Pic 0: The title card “Navigating Difficult Conversations” appears before transitioning to Dr. Owens.
Early in my career, I wasn’t sure how to deal with emotions that arose when I discussed unexpected changes or information clients didn't want to hear. I was intimidated, sometimes frightened, creating tension that made the visit uncomfortable.
Pic 1: The screen changes to one where Dr. Owens sits across from a blonde woman. The text “Peggy: in her 40s, liver problems” appears between them.
I can’t forget Peggy. She was in her 40s and had been with our care team for years when it became clear she had developed liver problems.
Pic 2: The text is replaced by new, blue text which reads “Alcohol Consumption.”
I asked about her alcohol consumption.
Pic 3: The screen zooms in on Peggy, and the background turns red. The text “No way it’s alcohol related!” appears. After a moment, the screen changes to Dr. Owens and Peggy again but Peggy is pointing at Dr. Owens and text appears that reads “You’re wrong!” in big red letters.
She argued there was no way it was alcohol-related, that she was too healthy, that we were wrong.
Pic 4: Dr. Owens looks down at a medical chart, and the words “Based on the screening” appear between the two women.
So, I said, just based on the screening, she needed to make some changes or she could be dealing with some pretty serious repercussions.
Pic 5: Peggy looks down and her face turns red.
Her face turned red as she held back tears. She gritted her teeth and said her father had an undiagnosed alcohol problem, that they all suffered from his drinking.
Pic 6: The screen zooms in on Peggy again, who has her arms crossed and is crying. The text “I’m nothing like my father” appears on a red background.
She told me she was nothing like him.
Pic 7: The screen returns to Peggy and Dr. Owens. Dr. Owens has her hands up defensively with a shocked expression as Peggy points at her while crying. After a moment, the words “I’ve had enough!” appear between them.
I tried to bring it back to the screening numbers, and she said she'd had enough, got up, and slammed the door so hard a picture frame smashed on the floor.
Pic 8: The screen returns to Dr. Owens, alone.
I’m Melanie Owens, and after that incident, I decided it was time to learn better techniques for telling clients things they don't want to hear.
I've trained extensively with evidence-based frameworks proven to de-escalate emotionally charged situations and work through frustrations with individuals.
Pic 9: The acronym “CAF” appears next to Dr. Owens, before expanding to read “Calm Assess Facilitate.” Below, the acronym “MI” appears, which expands to read “Motivational Interviewing.”
The two we’ll discuss today are the CAF framework and MI.
Pic 10: The text is replaced by “Safety” and “Health.”
Your overall goal for the conversation should be the safety and health of the individual. You may need to compromise on what you want from the visit to keep that at the forefront.
Pic 11: “CAF” and “MI” appear again next to Dr. Owens, replacing the previous text.
Thinking about Peggy, I wanted to share information and make a management plan. But Peggy wasn’t ready for that. She needed me to acknowledge her underlying challenges first, with CAF and MI.
In hindsight, I should have known that delivering the news could upset Peggy. I could have done more before, during, and after the visit to help her.
Let’s look at how we model the flow of a challenging visit:
Pic 12: A title card appears which reads “Strategies for Preparing for Difficult Conversations” before transitioning to a screen with three titles at the top, “Pre-Visit,” “Visit,” and “Post-Visit.” “Pre-Visit” is highlighted, and the following information is included in bullet points.
Pic 13: Now “Visit” is highlighted, and the following information is included in bullet points.
Pic 14: Now “Post-Visit” is highlighted, with the following information:
Pic 15: “Visit” becomes larger and the other categories disappear. After a moment, the screen changes to a title card which reads “De-Escalating During a Visit” before transitioning to a close-up on Dr. Owens. Text appears next to her which reads “External Factors.”
Let’s zoom in on the Visit portion.
Individuals can have emotional responses for any number of reasons, including external factors.
Here are some examples of external factors that could affect an individual's mindset:
Pic 16: The screen changes to one titled “External Factors.”
Pic 17: The screen returns to Dr. Owens.
