Persuasion in Clinical Practice

Helping People Make Changes

Lewis Walker

• Publisher: CRC Press
• Year: 2017
• ISBN:
  9781315346533
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

By the end of this book you are going to be part of an exclusive group. The skill-sets you are about to learn will help you become one of a select few who can, time and time again, help people make changes in any clinical encounter.A" Persuading and influencing are most effective as cooperative ventures that recognise the needs and wishes a person already has, but feels unable or disempowered to decide or act upon. Persuasion in Clinical Practice aims to improve outcomes for patients by helping them to change their own attitudes and behaviours more easily in pursuit of better health and well-being. Drawing on fields such as motivational interviewing, the Stages of Change model, positive psychology and neuro-lingusitic programming (NLP), the book provides skills and tactics to help clinicians avoid communicational roadblocks, find what is really important to patients, why they want it, and then empower them to make changes in key areas such as: * lifestyle adjustments * coming to terms with chronic or serious illness * learning coping strategies and behaviours * overcoming fear of change. Encompassing a five-step strategy for any change consultation, Persuasion in Clinical Practice is packed with information and approaches to enhance knowledge, skills, attitudes and understanding in influencing change. This book will be essential reading for family doctors and other health professionals supporting behavioural change in their patients.

CHAPTER 1

Foundations of Persuasion in Clinical Practice

This book is purposefully light on theory. I have structured it to be both practical and pragmatic . . . using only as much theory as is necessary to support your learning. I want this to be a book which you can easily pick up, quickly access the material you want and begin to use it immediately. The foundations of Persuasion in Clinical Practice are built very firmly on the common factors that apply across all change modalities, the Stages of Change model, the skills of motivational interviewing and the attributes of positive psychology. Before examining each of these in turn we need to say a little about the operating system that underpins them all, and that is language itself.

What Language Presupposes

We use language to communicate with each other every day and hardly ever pay conscious attention to the underlying assumptions of each sentence we utter. Yet insidiously and often perniciously, language structures our inner and outer world of experiences for both good and ill. The following principles are the invisible rules that govern persuasive communication.

1. ➤ Language creates realities
   Language does not simply represent the world we live in and experience day to day – it plays a major part in its construction and interpretation. The very words we use can paint a vivid picture that creates a heaven . . . or a hell. Words literally construct something out of nothing. By labelling something with a word we subtly create a boundary around that ‘thing’, separating it out from its surroundings. Our beliefs, values, ideas, problems and concerns are the labels we use to interpret our experience. We may think and act on them as concrete realities, yet fail to realise they are eminently malleable.
2. ➤ All communication focuses attention
   What we say, how we say it, and who actually says it, causes us to pay attention to some things in our field of awareness rather than others. We create foreground out of a background that is made up of everything else we could be experiencing at that time. Language is selective. We can use it directly or indirectly to sow the seeds of change. I might directly say: ‘You can learn persuasion skills from this book’.
   More indirectly and perhaps more persuasively: ‘I wonder just how easily you’ll find yourself learning persuasion skills from this book’.
3. ➤ We are always influencing
   Whatever we say will affect the other person’s state of mind and body. Our communication may cause people to move in certain directions . . . even if we say nothing at all. Influence is an inescapable fact of every interaction – for good or ill. Given this inevitability we need to use our language with care so that we can begin to influence with integrity.
4. ➤ All meaning is context-dependent
   This is one of the greater insights of postmodernism, especially with respect to language. The meaning of any word or behaviour depends on the frame or context in which it is used. Consider the word bark. We can speak about the bark of a dog or the bark of a tree. The word is the same in both circumstances . . . the meaning, however, is entirely different.
   In a similar way we can frame many behaviours – such as overeating, for example – as a problem to be rid of. Or, we can reframe its meaning as one of many possible ways of doing something to make yourself feel good in the moment. What other more healthy ways could get you the same result? This insight opens up the possibility for endless reframes of problem situations, making it a very useful persuasion tool.
5. ➤ Language conveys multiple perspectives
   Although we can take many different perspectives on a situation, there are three principal positions from which we speak. These are the personal pronouns of first, second and third position language (I, you/we and he/she/it/they). The interplay of these positions within any act of persuasive communication can be instrumental in creating a problem . . . or a solution. In general, people who are good persuaders recognise the importance of seeing things not only from their own eyes, but also the perspective of their current communication partner and any other third-party interests that might be involved. The information you glean from each viewpoint can allow the emergence of a more ecological change . . . a more tailor-made fit.

Throughout Persuasion in Clinical Practice you can be on the alert for how the various communication patterns you’re learning fit these five basic principles.

Common Factors Across all Change Modalities

There are many different approaches to treatment, therapy and change. In fact there seems to be an ever-increasing number of interventional modalities appearing every day – each with its own theoretical underpinnings, rationale and techniques of encounter; each portraying itself to be the best way to relieve psychological distress and effect behavioural change; each purporting to be the numero uno for a particular patient group. However, research within the last decade (see, for example, Hubble, Duncan and Miller, 1999, The Heart and Soul of Change) suggests that all approaches are, in the main, equally efficacious. Rather than getting results by the explicit techniques that differentiates them one from the other, it seems that they all share four common factors through which virtually all change is mediated. These common factors (with their suggested percentage effect on the change process shown in brackets) are of vital importance in the process of persuasion.

