Читать книгу Approaches to Behavior - Janis Roszler - Страница 10
ОглавлениеTwo monologues do not make a dialogue.
—Jeff Daly
In this chapter, you will learn the following:
● How to communicate more effectively with patients who appear emotional, distracted, or unreachable
● How to interact with patients you may not like
● When to refer your patient to a therapist
Connecting
Armed with the tools from Chapter one, you hopefully feel more prepared to start your day with a positive mind-set. Even if you enter your office whistling a happy tune, you still are likely to encounter patients who bring their own emotional baggage to their appointments. They may feel angry, sad, frustrated, hopeless, anxious, depressed, hurt, or even guilty about having diabetes or other medical issues. These feelings can be overwhelming, but they are normal. Anticipate them. After all, living with diabetes requires patients to adjust not only their lives but also many of their hopes and dreams. That, alone, can be highly distressing.
You may wish that your patients left these negative feelings at home; however, the fact that they show their emotions so openly may demonstrate how overwhelmed they are feeling as well as how much they trust you and believe you can help them. If you don’t acknowledge their feelings in some meaningful way, these emotions can become the proverbial “elephant in the room” and negatively affect everything that happens during your session together. Angry patients, for example, are so distracted by their clenched jaws and throbbing foreheads that they miss many of the important things you say. Your patients’ emotions and inability to listen also can affect your mood and prompt you to speak in a more harsh or inappropriate manner.
When Patients Arrive
When you meet with your patients, hand them a sheet of paper on which they can take notes. Think of this handout as their personal prescription pad. On it, they can jot down information you share and suggestions you make, and then they can choose to implement the plans you collaboratively develop more effectively. At the end of the session, ask them to summarize all they learned and tell you what they have decided to do differently before their next visit.
When They Arrive in a Difficult Mood
If you suspect that a patient is not in a positive mood, remember the stop, drop, and roll (SDR) intervention. Stop for a moment. Drop any negative judgment you have about seeing this person, and roll forward with a more compassionate stance before you step into the room. Once you enter the room, set the stage for a meaningful interaction. Think LEAP and follow these four steps:
1. Listen
2. Empathize
3. Affirm
4. Positively reframe
Step 1. Listen
Carl Rogers, the father of client-centered therapy, said the following about the value of being heard:
I can testify that when you are in psychological distress and someone really hears you without passing judgment on you, without trying to take responsibility for you, without trying to mold you, it feels damn good! (Rogers, 1980)
When you encounter distressed patients, listen carefully to their concerns. Ask open-ended questions to help find out what is really on their minds. If your time is limited, ask them to take a moment and state how they feel in a single word or sentence. That request will help your patients clarify their thoughts and get right to the point. When possible, invite them to share what they have accomplished so far, to remind them of their progress as they consider their struggles. Use body language to demonstrate your sincerity—lean forward, face your patient, and make eye contact. Fight the temptation to glance at your electronic notepad or other devices. We know that should be obvious, but it is a common patient complaint that deserves note (Gualtieri, 2010). Your goal is to feel and communicate genuineness, authenticity, sincerity, and compassion; none of which can be achieved if your attention is elsewhere. Don’t worry if you don’t know what to say or how to respond. The fact that you care enough to listen is healing; it shows your patients that you see them as individuals and want to know how they think and feel. Additionally, when you attend to your patients in this way, they observe how quality listening is done and, hopefully, will employ this behavior in their own lives with emotionally distressed loved ones.
Active listening isn’t just a matter of courtesy. There are real rewards for reaching out to others in this way. When you give your patients permission to express how they feel about their diabetes or other distressing concerns, they are more likely to share additional information with you, take their medication as prescribed, show up to follow-up appointments, and follow through with the lifestyle changes you recommend (Bayne, 2013). When you identify a problematic issue, you take the first step toward resolving it. If you aren’t convinced yet, consider your wallet as well as your peace of mind. One study showed that physicians who develop empathic relationships with their patients have a lower incidence of malpractice claims (Levasseur, 1993, as cited in Bayne, 2013). This may apply to educators and other professionals as well.
Step 2. Empathize
To reflect a statement your patient shares, repeat it back to him or her in your own words. You can do this compassionately or empathically. What’s the difference?
● Being compassionate: You feel sympathetic about someone’s situation, but you don’t try to understand how they feel or explore how deeply they are suffering. For example: Habitat for Humanity helps people in need, so you write a check to the organization and send it off in the mail. You don’t read the profiles on the website or try to learn more about the recipients of your gift. You give, because you know the organization is effective and helpful.
● Being empathic: You donate to Habitat for Humanity, but you go beyond writing a check. You make an effort to learn about the recipients of your gift—who they are, what matters to them, and how they feel about their current situation. According to Danielle Ofri, author of What Doctors Feel (2013a), “this is where doctors often stumble—empathy requires being able to communicate all of this to the patient.”
