Elizabeth Morrison, an expert motivational interviewing trainer, joins us to share best practices in empathy-based communication for virtual health care settings. This episode is for anyone who wants to practice these key techniques for phone and video visits.
Elizabeth Morrison, an expert motivational interviewing trainer, joins us to share best practices in empathy-based communication for virtual health care settings. This episode is for anyone who wants to practice these key techniques for phone and video visits.
Morrison tells us:
Here’s where you can learn more about the people, places, and ideas in this episode:
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This is an automated transcript. Please excuse any errors or hilarious mistakes.
today our topic is impacted communication and virtual practice, and we're joined by Elizabeth Morrison. Who's an expert trainer in motivational interviewing techniques. So I'm going to go ahead and hand it over to Elizabeth to lead us through the content today.
Uh, thank you, Jenny. Hello everybody. Thank you for, for joining us today here. and I just wanted to say sort of out of the gate that I I'm an LCSW and, um, I do, I still see patients. And so I've been doing, um, virtual therapy sessions for the last two or three months, either by telephone or by video. And, um, I recently just two weeks ago started therapy again for the first time in a few years. And so got to engage as a patient, um, with a therapist, uh, through video.
Um, so part of what I feel like has been my learning in the last couple months is looking at this big part of my personal and professional interests, which is around empathic communication and particularly its influence and impact on health outcomes of the people that we serve and that intersection with tele-health, um, and what the differences are. And what's similar and, um, sort of, so I've been shoulder to shoulder with you all since I know that all of you are, um, are most of you are helping professions who are directly serving people and are doing so through telephone and video, probably primarily with some in-person maybe cell. Um, and so I consider myself a fellow practitioner with you all fellow learner, um, and definitely not an expert.
Picture of my daughter and I wanted to just, um, share with you before we dive in that, um, I, when I said I was a fellow practitioner, I think sometimes my kids think it's funny that a lot of my interest and passion and research and career is around empathic communication because they, of all people are sometimes on the other end of very unskillful communication from me, um, which my son likes to tease me about, um, when I'm irritable or short with them, or, uh, I, once I, um, made a workbook with my daughter when she was about 10 or 11 and it had to do with empathic communication, and I still remember like her drawing the pictures and I was drawing one of the things that's kind of dismissive, you know, if parents, um, say to kids, something, you know, to the effect of, um, uh, you're, all of these feelings will pass.
And then of course, like the next time I said that to her, she said, it's in the box. Like, didn't you read the book that we made? Um, so here she is, she's 15 now. And I just had an experience very recently in the last couple of weeks that really brought it home to me, straight to my heart about why this issue has so captured my, um, my passion and, and it's really because it, I can see how it applies, um, with friends, with family, um, and with patients and how powerful it is. And that is this idea that
We can't
Give motivation to other people and motivational interviewing, which has a huge overlap with empathic communication practices. In fact, it's an empathy based communication strategy. Um, really assume that, that we don't need to give anybody motivation. We don't need to, because everybody all already has plenty. And, um, that our jobs as people, you know, as friends, as family members, as helpers who are helping clients and patients, that our job is really to help people, um, uncover it and amplify it and grow it and, um, be able to line up their actions along with it. And that, that we can be helpers along those lines. And of course, as you can imagine, um, with my kids, it's really challenging because I really want them to do like a lot of stuff. And I have strong opinions about who they should be. It's hard to lose our ID, like let go of our ideas about who we want our kids to be.
Um, so this is her on the last in her bedroom. And, um, you know, she's a very like still person and she's very indoor oriented. She's very, um, introverted, um, likes to sort of connect deeply, um, less active. And I am the, uh, on the other hand, um, like a Greyhound, right? I just want to be like moving all the time. I want to be thinking all the time, I'm doing stuff all the time and that's like, that's my temperament. That's how I've always been. And so just since the pandemic, when she's been out of school, I feel like I've just been pushing, pushing, pushing. Like I almost can't even remember that in my professional life. Like I work on empathic communication and helping me help me, like elicit from people what they really deeply want to do. You know, I've just been, you know, what do you, when are you going to exercise?
When are you going to get out? When are you going to get your schoolwork done? What do you know, just push, push, push. And then something interesting happened, um, two and a half weeks ago, um, when the black lives matter protests first started, she came out at four in the afternoon and said to me, we have to do something. We have to do something now. And I have a list of things that I want to do. And she had this notebook that she was like flipping through and she had made all of these notations about like, she wanted to check and make sure we were giving money here. And she wanted to know how she could get money from her own bank account. And she wanted to go to the protest that was in Modesto, which is where we live, um, and that she had all kinds of plans about how to stay safe with the virus.