1. ➤ Patient, person, client (40%)
   It seems that it is the personal strengths, resources and skills that the patient brings with them into the session that account for a whopping 40% of the change. These include the person’s beliefs and values, how they’ve coped with and caused change to occur in the past, and how confident they are in their belief that they can change in the future. How they motivate themselves to take action and what supportive factors are present in their home and work environments are also key issues. In short, it is fundamentally important to any persuasion process to highlight and harness these strengths, effectively putting them to work. Failing to do so will dramatically decrease the results you get.
2. ➤ Therapeutic alliance (30%)
   No matter what the clinician’s theoretical position, all successful change modalities require the presence of factors such as rapport, empathy, acceptance and encouragement. Believing that your patient can actually make the necessary changes is vital. Believing otherwise has been shown to significantly reduce the chances of achieving the stated outcome (self-fulfilling prophecies). Key to all of this is the patient’s perception of the degree of support available within your alliance. No matter how supportive you may think you are, it’s their perception of how well it is functioning that makes the difference. In fact the alliance may well account for seven times the amount of change attributable to specific technique alone.
   Together, patient strengths and therapeutic alliance account for the greatest part of a successful intervention. You must pay close attention to both.
3. ➤ Expectancy, hope and placebo (15%)
   This effect is due to the patient’s belief that this particular kind of intervention is likely to get them the result they want. Everyone entering a process of change has certain ideas about how it may turn out. These ideas can influence the process both positively and negatively. Equally important seems to be the congruency with which the clinician performs the ritual of therapeutic intervention. It is not necessarily the therapeutic model per se but the belief that both parties share about the model that helps get the result. Bear in mind, though, that this overall effect has seemingly much less impact than the first two factors.
4. ➤ Technique (15%)
   These are the specific rituals that make up the particular therapeutic intervention you are utilising to persuade your patients in the direction of their goals. They provide ways of seeing ingrained problems and issues in a new light. Their general aim is really to provide a rationale to prepare and convince patients to take some different actions on their own behalf so that they can alter previously entrenched behavioural patterns. Becoming aware of and utilising many different techniques for persuading change to occur, without 100% allegiance to any one methodology, will give you the flexibility to help many more people.

As I currently see it, the percentage for technique may actually be underestimated. This is because many change methodologies have specific techniques for each of the four areas. There are many techniques to recognise or discover pre-existing patient resources in other contexts, and revivify and bring them usefully into the problem arena to transform it. There are particular strategies that can enhance rapport. Expectancy and hope have a particular structure for each individual that can be elicited and intensified. And of course there are the specific change techniques that each methodology brings to the therapeutic table.

From the foregoing, however, we can see that key to any successful intervention is identifying and amplifying patient strengths within the context of therapeutic rapport. Keeping this clearly in mind will help you to stay firmly on track.

Stages of Change Model

The Stages of Change model as evinced by James Prochaska, John Norcross and Carlo DiClemente (Changing for Good, 1994) is a model of how behavioural change naturally takes place in a community setting without the need for professional intervention. Initially researching smokers who had quit mostly without outside help, they found that the process of change seemed to automatically go through various stages. And not only that, they recognised that different therapeutic and change strategies were more suited to certain stages than others. In fact, in applying any specific intervention they found that timing was crucial. Each stage demanded a particular approach. Using certain therapeutic strategies too early or in the wrong stage altogether could actually prevent the change from occurring.

The Stages of Change model is a transtheoretical model. It does not promote any one of the 400 or so therapies Prochaska investigated. It simply clarifies the processes of change and fits each intervention accordingly. It frees clinicians up from being blinkered prisoners of their favourite approach and promotes eclecticism and pragmatism. In a sense it is a meta-model of change, which is probably why it pops up with increasing frequency across the varied medical spectrum. In Persuasion in Clinical Practice it forms the backbone that supports the stage-specific persuasion tools.

In the way that I use the model there are five main areas to consider. We will devote a chapter to each in due course but for now here is an overview of the stages.

1. ➤ Raising awareness
   In this stage, often called pre-contemplation, many people are uninformed, underinformed, resistant, avoidant, demoralised, defensive, denying and more. They may not see that they have a problem and may only turn up in your consultation because someone else (a spouse, perhaps) has insisted they come. There are several different types of pre-contemplators – reluctant, rebellious, resigned and rationalising – and we will discuss specific strategies for helping each engage in change in Chapter 7. The main overall strategy in this stage though is to raise awareness about the potential difficulties, dilemmas and predicaments of the current situation. This may actually involve creating a problem for them to move away from. Having done so leads them on to the next stage.
2. ➤ Resolving ambivalence
   In this stage, often called contemplation, people are likely to be in two minds about what to do. They are now aware that a problem exists yet are undecided, unsure and ambivalent about taking action. In a sense they may want to change and also not want to change . . . at the same time. They experience mixed emotions and may feel very stuck, incongruent and often conflicted. They may even go round in circles stewing in the juices of behavioural procrastination....

Table of contents

• Cover Page
• Halftitle
• Title Page
• Copyright Page
• Contents
• About the author
• Acknowledgments
• Introduction
• 1 Foundations of Persuasion in Clinical Practice
• 2 Styles of change
• 3 Problems and solutions
• 4 Assessing importance, confidence and readiness for change
• 5 Present and curious
• 6 Avoiding roadblocks
• Interlude 1 Kick ‘but’ . . . without ‘try’ing
• 7 Raising awareness
• Interlude 2 Changing frames
• 8 Resolving ambivalence
• Interlude 3 Persuasive phrases
• 9 Preparing to make changes
• Interlude 4 Emotional messages
• 10 Taking action
• Interlude 5 You, me and them
• 11 Staying on track
• Appendix: Modal operators
• Bibliography
• Index