Title: The Therapeutic Sequence: An Interview Technique for Improving Communication in the Clinical Encount
1The Therapeutic Sequence An Interview Technique
for Improving Communication in the Clinical
Encounter
- Sheila Crow, M.A.
- Interim Director, Office of Educational
- Development Support
- College of Medicine
- Educational Grand Rounds
- October 21, 2005
2Learning Objectives
- Describe the steps in the therapeutic sequence
process. - Recognize primary emotions in others.
- Understand the role of the therapeutic sequence
in improving communication in the medical
encounter. - Understand how to teach the technique using
standardized patients.
3What do you seenoticeobserve?
4Introduction
- Most of what occurs between a patient and
physician is talk. - Physicians will conduct between 140,000 and
200,000 clinical interviews in a practice
lifetime. - Communication is more than words.
- Nonverbal expressions and cues.
- Give context and enhanced meaning to the words
spoken or not spoken.
5- Interview skills are procedural.
- Can be studied, taught, and learned.
- Residents and physicians do not follow any
particular model consistently. - Therapeutic Sequence / task introduced by Gordon
Deckert, MD (1978). - Use in Principles of Clinical Medicine Course and
Human Behavior.
6Qualities of a Good Interviewer
- What are the qualities of a good medical
interviewer? - Appropriately nurturing / supportive
- Provides patient with a cognitive model of
understanding (Disease and Dis-ease) - Involves the patient in the problem-solving
process
7Patient Outcomes
- Higher patient satisfaction
- Increased compliance with physician
recommendations - Improved recovery from surgery
- Decreased use of pain medication
- Shortened hospital stays
8Pre-Interview Tasks
- Conceptual task
- Be aware of the concepts you and the patient
bring to the clinical encounter. - Attitudinal task
- Be conscious of the attitudes you bring to the
encounter. - Hungry, Angry, Late, Tired (HALT)
9Interviewing a Patient
- Perceptual task
- Two categories of perceptual data
- Words used by the patient
- Digital / visual data that clues the physician in
to the patient - Determine primary emotion
- Acceptance, disgust, surprise, joy, fear, anger,
and sadness - Determine congruence between subjective and
objective messages
10Interviewing a Patient (continued)
- Interpersonal Task
- Determined by the accuracy of the perceptual
task. - Establish patient-physician relationship.
- Obtain accurate information.
- Relate to patient in a therapeutic manner.
11The Therapeutic Task
- Therapeutic Sequence
- Primary emotion
- Congruence
- Stress
- Consensus
- Contract
- Concurrence
- Outline treatment strategies
- Begin implementation
12Step 1 Primary Emotion
- What is the patients primary emotion?
- Is there evidence for the presence of anger,
sadness, fear/anxiety, acceptance? - Note patients facial expressions, observe
behavior, listen to the words.
13Primary Emotion Trigger Tape
- Anger
- Fear / Anxiety
- Sadness
- (Trigger tape demonstration is not available for
download.)
14Step 2 Congruence
- Establish congruence between the emotion
communicated and the emotion experienced. - If congruence is not present, try to establish it
or bring it to the attention of the patient.
15Step 3 Stress
- Explore what stress, psychologically or
physiologically that might be precipitating the
emotion. - Begin with the assumption that the category of
the stress and the usual emotional response will
correspond.
16Step 4 Consensus
- Agreement between physician and patient as to
what event, symptom, or concern is precipitating
the emotional response. - Primary emotion, congruence, stress, consensus
occurs rapidly in emotionally healthy
individuals. - Achieving these four steps helps to dissipate the
emotion and move the therapeutic process forward.
REALLY IMPORTANT!
17Skills Demonstration Video
- Dr. Rhonda Sparks / Rosemary Orwig (SP)
- Dr. Steve Orwig / Nita Folger (SP)
- (Video presentation is not available for
download.)
18Step 5 Contract
- Establish a contract with patient.
- Obtain patients chief expectationwhat the
patient hopes to accomplish. - Should be explicit rather than assumed.
19Therapeutic Sequence Model
1. What is the Patient's Primary Emotion? 2.
Seek Congruence - does the patient feel the way
they look? If not, consider neurosis, lying or
denial. 3. Stress What stress is leading to
this primary emotion? 4.
Consensus Legitimize the emotion and provide
empathy for the stresses causing the patient's
pain. 5. Contract Be certain to understand
the patient's primary expectation. (This may or
may not be the same as the chief complaint.)
20Step 6 Concurrence
- Physician and patient agree to the nature of the
intervention process. - Physician and patient have a clear understanding
of what is expected of the other.
21Step 7 Outline Treatment Strategies
- Discuss treatment strategies
- Some patients may know very little about
treatment options, others may know a lot. - Involve the patient in the problem-solving process
22Step 8 Implementation
- Proceed with implementation of agreed strategy.
- Repeat therapeutic sequence if there is
difficulty implementing strategy. - Success is usually indicated by, Sounds
goodthanks doc.
23Use of Standardized Patients with Students
- Trained to teach primary emotions and therapeutic
sequence process. - Multiple opportunities to practice.
- Students receive feedback from Standardized
Patient and peers. - Second year students required to pass therapeutic
sequence process.
24Summary
- Talk is the main ingredient in medical care.
- The Therapeutic Sequence is an appropriate model
for improving communication in the clinical
encounter. - Clinicians should recognize, acknowledge, and
empathize with a patients primary emotion.
25Summary (continued)
- The model has wide applicability.
- Standardized patients are excellent resources for
teaching the therapeutic sequence and primary
emotions.
26QUESTIONS?