Ineffective Path:
CLARK: Our last chat was six months ago. It’s good to see you again!
JANET: Good to see you too.
CLARK: Ok, so you’ve just seen the doctor, your blood pressure is good, and your recent blood work looks good. How are you doing?
JANET: I’m doing just fine. That said, I’m (coughs)(clears throat), I’m pretty busy at the moment.
CLARK: No problem, we’ll keep this as short as possible.
CLARK: Seems like your cough hasn’t improved since the last session.
JANET: Oh you noticed?
CLARK: Well, coughing is common in chronic smokers.
JANET: Coughing I can live with. These chest pains on the other hand. (sigh)
COACH: Good observation, though it would be better to ask open ended questions about Janet’s agenda for the visit and to explore her concerns.
CLARK: Let’s talk about how you’re doing with the chest pains that we discussed last time.
JANET: I still have them. And they’re not getting any better.
COACH: By choosing the agenda, you miss an opportunity to explore what’s important to Janet. Instead, you can try asking open ended questions about Janet’s agenda for the visit and her concerns.
JANET: Doesn’t feel like I’m about to have a heart attack or anything. Doesn’t make ’em any less annoying though.
CLARK: When have you been noticing the chest pains? Any times different from our previous session?
JANET: Eh, they’ve stayed pretty consistent since last time. Still only notice ’em when I’m stressed. Or sometimes if my grandkids try to get me to run around. Or I guess I notice it sometimes when it’s cold out, or I’m walking up the hill near my house. Just the price of doing what you enjoy, I suppose
CLARK: Smoking causes heart disease, and heart disease causes chest pains.
JANET: Well, I’m not an idiot. I know that. And for the record sometimes I want to have a smoke after the chest pains, just to get a little relief.
CLARK: So for you, the connection works both ways.
COACH: When you shared information without asking permission or asking what Janet knew, she felt belittled and pushed back. Next time, try exploring what she knows about the connection between smoking and chest pains.
CLARK: And how do you feel about smoking?
JANET: I mean, I’ve been smoking my whole life. I’m at a pack a day and I enjoy it. I know stopping would be better for my health, but I don’t have time to quit right now.
CLARK: Well, when WOULD be a good time to quit?
JANET: I don’t know, but just not NOW.
COACH: Though you asked an open question, it was a challenging one. Consider using reflections to respond to her concerns and her ’change talk’ and further explore her motivation.
CLARK: Since you recognize the damage smoking causes, maybe you should consider quitting smoking.
JANET: Yeah, but I also recognize ’should’ and ’could’ are not the same thing: just because it’s better for me, doesn’t make it any easier to contemplate, let alone do.
CLARK: Quitting is difficult to even think about right now, while at the same time, you know that you’d be in better health if you did quit.
JANET: I mean, yes in that I know if I had never smoked I probably wouldn’t have these health issues to begin with. And well, I suppose there would be some other (sigh) benefits.
COACH: Instead of suggesting quitting, consider using reflections or questions to explore Janet’s beliefs and motivation (e.g., desire, ability, reasons, need). Note the benefit of Nurse Clarke’s subsequent reflections.
JANET’S THOUGHT: Some more important than others.
CLARK: Other benefits?
JANET: Yeah. But look, I got a lot going on right now.
JANET: I have another exhibit coming up, it’s taking up most of my time lately.
CLARK: Art, right? Painting?
JANET: That’s it.
CLARK: I can imagine that putting something together like that takes a lot of energy and focus.
JANET: Yes. But I fit in a little exercise when I can like we talked about last time. Something’s better than nothing, right?
CLARK: A ’little’ exercise is nice, but last time we discussed more than ’a little’.
JANET: I walk along the beach and chat on the phone with my friend Margaret. Seems like it does the job.
CLARK: So how often are you walking and for how long?
JANET: Eh, around half an hour. Like two or three times a week.
CLARK: Half an hour is okay, but really you should be aiming for five or more days a week.
JANET: I’m fifty six years old. Walking three times a week is as much as I can manage.
COACH: You may be well intentioned in telling Janet that she should be exercising more, but she felt as if you were pushing her to do something unrealistic. If you had reaffirmed the efforts Janet already made, she may feel more encouraged to continue making healthy choices.
JANET: And with my work and the exhibit and everything.
CLARK: Maybe this isn’t the best time to be doing something so stressful.
JANET: What do you mean ’best time’? Look, my show’s really one of the most important things I have right now. I’ve already got my website together, figured out my painting placements with the gallery. Look, the exhibit’s very important to me. That’s all you need to know. Let’s talk about something else.
CLARK: Sure, we can change topics.
COACH: Rather than make a suggestion, consider using an open ended question to ask Janet about her concerns, needs, and priorities, especially early in the visit.
JANET: There’s just other things I’d rather talk about while I’m here.
JANET: Like I’m thinking about taking my family on a trip, but I’m wondering if given my health it might be a little too much for me. Not to mention travelling just isn’t as cheap as it was in my day.
CLARK: If you didn’t smoke as much, you’d have more money for a vacation.
JANET: I mean I’m not skimping out on my family. I give them as much as I can afford. We go to the beach near my house, I buy my grandkids what I can: burgers, ice cream,
CLARK: (nods)
JANET: But I see the beach every day. Heck, maybe a bit of fresh air might even be good for my health. And it’d sure be nice to take my family somewhere new. I did the math and if I booked a trip I wouldn’t have the budget for my smokes for like six months.
COACH: Janet felt judged when you admonished her for spending money on smoking. While you want to help her find reasons to be healthier, you can do so by using reflections and by asking open ended questions about her motivation (e.g., beliefs, reasons, ability).