Consider the following compassionate exchange between Mike and his dietitian, Susan:
Mike: Susan, I want to follow my meal plan, but my schedule is too hectic.
Susan: It’s not easy to fit diabetes into your busy life. It sounds like you want to follow it, but haven’t figured out how to fit it into your life. Is that right? (Reflect/confirm.) Let’s see what you are willing to do.
Compare that exchange with this empathic exchange:
Mike: Susan, I want to follow my meal plan, but my schedule is too hectic.
Susan: It sounds like you might be upset because you’re too busy to follow the meal plan we created last time. Is that right? (Reflect/confirm.)
Mike: Yes, I really want to eat well, but my schedule is crazy.
Susan: That must be frustrating, because I know you care a lot about your diabetes. I’d really like to hear about what’s getting in your way. (Empathy.)
Both being compassionate and empathic are important options that require good listening skills. Being empathic, the gold standard in connecting, takes a little additional time and effort that we believe is well spent. But being compassionate is valuable too. If you don’t have time to be empathic with each of your patients, be compassionate.
Step 3. Affirm
The way our patients feel and act is common; they are not alone. Assure Mike that his feelings, even uncomfortable ones, are natural feelings that many people have and will most likely pass:
Susan: Hi, Mike. You’re too busy to follow the meal plan we created last time? Thanks for letting me know. That must be aggravating, because you told me how much you care about your health. Many of my patients find that following a new meal plan gets easier with time. (Affirm.) Your frustration should decrease as you become more familiar with your plan and start to get into a new routine. It’s not easy, but it’s worth it.
People respond more positively when they know that others behave the same way they do. In 2010, Dr. Nat Strand became the first individual with type 1 diabetes to win television’s The Amazing Race, an intensely demanding, global scavenger hunt. Over the course of 23 grueling days, she and her teammate, Dr. Kat Chang, traveled 32,000 miles across four continents, 10 countries, and 31 cities. They raced dog sleds in the Arctic Circle, speed skated in South Korea, and even got lost for a frustrating 6 hours while driving through the deserts of Oman. Their ultimate goal? To win the $1 million prize. Throughout the competition, Nat struggled to keep her blood glucose well-controlled, which dipped into the low 40s and soared into the high 300s when the race became particularly stressful—like the time when she battled her intense fear of heights to leap off a 150-foot crane that hovered over California’s Long Beach Pier. Although her experience was far from typical, viewers with diabetes empathized with her efforts to maintain control of her diabetes. After the competition, she received hundreds of supportive messages from folks who were happy to see that, like them, Nat also struggled with abnormal glucose levels (affirmation).
Step 4. Positively Reframe
During your session, Mike complains that his wife meddles too much in his diabetes care. She questions his food choices and reminds him to check his blood, even though he doesn’t need reminding. He says that she acts this way because she likes to annoy him. You ask if he thinks it is possible that she may do these actions because she cares so deeply about him and his health. The new more optimistic “spin” you offered is a positive reframe. You encourage Mike to thank his wife for caring about him and assure her that she doesn’t have to monitor him so closely. If her actions continue to bother him, the couple can meet with the therapist on your team who can help them communicate more effectively with one another.
If the above supportive exchanges aren’t your approach, what comes out of your mouth may feel awkward or phony. This is partly because it is new for you; learning to ride a bike or play tennis is also awkward in the beginning. The more you engage in this type of interaction, the more easily you will find wording that fits your personal style and point of view. Even Carl Rogers, quoted earlier, struggled to become adept as a listener (Rogers, 1980). If you want, you can use the “fake it ‘till you make it” approach. The truth is that you don’t have to feel empathic to act empathic. As a matter of fact, the more heartfelt comments you make to those around you, the more empathic you are likely to become (Wise, 2013). The good news is that your efforts are not one directional. When you help patients see an issue in a more positive light (positive reframe) that optimistic message also can positively affect how you perceive the issue. Try this technique with your family, friends, and others you deal with each day. Observe how it affects your attitude. As you read through this book, we will share additional ways to apply this.
If you think showing empathy compromises your ability to be seen as an expert or crosses some sort of professional boundary, you are mistaken. It increases your competency. When you connect to your patients as individuals and recognize their feelings, you give them permission to have empathy for themselves. Your professional behavior demonstrates how people can take a momentary break from their troubling issues, yet still be aware and responsible. As they follow your lead, they, hopefully, will give themselves emotional breaks as well. When they do, great changes can happen.
After you respond to your patients’ initial comments, ask what they’d like to do to take better care of their health. Here is an example: Joan says she feels depressed because the neuropathic pain in her feet forced her to drop out of her favorite aerobics class. This class was an important social outlet for her, which had a positive impact on her mood. Now that it is gone, she fears that she may lose even more parts of her life as her diabetes progresses. How would you respond?
