Case in Point   |   CMRG   |   Patient Advocacy   |   OR Manager Monday, May 21, 2012
Case Management

Case In Point | CMRG | Continuing Education | Trends | Clinical | Best Practice | Reports | Awards | Jobs | Store

Sign up for Dorland Health
news sent to your inbox
Facebook Twitter Linked in Google+ RSS
Publications
Dorland Store
Webinars
Continuing Education
Awards
Conferences and Events
Jobs
Advertise
Case in Point
Social Work

Navigating Difficult Discussions
By Vergil Metts, PhD
June 7, 2010

The art and depth of managing conversations

Rare is the person that relishes a difficult conversation: the kind that can escalate to argument and potentially mar personal and professional relationships. But even the most conflict-averse among us can’t completely avoid tough talks. So how can we make them easier? And their outcomes positive?

I find it a particularly relevant question for case managers, in your sometimes de facto role as mediator, navigating among disagreeing factions of a patient’s support group. Understanding the dynamics of difficult discussions, you may more readily guide those so engaged to common cause, to a greater clarity of comprehension, and to more informed, levelheaded decision-making.

The big insight? Every difficult conversation is actually three, simultaneous discussions. There is a surface conversation about facts, another involving feelings, and a third dealing with identity. Learning to manage each can produce the outcome you want.

Let’s examine each conversation and how to best deal with it, using Douglas Stone’s Difficult Conversations as a rough guide.

 

The “What Happened” Conversation

The “what happened” conversation is the surface conversation: the exchange between parties involving what each believes is happening. However, our version of “what happened” may not be what actually happened at all but how we perceived or interpreted events. What happened is loaded with critical, under-the-radar issues: assumptions of truth, assumptions of intent and blame. Let’s look at these more closely.

Assumptions of Truth. It’s common and natural to assume we know the whole truth about a situation and for someone on the other side to feel the same way. Such assumptions form the base of what psychologist Chris Argyris calls the “ladder of inference.” We start at the bottom with available information, then climb successive rungs: our observations, our interpretations and our conclusions, ultimately reaching our actions.

Each party has his own story of what happened because each takes in different information and notices different things. Moreover, each side has different interpretations of what happened (powered by beliefs and past experiences), applies different rules, and has a view colored by self-interest.

Avoiding assumptions of truth—dismantling that ladder of inference—requires commitment to understanding the other person’s story. It involves moving from certainty about, and advocacy of, our own position and thoughts, to curiosity and inquiry about theirs.

Start by doing an honest self-check of your own story, holding it up to the truth to understand it better. Take the path charted in the graphic below, and follow it from left to right to gain clarity.

From there, get past assumptions of truth by choosing not to choose between your and their stories. Embrace both by taking the “and” stance, abandoning the typical “or” that creates dismissal of the other’s story. You can then move from “who’s right?” to “now that we understand each other, how can we deal with this problem?”

Assumptions of Intent. As with the basic truth of a situation, we assume we know others’ intentions, and from there paint their characters with a dark brush. Conversely, we take rose-colored views of our own intentions. Each attribution easily becomes self-fulfilling and creates defensiveness.

Simply clarifying intent doesn’t eradicate its negative impact. Often, our intentions are a combo platter, neither inherently good or bad. And focusing primarily on clarifying intent can make you miss significant pieces of what the other party is saying and feeling.

Overcome assumptions of intent by recognizing that the impact of someone’s behavior and their actual intention are two different issues, but ones you must untangle. Just because you feel hurt or offended by someone’s comment doesn’t mean that was the intention. Using “I” language to describe your feelings (“I’m really uncomfortable with that”) instead of “you” language (“you offended me”) can help separate the impact of what you’re experiencing from the other person’s intent.

Acknowledging the other party’s feelings is a concrete step toward making the conversation easier and more productive. “Sounds like you were angry about what I said,” for example, moves the dialogue from disputes about fact and intent to a footing of understanding.

The Blame Game. Fact of life: we mistakenly assign blame to others. Blame is backward-looking, judgmental, emotionally charged, a precursor to punishment, and accounts for only one’s own story and views. It plays a starring, villainous role in most tough conversations, obscuring what’s really causing a problem.

Acknowledging that a bad situation is borne of mutual parts—yours and mine—is a huge step toward ending the blame game. Explicitly ask yourself and the other party: How did we each contribute to cause this situation, and what can we do differently in the future to avoid a sequel?