CLARK: So you recognize there are some other benefits to quitting smoking.
JANET: Yeah, I guess there would be some other benefits, too
JANET’S THOUGHT: Some more important than others.
CLARK: Like saving money to use for something else.
JANET: Yeah, exactly.
JANET: Having a little more money in the pocket couldn’t hurt. There’s a lot of the world to see and I’d love to have enough money to help my family see it. Only thing. trips are expensive. And cigarettes aren’t cheap.
JANET: Don’t get me wrong, I have tried quitting a bunch of times in the past. But nothing worked. The patch gave me a rash. Cold turkey just made ME feel like a turkey when I started smoking again two days later. I tried the gum, too. Felt nice to be chewing something, I guess. Lasted a couple of days, but it didn’t do it for me.
JANET’S THOUGHT: If it didn’t work in the past, it’s not going to work now. But might as well get this over with.
CLARK: You’ve tried to quit smoking in the past and met with some obstacles.
JANET: Yeah. But we’re not talking twig in the road obstacles. We’re talking mountains.
COACH: Though you intended to affirm Janet’s past attempts, your reflection focused on the obstacles, which Janet amplified in her response. Try exploring reasons for past attempts as well as benefits and small successes.
CLARK: Sounds frustrating. The good thing is, your past attempts to quit can actually serve as opportunities for learning.
JANET: Learning what? How not to quit?
CLARK: You’re concerned you just haven’t found the right smoking cessation program yet.
JANET: What?! No. I don’t think ANY of them work. Not for me at least.
COACH: Though a reflection is preferable to providing advice, Janet is not ready to consider cessation and responded with sustain talk. Consider affirming past attempts and exploring success she had in the past. Remember, undoing is an option.
JANET: It’s just, quitting is already hard to even think about. So to actually do it again and deal with all the other crap that happens to your body? Please. I do not need that in my life.
CLARK: I’m hearing this isn’t a good time. When might be?
JANET: I’m not sure. I gotta think about this.
CLARK: It’s perfectly normal for your body to respond negatively at first when you quit smoking.
JANET: Well, the things that happened to my body didn’t seem perfectly normal to me.
JANET: I suppose the biggest one was I would get cranky. Like Frankenstein cranky. And I’m supposed to be the nice grandma! (laughs) You seem nice enough to me! Besides getting cranky, were there any other issues you were concerned about?
JANET: Well, not to be superficial or anything, but I really don’t want to get, well, fat. It ain’t easy for a lady to lose weight at this age, you know.
JANET’S THOUGHT: How am I supposed to even consider quitting knowing I have to go through all this all over again?
CLARK: While you may gain some weight, the benefits of quitting smoking would be worth it.
JANET: I know that, but you didn’t see what happened to my friend Susie when she tried to quit. Blew up like a blimp and kept it.
CLARK: You’re worried you’ll put on weight like your friend.
JANET: Yeah, poor Susie. She was so stressed from the weight gain, she started smoking again.
COACH: When you tried to persuade Janet to overlook the challenges, she felt that you weren’t taking her concerns seriously. Instead, consider exploring her concerns and challenges regarding quitting and her ideas for addressing them.
CLARK: There is a chance you’ll gain some weight, that’s true. Though the average person who quits smoking only gains around 5 to 10 pounds. How do you feel about that?
JANET: Hmmm, that’s a bit less than I thought. More like a parade float than a blimp, I guess.
COACH: Though it’s good that you shared additional information about weight gain with Janet, next time try asking for permission or asking what she already knows about the topic before sharing facts.
CLARK: When someone quits smoking, their nicotine cravings are often replaced with other habits, like food cravings, which is why weight gain sometimes occurs.
JANET: That’s interesting. So I just need to watch what I eat is what you’re telling me. Not the first time I’ve heard that one.
COACH: Though you’re taking Janet’s concern about weight gain seriously and shared additional information about it, you missed an opportunity to ask her to think of how she might address her concern. You could have also affirmed the efforts she has already made.
JANET: Something to think about, I guess.
JANET: What about me becoming a grinch? And all that other junk that’ll happen to my body?
CLARK: Let’s put aside withdrawal symptoms for a moment and focus on the smoking induced issues.
JANET: It’s not that easy for me. Sometimes the withdrawal symptoms ruin my whole day.
CLARK: Can you tell me more about how they’ve affected you in the past?
JANET: Well, besides getting cranky, my hands shake, which makes it hard to paint. And after a long day of not smoking and not painting, I end up not sleeping. Which makes it even harder to concentrate on anything the next day.
COACH: Janet felt like you weren’t taking her concerns seriously. Consider responding to Janet’s concerns about withdrawal symptoms and exploring strategies to mitigate them.
CLARK: You need to focus more on your health at this point. The withdrawal symptoms are temporary, but the problems created by smoking can have dangerous and long lasting impacts on your life.
JANET: Why else would I be here if I wasn’t concerned about my health? I may not be as young as I used to be, but I don’t want to give up on my health.
CLARK: Exactly, which is why I don’t need you to lecture me about what I already know.
COACH: When you told Janet what she needs to focus on, she felt as if you were talking down to her. You missed an opportunity to take her concerns about withdrawal symptoms seriously.
JANET: It’s kinda like you’re not listening to me.
JANET: UGH. I JUST can’t concentrate on any of this right now. I feel like I don’t know. I hear you, but I need more time to think.
CLARK: You’ve got a lot going on so it’s hard to focus, even though you might be interested in learning more about quitting later on.
JANET: You got that right.
CLARK: Tell me more about what in particular is making it so tough right now.