Case managers have the power to help their patients change their own narratives about their illnesses and injuries. They can achieve this through helping patients develop more functional stories about their situations in the following ways:
• Make empathetic statements. “Empathetic statements are nonjudgmental comments that help a person continue and talk some more,” says Janice Gasker, DSW, LCSW, ACSW, professor, bachelor of social work program director, and director of the department of social work at Kutztown University in Kutztown, PA.
These can include the following:
- “You’re feeling sad/bad/unhappy/etc.?”
- “Could you say that again?”
- “Tell me about…”
- “I would feel sad/bad/unhappy in your situation. Do you feel that way?”
It is important to make a comment that helps the patient feel validated, Gasker says. And be specific: “Don’t just say, ‘I hear you,’” she says. “Say, ‘I hear you that the nurse has been showing up late.’”
• Fixing problems isn’t everything. “It’s not that you don’t fix their problems,” she says. “It’s that you can begin to hear them talk, and maybe there’s nothing you have to fix.”
It could be the patient just needs to start thinking about problems in a positive way, she adds.
“Remember, this story gets told in interaction and developed in interaction, so you need a trusted person to talk with so you can start shaping that story,” Gasker says. “Say, ‘I want this story to have a happy ending, so let me tell you what happened.’”
• Find the right person. Patients, case managers, or anyone looking to write a more positive story need to find someone who will validate their feelings and not try to fix them immediately, Gasker says.
It also is not important to make a person feel better immediately. “Many of us who do this kind of work want to help people get rid of their pain right away, when what they need is a new way to think about this,” she says.
The listener does not have to believe everything the person says, but the listener should not demonstrate a lack of trust in the narrative. This means the best listeners will not be people who look at life through a negative lens, she adds.
• Memory is malleable. It is possible for people’s memories to change over time. They might even believe something occurred that never happened.
For example, a study of people’s memories after the 9/11 terrorist attacks showed that people’s memories of specific details of where they were, who they were with, etc., when they first heard of the attacks deteriorated over time. They remembered details incorrectly, including even how they first heard of the attacks and who they were with when they found out. (More information on the studies is available at: http://bit.ly/2zA8TZ9 and http://bit.ly/2qsehZT.)
“This points out that it’s not your job to believe or disbelieve a person’s memory,” Gasker says.
The key is to listen and validate. If the person reports something disturbing, such as abuse, the case manager should report it to appropriate authorities. It is up to experts to investigate it. But for other memories and stories, the goal is just to acknowledge that the person is being heard.
• Ask how the patient feels. The next step is to ask patients how they feel about what they are discussing.
“Then you talk about their story as they talk about it, helping the person see there’s another way to look at things,” Gasker says.
For example, the case manager dealing with a car accident patient could say this: “I hear you say the car accident was very troubling for you. Tell me more about that. How are you feeling about that?” she says.
The patient might be sad or angry, and the goal is to acknowledge the person’s emotions.
“Say, ‘I hear you say you’re sad/angry/etc.’” Gasker says. “But don’t settle for the word ‘upset.’”
When patients say they are upset, the case manager can ask them whether they are mad or sad or something else. By digging a little deeper, the patient might open up and share more.
“If you say, ‘Tell me what that means for your life?’ the patient might say, ‘Well, I can’t move my legs, and it’s over,’” she explains.
“So you can say, ‘OK, let’s think about that in a different way. You have told me that you’re an artist. And it’s true that it’s bad for an artist not to go around and see things. But, on the other hand, you will have time to let the artist come out in you,’” Gasker says. “And you ask, ‘Can you think about some ways you can find some things you can do when you’re here that you have not had a chance to do if you were not here?’”
Likewise, if a patient shares that she is sad that her daughter never visits her, then the case manager can suggest that the daughter could visit more now that the patient needs more help to manage at home.
“You have to hear the person first to know where to go with it,” Gasker says. “Just be careful to not invalidate what they’re feeling. So if they’re saying they are very sad, don’t say, ‘Really, it’s not that bad.’”
“Instead, ask, ‘Is there a different way we can think about this?’ Gasker says. “Maybe this is something that stays a sad story for a while, but the person gets the idea they can think about things differently.”
• Use silence strategically. Empathic statements help to build trust. Silence provides the space for the patient to tell his or her story.
“People need to know that the most important gift you can give someone is silence,” Gasker says. “We do not allow silence in conversations. Someone always jumps in to fill that gap.”
And when people have suffered a trauma or illness, others may be unwilling to hear about it. They cut the patient off when they start to talk, she says.
The silence might last 30 seconds, which will seem like an enormous amount of time, she notes.
“You say, ‘Can you tell me more about that?’ Then let them sit with that. Just let them talk first,” Gasker says.