Effective communication is not what you mean to say, but what the other person understands.—Medical NLP Presupposition
This final chapter draws together the Medical NLP consultation process into a coherent whole, discusses ways of increasing patient adherence, and points the way forward. We hope, by incorporating even some of the principles and techniques we have discussed, that you will have the means to equip the patient for future challenges, so that the symptoms that brought him to you in the first place will have served their purpose—to prompt him to reorganize at a higher, more complex, and more effective level of functioning.
The three phases of the Medical NLP consultation process (Figure 24.1) below function as a map by which the practitioner can locate his present position and then move to whichever other area may become necessary.
She should not be constrained by the structure; like all sufficiently detailed maps, it should be used as a guide only. Navigating through the landscape in partnership with the patient, and with curiosity, flexibility, and ‘attitude’, is the crux of the healing journey.
The clinical effectiveness of all but a few treatments depends on two factors: how well the patient remembers information and instructions, and how closely he adheres to them. Recall and adherence are automatically improved when practitioners follow some of the principles and techniques referred to elsewhere in this book (for example, providing orientating statements (see page 231), entering and working from within the patient’s model (see page 80), and discussing and agreeing treatment programs and well-formed outcomes (see pages 196 to 198)). Further suggestions follow below.
| Phase | Purpose | Tools | ||
| 1. Engagement | Managing first impressions | Instant Engagement | ||
| Rapid engagement | Technique | |||
| Achieving concordance | Yes-sets + negative framing | |||
| 2. Alignment | Gathering quality data | The Uninterrupted Story | ||
| Entering the patient’s world | Patterns, metaphors and meaning | |||
| Accessing and stabilizing resources | ||||
| Anchoring | ||||
| Shaping | ||||
| Feedback | ||||
| Priming | ||||
| Preframing, framing and reframing | ||||
| Negociating outcomes | ||||
| Patient-generated metaphors | ||||
| Sub-modalities | ||||
| Glyphs | ||||
| 3. Reorientation | Developing and applying interventions | Medical NLP change algorithms | ||
| Increasing patient self-efficacy | ||||
| Hypnosis | ||||
| Conditioning and futurepacing |
Research consistently shows that the patient forgets between 40% and 80% of medical information provided by healthcare professionals, often within minutes of leaving the consultation. The more details provided, the fewer are remembered.306 Furthermore, almost half the information given is incorrectly recalled.307
The following strategies can help patients remember better for longer.
Fewer than half of all patients follow treatment plans and instructions. Britain’s National Audit Office reports that wasted drugs alone could be costing the country up to £100 million a year,313 whereas in the United States, the cost has been estimated at more than $100 billion.314
Adherence is a function of many processes. These include:
Remember: if both practitioner and patient cannot put the requirements into specific, sensory-based (factual) words, they are unlikely to be carried out.
One of the important messages of this book is that patients do not necessarily know how to get better—or, to put it differently, they may lack the solution-oriented neurological pathways necessary for change. Also, it is important that new neural paths need to be activated, preferably several times (conditioning), in order to function.
New pathways and a mechanism to set them in motion may be installed as follows:
Take, for example, balance-assisting exercise instructions given to a patient diagnosed with labyrinthitis (inner ear disturbance):
Step 1: Take a look at the instruction sheet.
Step 2: As you can see, the exercises are simple…(the exercises are then repeated/demonstrated)
Step 3: and you need to do them regularly five times a day for the next four weeks so you can start feeling better.
Question: Now, when do you think would be the best times of day to do them so you can easily fit them all in?
After the question has been asked, be sure you allow the patient time to consider his response. If he answers too quickly, back up and have him go through it step by step.
Both recall and adherence are directly affected by two factors: attentional narrowing, and state-dependent learning.
Attentional narrowing occurs when stress and anxiety trigger sympathetic arousal—a common result of carelessly delivered diagnosis, prognosis and treatment options. The central message of a communication (‘You have X disease’) can severely occlude supporting information, impairing both memory and recall.315
State dependency is an equally common phenomenon whereby information acquired in a particular psychosocial/physiological context (environment, mood, degree of sympathetic arousal, etc) can only be fully retrieved when that state is reactivated.