Consider the following possible response:
Tell Joan that you are impressed that, as depressed as she feels, she is still able to recognize how dropping out of this class affects her mood, her diabetes, and her social situation. Next, ask her what she thinks she could to do to meet her physical and social needs. Let her know that therapy can help her manage her fear and keep her negative feelings from affecting her ability to care for her health. If a therapist is not readily available, urge her to participate in a local support group, meet with a spiritual advisor, or reach out to another member of her personal support system. If you are available, you also can offer to set up an additional appointment with her so that the two of you can discuss more of her concerns.
Team Up
Be collaborative and invite your patients to share behavioral changes they feel ready to try. If you want them to become more active, for example, ask what type of physical activity they’d like to do, with whom, and at what time. When you tell people what to do, you assume that you know what is best for their lives. If you urge them to do what you think is best, you initially may get positive results, but you also may undermine their confidence and ability to come up with future self-care strategies of their own. Inviting them to brainstorm with you helps them develop healthy problem-solving behaviors when you are not around (Berg, 2012).
If you have a secure work e-mail, share it with your patients and invite them to tell you about positive moments they encounter between appointments. According to the U.S. Department of Health and Human Services, HIPAA’s Privacy Rule “allows covered health care providers to communicate electronically, such as through e-mail, with their patients, provided they apply reasonable safeguards when doing so” (Health Information Privacy, 2008). It is not necessary to send a lengthy response. Just tell them to expect to hear back from you and then reply with a happy face “:)” or a simple “Great!” to let them know you received and enjoyed their message. Positive e-mail interactions and other innovative communication options help support your patients and reinforce important health messages while you are apart.
Explore Cultural Beliefs
To help you learn more about your patients’ cultural views about diabetes, ask the following three questions (Anderson, 2002):
● What does having diabetes mean to you?
● What does having diabetes mean in your family?
● What does having diabetes mean in your community?
Then work with your patients and their family members with areas of concern.
In some ethnic communities, “a diabetes diagnosis reflects a personal failure of consuming excess calories, behaving immorally, or being unspiritual” (Anderson, 2002). A wife of a Latino man, for example, may blame herself for causing her husband’s diabetes, if she is the one who is responsible for food preparation in the family (Anderson, 2002). Ask about family, holiday, or religious customs that affect how your patients care for their diabetes. If they participate in the month-long practice of fasting until sundown to mark the holiday of Ramadan, you may need to help them adjust their insulin dose, so they don’t experience fasting-related hypoglycemia or hyperglycemia (Anderson, 2002). For assistance with Ramadan, we suggest Recommendations for Management of Diabetes During Ramadan (Al-Arouj, 2009).
If your patients are of the Jewish faith and want to follow the Passover holiday’s dietary restrictions, help them locate dietary information that helps them consume appropriate portions of the foods commonly eaten on that holiday, such as products prepared with matzo. One website that offers helpful diabetes-related Passover information is http://www.Friendswithdiabetes.com.
Lessons That Linger
Here is how the supportive interactions you have with your patients can positively influence their behaviors in the future:
Ted stopped at a nearby coffee shop to pick up a decaf coffee. While waiting in line, he spied a croissant that had his name written all over it. In the past, he would have impulsively added it to his order, gobbled it down, and then hated himself for the rest of the day regardless of how well he ate later. But this time was different. At a recent appointment, his diabetes educator, Samantha, recognized how frustrated he was about his eating urges and reminded him that he tended to feel that way when his blood glucose level ran high. They brainstormed and Ted identified several ideas he thought he might like to try:
● He could go to a different coffee shop and develop a new, croissant-free, coffee-purchasing tradition.
● He could bring exact change for the coffee, so he wouldn’t purchase anything else.
● He should give himself permission to stop feeling guilty because he wants to eat the croissant. Having diabetes doesn’t mean he has to deny himself everything he loves.
● He could use pre- and post-blood glucose checks to see how the croissant affects his efforts to manage his diabetes and then adjust his medication, physical activity, and intake accordingly.
Samantha even joked about how he might have an easier time sticking to his health goals if he stared at the cashier’s lovely eyes instead of at the croissant. Ted smiled as he recalled their conversation, how much they both laughed, and how good it felt to have Samantha understand him. He felt he could make a better decision and not just follow a thoughtless reflex. He excused himself from the order line, turned around, and walked down the block to a rival shop. He decided to start a new coffee-buying ritual: one without croissants, cake, or other baked goods. Ted felt proud. He made a mental note to e-mail Samantha and thank her for her help.
What If You Don’t Like Your Patient?