Um, and since that period of time, this is, um, as she saw the interactions with the police, she's gotten increasingly interested in nonviolent conflict resolution, and now has done a ton of research around everything from hostage negotiations, um, to other sort of, um, um, more social service, uh, um, strategies, uh, or, uh, social service jobs that use conflict resolution mediation, et cetera. I have never seen her so interested and so excited and doing so much research and so called to action around this. And I just felt like I just had to take a deep breath and remember that, um, everybody, everybody has their own, um, sort of internal DNA, or I don't know if it's DNA. I don't know if it's spiritual, like stamped around like who they are and their expression of who they are and their own creativity and their own desires and preferences and beliefs and values.
And, um, and that really kind of getting out of the way and waiting for clues about that, and then figuring out how we can create this empathic space where people can explore that and grow. That is so much a part of what is really, you know, our supportive relationships, whether it's like our kid or whether it's, um, uh, patients that we're serving. So this was my, like most recent example of like, remember, remember Elizabeth, you know, um, remember it's about looking closely at who people really are and inviting them to share that, um, with us.
I would say that all of us, and particularly those of us in the helping profession tend to use many of these strategies naturally and are quite skillful. Um, sometimes, um, you know, w once I name a few of these things, cause we're going to practice to empathic communication strategies, uh, today. And once I named two of them, you'll recognize that you're doing them. And then you'll know that they're motivational interviewing strategies and pathic communication strategies, um, and great to know about the majority of you as well.
Um, uh, so I just wanted to, this is the conceptual framework of motivational interviewing, and I just wanted to just briefly talk about these first two areas, which are the most impacted by empathic communication. Um, the first one is pre-contemplation and that is what we sometimes call denial, um, really where, um, somebody hasn't even thought about making a change. So this is, you know, this is somebody that you have in your life that consistently has like terrible, terrible, terrible boyfriends, and keeps telling you that there just must be no good men out there, angry thinking. I just saw you walk by like five good men to the one at the end who had all kinds of red flags. Um, you know, they just don't see it. Um, so we've all been there. We've all been there with particular, um, behavior changes where we just don't it.
Um, the second one, the next stage is contemplation, which is ambivalence. And that's when we have strong feelings for and strong feelings, sort of on the other side of taking action. All, all of us are in one of these, you know, have contemplation right now, um, about something I am always in contemplation about, um, daily exercise. Yes. I think it's super important. Is it more important than spending time with my kids in the evening when I have those few hours, maybe not. Um, I used to be a smoker, you know, uh, I always wanted to quit. Part of me, always wanted to quit. And the other part of me just felt like there were many times, I just couldn't, um, too stressful, um, too worrisome, you know? Um, so we all, we all sort of have, you know, this many, many areas that we're in this, um, in contemplation about, and these two stages when we're trying to help other people, um, people in our families, our patients, um, ourselves, in terms of how we talk to ourselves, these two stages, are there ones where it's deeply, deeply important, that we are able to communicate, um, empathy and care to others.
Um, and because if we don't, if we don't successfully communicate that, then people no longer want to talk to us about, um, the, these things that they're grappling with. We, we, we sort of fall off the map and it's even, even when we, um, even when those people love us. And we've when we love those people, we don't want to talk to people where we feel a little bit judged or not comfortable and judgment is the opposite of empathy. Um, so we can inadvertently sometimes convey judgment even when we don't mean to. And my favorite example of that is Jean Morrison, my mom, who is a very, very like in her heart, a very loving person, and yet is not as skillful communicator. So, um, she often says things like, well, what did you expect to happen? Um, or you need to get more sleep or, you know, she sometimes gives them close to those advice.
She sometimes tells my son, why were you doing that when he was, when he was crying, you know, um, so probably common to all of us. We probably have people in our lives like that. And the reason I use her as an example is that just feeling empathy in our hearts doesn't necessarily mean that we're communicating it. Um, that's why we talk about them as skills that we, and that's why if I'm a fellow practitioner, you know, that we can always get more and more skilled and more practice at really conveying empathy in the way that we want to
Talk about this for just a minute. Um, the why we talk about empathic communication and why it's the core of motivational interviewing, which is, this is sort of the foundational premise of all of this work, which is the empathy is and judgment, which is also stigma and bias. We sort of cluster those things together. All of those things are a cluster of negative beliefs around a particular group of people or conditions. So people with those conditions and judgment and stigma and bias are harmful. And for all of us who work in the helping professions, this is deeply important because what it means is by skillfully being able to show empathy, like all of us are doing every day in some respects, um, it's actually healing. So, um, blood sugar levels, A1C of diabetics, when they feel empathy from the healthcare team, they go down. When they feel judgment from the healthcare team, they go up really, really good research and replicated research on that.