Visual cues that indicate frustration can hint at external factors. In Peggy's case, I didn't realize she had an emotional past linked to alcohol use.
Pic 18: The screen returns to an image of Peggy pointing angrily at Dr. Owens.
What I should have noticed were the visual cues she was becoming upset and stopped pushing the subject.
Pic 19: The screen changes to one with text at the top which reads “These are examples of body language you may notice in an individual who is feeling frustrated.” Below is a blue figure outlined in black sitting on a chair who is looking downward. Text next to the figure reads “Avoiding eye contact.”
Pic 20: The top text stays the same but the figure is now fidgeting with their fingers. Text next to them reads “Fidgeting.”
Pic 21: In this slide, the figure has clenched fists with exaggeration marks around it. The text next to it reads “Clenching fists.”
Pic 22: In this slide, the figure has one clenched fist and the other pointing with exaggeration marks. The text next to it reads “Aggressive hand gestures.”
Pic 23: In this slide, the figure has narrowed eyes, and they are now purple. The text next to it reads “Leering.”
Pic 24: In this slide, the figure is now pink and has clenched fists with narrowed eyes and an open mouth with marks denoting a loud volume. The text next to it reads “Raising voice or shouting.”
Pic 25: The figure is standing and has clenched fists with downturned eyebrows with anger marks. The text next to it reads “Standing up.”
Pic 26: The figure is red, and walking past the chair with a little storm cloud above its head. The text next to it reads “Leaving the room unexpectedly.”
Pic 27: The screen returns to Dr. Owens.
Peggy gave several of these signs. I could have realized that pushing forward with my agenda would only make things worse.
Pic 28: The acronym “CAF” appears next to Dr. Owens before expanding to read “Calm Assess Facilitate.”
When we see these signs, we should consider using steps in the CAF model to de-escalate confrontational situations.
Pic 29: The screen changes to one with the word “Calm” at the top, and the following information:
Decrease the emotional, behavioral, and mental intensity of the situation.
Pic 30: This screen is titled “Assess.”
Determine the appropriate response based on the facts.
Pic 31: This screen is titled “Facilitate.”
Promote the most appropriate resolution based on information gathered.
Pic 32: The screen returns to Dr. Owens. Next to her, the word “Calm” appears, with a curved arrow pointing from it to the word “Assess.” After a moment, another curved arrow leads from “Assess” back to “Calm.”
CAF is a fluid process. As tension fades in the Calm step, you can move into the Assess step where you can learn more. You can build on what you learn to de-escalate even further.
Pic 33: The word “Calm” is highlighted.
In the Calm step you’re showing empathy, partnership, and validation.
Pic 34: The word “Assess” is highlighted.
In the Assess step you’re using clear language to get at the root cause of their problems. You want to show them you’re there to solve problems, not add to them.
Pic 35: The top and bottom arrows alternatively flash yellow.
You can alternate working through the Calm and Assess steps as needed.
Pic 36: An arrow points down from the “Calm/Assess” circle with the text “Facilitate” at the end.
Once the client seems calm and you've assessed the root cause of their problem, you can move towards talking about solutions and next steps which happens in the Facilitate step.
Pic 37: The previous image and text disappear, and the word “Techniques” appears next to Dr. Owens.
Let’s discuss specific techniques of how to work through the Calm and Assess steps.
Pic 38: A title card appears that reads “Techniques for Calming and Assessing” before transitioning back to Dr. Owens. The acronym “MI” appears next to Dr. Owens before expanding to read “Motivational Interviewing.”
MI has been proven as a highly effective, evidence-based framework for having difficult conversations.
The overall approach is simple:
Pic 39: This slide is titled “Motivational Interviewing” with the following text below:
MI is a way of being with clients and treats decisions about change as a conversation, not a lecture. Clients already have what they need to resolve internal conflicts, and we’re here to facilitate. (Stanhope 2020 p. 420)
Collectively known as the “OARS” techniques. (Weaver 2017 pp. 200 to 201)
You can learn more about these MI techniques in the Supplemental Materials.