Clinical support and encouragement versus manipulation (includes motivational interviewing)

Midnattsol

Midnattsol

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Posts moved from Anomalies in the review process and interpretation of the evidence in the NICE guideline for (CFS & ME), 2023, White et al


On the negotiating bit. With lifestyle changes, as I think "getting patient to exercise more" can be described as, there is a method that is encouraged to be used by professionals called "motivational interview".

The Norwegian Directorate of Health has a good site on it. I think specifically the "partnership" and "acceptance" part that is mentioned as basic values of in the motivational interview sounds like the negotiation that could take place with GET:
The basic values in MI are:
  • Partnership
    Helper and person must together find out what the problem is and what the goal is. Even if the helper directs the conversation, it should not be a manipulative relationship.
  • Acceptance
    It will be more difficult to change when you feel unaccepted than if you are met with acceptance for what you do. Learning this paradox is an important and at the same time demanding task for healthcare professionals. Despite recommendations, the patient always has a choice and this must be recognized in conversations about change.
  • Compassion
  • Curiosity/provocation
    Helper makes an active effort to understand how the person is feeling. Helper listens, and shows that she listens by mirroring what is said.
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And for anyone familiar, yes, there are SMART goals to be set during the motivational interview ;)
 
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Sean said:
What a bunch of infantilising insulting demeaning oppressive crap.
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Midnattsol said:
I think you'll find "effective and empathetic" are the words used to describe it.
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I think that protocol probably can be either of those things, depending on the situation and clinician. I can imagine that there are times when it is a reasonable approach. What if a dietician is talking to a person who eats mostly crisps and hot chips, and drinks only energy drinks? I still wouldn't call it a negotiation though. If "despite recommendations, the patient always has a choice" is really true, then it's not negotiation.

The difference between the protocol being applied to the diet situation and GET is that there is reasonable evidence that fried potatoes and Red Bull is not a complete diet, and that you will have problems if you treat it as one. But there isn't evidence for GET being helpful in ME/CFS. So the difference is whether the clinician has any sound basis for offering the information and encouraging change.
 
Midnattsol said:
On the negotiating bit. With lifestyle changes, as I think "getting patient to exercise more" can be described as, there is a method that is encouraged to be used by professionals called "motivational interview".

The Norwegian Directorate of Health has a good site on it. I think specifically the "partnership" and "acceptance" part that is mentioned as basic values of in the motivational interview sounds like the negotiation that could take place with GET:


And for anyone familiar, yes, there are SMART goals to be set during the motivational interview ;)
Click to expand...

"it should not be a manipulative relationship."

Isn't this precisely what this is, and is embedding scarily whilst telling those they are training in it that 'it isn't really manipulation'. This is what I worry about with the CBT embedding, it is just a technique in manipulation and manipulative communication techniques that worryingly they tell those they are teaching to do it that it isn't.

These things are basically like taboos: once you lose your integrity and begin to use manipulation - just a little bit here or there then I've watched so many people lose sight of true north. You either don't manipulate or you are manipulative. There isn't a middle ground on it and those who engage in it 'slightly' or 'just in these professional terms' really do lose who they are and morals and etiquette get pretty screwed and delusion happens.
 
Hutan said:
I still wouldn't call it a negotiation though.
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No, it can never be that. It's reasonable to explore whether there might be explanations for the behaviour, it's reasonable to offer advice, information, and encouragement, it's reasonable to ask whether the patient would like support or would prefer to revisit it at a different time. But if it's healthcare we're talking about, it's not a bargaining situation. People with capacity to make decisions are free to make bad ones.
 
Hutan said:
I think that protocol probably can be either of those things, depending on the situation and clinician. I can imagine that there are times when it is a reasonable approach. What if a dietician is talking to a person who eats mostly crisps and hot chips, and drinks only energy drinks? I still wouldn't call it a negotiation though. If "despite recommendations, the patient always has a choice" is really true, then it's not negotiation.

The difference between the protocol being applied to the diet situation and GET is that there is reasonable evidence that fried potatoes and Red Bull is not a complete diet, and that you will have problems if you treat it as one. But there isn't evidence for GET being helpful in ME/CFS. So the difference is whether the clinician has any sound basis for offering the information and encouraging change.
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I don't think it is the correct technique even in that context.

ANd I certainly get the impression that any listening is shallow/skin-deep which makes it false question-asking which I find a disgusting and violating habit some have been encouraged in. For example there may be deep or good functional reasons for what you suggest, if the person askign the questions is just going through the motions rather than genuinely intrigued to ask in order that they can help e.g. by if the answer is digestion issues then looking at a referral or if it is access issues then putting in place functional help there then there is intention to be interested.

