The Therapeutic Sequence: An Interview Technique for Improving Communication in the Clinical Encount

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The 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

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Learning 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.

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What do you seenoticeobserve?
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Introduction

• 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.

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• 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.

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Qualities 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

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Patient Outcomes

• Higher patient satisfaction
• Increased compliance with physician
  recommendations
• Improved recovery from surgery
• Decreased use of pain medication
• Shortened hospital stays

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Pre-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)

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Interviewing 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

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Interviewing 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.

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The Therapeutic Task

• Therapeutic Sequence
• Primary emotion
• Congruence
• Stress
• Consensus
• Contract
• Concurrence
• Outline treatment strategies
• Begin implementation

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Step 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.

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Primary Emotion Trigger Tape

• Anger
• Fear / Anxiety
• Sadness
• (Trigger tape demonstration is not available for
  download.)

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Step 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.

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Step 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.

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Step 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!

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Skills Demonstration Video

• Dr. Rhonda Sparks / Rosemary Orwig (SP)
• Dr. Steve Orwig / Nita Folger (SP)
• (Video presentation is not available for
  download.)

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Step 5 Contract

• Establish a contract with patient.
• Obtain patients chief expectationwhat the
  patient hopes to accomplish.
• Should be explicit rather than assumed.

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Therapeutic 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.)
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Step 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.

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Step 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

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Step 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.

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Use 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.

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Summary

• 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.

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Summary (continued)

• The model has wide applicability.
• Standardized patients are excellent resources for
  teaching the therapeutic sequence and primary
  emotions.

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QUESTIONS?