We know that people who struggle with their weight when they feel judged about that, that their weight goes up. We know that when people feel care and empathy, and non-judgment around that from their healthcare team, there's a better chance that they're able to make changes in their diet. This is true of depression. It's true of alcohol use disorders. In fact, the research on alcohol use disorders is one of the most stark examples of this, where they studied, um, therapists. And when the therapists conveyed lack of judgment, when they convey deep empathy, people were able to make changes in their drinking. And when the therapist conveyed judgment, um, any sort of subtle judgment that people who had alcohol use disorders use more alcohol. Um, so it's very, um, it's very strong research. And I think for most of us, it, um, underscores what we already know intuitively most of us, even if we didn't know the research, know that this is the case, um, it's even true for the common cold.
So when people come in with a common cold, into a healthcare environment, um, if their healthcare team conveys care, their symptoms are less severe and lasts for fewer days. Then if they come in and the healthcare team conveys some kind of judgment, um, then their symptoms go on for longer and they're more severe. So very, very, very stark. And I just want to say, since we're in this moment right now, where we have racial justice protests going on around the country, um, that judgment and stigma and bias, we might group those together and talk about those as, um, toxic stress. And so chronic exposure to those things is actually a social determinant of poor health. And so I think for those of us in the helping professions, those of us who work in healthcare, um, this has sort of an almost deeper ethical, um, and maybe spiritual mandate around trying to be as skillful as we possibly can around becoming aware of our judgments, um, and really being willing to counter them actively and practicing our empathic communication skills.
Um, I wanted to just talk for a second about why it's so hard, you know, when I said that, um, I know all of you are for sure doing, you know, engaging in this already. Now, there are also times like I was talking about with my kids and I've certainly made missteps multiple times with patients and friends where it just seems really hard and you know, why can't gene Morrison be more skillful about this? And I think there's a lot of reasons why it's so hard. Um, one of them is that typically the way we were raised, just in terms of the people who raised us and how they interacted with us, um, however, they tried to get us to behave or however, they tried to kind of push us to do certain things often. That is what we revert to, especially in times of stress while we're Burt to that particular way.
You know, if people, if our families, um, tried to motivate us through fear, if they tried to largely motivate us by punishment, um, and we live in a country that's pretty obsessed with punishment. The us, um, is very, very punitive as a culture. And so if we, if in our families, they were very punitive and punishing that two would add to that. Um, and then shame. I, you know, I grew up in a, in a family that has, uh, used shame a lot to try to get people to do things. Um, I work a lot with pregnant women and pregnant women who are using substances and often I'll get a new intern or something that I'm supervising who says to, um, some of these women, well, it's not about you anymore. You need to think about your baby. Um, which I know the motive, the motive of was really, um, good.
They wanted to help these women. Um, and of course the way it comes out is shaming. Um, and then these women don't want to come back and see us. Um, so, uh, we might revert to these ways that we were raised, um, unknowingly, the other things that make it really challenging, um, is negative judgments or implicit bias. It's really hard to empathize. Um, uh, I mean, because John's judgment is the opposite of empty. If we're actively judging something or unconsciously judging something implicit bias, it's really tough for us to convey empathy, um, mirror neurons, um, mirror neurons are those, uh, right now we're all have masks like this, right. And mirror neurons are those things that like when a baby smiles at you, you smile at the baby back. Um, and when a baby looks at, like he looks out at the baby, Oh, um, so we're all born with these mirror neurons where we tend to mirror, um, the faces of the people in front of us.
And, uh, now that we have masks, we can't see each other's faces and it's really messes up our mirror neurons. So if you're wondering why everyone at the grocery store seems more irritable. Yeah. It might be stressful times. Yes. They might want to just get in and out. And on top of that, we can't see each other's faces. So even when we think people might be smiling at us, because we see the wrinkles, our brain is not registering that smile in the same way. Um, so we don't see the Goodwill and friendliness that we're accustomed to seeing. Um, and then being tired, stressed, or fearful or angry, um, really has a deep, deep impact on our ability to convey empathy. And we could talk about that for eight hours because we've built our, our helping systems really around systems that often are built to create this in, um, in people who are providing care.
And so then the question becomes like, you know, how do we build systems that actually support, um, you know, us being able to communicate empathy. Um, but I did want to just point out that it, it, it is a barrier and there's good research on this as well.we're going to practice the open ended questions. And the reason that we're going to practice open-ended questions is they are a primary technique for conveying empathy. So when we ask people open-ended questions, they feel they, we even, when we're on the other end of it, we feel like people want to hear what we want to say. We feel like maybe that person doesn't have an agenda for us, or want to get us to do something or answer something.
Um, so these are closed questions. Open-ended questions. Someone can answer, however they want closed questions are. Um, when we ask things that elicit a yes or no, um, the top two are what we would call narrow questions. Maybe they're not technically closed, but you can barely answer anything to them. You know, it narrows you into like a box, which medications are you taking is like, well, you can only answer, you know, a few things. Um, how many siblings do you have? Uh, it's going to be a number. Do you want to quit drinking? You can only answer yes or no. Right? So these very narrow and closed questions really box people in, um, which is a shame. I know a lot of our assessments in healthcare are built, you know, on these, um, and they're very habitual for us. Um, so, uh, open-ended questions look a little bit more like this.
They tend to start with what, um, tell me, uh, tell me about fill in the blank, um, or how often they start with how, uh, so these are open-ended questions stems, and they tend to open up and really convey carrot empathy, just through the question. Um, there's also just really super interesting research. Um, for those of you who are kind of eggheads about this stuff, um, um, around the more open-ended questions that healthcare providers ask us, the more accurate their is, and the more closed questions they ask us, the more inaccurate the diagnoses are. And that research was originally done in ERs, where you really need a quick, accurate diagnosis. And now it's been replicated in ambulatory care settings and with therapists as well. So it really just points to, we get such higher quality information, um, because we're conveying care and empathy and people feel like they want to share with us.
I'm just going to do, uh, a mini demonstration, uh, with Alexis who has agreed to be my partner in this. So I'm going to ask Alexis an open-ended question and she's going to answer, I don't know what she's going to say. It's not scripted. Um, and we're not, role-playing, she's just herself. I'm just myself. Um, and, um, I may ask her a follow-up one. I'm not sure. So, um, Alexis, I was wondering if you can tell me a little bit about what you feel is sustaining you right now during this time.
This is, um, it's a great question. I love, I love the positivity to that question. Um, I, um, I think this has really changed over the course of the shelter in place for me. Um, there's been different things that have been more sustaining, but right now, just getting outside and spending time outside. I mean, it's ideal if I could get to a park or a green space, but, um, but that's rare. And, um, even just being able to walk around my neighborhood outside, um, is, has been really sustaining what I've been spending days on end indoors. Thanks for sharing that, that it's changed over just over the last few months during the shelter in place. And that right now, it feels like
Just getting outside. Um,
So if I was going to ask Alexis a follow-up open ended question, I would love to ask her more about what it feels like when she gets out of the out of her apartment, because she kind of described just getting out. Like, it seemed like there was a lot of, there was something about that. I would like to know what would happen once you get out, you know? Um, so thank you Alexis for doing that with us.
Um,
advice is the kryptonite of empathic practices, um, because it is so well-meaning, and almost never lands as empathic. It almost never lands as a topic. And particularly for those of us who I think work in help, the helping fields, um, we have a really strong tendency to help people by telling them what to do. Um, and even sometimes when we ask people to ask questions, they'll say, have you thought of, you know, kind of a covert way to give advice? So I just wanted to just put in your minds a little caution, um, to make sure that if you're feeling that draw to what, you know, stop yourself.
the second technique that we were going to talk about is reflective listening and, um, it's one of the most powerful strategies to convey empathy. And it's one of the strategies that often people have really strong feelings about. Um, because many of us have been the recipient of really unskillful, reflective listening, and then you feel really annoyed about it, you know? Um, why are you parenting me? And isn't that what I just said?
You know, that sort of thing. Um, it makes me think of like, almost like a cartoony, um, marriage therapist, you know, Martha repeat back to Sam, what did Sam say? You know, you have to repeat everything. So that, isn't what we're talking about. We're talking about, um, the kind of reflective listening where we so want to understand and, and really hear what people have said that we hand them back kind of what we heard, um, in a, in a short version, um, to make sure we got it. So if we did people tend to say yes, exactly. And then they go on talking, which is amazing. Um, and if we didn't get it quite right, people will say, no, no, I don't feel frustrated. I feel mad. And so, so there's never, there's never a downside to doing it because even if we're not quite right, it gives people a chance to make sure they were able to tell us what they, you know, what we missed.
