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Why is Reflective Listening so difficult? And so important to clinical practice?

We all want to be understood – that’s the major impetus for any form of communication. And the trouble is that there are so many ways that communication can go wrong. In Thomas Gordon’s model of Parent Effectiveness Training, it’s evident how easy it is to misunderstand the intent and/or the content of another’s communication as our messages are coded and decoded through a series of filters:

thomas gordon listening

Reflective listening, considered to be THE foundation skill of Motivational Interviewing, is like offering a hypothesis about how we perceive someone else’s meaning. Reflections are offered in the spirit of “I’m listening to understand (not to judge, persuade or correct)”. True, unadulterated listening is rare, refreshing and affirming. It communicates respect and builds relationships. It goes “below the surface” and articulates the underlying meaning – thoughts, feelings, ideas, hopes, values – that a person may be expressing.

Bonus tip:  Reflections can sound contrived when they are prefaced by “stock” phrases such as:

“What I hear you saying is…”

“So you are saying that…”

“I am hearing that…”

I think practitioners use these phrases to (a) buy time while we’re busy figuring out what exactly we’d like to reflect; and (b) because we’re concerned that we might be ‘putting words into the other person’s mouth’. However, when we offer reflective listening statements with a spirit of partnership, acceptance, compassion and collaboration, it’s OK if we’re a little off-target with respect to the other person’s meaning, affect or intent. Our reflections can still evoke further elaboration.

Also: it might seem counter-intuitive, but reflections are more genuine and engaging when we just come right out with a statement (not an question, and no ‘stock phrase’ preface):

“You wish that…”

“It’s frustrating because…”

“It would be nice if…”

“You’re not too happy that…”

Understanding is at the heart of effective communication. It’s also key to building trust, rapport and safety. The saying: “I learn what I believe as I hear myself speak” articulates the power of dialogue in fostering insight and enhancing motivation for change. Reflective listening holds up the mirror.

Related articles:

Reflective Listening: The Most Powerful Tool in the Tool-box?

Reflective Listening Reflections

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The latte factor in Motivational Interviewing

 

Reflective listening, as it’s used in Motivational Interviewing, can include both simple (content-focused) and complex (beneath-the-surface) reflections. I like to use the analogy of an iceberg to illustrate the difference between simple and complex reflections (link to article); but the iceberg image doesn’t quite to do justice to the richness of what’s “below the waterline”.

 

At a recent professional development workshop I attended, the facilitator used the image of a café latte to illustrate listening for varying verbal and non-verbal content. This got me thinking: a better (and better-tasting) analogy for reflective listening might well be a macchiato versus an iceberg:

The top layer of foam represents the spoken content that the person offers.

The middle (espresso) layer represents the person’s thoughts and feelings.

The bottom layer – the foundation, as it were – represents the person’s values and beliefs.

 

 

Accurate empathy (that is, listening with ears, eyes, undivided attention, and compassion/heart) is needed to hear and reflect a person’s unspoken emotions as well as underlying values.

 

Here’s a quick example:

 

Client: “It is way too stressful right now for me to make this change.”

 

Now you have three choices:

Reflect the spoken content (simple reflection)

Reflect your sense of what the person might be thinking or feeling (complex reflection)

Go for the underlying values/beliiefs as you understand them (complex relfection)

 

It goes without saying that this is offered in the spirit of Motivational Interviewing: Partnership, acceptance, compassion and evocation. You might be on target or not quite accurate, but in the end your reflective response – especially complex reflections – will forward the conversation (and exploration) in an affirming and supportive way.

 

 

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Every audience comes with varying levels of motivation to learn: What can you do to engage them?

 

A recurring challenge in facilitating continuing professional education workshops is how to respond to participants who do not see a value in attending. This isn’t uncommon, given that training is often mandated by management and the topic or content of your session doesn’t necessarily align with their individual learning goals or perceived needs. It’s easy to get focused on (or distracted by) these less-than-enthusiastic folks, but people participate along a diverse spectrum. A strong facilitator reaches out to everyone in the room.

