I did a demonstration of this strategy in a workshop and a number of practitioners wrote to me asking if anything was written down on this subject. The piece below was originally written for a new book, but my publisher and co-author felt it overlapped too much with other material. So I include here in full. Feel free to copy or distribute it as you wish, and I assume that you will acknowledge its source.
-Stephen Rollnick, July 2006.
Introduction
Do you often have around 20 minutes or more and a routine assessment to complete?Does formal questioning make it difficult to use a guiding style?
Does it tend to dominate the opening exchanges in your interviews?
Do you feel pressure to complete pages of assessment designed by the service?
- In our service, we’ve been told that we must complete the assessment in the first interview
- We wont get paid for the service unless these forms are completed
- We need to get basic facts about these patients so we can make sensible decisions
One practitioner we met said that his job involved a 17-page intake assessment with an average consulting time of 15 minutes; and the goal of the exercise was primarily to encourage behaviour change. While this story is perhaps unusual, there’s nothing like an assessment battery to provoke conflict between the needs of the organisation and your desire to work within a guiding style. The winner is often the organisation, particularly if you are under time pressure. The almost natural inclination is to fall back on a directing style, and fire the questions at the passive patient.
Skilful assessment makes a difference
Assessment can be lively and patient-centred. The aim of this exercise is to provide you with guidelines for ensuring that what one practitioner called “death byassessment” is avoided at all costs. It involves the integration of the “Typical Day” strategy into assessment. With practice, you can get the assessment done and lots more, without the patient ever feeling investigated. You can also, with a few minor adjustments, focus the attention not on a typical day, but a typical episode or experience or problem.
-
Convey acceptance. Keep this as your main priority: it’s a person you are talkingto, and your role is to serve them; the assessment is secondary. Look for ways of conveying this acceptance to the patient. Try not to let go of this idea; you have no desire to pass judgement on them, and you consider anything they say or do as acceptable, or as at least something that does not surprise you.
-
Know your assessment schedule. After familiarising yourself with it, keep the key headings in your mind while you are talking to the patient. You can then take a mental note, as the conversation unfolds, of which areas of assessment are being covered, or not.
-
Fit the assessment into the interview, not the interview into the assessment. This is not just reflected in your attitude, but in where you put the paperwork. It helps to actually take the forms and place them aside, on the table. Then, later on, when you look at them, try not to put them on your lap, which can make the patient feel investigated; if you place the schedule between you, or on the table between you, it has the effect, in the eyes of the patient, of seeing you as someone separate from the assessment schedule, which helps.
-
Stay curious. Your only goal is to encourage the patient to tell the story of a typical day. Its like asking them to paint a picture. Don’t hesitate to interrupt with a request for help with more detail.
-
Resist the investigative impulse. The one kind of interruption for clarification that can kill off the atmosphere of acceptance and curiosity is to invade the account with questions about problems. For example, a practitioner interested in drug abuse might say, “Excuse me, can I just stop you there, did you realise that this food was bad for your diabetes?” The patient’s account will be stilted accordingly.
-
Behaviour and feelings. A much more colourful picture is painted if you focus on both behaviour (“What happened then?”) and feelings (“When you closed the front door, heading for the shops, how were you feeling?).
AN EXAMPLE: A patient with a lifelong illness: “Please paint a picture”
You want to have a normal conversation with the patient that has the following aims:
- rapport is enhanced
- they do most of the talking
- you learn a great deal about how they feel and behave
- you learn about their readiness to change health behaviour
- you understand their personal and social background
- it takes 8-10 minutes
- and many or most of your assessment questions are answered.
This example comes from an intake interview with a man recently diagnosed with
diabetes.
- Set the scene clearly
Acknowledge assessment and ask permission
“I have a whole lot of questions on this form here, but I find it much easier to put this to one side, and ask you to spend 5-10 minutes just taking me though a recent typical day in your life. This way, many of my questions are answered. I might go back to the form once we’ve done this to fill in the gaps, is that OK? Then I’ll ask you more about the diabetes as well. I hope you wont feel I am being nosy or anything about your everyday life, is that OK?.” Most patients don’t mind this at all, if you set it up clearly and sensitively.