Those asking because they 'think' they are 'doing that thicko a favour because they never thought of it' well....... really empathetic assumption isn't it, when actually should be the other way around that said 'helper' should be looking at themselves and wondering why they could be so stupid to assume its easy and reframe everyone else's problem to something simple that they aren't then refuse to see or hear past it. That is thicko. Again it is about reframing by people to make their jobs easier, rather than real and useful to real, actual things. Imagine if you drove your car into a mechanic with a knocking sound and they just changed your windscreen wipers because they want to assume every problem is simple - that, sadly, tends to be what this mindset that is programmed into so many has been encouraging. Reframe the problem. Simplify it even if not accurate.
 
Kitty said:
No, it can never be that. It's reasonable to explore whether there might be explanations for the behaviour, it's reasonable to offer advice, information, and encouragement, it's reasonable to ask whether the patient would like support or would prefer to revisit it at a different time. But if it's healthcare we're talking about, it's not a bargaining situation. People with capacity to make decisions are free to make bad ones.
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Most importantly for anyone to be helpful they need to be informed better on the actual condition - which they refuse to be because they don't want to hear about the fact they only treat those without PEM because what they do damages others and refuse to hear about stories of failure of what they do and harm.

And........for any real problem solving in any context you need to get to the bottom of understanding what the problem is - which involves complexity - and this paradigm has an allergy to that idea to the extreme delusion that it tends to reframe the problem to something utterly different in order they can say 'I can provid a simple solution'. That is not only minimising of course it is missing the point. And is stupidity dressed up in arrogance and power differential.

And of course these two issues interact to lead to the situation we have with ME/CFS but scarily is clearly starting to seep through to other areas too. It's just a sales technique from a tired area that only wants to do and offer what it wants to do then makes the problem fit what they want to offer. Except as you say it is health. It shouldn't be all about the needs of the staff and the people at the top of the pyramid.
 
I don't like how they write it should not be a manipulative relationship, because as a clinician the goal is after all to coax the patient into the "correct" behavior. To me this feels manipulative, even if one is supposed to listen, find obtainable goals together with the patient that the patient feels are important and so on. As long as certain researchers and clinicians sees ME/CFS as a behavior issue, I think it would be easy to nod along to the "treatment should be collaborative" idea since approaches like the motivational interview is already agreed upon.

Today forskning.no wrote about the "Anomalies" paper, I'm surprised it took this long. The person writing it has been a defender of the BPS paradigm and written quite a few pieces on the anti-science ME patients. Not surprisingly the omitted roundtable event is not questioned, and no mention of the wide support by ME organisations (though in fairness the replies to the paper may not have been published at the time of writing. It is commented on that the Norwegian ME Association is positive).

They even got comments from Trudie Chalder, I don't know why that surprised me.

Researchers criticize offer to UK ME patients
 
bobbler said:
"it should not be a manipulative relationship."

Isn't this precisely what this is, and is embedding scarily whilst telling those they are training in it that 'it isn't really manipulation'. This is what I worry about with the CBT embedding, it is just a technique in manipulation and manipulative communication techniques that worryingly they tell those they are teaching to do it that it isn't.

These things are basically like taboos: once you lose your integrity and begin to use manipulation - just a little bit here or there then I've watched so many people lose sight of true north. You either don't manipulate or you are manipulative. There isn't a middle ground on it and those who engage in it 'slightly' or 'just in these professional terms' really do lose who they are and morals and etiquette get pretty screwed and delusion happens.
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"I'm not gaslighting you, I'm negotiating you", says the gaslighter, trained, by gaslighters, not only in gaslighting but in gaslighting about gaslighting, which is gaslighting, about gaslighting, to the gaslit, with a large "No gaslighting allowed" sign looming behind.

"Don't you mean negotiating with me?"

"Of course..."
 
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rvallee said:
"I'm not gaslighting you, I'm negotiating you", says the gaslighter, trained, by gaslighters, not only in gaslighting but in gaslighting about gaslighting, which is gaslighting, about gaslighting, to the gaslit, with a large "No gaslighting allowed" sign looming behind.

"Don't you mean negotiating with me?"

"Of course..."
Click to expand...