So, you might wonder, how is an individualized, motivational approach possible with more than just a handful of participants? In my experience over 15 years of leading professional courses and workshops, I have found that groups of all sizes generally coalesce into five sub-groups:

  1. “Keeners”: It doesn’t matter whether they came voluntarily or because their manager made them attend. They are hungry for any and every opportunity for learning: 100% intrinsically motivated.
  2. “On the Fence”: These folks aren’t unhappy to take time off work for your session and are open to learning, but they are looking for a practical demonstration of how and why the topic/content is relevant before they will engage.
  3. “Open-minded Skeptics”: They are generally seasoned and respected experts in the group who are provisionally willing to give you a chance. However, because of their super-strong skill-set they have lots of experience sitting in courses with not much to show for it, and this can impact their motivation for learning in your course.
  4. “Convince Me”: These individuals can be hard core for even the most experienced trainer. They are not happy campers from the get-go, and they are not afraid to show it openly and repeatedly.
  5. “Multi-taskers”: This sub-group has other things on the go besides your training. Often arriving late, leaving early, on their mobile, or otherwise occupied, they are polite and willing to participate when present, but your workshop is not necessarily a high priority.

 

How can we best respond to and motivate these diverse groups, all at the same time, over a course that might range from an hour, or a day, through to multiple days? Let’s look at some quick tips for each:

The “Keeners” are on your side. You really need to mess up in order to alienate them. You will know who these individuals are right away because they are quick to raise their hands, offer insights and opinions, and generally smooth your path. Make sure to explicitly thank and encourage them.

Those who are “On the Fence” can (by definition) go either way. It’s important to prepare a strong start to the session by engaging the group in a conversation – or for a large audience, a demonstration –  of the practical value of the topic/course. A quick “Turn to the person next to you and identify the most important take-away”, or a video demonstration, case example or personal story can accomplish this. The key is to spark peoples’ interest and invite them in.

The “Open-minded Skeptics” can be your best friend or your worst enemy. Adult education affirms that learners come with pre-existing knowledge and skills, and that is never truer than for this group. Because they are, themselves, experts, it’s essential to explicitly acknowledge and invite their and others’ contributions to the content you have prepared. These folks often ask specific, technical questions, and they will know if you try to fake it. Probably everyone else will know too. My own approach is to be up front with the group, respectfully affirm where others’ knowledge and skills exceeds mine, and encourage a collaborative learning environment where everyone – regardless of months, years or decades of experience – has something of value to contribute (check out this link for a nice way to establish this climate from the start: First, empty your cup). In addition, I make a point of naming and reinforcing participants who demonstrate their skills and effectiveness – they are a resource to the whole group.

Now let’s consider those who come across as somewhat difficult, or even openly antagonistic: “Convince Me”. I don’t see these individuals in every workshop, but it’s happened often enough to be worth coming prepared. This is where skills in group facilitation and knowledge of group dynamics are essential. I need a large chunk of the group to be “with” me, in order to help manage what can become a facilitation disaster (I am not exaggerating). If the majority of participants are engaged, enjoying themselves, and find value in the material, it is hard for one or two naysayers to sabotage. On the other hand, if the group as a whole are “On the Fence”, the “Convince Me” contingent can bring it all down. If you do run into problems, here is a tried-and true strategy for How to TAME difficult, skeptical, hostile or challenging participants.

Last but not least, “Multi-taskers” should not be ignored. Artful facilitation can help them shift to “Open-minded Skeptics” or even “Keeners”. The thing is, you may never know because they aren’t totally present (literally). But that doesn’t mean your workshop didn’t make an impression – these individuals are often opinion leaders and influencers with large professional networks (that’s why they’re so busy). Articulating everyone’s right to participate however they choose is a win-win. They will do it anyway, and affirming personal choice and control communicates respect and positive regard.

One caveat: The real world is messy and disorganized, and slotting people into categories is perilous at best. Individuals and groups are dynamic, organic and open to complex reciprocal influences from you, one another and the environment. Thus, my most important tip? Don’t stand in the middle of the stream; go with the flow.

 

Check out more learner engagement strategies:

Classroom Management 101

Five Things About Teaching

That’s just how we roll

ideas lightbulbs

 

 

 

 

 

 

 

 

 

 

 

“What I don’t know I don’t know” – That’s the most essential learning

 

In nearly every course or workshop I teach on Motivational Interviewing (MI), there are nearly always practitioners who express some variation of “I already do MI naturally”. In other words, why spend time “learning” about something that I already know how to do? A reasonable response, if accurate.

