Andrea: Hi, thanks for coming in. I’m Andrea, and I use she/her pronouns. How would you like me to refer to you?
Kai: Kai, he/him, and you sure didn’t make it easy for me. I had to wait weeks to get in for a prescription refill, and then, the only appointments were in the middle of the day. And you know what I do during the day? I work, which I’m not doing right now because of this.
Andrea: I’m sorry the timing of your appointment is inconvenient, but the care team and I noticed that you were requesting an early refill, and also that you’d gotten early refills other times in the past.
Kai: Yeah, I have some bad days every month, days where I need to take a little bit more to get through work.
Andrea: Okay, before we go on, how many bad days do you usually have per month? And how much extra do you take?
Kai: Are these questions necessary? I don’t have a lot of time.
Andrea: Well, I know you’re here for the refill, but I wanted to talk a little more broadly about your health right now.
Kai: (agitated) I already had to sit in the waiting room for half an hour. I don’t have time for that! I’m not interested in talking about anything other than how I can get my refill.
Andrea: I want to understand more about those bad days you mentioned. I'm here to listen and help, not to judge.
Kai: If you really want to help, you'll write me a refill and let me get out of here. Listen, my back pain is really bad. So I started taking a little bit more per day, just to manage it. No one has said anything about it, so I don't get why I'm being hassled now.
Andrea: It sounds really difficult to have to take time out of work to come in, and I appreciate it.
Kai: It is difficult. But the meds are the only option I have. So just refill it. I have to keep working, and this is the only way I can do that.
Andrea: I know this system isn't ideal, but can you tell me more about your concerns with working?
Kai: I mean, I need my meds to do my job. My wife hasn't worked since we had our daughter fifteen years ago, so it's all on me.
Andrea: What do you do?
Kai: Construction.
Andrea: And you have to be pretty active?
Kai: I'm a site manager, but it's not like I'm sitting around all day. I still gotta be able to get from here to there, and help out sometimes.
Kai: (sigh) You know, with the last guy I saw, I didn't even have to come in. I'd just call and ask, and he'd give me the refill. But for you I have to take off work and deal with this.
Coach: By asking a question, Andrea is decreasing the emotional intensity of the situation. Kai is starting to share more about the root of his concerns.
Andrea: It makes sense that this would be frustrating, if that's how it's worked for you in the past. The reality is that we're learning a lot more about these medications, and about the risks, and recognize there's more steps that need to be put in place to ensure that they're working safely and effectively for people. And it does take more work, on your part and mine.
Kai: (sigh)
Kai: (somewhat defeated) Listen, are you going to give me the refill or not?
Andrea: I want you to know that I'm in this for the long term. I want to make sure that you can still work five, ten years down the road. I also want to emphasize that these opioids aren't healing anything, it's just blocking you from feeling your body's limits. So that when you do push yourself over that limit, you could be doing more damage. And in the short term, that may feel okay, but you could have a serious injury that might leave you in a position where you can't even walk.
Kai: (processing) Okay.
Andrea: So that's why we're having this discussion, so I can see what the best option is.
Kai: Fine.
Andrea: Let's talk about your function. What do you want to be able to do at work, that you're not able to do now?
Kai: I'd like to be more helpful. Sometimes guys don't show up, and I feel useless sitting there, not being able to pick up the slack like I could a few years ago.
Andrea: It must be really frustrating to want to do things like you used to, but to be unable to.
Kai: I used to be handy, you know? Neighbors need their driveway shoveled? I got it. Leaky faucet? Fixed that a hundred times. Now I'm always having to ask other people for help. I hate it.
Andrea: You don’t like having to ask people for help with things you feel you should be able to do yourself.
Kai: Yeah. (sigh) One day, our sink was leaking, and when I got down on the floor to take a look, I couldn't get back up. My wife was out getting groceries, so I had to wait down there for half an hour. Once she helped me up, we called a plumber. He ended up taking an hour and charging a hundred bucks to do something I could've done in five minutes. It was embarrassing, to say the least.
Andrea: I’m sorry to hear that.
Kai: (nods) Hmph.
Andrea: (transitioning) I don't want you to suffer or to be in pain all the time. So, I'd like to talk about some other approaches to addressing your pain because giving you additional opioids is not a solution, and it's not something we're comfortable with.
Kai: (relenting) Doesn’t seem like I have a choice.
Coach: Andrea did a good job showing empathy. She’s showing Kai she’s there to solve problems, not add to them.
Andrea: Could you tell me some more about what other methods you've tried?
Kai: I tried physical therapy, but it ended up making the pain even worse, so I gave up on it.
Andrea: It's actually normal to feel some pain after the first session. You're working out new muscles, so you're going to be sore at first. But physical therapy can be really effective in the long term. There are other ways we can address pain as well, like therapists who specialize in pain, aqua therapy, relaxation and meditation, or acupuncture.
Kai: (reluctant) I might be willing to try out physical therapy again, but I really don’t have the time to be going to sessions twice a week or whatever.
Andrea: Actually, after the first couple sessions, you can start doing the exercises on your own at home or work, any time you have a few minutes to spare. There are also virtual appointments, and some offices offer hours later in the day.
Kai: (grumbly) That doesn't sound too bad, then.
Kai: I get that you don’t want to give me an early refill because of safety. (sigh) Well, I’m willing to hear about what other options I have.
Overall Feedback
Kai felt open to hearing what his options are.
The provider focused on his safety and function, and avoided creating additional conflict. Kai felt like she was listening and on his side, which left him feeling calm and willing to consider what she was saying. He is ready to move onto the Facilitate step.
Let’s take a closer look at how the provider used MI techniques in partnership with the CAF steps.
Techniques Feedback
Empathy: Andrea affirmed, validated, and normalized Kai’s feelings to show understanding.
She said, “I want to understand more about those bad days you mentioned. I’m here to listen and help, not to judge,” which showed Kai she was there to help him solve problems, not add to them.
This was part of the Calm step and helped the provider decrease the emotional intensity of the situation.
Open-Ended Questions
The provider asked questions that helped Kai share more about his experiences which helped her understand where he’s coming from.
She said, “I know this system isn’t ideal, but can you tell me more about your concerns with working?” which was an open-ended question that helped Kai open up and focused the discussion on problem solving.
This was part of the Assess step. This clear language helped the provider get at the root cause of Kai’s problems
Recommendations
In future conversations with clients, remember you can use both the CAF (Calm, Assess, Facilitate) model and MI (Motivational Interviewing) to discuss sensitive topics and address emotions in a way that helps de-escalate the situation.
CAF Model:
Calm: Decrease the emotional, behavioral, and mental intensity of the situation.
Assess: Determine an appropriate response based on the facts and on the individual’s willingness to discuss.
Facilitate: Promote the most appropriate resolution based on information gathered by discussing next steps.
MI:
Express Empathy: Affirm, validate, or normalize the individual’s feelings and show them you understand.
Open-Ended Questions: Help the individual share more about their experiences and help you better understand where they’re coming from.