We need some ‘business speak/sounds like/does what it says on the tin terms’ gir these habits and quality of ‘care’ that people pretend are acceptable

‘politely coercing’ or ‘sanitised coercion techniques’

would be one term i think is needed where the person is basically just engaging in coercion and ignoring very rudely with a dismissive line anything they say with a ‘I ring care/can’t hear’ equivalent - but it’s ok because those people and their mates around then have perfected the terms they use being fake-polite so others don’t see it is basic bullying with a posh accent
 
Not every person seen by medical professionals behaves as a 'rational actor' and there is widespread non adherence to prescribed treatments e.g Adherence to treatment and related factors among patients with chronic conditions in primary care: a cross-sectional study Additionally medical professionals increasing have a joint responsibility, firstly to the individual patient but they are also responsible for implementing public health policy. In the face of patient non compliance a negotiated contractual arrangement between the medical professional acting as representative of the community and the individual seeking healthcare is an inevitable outcome of resource limited health and social care.

One of the reasons why medical progress on difficult illnesses like ME/CFS has been slower than the historic thrust of medical breakthroughs would suggest it should by now have been achieved, is that lifestyle illnesses and diseases of ageing have rapidly replaced the early and mid 20thC challenges as the focus of political concern, so Type 2 Diabetes not Diphtheria is where the social costs now are, and in turn where political concern is and therefore research focus. And where effective treatments have been established but are failing to have societal gains because of non compliance it is not surprising that there are systematic responses to change that.

Unless the epidemic of avoidable ill health in developed societies is brought under control there will be little room for resources going to the difficult stuff like ME/CFS. It may not be ideologically appealling but if negotiated healthcare (or whatever jargon) actually increases treatment compliance for avoidable ill health, then that may well be a gain for ME/CFS patients who have no treatment regimes to comply with.
 
CRG said:
Unless the epidemic of avoidable ill health in developed societies is brought under control there will be little room for resources going to the difficult stuff like ME/CFS. It may not be ideologically appealling but if negotiated healthcare (or whatever jargon) actually increases treatment compliance for avoidable ill health, then that may well be a gain for ME/CFS patients who have no treatment regimes to comply with.
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Not to go off topic, but the epidemic of avoidable ill health is not just a personal issue of people choosing to eat the wrong diet or not exercising. This approach of motivational interviews are for example used in Norwegian "Frisklivssentraler" ("healthy life centers" where they have courses in healthy eating, exercise, sleep hygiene, quit smoking etc), and we have very little data that shows it works. Especially for weight loss or to make people be more physically active that are typical goals.

There are a multitude of reasons for why people are non-compliant; for example economy is said to be one of the biggest hurdles for healthy eating. Since 2017 (I think this is when this statistic started) there has been an increase in people unable to buy a "standard" healthy diet due to lack of income. Prices on food have continued to increase since then.

That's not to say I don't prefer a "collaborative" approach to me just telling someone what to do.
 
bobbler said:
We need some ‘business speak/sounds like/does what it says on the tin terms’ gir these habits and quality of ‘care’ that people pretend are acceptable

‘politely coercing’ or ‘sanitised coercion techniques’

would be one term i think is needed where the person is basically just engaging in coercion and ignoring very rudely with a dismissive line anything they say with a ‘I ring care/can’t hear’ equivalent - but it’s ok because those people and their mates around then have perfected the terms they use being fake-polite so others don’t see it is basic bullying with a posh accent
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Many countries have rules for advertising that explicitly forbid this kind of misleading language and tactics. Not that it doesn't happen in private, but at least it's explicitly not allowed, certainly not encouraged.

Advertising has stricter rules than health care when it comes to telling the truth, because most companies spend a lot of money on ads and understand that if people reflexively dismiss ads as possibly misleading, they won't have as much effect. They want a return on their investment, although that's an entirely selfish reason, it's not like they want everyone to benefit, but there is an understanding that to achieve those benefits, there has to be some truth. And those are all legislation so it's not like it's the companies themselves being benevolent.

The opposite is happening in health care, where everyone seems to understand that they have to be able to mislead patients, otherwise it, uh, is unpleasant for them for a few minutes. Although those few minutes would add up to quite a lot if they didn't effectively kick patients off with the intent to never see them again. The profit motive is often bad, but sometimes it actually creates better incentives than a profession whose actual motto is basically to never do that.

But most companies want repeat business, while healthcare can't even meet half the demand that's out there, has to "triage" large numbers of people out. Different priorities, and it's not really possible to do the unethical, neglect a lot of people because the resources aren't there, while being ethical in making it happen.

The fiction of the right to healthcare has to be maintained, even though it was always a lie. There is no such thing, a right that cannot be enforced is just a bunch of words, and in healthcare, the people who enforce this particular "right" are the ones who also have to "triage" about half of the needs out of their workplace. It would work out better if people just told the truth, but it sounds bad and so they just make up elaborate fiction to excuse it.
 
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