I say ‘if accurate’ because research on MI practice suggests a disconnect between what practitioners say they do versus the MI skills they can actually demonstrate. We’re talking video recordings of actual client sessions, coded by skilled clinicians trained in the use of a standardized instrument. So while there may be a small proportion of therapists who really are “MI naturals”, it’s likely that most practitioners, whether they know it or not, can not or do not demonstrate the skills of MI without training, coaching, practice, coaching, and practice.

 

Motivational interviewing is essentially a way of being with a client (Dr. William Miller, the originator of MI, calls this “MI Spirit”), comprised of partnership, acceptance, compassion and evocation. It seems intuitive, but the “Righting Reflex” is hard to resist. Additionally the processes of MI – engaging, focusing, evoking and planning – are accompanied by a range of skills and strategies. Integrating both spirit and skills demands artful practice, and integrating MI with other approaches (for example Cognitive Behavioural Therapy, CBT) involves even greater therapeutic sophistication.

No practitioner ever reaches the apex of clinical perfection – it doesn’t exist! Just like the clients we serve, practitioners are engaged in an ongoing process of development. And it’s the basics (reflective listening is a good example) that can be the most challenging.

 

People come to a learning environment with four general categories capturing both pre-exisiting knowledge and knowledge deficits:

  1. What I know that I know: Everyone comes in with something of value
  2. What I know that I don’t know: Everyone has areas they can identify as avenues for further learning
  3. What I don’t know that I know: Everyone has knowledge and skills of which they aren’t aware
  4. What I don’t know that I don’t know: We all have a blind spot when it comes to what we still need to learn. When we can shine a light on it, that’s the “aha” moment! 

 

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Patient safety includes patients’ subjective feelings of safety

I have participated in and taught about interprofessional collaboration (IPC) for many years, but last week I experienced it firsthand from a new perspective… as a patient.

Here’s a quick replay:

It is 6:15 AM. No coffee. Emerging from the changing room in a hospital gown and disposable slippers I re-enter the Admitting waiting area with others similarly attired, accompanied by our respective escorts. The only exuberance is among a group of three teenage girls, whose noisy laughter and nonchalance exudes the indestructibility of youth.

From Admitting, on to the Pre-Op waiting area. One by one patients are called, and then it’s my turn. Past the swinging double doors, down a wide corridor, more people in surgical scrubs, into the Operating Room. It’s kind of freaky being the one with the IV: “Just hop up here onto the operating table.”  A narrow bed in the centre of that big room, with really bright lights just like on TV. Ummm…sure. Too late to back out now.

Have you noticed how right away you can feel a room’s atmosphere (positive or negative)? Well in that moment of total vulnerability, I sensed the camaraderie of a super-high-functioning team. I felt respect, cooperation, kindness and compassion. Not just toward me but to each other. More than anything anyone actually said or did, the underlying atmosphere was like a warm blanket of reassurance and comfort.

Health and counselling practitioners universally affirm the importance of positive regard, mutual respect, trust and acceptance in relation to our patients or clients. Last week was a good lesson about how profoundly our interprofessional relationships – those same elements of positive regard, mutual respect, trust and acceptance – are visible, impactful and meaningful. Just like kids know when their parents are fighting (even in the absence of verbal cues), patients know when there is discord in the team.

As I discovered firsthand, IPC is not just about patient safety, it’s also about patients’ subjective feelings of safety. A skillful surgeon is key. An outstanding team takes it to the next level.

 

P.S. The biopsy was negative.

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It’s all about creativity, reflexivity and connectivity

Teaching as informing is a short-term solution to a long-term problem. Today, providing information is secondary to engaging peoples’ interest and motivation so much that they will want to seek out more and more, beyond the boundaries of the boardroom, lecture hall or online discussion forum. It’s about meta-teaching…teaching others to become their own teachers.

Daniel Pink, in A Whole New Mind, describes how the information age has undergone a seismic shift to the conceptual age. Meaning that the left brain skills of information management/analysis have been surpassed by the right brain skills of creativity, reflexivity and connectivity.

We’ve progressed from a society of farmers [the agricultural revolution] to a society of factory workers [the industrial age] to a society of knowledge workers [the information age]. And now we’re progressing yet again – to a society of creators and empathizers, pattern recognizers, and meaning makers [the conceptual age].

