicion that people have about being judged about the reality of their pain.

I wonder whether some of the reluctance people have about acknowledging the psychosocial is that we may be inadvertently suggesting these issues ’cause’ pain, which immediately suggests to the person that they are being judged as ‘not coping’. So, perhaps coming alongside (metaphorically speaking) and acknowledging the distress the person could be having is one way to begin to explore these factors.

Some phrases that might help in this:

  • ‘It sounds like the past few weeks have been pretty tough for you – can I ask, how are you feeling in yourself?’
  • ‘When you start talking about your pain it makes me wonder how you’ve been managing day-to-day?’
  • ‘Sometimes people find their pain disturbs their sleep – is it OK if we talk about this for a while?’
  • ‘Would it be all right if we spent some time looking at how your pain is affecting you at work?’
  • ‘Pain is invisible, and no-one can tell how much pain you’re actually in, would be it OK with you if we talked about what that’s been like for you?’

I think a couple of techniques can break the ice – but most importantly, an attitude of sensitive inquiry and acceptance. Pain is a stressor, irrespective of the ’cause’ – and remember that most pain has a physical initiator, even if it’s not being maintained by nociceptive input.

One of the techniques is to ask permission to discuss how the person has been coping/managing/feeling in him or herself. By being respectful of how ready the person is to talk about this area can open the doors to them being open with you.

Another is to reflect what they’ve been saying to you to demonstrate your understanding. By doing this you show you have been listening, and if you’ve got it slightly wrong, it allows the person to correct you. For example: ‘Let me summarise what I think you’ve been telling me: no-one has been able to tell you why your pain is going on, it’s not responding well to medications, and you’re feeling pretty frustrated about the process of diagnosis. Have I got that about right?’

Open-ended questions such as ‘How have you been sleeping?’, ‘What’s it been like for you at work?’, ‘How are you managing with this pain at home?’ give the person an open door to start talking about the impact of pain.

Even if you think the person’s pain behaviour is ‘exaggerated’, or their disability is more than what you would expect if you had their problem, suggesting in any way that this is something they are choosing to do deliberately won’t help bring them onside.

Remember ‘resistance’? This happens when people feel they are being asked to move beyond their stage of readiness. Our job is to help them move only one step forward along that continuum – and that will only happen if we’re respectful and genuinely believe that they have arrived at the position they’re in because they’ve been making what they think are the best decisions at the time. We may not agree with those decisions – but our job is to help the person identify the ‘good’ and ‘not so good’ about their position, and to provide information (when invited) so they can make new choices.

To reduce resistance, the best step is to reflect empathically with the person, even admitting that we might be wrong! And then suggest helping them look at what is working and not working about their current situation. This might mean agreeing that they might be feeling confused, frustrated, even fed up with suggestions that they might be able to cope better with their pain if they had some help from a psychologist, occupational therapist, social worker or nurse. Asking their permission to expand on why these people might be able to help will give the person a choice – and being offered this is what people respect.

I’ll post some more about this topic tomorrow – you can see it’s dear to my heart!

For the visual amongst us – CB Worksheet


I’m a very visual person, I love to see what I’m doing, and I use visual imagery a lot in my language and my processing. Many of our clients are also visual – or they’re kinaesthetic – and they need to see and manipulate rather than listen and talk.

At some point while working with a person it can be helpful to diagram a situation so that you and the client can see what is going on – and the influences that may be having an effect on the situation. In some CBT language this is called ‘psychoeducation’ but I prefer to call it ‘mapping’. To me, the client and I are mapping what happens so we can both discover new ground.

It often starts when I’ve been asking about automatic thoughts – those quick images or phrases that fly through when we encounter a situation. They happen all the time and reflect underlying processes and judgements that influence our emotions and actions. Often they pass through without us being aware of them, but their influence is very strong. Sometimes untangling the thought, the emotion and the action can be difficult, so I start with the event and remain open to working out, with the client, what happened next.

I’ve attached a worksheet that you can use with a person, although I have to admit to mainly drawing in freeform on a whiteboard or handy pieces of paper! Whiteboards are great because if you make an error or want to revise something you can easily wipe it out, which can really make an impact on the person when they reflect on the effect of changing their automatic thought.

cb-model-worksheet

You can start with almost any situation – but for occupational therapists or physiotherapists, I find it can be a great tool to use when someone hasn’t followed through with home learning (their ‘mission’). You can pick a time when they didn’t do their exercise, for example, and work out what went through their mind, and find out any underlying beliefs – or external influences – that made it difficult for them to choose to do what they had agreed. For example in this situation – I’ve added in colour some of the therapeutic processes being used.

Therapist: “How did you go with your walking plan over the week?”

Client: “Uh, only got out once – I just had one of those weeks”

T:”How about we go through exactly what happened one of those days you meant to do it but didn’t?”

C:”OK, I suppose so”

T:”So what day can you remember most easily?”
Elicits readily remembered event

C:”Thursday morning, the weather was foul and the kids were playing up and my back was sore and I just didn’t feel up to it”

T: “Let’s start from the first time you thought about your walk. What went through your mind?”
Eliciting automatic thought or image

C: “I thought, Oh no, my back is just too sore and I’m going to be too tired today”

T: “Let’s put that down on the map. Then can you remember how you were feeling at the time?”
Moves to identify the emotion. For some people, this is very difficult and the therapist needs to work through behaviours and thoughts several times, or provide prompts for the type of emotion being experienced.

C: “Guilt! I knew I should be going, but I just didn’t feel up to it.”

