The Therapeutic Sequence: An Interview Technique for Improving Communication in the Clinical Encounter

1. The Therapeutic Sequence: An Interview Technique for Improving Communication in the Clinical Encounter Sheila Crow, M.A. Interim Director, Office of Educational Development & Support College of Medicine Educational Grand Rounds October 21, 2005

2. Learning Objectives Describe the steps in the therapeutic sequence process. Recognize primary emotions in others. Understand the role of the therapeutic sequence in improving communication in the medical encounter. Understand how to teach the technique using standardized patients.

4. Introduction Most of what occurs between a patient and physician is talk. Physicians will conduct between 140,000 and 200,000 clinical interviews in a practice lifetime. Communication is more than words. Nonverbal expressions and cues. Give context and enhanced meaning to the words spoken or not spoken.

5. Interview skills are procedural. Can be studied, taught, and learned. Residents and physicians do not follow any particular model consistently. Therapeutic Sequence / task introduced by Gordon Deckert, MD (1978). Use in Principles of Clinical Medicine Course and Human Behavior.

6. Qualities of a Good Interviewer What are the qualities of a good medical interviewer? Appropriately nurturing / supportive Provides patient with a cognitive model of understanding (Disease and Dis-ease) Involves the patient in the problem-solving process

7. Patient Outcomes Higher patient satisfaction Increased compliance with physician recommendations Improved recovery from surgery Decreased use of pain medication Shortened hospital stays

8. Pre-Interview Tasks Conceptual task Be aware of the concepts you and the patient bring to the clinical encounter. Attitudinal task Be conscious of the attitudes you bring to the encounter. Hungry, Angry, Late, Tired (HALT)

9. Interviewing a Patient Perceptual task Two categories of perceptual data Words used by the patient Digital / visual data that clues the physician in to the patient Determine primary emotion Acceptance, disgust, surprise, joy, fear, anger, and sadness Determine congruence between subjective and objective messages

10. Interpersonal Task Determined by the accuracy of the perceptual task. Establish patient-physician relationship. Obtain accurate information. Relate to patient in a therapeutic manner. Interviewing a Patient (continued)

11. The Therapeutic Task �Therapeutic Sequence� Primary emotion Congruence Stress Consensus Contract Concurrence Outline treatment strategies Begin implementation

12. Step 1: Primary Emotion What is the patient�s primary emotion? Is there evidence for the presence of anger, sadness, fear/anxiety, acceptance? Note patient�s facial expressions, observe behavior, listen to the words.

13. Primary Emotion Trigger Tape Anger Fear / Anxiety Sadness (Trigger tape demonstration is not available for download.)

14. Step 2: Congruence Establish congruence between the emotion communicated and the emotion experienced. If congruence is not present, try to establish it or bring it to the attention of the patient.

15. Step 3: Stress Explore what stress, psychologically or physiologically that might be precipitating the emotion. Begin with the assumption that the category of the stress and the usual emotional response will correspond.

16. Step 4: Consensus Agreement between physician and patient as to what event, symptom, or concern is precipitating the emotional response. Primary emotion, congruence, stress, consensus occurs rapidly in emotionally healthy individuals. Achieving these four steps helps to dissipate the emotion and move the therapeutic process forward. REALLY IMPORTANT!

17. Skills Demonstration Video Dr. Rhonda Sparks / Rosemary Orwig (SP) Dr. Steve Orwig / Nita Folger (SP) (Video presentation is not available for download.)

18. Step 5: Contract Establish a contract with patient. Obtain patient�s chief expectation�what the patient hopes to accomplish. Should be explicit rather than assumed.

19. Therapeutic Sequence Model

20. Step 6: Concurrence Physician and patient agree to the nature of the intervention process. Physician and patient have a clear understanding of what is expected of the other.

21. Step 7: Outline Treatment Strategies Discuss treatment strategies Some patients may know very little about treatment options, others may know a lot. Involve the patient in the problem-solving process

22. Step 8: Implementation Proceed with implementation of agreed strategy. Repeat therapeutic sequence if there is difficulty implementing strategy. Success is usually indicated by, �Sounds good�thanks doc.�

23. Use of Standardized Patients with Students Trained to teach primary emotions and therapeutic sequence process. Multiple opportunities to practice. Students receive feedback from Standardized Patient and peers. Second year students required to pass therapeutic sequence process.

24. Summary Talk is the main ingredient in medical care. The Therapeutic Sequence is an appropriate model for improving communication in the clinical encounter. Clinicians should recognize, acknowledge, and empathize with a patient�s primary emotion.

25. Summary (continued) The model has wide applicability. Standardized patients are excellent resources for teaching the therapeutic sequence and primary emotions.

26. QUESTIONS?