Place the assessment schedule to one side - Locate a day
“Can you think of a recent day that was fairly typical for you, an average sort of day”. Agree on this, and remember to refer back to this if the patient wanders off into generalisations dur ing the conversation. - Go through a “typical day”
One needs to be mindful of the time and the pacing. Examples of both speeding it up and slowing it down are included in the dialogue below.
The beginning
You: If we take yesterday, take me through it and just tell me what happened,
and feel free to tell me how you felt about things as well, as the day unfolded.
You woke up, then what?
Pt: I went straight out because there was nothing else to do, you know what I
mean? Ive got this routine because one has to avoid just sitting around all day.
You: Let me slow you down a bit. Can I ask you, how did you feel when you
woke up?
Pt: Not good.
You: In what way?
Pt: It was just another day of no work, little money and just my few little
things I do. There I am alone in the flat again.
You: So you live alone, and you wanted to get out. You got dressed, and did
you have any breakfast?
Pt: Yes, my usual, cornflakes and coffee.
You: And you went out quite early then.
Pt: yea, I was out there by 9.00 and went down to the shopping centre, for my
usual.
You: What was that?
Pt: Newspaper, coffee, sandwich and donut in the café.
You: How long were you there for?
Pt: Oh my usual couple of hours, then across to the bar, study the horses, and
place a bet on the way home.
You: Did you meet anyone or have any conversations, or were you really just
on your own?
Pt: …. Continues story. Describes meeting a friend in the bar. Said it was the
best part of the day. Enjoyed talk about the horses. You deliberately avoid
the inclination to ask investigative questions about how much alcohol or about
lunch, and continue…these can come later..
You: So you came home, you’d had your few hours out, met your friend,
placed your bet, and can I ask you, when you walked in the door around 3pm,
how did you feel?
Pt: OK, I’d had a beer or two, and now it was time to have a sleep.
You: You like to have your siesta.
Pt: That’s right. Do it every day.
You: And then what?
Pt: I woke up an hour or so later, and went back down to the betting shop to
see the results.
You: So that was something to sort of wind up the morning’s betting.
Pt: Exactly, Ive got this buddy, and we meet there most days.
You: How did you get on yesterday?
Pt; Lost the lot, but that’s OK, you get those days. La st week I scored a big
one, so you learn not to get too worked up.
Describes his friend, how long he’s known him, then talks about going home
for supper.
You: So that was around 8pm, you finished supper, and then what happened
yesterday?
Pt: I watched TV, had a can of beer, and went to bed.
You: How did you feel when you went to bed?
Pt: Not too bad, thanks.
Ends
4. Check if the patient wishes to add anything
Is there anything else about yesterday you want to say more about?
Is there anything youd like to know about diabetes?
What were you hoping to get out of this meeting today?
5. Ask any questions of your own
If the Typical Day has worked well, most patients wont mind you raising your own questions. In the above example, now, after 8-10 minutes, it can be a really good time to ask about the illness:
How do you feel about your diabetes?
How does your diabetes fit into your everyday life?
6. Go back to your assessment to fill in the gaps, or do this later on.
Most patients don’t mind your doing this after you have gone through “A Typical Day”. In fact, if you remember keep the form off your lap and avoid entering an investigative mode, many patients will actively help you complete the gaps quite willingly.
You: Well you’ve answered many of the questions I have on this form. Would you mind if I just checked, and asked you a couple of things just to fill in the blanks?
Pt: No, go ahead.
You: Then once I ve put this form away,. I want to make sure I understand
how you were hoping we could be of help to you.
Pt: Fine, go ahead, no problem.
Wherever you go next, it can be useful to link your opening question to the account you have just heard. For example, “Remember when you said that you came back to the flat, and there was nothing. That sounds depressing, to live like that” Another obvious but useful thing to do is to summarise what the patient has said, and then move on.
7. Practice
You know you are getting better when you interfere less and less with the Typical Day story, perhaps only coming in to change the pace (either slowing it down or moving it on), to ask how the patient was feeling or behaving, or to make a reflective listening statement. You’ll also find it increasingly easier to not ask investigative questions. The patient’s degree of comfort in telling the story is your indicator of success.
8. Creative adaptation
Once you get more skilled at this, consider its wider application to a specific problem, event, episode (of pain, for example) or experience.
