After decades of working with children, teens, and parents as a pediatrician, I felt pretty confident in my communication skills. However, one of the challenges that awaited me when I accepted the position of medical director of the MedPsych division at Hasbro Children’s Hospital was to focus on a consistent therapeutic message. Carefully chosen words were required that blended smoothly with what patients and families were hearing from other members of the team.
At first, some of my word choices felt self-conscious. I made fun of psychiatrists for avoiding the word “but.” They avoided it during treatment, team discussions, and meetings.
So when a frustrated teen says, “You don’t know what you’re talking about!” and demands to go home, she’ll ask, “I don’t know what I’m talking about!” It is important to know your true feelings. And we truly believe that our plan will help you achieve your goals. ”
I enter patient team meetings with a mixture of curiosity and skepticism, and I say what I’m likely to say, consciously trying not to move a knowing eyebrow at the minute semantics. I wondered how it was different. Well, I’m glad you’re being honest, but we believe that…”
I didn’t hear the invalidity of the word “but”.
There were other linguistic minefields as well. Carla had conversion disorder and believed she would never be able to walk. She made great progress in our program and was no longer using a wheelchair. Kara was ready for an outpatient program. The entire treatment team was there, but I was running the meeting.
“Can’t we keep a wheelchair in the day’s program in case we need it?” she asked.
“We now know that your body has learned how to walk, and that your weakness was due to illness,” I answered. “We don’t want to reintroduce wheelchairs that are no longer needed and cause failure.”
Both the patient and the father moved their heads a little and looked a little anxious, but overall I felt it was a good meeting and I was doing a good job of preparing this family for the next level of care. I went home satisfied that I was able to do it.
A few minutes later there was a soft knock on my office door and Dan came in. “It was great,” he said. “You’ve done a really great job. I’m sure you’ll do well.”
What I didn’t immediately realize was that this was the beginning of the “feedback sandwich.” Say something positive, then give feedback, and end with more encouragement.
“You did a great job of reminding Carla why she doesn’t use her wheelchair anymore,” he added.
I heard a voice in my head saying, “But.” Yes, even if he did not use that word exactly, it would be a distant relative of “but”.
Instead of a conjunction, Dan paused and immediately started a new sentence without using any “if” or “but” words. I have to admit it worked. What he was about to say next didn’t invalidate the positive message he had just delivered.
“You said you didn’t want them to fail,” Dan continued. “The word failure is a very heavy and negative word, especially for patients who tend to lack self-confidence at the moment. Carla had a bit of a reaction to that. “The most important thing we offer our patients is is hopeful. And we really expect her to do well in the partial program. If she regresses, we know it’s a predictable recovery process. I don’t. Do you see the difference?”
i couldn’t. At least not at that moment. All I thought was, “You’ve got to be kidding me!”
What I actually said to Dan was, “But it happened again!” Doesn’t that mean the same thing? Don’t they know it means the same thing? ”
As I stared into the space above Dan’s head, I could see his face scrunched up in confusion. Dan just sat there with a friendly look on his face. The important thing about therapists is that they don’t have to say anything. I’ve learned that I tend to fill in the gaps with words, which can be a communication problem in itself. By pausing briefly, you can invite the other person into the conversation.
Therapeutic Alliance Essentials
“Okay,” I finally said. “But you have to keep helping me with this. I feel like I need to learn a whole new language.”
“And you will. You’re already doing great things. We’re so lucky to have you,” he replied with a smile.
Your feedback sandwich is complete. I had to admit that a formulaic approach to dialogue does not necessarily preclude authenticity and warmth.
Dan patiently messaged me over the first few months and often gave me kind reminders. During our morning meeting, I said, “I know the environmental therapists are frustrated, but I really want them to do this,” and Dan smiled broadly. He said this.
It didn’t take me long to understand. Mainly because I’ve experienced firsthand that subtle word choices can help patients listen to what they’re actually hearing in a conversation. I realized how often we choose negative thoughts throughout the day, such as “but” or “avoiding failure” instead of “preparing” for success. ”
The person fixing your muffler probably won’t notice or care about this, but the more personal the conversation, and the more likely the person you’re talking to The weaker it is, the more useful this kind of dialogue can be.