In the conceptual age, educators and presenters need to go way beyond informing because:

a. The information that the presenter deems essential may not align with the relevance and priorities of the audience; so that means little incentive for long-term retention.

b. People generally don’t remember much of what they hear. Or if they do, the half-life of information is pretty short, so there isn’t much impact to be realized if our focus is on the content of a presentation.

c. Even if the information is relevant and memorable, our knowledge landscape is a moving target – information changes so rapidly that what is current today quickly becomes out of date.

And that is where transformative learning comes in…

Introduced by Jack Mezirow in 1997, transformative learning is about engaging peoples’ underlying assumptions and facilitating change in frames of reference. Think of it as that “aha!” moment, when a whole new concept seems to snap into place and suddenly we see things from a new and broader perspective. Signal moments in learning are accompanied by affect – delight, surprise, disappointment, satisfaction, excitement – extending beyond solely cognitive-based insight or understanding.

A defining condition of being human is that we have to understand the meaning of our experience. For some, any uncritically assimilated explanation by an authority figure will suffice. But in contemporary societies we must learn to make our own interpretations rather than act on the purposes, beliefs, judgments, and feelings of others. Facilitating such understanding is the cardinal goal of adult education. Transformative learning develops autonomous thinking.

How can we as educators make this magic happen in our day-to-day work? Well, transformative learning presupposes transformative teaching (if teaching is the right word in this context) (a.k.a. transformative faculty development?). And in turn, transformative teaching implies…teaching about teaching. Meta teaching.

Both the words and the music. Play that funky music.

 

 

 

Auto repair

 

 

 

 

 

 

 

 

 

 

The foremost decision is the decision to provide treatment

 

Last week I met a colleague who leads a community college program on auto maintenance and repair. This arena of study and practice has always seemed fairly straightforward to me: learn the mechanics of engines and other things that make cars work, and learn how to fix them. I confess it was surprising to me when he shared that the most important skills his students need to learn are critical judgment, reflection and decision-making. That’s partly because car design has changed so dramatically over the last two decades that cars have become complex electronic as well as mechanical systems. Just like in health care, for a good mechanic the foremost decision is whether to provide treatment.

 

Who knew that our most important teaching goals and teaching challenges – his in auto repair and mine in counselling and health behaviour change – were so aligned?

 

This reminded me of another conversation I had with a surgeon a couple of years ago. We were talking about laparoscopic surgery, and I wondered whether today’s medical students had a learning advantage due to their years of experience playing videogames. The doctor stated that it doesn’t take long to teach anyone to how to perform laparoscopies (although video game players might learn a little faster). He said that what takes years to teach and learn is when not to do the surgery.

 

When and how to intervene may be the most challenging things for anyone to learn because the skills are so complex. Education for diverse fields of practice – from car repair to medicine and lots in between – demands that students master three essential foundation skills:

 

1. Critical reflection: Meaning-making and interrogating the limits of one’s knowledge and skills; considering costs, benefits and outcomes of different possibilities

 

2. Attention: Including listening, observation and data-gathering, from a stance of care and concern

 

3. Decision-making: This includes decisions regarding a specific course of action, as well as decisions about what additional information might be needed; acting with integrity and ethics.

 

A nice article on how diagnosis is more art than science features wisdom from “master diagnosticians”, and underlines the importance of the above three skills, along with humility and a commitment to continuous learning:

 

“If you want to be a master diagnostician,”  says Dr. Lewin,  ”you’d better be prepared to be a master student.” It’s a lesson Dr. Goodgold, now in his fifth decade of practice, still takes to heart.  ”Being a good diagnostician means being good at solving problems. It starts with being intellectually honest.  You must admit to yourself that you don’t know everything. Not a week goes by that I don’t see something new. I must continue to be a student of medicine and science.”

[…]

Consider the wisdom of Sherlock Holmes, who was modeled by his creator, Sir Arthur Conan Doyle (a physician turned fiction writer), after one of the most renowned diagnosticians of his day: Dr. Joseph Bell, professor of medicine at the University of Edinburgh.  ”I see no more than you,”  the super sleuth explained to his sidekick, Dr. Watson,  ”but I have trained myself to notice what I see.”

 

 

 

 

 

 

 

 

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