 

The Feelings Conversation

Feelings form the core of many difficult conversations and are often the actual business at hand. The problem is, most find it easier debating raw facts and “if A, then B”-style problem solving than dealing openly with feelings.

Feelings aren’t easily contained: they just are. How we deal (or don’t deal) with them is what leads to problems. Unspoken, feelings seep out in facial expressions, tone of voice, gestures, posture and backhanded comments. Unexpressed, feelings crowd out your capacity to listen closely and to say what you really want to say.

First, accept that even in a workplace disagreement, feelings are natural, normal and need to be expressed. Then, accept that everyone’s feelings are of equal importance.

When discussing your feelings, don’t vent. Instead, describe. Avoid blaming language like “you made me” and opt for “I feel.” Get your feelings out, and then move on with better mutual understanding. Don’t try to fix your or someone else’s feelings; acknowledge and understand that they just are.

 

The Identity Conversation

Finally, there is the identity conversation—almost always unspoken, but central to many difficult conversations. A good deal of anxiety surrounding tough discussions may stem not from facing another person but from facing oneself.

Three identity questions are common to difficult talks: Am I competent? Am I a good person? And am I worthy?

Together they fuel an identity conversation that can generate anxiety or anger, produce tangible, physical effects, and make the overall discussion move from difficult to tortuous.

There’s no quick fix for identity challenges. Improving your ability to manage identity conversations requires awareness of your issues—knowing what makes you feel at risk—and adopting the “and” stance, accepting that your identity is a mix of strengths and weaknesses. Acknowledging that the other person is having a simultaneous identity conversation is also helpful.

 

Putting It to Use

Helping disparate parties within a client’s support group get through a tough discussion doesn’t require a lecture on these three kinds of conversations. Instead, consider incorporating this information into a script you can follow to facilitate productive conversation.

For example, explain that it’s common for different versions of “the story” to exist, and natural to feel frustrated when one’s own story isn’t taken at face value. Move them from “but” and “or” to “and“ to gain basic agreement on the situation. Explain that everyone has feelings wrapped up in what’s going on, and encourage an open exchange, keeping blaming language out and “I feel” phrasing in.

Remind people, if you need, that everyone brings their own issues to the discussion—that’s normal and natural—but that getting to the best decision-making and outcomes is the point of any discussion about the matter at hand.


Dr. Vergil Metts, president and CEO of Impact Associates, has extensive experience working for and consulting with public and private organizations. (vmetts@impactassociates.org)

Comments (1) for Navigating Difficult Discussions
1.
Great article.
Posted by tonya on Friday, February 3, 2012 @ 11:53 AM

Tell us what you think...

Name:
Email:
Comments:

Please enter the letters or numbers you see in the image. (refresh)
 
 

RELATED ARTICLES

A Guide to Referrals
What case managers need to know about referring physicians and post-acute providers Discharge planners and case managers may encounter physicians who insist upon making referrals to specific post-acute providers. These physicians may...

An Effective Case Model
Case management and behavioral health In 2007 the HIP Health Plan of New York restructured its case management program for clients at highest risk of re-hospitalization for psychiatric conditions to capitalize on previ- ous lessons...

Caring for Caregivers
Those who provide care are often at need themselves Caregiver burden is a growing public health concern. Recent estimates reveal that more than 52 million caregivers are providing long-term care in the home setting. These numbers are...



Article Toolbox

CASE MANAGEMENT RESOURCE GUIDE

 

CONTINUING EDUCATION

NEW! The Essence of Case Management

This e-learning course brings it all together. It explores venues where case managers are practicing; looks at legislative activities that impact the practice; and discusses tools and principles utilized by case managers across the broad healthcare landscape. Earn CEs »

MOST READ STORIES
HIV/AIDS: Bringing an Epidemic to Light
Multiple Medication Dilemmas
Behavior-Based Ergonomics: Breakthrough Alzheimer’s Therapy
Transitioning Complex Patients From the ICU
JOBS
Anchorage, Alaska
Southcentral Foundation
Villa Rica, GA
Tanner Health System
Hershey, Pennsylvania
Milton Hershey School
Durham, NC
Durham Regional Hospital
Charlotte, North Carolina
Carolinas HealthCare System
San Diego, CA
RGB Group, Inc
Lake Forest, IL
Northwestern Lake Forest Hospital
Springfield, IL
Memorial Medical Center
Job Seekers: View All Jobs | Post a Resume
Employers: Post a Job | Search Resumes