…it just hurts!

I was taking a quick wander through some of the headlines on my MedWorm feed this morning, when I stumbled on a headline saying ‘It just hurts’. I had to click on it and here is what I read:

Me: “Hello, so you’re having some chest pain?”

Patient: “It just hurts.”

Me: “When did it start?”

Patient: “It just hurts.”

Me: “Where on your chest?”

Patient: “It just hurts.”

Me: “Anything make it worse?”

Patient: “It just hurts.”

Me: “Ever had this before?”

Patient: “It just hurts.”

Me: “Fine, enough, I’ll just order a bunch of tests.”

Now I know this is in an emergency department setting, so things are a bit different from my chronic pain setting, but my immediate thought was that this patient was so scared he couldn’t find words to say what was happening to him – but all I read in this exchange was a doctor trying to diagnose.

It could be a life and death situation – ‘heart attack’ or something – but at the same time, I wonder what would have happened if someone had spent a moment or two reflecting to the patient that he sounded scared, that all kinds of feelings can take over when you have a pain, and that it can be hard to think straight at those sort of times. Some reassurance that things are under control now and he’s in a safe place.

I also wonder whether explaining why the doctor was asking the questions, and some of the train of thought of the doctor might have helped.  And finally, I do wonder if the patient had been told to breathe out slowly, and take some time to relax his body whether the patient might have been more ready to describe what was going on.

Sometimes in our rush to diagnose and fix, or work on ‘problems’ we can forget that developing rapport by listening and showing that we understand the emotions that happen when people experience pain is possibly the best medicine we can give.

Psychology Today has a self-test for listening skills, the brief results from which are free… fun to try out anyway!

The Motivational Interviewing website has a summary of the OARS acronym – Open ended questions, affirmations, reflections and summarising, it also gives a good description of levels of reflection:

Simple Reflection
One way to reduce resistance is simply to repeat or rephrase what the client has said. This communicates that you have heard the person, and that it is not your intention to get into an argument with the person.

Client: But I can’t quit drinking. I mean, all of my friends drink!
Counselor: Quitting drinking seems nearly impossible because you spend so much time with others who drink.
Client: Right, although maybe I should.
Amplified Reflection

This is similar to a simple reflection, only the counselor amplifies or exaggerates the point to the point where the client may disavow or disagree with it. It is important that the counselor not overdo it, because if the client feels mocked or patronized, he or she is likely to respond with anger.

Client: But I can’t quit using. I mean, all of my friends use!
Counselor: Oh, I see. So you really couldn’t quit using because then you’d be too different to fit in with your friends.
Client: Well, that would make me different from them, although they might not really care as long as I didn’t try to get them to quit.
Double-sided Reflection

With a double-sided reflection, the counselor reflects both the current, resistant statement, and a previous, contradictory statement that the client has made.

Client: But I can’t quit drinking. I mean, all of my friends drink!
Counselor: You can’t imagine how you could not drink with your friends, and at the same time you’re worried about how it’s affecting you.
Client: Yes. I guess I have mixed feelings.
Shifting Focus

Another way to reduce resistance is simply to shift topics. It is often not motivational to address resistant or counter-motivational statements, and counseling goals are better achieved by simply not responding to the resistant statement.

Client: But I can’t quit drinking. I mean, all of my friends drink!
Counselor: You’re getting way ahead of things here. I’m not talking about your quitting drinking here, and I don’t think you should get stuck on that concern right now. Let’s just stay with what we’re doing here – talking through the issues – and later on we can worry about what, if anything, you want to do about it.
Client: Well I just wanted you to know.

This example is from problem drinking, but it applies to many situations – such as when people are trying to explain why they can’t use a pain management strategy!

James T Hardee writes about Empathy in healthcare‘Unfortunately, many physicians were trained in the world of “Find it and Fix it” medicine, a world where empathetic communication was only an afterthought–if this behavior was considered at all. Empathy was known as “bedside manner,” a quality considered innate and impossible to acquire–either you were born with it or you weren’t. More recently, greater emphasis has been placed on empathy as a communication tool of substantial importance in the medical interview, and many experts now agree that empathy and empathetic communication are teachable, learnable skills’.
I think we could add in a number of other health care professionals who may have been taught listening skills early in training, but in the busy-ness of clinical life, might forget the basic skills.

Remember the reasons you decided to start working in healthcare? And the reasons you stay? There are other less demanding ways to earn a living – but we all chose healthcare. This article from Positive Psychology Daily discusses meaningful work. Perhaps one way of reminding ourselves to be empathic, compassionate and human is to remember the meaning in our work.

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Motivating people to make changes (iii)

The third of a series about using values and empathy to help people make choices

The previous two installments in this series have introduced the concepts of stages of readiness for change, rapport and empathy and appreciating that the people we work with have their own values influencing the choices they make. This paper introduces two strategies that can help people directly influence the focus of therapy while at the same time enabling you as a therapist to signal areas that are important.

From the outset of a clinical encounter, you as the therapist direct the interaction. This means you have the responsibility for ensuring the person you are working with has opportunities for choice. In order for you to find out what is important to the person, you need to ask about how their health situation is affecting them. This sets the agenda for your session.

Agenda are usually set by you – so giving the patient/client the opportunity to set what that is important to them at the outset immediately establishes your credentials as someone who will take them seriously.

We often do things that have unintended consequences in the medium to long term, while satisfying immediate desires. While we don’t always like the unintentional outcomes, it can be very difficult to resist instant gratification! While we satisfy our craving for chocolate, we risk gaining weight. Our taste for chocolate might make us feel better – but our good feelings disappear when we step onto the scales in a fortnight’s time… Similarly, the person who doesn’t want to work to quota because he ‘has to mow the whole lawns – and cut the edges’ may be reducing the immediate distress of letting the family down, but ends up being unable to go to work for a day – letting his employer down.chocolate

Part of what we are doing as we establish rapport is becoming aware of what is important (therefore valuable) to the person – and from this we can develop goals with the person that (hopefully) align with their values in the medium and long term.

Read further on this topic in my Coping Skills section.
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Motivating people to make changes (ii)

The second of a series about using values and empathy to help people make choices

The first installment in this series looked at why people might not be doing what we think they ‘should’ and how they might show this. This installment looks at developing rapport and reviews the essential interpersonal skills that are needed.

Rapport – what does it really mean? Is it just making small talk so the person calms down and is ready to listen to what we want to say? Or is it something much deeper?

Superficially, rapport is really about ensuring you and the other person are on the same wavelength. It can be as simple as asking them about the weather, or did they have a good day, or ‘what can I do for you?’ Done glibly it can be shallow and forced – and you know the person will only tell you what they think you want to hear (until they are just walking out the door and say ‘oh by the way…’!)


To respect this person’s situation, we need to believe that they have made the best possible choices given the resources they had at that time, and that to them their choices made sense at least once. Something about their choice was important to them at the time. Their choices reflect their values – what is important to them.


Although there are specific skills to help develop rapport, the first and most essential element is actually an attitude: ask yourself ‘Do I really respect this person?’ Respect means accepting that although the person is different, and has made choices that are different from yours, you can honour their position and understand that they have done so to make the best possible decision at the time.

Reflective listening is a basic skill taught (usually) early on in health professional training. It’s often assumed by both ourselves and others that we know how to use reflective listening, but sometimes our skills haven’t developed since we first learned them!

For more details – click here to go to this post in my Coping Skills section!