Thus, if the patient’s anxiety levels rise during the consultation, she is unlikely to remember instructions and advice in a more relaxed environment at home.316 It is important, therefore, to remember to recognize and reduce the patient’s allostatic load before you proceed.
We began this book by wondering how it could be that, at this highly advanced stage of human development, our species could find itself so profoundly disabled by such a wide range of physical and emotional disorders that appear to have no medical explanation. One of our suggestions was that scientific inquiry, responsible for so many other extraordinary achievements, continues to approach the human body-mind as an assemblage of almost unconnected parts rather than the deeply complex and highly organized dynamic system it is.
The purpose of Magic in Practice, therefore, was to outline a three-part ‘whole-person’ consultation process that develops and maintains a ‘healing relationship’ between patient and practitioner, respects the patient as a unique individual, and helps him learn, or re-learn, more resourceful patterns for physical and psychological wellbeing.
In doing this, we acquired a mongrel approach. We foraged in many different fields for fragments we could model and use to create a more coherent picture, not simply of how people become ill, but how they can get better.
We were guided in this by the organizing principles of Neuro-Linguistic Programming, as co-created and developed by Dr. Richard Bandler. We have acquired from his guidance and inspiration the compulsion to be curious, experimental, flexible, and (we have been told) argumentative.
We also rooted through books and journals, articles and websites that spanned dozens of different approaches, and spoke to, and observed, experts in many different fields—not least those doctors who consistently achieved exceptional results, and those patients who were equally extraordinary, often recovering their health and wellbeing against all odds.
A lot of what we found on our journey was dross. But we also uncovered pure gold; some of the latter we’ve shared with you in this book. Substantial additions and revisions have been made for this second edition, and, given the speed with which knowledge expands, we are confident that more will appear in later works.
If we have achieved nothing else, we hope that we have been able to drive home the message that what is most important about any consultation is the patient and the result she gets. More than science, more than research, more than targets, audits, or statistical proof, it is the patient and the uniqueness of her experience that matters most.
Remember, however intelligent you might be, however much you pride yourself on your communication skills, it’s not what you know or what you meant that matters, but what the other person understands.
And it is the quality of your relationship with him that can open him to new insight, behavior, and change.
306. McGuire LC (1996) Remembering what the doctor said: organization and older adults’ memory for medical information. Experimental Aging Research 22: 403-28.
307. Anderson JL, Dodman S, Kopelman M, Fleming A (1979) Patient information recall in a rheumatology clinic. Rheumatology Rehabilitation 18: 245-55.
308. Tuckett D, Boulton M, Olson C, Williams A (1985) Meetings Between Experts. London: Tavistock.
309. Bertakis KD (1977) The communication of information from physician to patient: a method for increasing patient retention and satisfaction. Journal of Family Practice 5: 217-22.
310. Thomson AM, Cunningham SJ, Hunt NP (2001) A comparison of information retention at an initial orthodontic consultation. European Journal of Orthodontics 23: 169-78.
311. Blinder D, Rotenberg L, Peleg M, Taicher S (2001) Patient compliance to instructions after oral procedures. International Journal of Oral and Maxillofacial Surgery 30: 216-19.
312. Houts PS, Bachrach R, Witmer JT et al (1998) Using pictographs to enhance recall of spoken medical instructions. Patient Education and Counseling 35: 83-8.
313. Available from: www.nao.org.uk/publications/nao_reports/0607/0607454.pdf.
314. Berg JS et al (1993) Medication compliance: a healthcare problem. Annals of Pharmacotherapy 27: 1-24.
315. Ley P (1979) Memory for medical information. British Journal of Social and Clinical Psychology 18: 245-55.
316. Schramke CJ, Bauer RM (1997) State-dependent learning in older and younger adults. Psychology of Aging 12: 255-62.