Occasionally, we have to deal with patients we don’t particularly like. For some reason that may be related to our own life experiences, they push our buttons. These feelings are perfectly normal, so don’t dismiss them. Instead, use them diagnostically as a way to learn more about your patients and yourself. If Mrs. Leaf always had a lovely disposition, but suddenly comes to her appointment disgruntled and rude, SDR and then consider what physical and mental changes she may be experiencing. Is her glucose level abnormal? Is she becoming depressed? What else is happening in her life? If you feel uneasy around particular patients, your discomfort may highlight a behavior that they use with others. Note these red flags and investigate the physical, interpersonal, and emotional health issues they may represent.
Occasionally, our strong feelings can compromise the care we provide. We may not be able to connect with some patients, and they may have a harder time accepting help from us. John Bowlby’s attachment theory offers a possible explanation for the negative encounters that occur between us and some of our more challenging patients. According to Bowlby, when all of us were young, our caretakers met our needs in ways that either comforted and reassured us or left us feeling anxious, lost, and unsupported. These early experiences helped us form “enduring cognitive models or ‘maps’ of caregiving that persist into adulthood” (Ciechanowski, 2002).
Adults with secure attachment histories are more at ease with those who reach out to assist them. Those with less or unresponsive early caregivers may have more difficulty trusting health care professionals, while individuals whose caregivers’ attention was inconsistent try much harder to gain approval. These are the patients who may act more clingy and needy. Finally, individuals who experienced “overly critical or harsh rejecting caregiving” are more apt to demonstrate approach-avoidance behavior as a “manifestation of their fear of intimacy” (Ciechanowski, 2002). Their behaviors have both negative and positive aspects. For example, they may be excited to try what you suggest, but they won’t actually do it. These different attachment responses are most apparent when the individuals need assistance, which is when most of us see our patients. When they meet with us, their attachment history helps them determine whether they can trust us as their caretakers and whether they feel they deserve to be helped. Understanding the basics of attachment theory can help us all see our patients’ behaviors through a new lens and respond to them in a more positive way.
What About Our Own Attachment Issues?
We health care professionals have our own attachment histories, and develop attachments with our patients as well. We expect our patients to value us and turn to us when they are in need. We believe they should come to their appointments and follow the guidance we offer. At times, we may find ourselves trying too hard to get their approval. Our professional values also may be affected, if our attachment feelings start to unravel when patients miss multiple appointments. We may feel less committed or even threatened when patients bring conflicting opinions from other sources, such as the Internet. Instead of praising their efforts to find answers, which reflect the dedication they have to their health (and then discuss why the info may be incorrect), many of us express such strong negative responses that our patients become reluctant to share in the future:
After Maxine shared an Internet article she printed out about hearing loss, which she was developing, her doctor went on a lengthy tirade about the unreliability of Internet medical information. Maxine felt hurt and dismissed. Today, she still looks things up on Webmd.com, a reliable website, but never shares it with her doctor. She also refrains from letting him know when she tries any of the suggested treatments posted on the site. Sadly, their relationship continues to suffer. Her doctor missed an opportunity to listen to Maxine’s concern, acknowledge her efforts to learn more, and reflect back on the issues that worried her. His efforts could have positively affected the way she cared for her health.
Why Do They Push Our Buttons?
To understand and, hopefully, adjust the highly negative responses we have to some of our more frustrating patients, for their well-being and ours, we need to consider three things:
● Others may find these individuals frustrating too, so we shouldn’t take their behavior personally.
● Their behavior may remind us of the behavior of others in our past or present.
● We may have a strong response because we possess the potential to behave the very same way.
“What we see in others may exist in ourselves, both the good and the bad. If you admire someone’s courage, you notice it because it is in you as well” (Ford, 2010). What we dislike in others, we may dislike in ourselves. Think about a patient you find hard to tolerate. Identify what bothers you the most. For the sake of this discussion, let’s say that you cringe every time you encounter Mrs. Groan’s rudeness; it sets you on edge. You don’t like how she speaks to you and ungratefully disputes everything you say. True, no one would appreciate that behavior, but why does it bother you so much? Why you feel this way may surprise you: You might dislike Mrs. Groan because her behavior reflects the rudeness you dislike in yourself. You may bend over backward to keep that side of yourself hidden, but it is possible that you have it. In fact, all the qualities we notice in others, both good and bad, may be qualities we have in varying amounts in ourselves.
To better accept or understand Mrs. Groan’s behavior, try to reflect on and embrace that part of yourself. Look at the positive side of this hidden area of your personality—what Carl Jung refers to as our “shadow”:
Everyone carries a shadow, and the less it is embodied in the individual’s conscious life, the blacker and denser it is. “If we are aware of a particular issue or pattern, one always has a chance to correct it … But if it is repressed and isolated from consciousness, it never gets corrected (Jung, 1975).
Let’s give it a try:
