In humanistic approach, patients are agents of their own health care
By Louise Kinross
What do elite sports and medicine have in common? It's about who is in charge.
Both systems are "triangular-shaped, with power and control and authority at the top of the pyramid, and people who have been conditioned to be compliant and docile and passive receivers of expertise on the bottom," says Elaine Cook, a scientist who heads Holland Bloorview's Humanistic Health Care Program.
In fact, it was Elaine's PhD research teaching University of Toronto varsity coaches how to use strategies that elicit the wisdom of athletes that laid the groundwork for her joining our hospital three years ago. "Sports coaches are in a culture where coaching is considered directive," she says.
"The coach has all the power and the athletes do what they're told, when they're told, and how they're told to do it. The same is true of health care. So to flip that is extraordinarily difficult, because it's so counter-cultural. It's the opposite of how we train people in health care." We spoke about the culture change Elaine is championing at Holland Bloorview.
BLOOM: How did you get into this field?
Elaine Cook: It's a weird story. I was married to a professional athlete for a decade and we lived in Belgium, where our kids were born.
BLOOM: Who was the athlete?
Elaine Cook: Steve Bauer. He was a professional cyclist and one of the best in the world. He did the Tour De France. I became fascinated with the psychology of sport. What is it that motivates people to do their best and to persevere despite incredible odds, pain and injury? When my husband and I split up, I went back to school and did my undergrad in sport management and then a master's in sport psychology and my doctorate in applied behavioural psychology.
BLOOM: What is solution-focused coaching?
Elaine Cook: What we teach in our workshops and our new certificate program is a model of communication that elicits clients' innate wholeness, strength and resources. In terms of turning the pyramid upside down, it's client-driven and collaborative.
The client is recognized and acknowledged as the expert of their own lived experience, while the clinician is recognized as an expert in their discipline, and in facilitating a conversation that best elicits, amplifies and reinforces the client's strengths and resources. The clinician comes to the conversation with a sense of curiosity, and they lead from behind.
There's no giving advice and they're discouraged from being directive. In order to lead from behind, it's also a question-driven model. So the clinician leads with questions because they're trying to elicit strengths and agency and autonomy, or what we call 'personal enduring resources,' in the client.
BLOOM: Do clinicians who take your program come to think of themselves as 'coaches?'
Elaine Cook: That would be our hope. It's difficult in health care because clients and families come to us for specific expertise. So how do we share that expertise in a way that's not directive, that engages collaboration and inherent strengths? That's challenging.
If we think simply of the system, the way the system works is that we give the information. But we know that doesn't work, because then clients are docile and compliant. There's no motivation for them to become the agents of their own health-care journey. We say clinicians have one foot in acknowledgment and one foot in possibility. The real art is that tension between their expertise and the client's expertise, and they must be able to navigate that space.
BLOOM: I'm imagining that it might be faster to 'dump information' on clients, as opposed to engaging them in a robust conversation. Do clinicians have trouble finding the time to have these conversations?
Elaine Cook: While you may invest more time upfront with this model, the rewards on the back-end are transformational to the system, and save time and money. Every conversation we engage in is about facilitating the client's learning and helping them to understand that they have so much to give, that they're inherently whole and they can tap into their wholeness.
What we've found with 'dumping information' is that a client will come back in two weeks and they haven't contacted the community organization that was suggested, or they haven't done their exercises. That's because they're overwhelmed. When they're conditioned to be passive receivers of information, they're not engaged in the process.
I have a banner on my fridge that says 'ruthless efficiency.' I keep it there to remind myself that when we start sacrificing our humanity for efficiency, the system falls apart. And that's what we've done in health care. We have to turn it around.
It might be a steep learning curve, but you hit that tipping point when a client gets that 'aha' moment, and they realize that they're the authority on their own lived experience. Then everything shifts in meaningful ways that benefit the system.
BLOOM: In what way is solution-focused coaching humanistic? I have to say that personally, I've been wary of the term 'solution,' because it's often associated with cure in medicine.
Elaine Cook: Solution-focused practice evolved from family systems theory in the 1970s. It was a counselling model that was influenced by the greatest humanistic psychologists of our time.
Three fundamental principles undergird our training here: all human beings are considered to be inherently whole; all human beings have an innate desire to move toward self-fulfillment; and all human beings have inherent strengths and resources that, when activated, help them to move to self-fulfillment. We call it 'personal wisdom.' All human beings have a desire to move toward personal wisdom.
BLOOM: How does solution-focused coaching work for a problem where there isn't a solution that the person wants? For example, let's say my child has a terminal condition. Or my child is not able to do something I consider to be an essential part of life?
Elaine Cook: It's so astute that you recognized that. One of the reasons I've reframed our education and training to call it humanistic is that I think what's most important is the humanistic piece. It provides the framework for all of the other skills that we build. So yes, there are circumstances that can't be changed where the outcome is not what anybody wants. We position that as 'leading with constraints.'
So I might say to you 'Despite the challenges, Louise, that you face on a day to day basis with your child, I'm wondering, what might, even just a little bit, help you and your family to cope in a way that might be different?'
We never, ever diminish the current circumstances, and, in fact, that's why we say we have one foot in acknowledgment and one in possibility. The solution is how do we elicit, amplify and reinforce innate strengths in the present moment to help a family cope in ways that are going to be meaningful for them.
BLOOM: What are some of the topics you cover?
Elaine Cook: The humanistic principles provide the framework for our toolbox, and solution-focused communication skills are the tools. We help people build their toolbox and tools, and then we look at different contexts in which they can use them. So 'difficult conversations in health care' is one topic. 'Conflict' is another. 'Concepts that help families to cope better' is another, and includes the concept of 'good enough.' Clinicians are exposed to many different pieces of the puzzle.
We also have a series of six family workshops. The first is an introduction to solution-focused fundamentals. Once parents have been exposed to those skills, then we put them in context for parents. So topics might include self-care, which is incredibly important, advocacy, reframing and goal-setting.
BLOOM: What's an example of how they might use their skills?
Elaine Cook: Clinicians and parents learn to 'lead with constraint.' That is the idea that you acknowledge, right upfront, the challenges and problems, and then you use key words to reframe.
I'll give you an example with my son. He has an extreme sensory processing disorder. When he was younger he had profound difficulties at school. He escalated really quickly and was the target of extreme bullying. His days were super challenging and then he'd go to after-school care where things would be a bit better. I'd pick him up and he'd get in the car and I'd never, never ask him how his day went. Why?
BLOOM: Because you were afraid to hear the answer?
Elaine Cook: Because I knew it wouldn't be helpful. I'd say 'Garrett, can you tell me one thing that made you smile today?' And he would answer me, usually in tears: ''Johnny pushed me, I ate alone, no one played with me at recess.' I would nod, so he could see me listening, and I might say 'So Garrett, despite all of these challenging things that happened,' and then I would go back to the original question: 'Can you tell me one thing that made you smile?' 'Oh, well I got 100 per cent on my French test.' The challenging things seem so prevalent that if you don't ask, they won't recognize the small wins during the day.
BLOOM: Why is it important psychologically that they identify the one thing that went right?
Elaine Cook: Because where your attention goes, neurons fire. That's the simple answer, based on neuroscience. If our attention is constantly on the problem, you're just embedding those neural pathways. By nature, our negative neural pathways are our default pathways, so we don't need to enrich those pathways in any way, shape or form. What we need to do, positive psychologists tell us, is to enrich positive neural pathways.
The analogy I use with parents and clinicians is to ask yourself, with every question to a child, 'Are you watering the weeds or the flowers?'
Another analogy is to think about the negative neural pathways as being the express lane on the 401, where information travels at a gazillion kilometres an hour. We're trying to get on the off-ramp into the collector lanes, where we can slow that down. We want to embed and enrich positive neural pathways. We want to put our attention into thoughts that help release dopamine and serotonin, which help to embed those pathways.
BLOOM: What is a typical day like for you?
Elaine Cook: It's a combination of teaching, doing consultations with teams in the hospital, building content, meeting with facilitators, and meeting with outside organizations about our training. We now have a program assistant who was a former client of Holland Bloorview, Nikky Henderson. She does all of our organizing and logistics and co-facilitates almost all of the workshops.
BLOOM: In addition to workshops you have a 12-month intensive certificate program. Is that just for clinicians?
Elaine Cook: No, in our current cohort that graduates in February, we have five family leaders who will graduate as certified solution-focused healthcare coaches. In our new internal cohort we have occupational therapists, physiotherapists, nurses as well as Irene Andress [VP of Programs and Services] and C.J. Curran [Director of Transition Strategy]. Last year Dr. Anne Kawamura graduated. It doesn't matter what your role is, as long as you're affiliated in some way with health care.
Something new that's exciting is that Hamilton Health Sciences is sending a team of people from across their 11 organizations as a new cohort.
BLOOM: What's the greatest challenge of your work?
Elaine Cook: It's having leaders within organizations come on board. Even within our organization, that's the hardest work. It's getting leaders to recognize that we need to embed these practices in ways that are going to create systemic change, and to provide the level of support we need to do that well.
For example, how do we make medical intake forms and documentation match the conversation and communication skills and practices we're adopting? Right now they're dissonant. We engage in all of these positive communication practices and when clinicians go to document in Meditech, everything is problem-focused. It's hard for clinicians to straddle these two worlds. How do we keep implementing practices and processes that support what they're learning?
BLOOM: What's the greatest joy?
Elaine Cook: Even when we're listening to stories that people would typically find heartbreaking, we have the ability to be compassionate in ways that are going to be eliciting and reinforcing the strengths and resources of everybody involved. That is super important, and benefits the clinicians as much as the clients and families.
When we enter into these conversations without the traditional burden of believing that it's our job to fix people, because it's not, that shifts everything for the clinician as well. That's what the clinicians enrolled in our program rave about. Cathy Petta [Registered Nurse] is now seconded to our program half-time. She said that two years ago she was ready to retire because she was so burnt out, and learning this way of communicating with clients and families transformed her life and practice. So it's important for both clinicians and families that we make this shift.
Holland Bloorview's solution-focused workshops for families are free. Check out more about our family program here. Like this story? Scroll down to the blue banner and input your e-mail address to receive our monthly BLOOM e-letter in your inbox.