Um, so I love it when people use reflective listening with me. And I have noticed, you know, when we're talking about the computer and the telephone as modes of service, this particular strategy, I think is by far the number one strategy for conveying empathy, particularly on the phone, but on video too. And the reason is we've lost all facial, um, cues about whether people are listening to us or not on the phone. We can't look them in the eye. They can't look us in the eye. They can't see us nodding, um, almost all of us multitask while we're on the phone. Um, I know I've, I, for years I've, multi-tasked on the phone. We typically assume other people are multitasking. If we don't hear from someone for a while, we think they might've been, you know, a dropped call. So when we're talking to someone on the phone and it's important, you know, we're a care manager and we're reaching out to patients and we're talking to them on the phone.
When we're talking to our aunt, who's deeply, deeply anxious about her husband getting COVID, you know, when, when it's really important for us to show empathy and we're feeling empathy, um, really being able to reflect back to show we've heard is so important. And I do just want to take a second and say that, um, I wrote kind of a tip sheet, um, just coming from sort of my own learnings about conveying empathy on the telephone and also one around conveying empathy on video.
So there's, there's
A few different kinds of reflective listening. Um, we're gonna practice one of the first two. You can pick the first one is just summarizing. So, um, you know, when somebody, uh, like, like in the morning, when I say to my son, how'd you sleep, he, he struggles with sleeping. And he says, well, I had a super bad dream. And then I got up and then I wanted to get down. And then I did this and then like, I slept wrong. Like my neck hurts and blows them over that. So I'm not going to repeat back everything he says, but I want him to know, I, I heard him and this is, this is a big issue for him. It's really stressful for him. So I might say to him a man yet another really hard night. So that's a summary, you know, not, I'm not going through the list of everything that he told me, I'm summarizing kind of what the experience is and, and handing it back to him to see if I got it right.
Um, the second one, his exact words, which I was really against using exact words. When I got taught this, I was in an intensive, um, empathic communication training about 12 years ago. And up until that point, I'd been doing all kinds of reflective listening, but never using exact words. And when the research was shared about using exact words, I gave it a try. And the research is that when we use one or two, just one or two of the same words, that someone who is talking to us as you, especially high emotion, words, words that have kind of a little bit of a punch or a feel behind them. Um, then when we repeat them back to people, people feel very hurt. And I know when I'm on the other end of that, that's how I feel. And so if somebody says, I'm just, I'm just sick of it.
I'm sick of it. I can't stand for one more minute. They said I'm sick of it twice. So that's another clue about what's like high emotion. If someone, you know, repeat something twice. Um, so I might say back to them, I hear you. You're sick of it, right? That was the phrase that they repeated to me. I can tell there's a lot behind it. They repeated it. Um, those are that's exact words where you just pick something else. Um, so I, Alexis and I are going to do another demonstration. Again, just want you to know we didn't script this or practice this at all. And I even told the team before we hopped on, I said, well, yeah, to make a mistake, like often I'll make mistakes or say something. That's not an open question or do something that's not very skillful. Um, and that's okay too, because I'm just a practice or, you know, like everybody else. Um, so, um, so what we're going to do for this practice is I'm going to ask Alexis to talk just for a minute about, um, something that's worrying her, obviously, since it's real something she feels comfortable sharing about so that I can reply, I can practice reflective listening with her for the demonstration. So Alexa sweats, why don't you go ahead and share with them?
No,
Um, I think the thing that's top of mind for me right now moving into the summer is just about what's going to happen in the fall, um, with schools and selfishly, you know, for my own child, I'm, I'm worried about what's going to happen, um, at the schools don't reopen. Um, but I'm also just really worried about how, um, like in a system that's already so fraught with inequities, like what's going to happen, that those inequities are going to be really exacerbated by whatever ends up happening.
Um,
Yeah. Thanks for sharing that, Alexa, it sounds like, it sounds like you're really worried about, um, what's going to happen in the fall with the schools. And part of you is worried for you have a small sentence. So you're thinking about him. And then you're also thinking about the inequities in our system and, um, all the ways that gets exacerbated. And what's that going to look like, uh, in the schools, in the fall around that
If we were going to continue to talk, Alexis could have told me whether, you know, whether I missed in some certain places or she might have listened, it felt like I got it. And moved on to talk more about something. Um, I, I didn't, what I could have done is say, that's interesting. You used the word selfishly, when you were talking about worrying about your son, I'd love to hear more about what made you use that word. Um, because that's kind of a, it's an interesting word, right? Like it kind of caught my ear, um, or I could say it sounds like you have like really deep concern about inequity. That that's a really important value for you. Can you tell me more about that? Right. You could hear that there was like some of these, they will go in different directions. Um, am I guess it is right.
They could be related. We might find out. Um, so, um, so that's, that's the demonstration.