T: “So you felt guilt then – any other feeling? What about when you though you would be too tired today?”
Simple reflection, but working through the superficial emotion to a deeper emotion more relevant to the thought the client had.

C: “I suppose I felt quite down then”

T: “So you felt quite down. What does that feel like in your body?”
Simple reflection. Links this with physical/behavioural changes in the body, drawing together the link between thoughts, emotions and pain.

C: “Heaviness in my chest, and my back feels so stiff and sore”

T: “What did you do then?”

C: “I carried on with the housework, but I went quite slowly and was grumpy all day. It was a bad day.”

T: “So, what else was going on that day?”

C: “The kids were being awful and shut in, and all I wanted was a bit of peace and quiet”

T: “Sounds like a real challenge to keep it together when all these things stack up – how did you manage before your back was sore?”
Slightly more complex reflection, elicits previous positive coping strategy. Therapist would draw on the map that the kids were influencing the situation too, also the client’s thought that ‘all she wanted was a bit of peace and quiet’

C: “I would have packed them up and headed out to the park to give them a breather, and myself a break.”

T: “Am I reading you right that getting out is a good thing when you’re feeling a bit stressed?”
Further reflection, this time extending it to include the concept of responses to stress – this could be explored further in another session. What are her typical responses to stress, what situations stress her, how does stress manifest itself in her body, how does pain and exercise influence stress. At this stage the therapist could simply record ‘stress’ on the map, with an arrow pointing to the event ‘going for a walk’

C: “Yup. My back just gets in the way so much”

T: “So it seems that on a horrible day, when the kids are acting up and you’re feeling a bit sore and down, you’d usually get out and about and take a break, but you thought on that day that you would be too tired to do that. Have I got it right?”
A longer reflection, which could almost be called ‘a bouquet’ – gathering together all the relevant pieces of information, summarising and asking whether the therapist has heard it correctly.

C: “Yes, that’s about it”

T: “On the one hand you felt too sore and tired to do anything much, but on the other hand you had a whole day when the kids were acting up AND you were sore and now you feel guilty for not exercising! Where does that leave you?”
Therapist starts to develop ambivalence about the situation, and ensures responsibility for working a way through this rests with the client.

C: “Stuck!”

T: “What are some of your options on a day like that?”
By asking the client for options, the therapist demonstrates faith in the clients own abilities, builds on the client’s strengths and preferences, while helping the client remain focused on achieving both of her valued activities – being a good parent who can keep her cool, and getting a bit fitter despite her pain.

At this point, the therapist is opening up the opportunity for the client to start problem solving ways to achieve both exercise goals and being a good parent.

I hope you’ve enjoyed this wee piece of how I might have worked through a situation where someone hasn’t followed through with home learning – it’s a very common situation, but allows us a chance to work through the factors that will probably influence lapses or relapses once the client leaves us.
More tomorrow!

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!

Welcome to the first post! Values


You can talk to Merrolee about this blog, it was seeing hers that ‘inspired’ me to get around to starting this blog. An idea that had, I must admit, been kicking around in my brain for quite a wee while…

Finally I got around to it…

This will be a ‘from time to time’ blog, just as my photography one is. Every now and then inspiration hits and away I go!!

But for today – values in health.

Almost all health professionals have a code of ethics in which there is something about ‘respect’ for the client/patient/consumer. All throughout health care we are asked to compromise our values (How much therapy ‘should’ we offer this person? How much time can I afford to spend with that person? Should I tell this person about this therapy – when I know they won’t be offered it here…).

Personal and professional values are challenged directly and indirectly every day we work with people. If it’s about equity in funding (in New Zealand, the difference between funding for accidental injury and health conditions can be vast), about whether a person wants to engage in new behaviour, or how much we compromise our own beliefs about what is and is not important (documenting patient statistics versus spending time with a person?) we make decisions about what is important to us in our practice.

On the NZAOT Values Exchange , participants are asked whether equipment should be offered to an individual with obesity, initially described as developing before the diagnosis of osteoarthritis was made, but later described as being diagnosed at the same time (and presumably as a result of the OA). Ministry of Health determines that equipment needed because of obesity cannot be funded, while equipment needed because of disability from other health problems can be funded. A value-laden judgement suggesting that obesity is a choice, while disability from other causes is not. Perhaps not a value judgement that is explicit, but nonetheless, a judgement about what is and is not important. Is this respectful?

In cognitive behavioural therapy we are often called to ‘challenge’ the beliefs or assumptions of the person we are working with. Some cognitive therapies are very direct, calling the beliefs ‘maladaptive’ or erroneous. To the person hearing someone say ‘your thinking is wrong’, is this respectful?

Can I suggest some things to consider:

  1. Spend some time with yourself to work out what your values are both personally and professionally
  2. What are the stated and unstated values of the organisation you work for?
  3. There will be areas of compromise – have you spent time considering the effect of this compromise on you as an individual and as a professional?
  4. Think about offering choices to the people you see – what is important to you (their health status) may not be important to them (their kids schooling may be more important than their diabetes!)
  5. Drawing on motivational interviewing we can be both directive (being clear about our own position on the effects of a course of action), while being respectful of the choices that the person makes (based on what is important to the person).
  6. We can ensure we provide the person with a range of options so that they can an informed decision on what to do next (and the implications of that decision). Done sensitively the person will feel that you trust them, that they do have the resources to draw on, and that you both respect them and will welcome them back.

I hope this first post provokes thought. Comments are welcome!!