Non-pharmacological

Interventions in Clinical
Practice (NPIs)
Prof. Dr. Fazaila Sabih
Department of Behavioural Sciences
Mohi-ud-Din Islamic Medical College
(MIMC)
Non-pharmacological
Interventions (NPIs)
◼ Non-pharmacological interventions (NPIs)
or non-pharmacological therapies (NPTs)
are defined as any non-chemical
intervention, which is theoretically
supported, targeted and replicable,
performed on a patient or caregiver and
potentially capable of obtaining a relevant
benefit.
 Why NPIs
◼ Enhance patient satisfaction

◼ Improve adherence to treatment

◼ Strengthen the bond between the doctor and

his patients
 Types of NPIs
◼ Communication Skills
◼ Counseling
◼ Informational Care (IC)
◼ Handling Difficult Patients and their Families
◼ Breaking Bad News
◼ Crisis Intervention and Disaster Management
◼ Conflict Resolution
◼ Psychological Interventions (Stress
Management, cognitive-behavioral interventions)
◼ Adoption of a healthy lifestyle
Communication Skills
◼ Allah (SWT) describes the good believers in
the Qur'an and says:

"For they have been guided to the

purest of speeches ..."
Qur'an: 22/24
What is Communication?

Communication is an exchange of information,

ideas, feelings, or meaning between two or more
persons.
The Consultation
Relative contribution of investigations,
physical examination and history to final
diagnosis
9%
9%

82%

diagnosis changed after investigations

diagnosis changed after physical examination
diagnosis made on history alone
Purposes of Communication

reassurance

To solve problems Form & maintain relationships

To alleviate distress communication To convey feelings

To give information To persuade

To make decisions
Types of communication
◼ One way (Didactic Method)
◼ Knowledge is imposed
◼ Passive learning
◼ Little participation
◼ No feedback
◼ Doesn’t influence human behaviour, e.g.?

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◼ Two way (Socratic Method)
◼ In which both communicator & audience take
part
◼ Active learning
◼ Encourage participation, exchange of ideas

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 Types of Communication

◼ Verbal communication
➢ Oral
➢ Written

◼ Non-Verbal communication
➢ Body language (posture, movement, hand gestures,
space)
➢ Voice Tone
➢ Facial expressions (eye contact)
3 V’s of Communication

❑ VERBAL
❑ VOCAL
❑ VISUAL
Common Body Languages
Facial Expressions
The Arms and Legs
Posture
Conversation Distance
Eye Contact

◼ You need to make eye contact with the person

you're talking to if you want them to feel

comfortable with the conversation and accept
what you have to say.
Deception

◼ When one lies Non-verbal cues help in

recognizing deception:

• Eye contact

• Exaggerated facial expressions

Communication Apprehension

Group Discussions
Public Speaking
One on One
Formal Meetings

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Basic Communication Skills

❑ Attending
❑ Active listening
❑ Verbal and non-verbal techniques
❑ Funneling
❑ Paraphrasing and summarising
❑ Reflection of feelings
❑ Empathy
Attending

◼ It is the act of truly focussing on the patient. It is

the conscious effort to be aware of what the other

person is saying and trying to imply.
 Standing on a patient’s bedside with fellow
students, attending to mobile calls
simultaneously or eating/drinking while
talking to the patient may show that you are
not attending or listening to the patient.
Active Listening

◼ This is a process that goes beyond merely

hearing and making notes of what the
patient says. It involves a simultaneous
focus on the linguistic (verbal) and
paralinguistic (non-verbal) aspects of
speech.
Non-verbal (SOLER)

Five nonverbal skills involved in initial attending.

◼ S, to face the client squarely

◼ O, adopt an open posture, free from crossed arms

and legs and showing non defensiveness.
◼ L, to lean forward the client

◼ E, represents eye contact

◼ R, a reminder to counselor to relax

Verbal Techniques

• Close ended questions

These questions elicit a limited response such as yes or
no. e.g. “what is your name?” “Are you married?” “Do
you get nausea after taking your meal?”

These questions are vital at the start of an interaction,

both to collect data as well as establish familiarity and
comfort with patient.
• Open ended questions
These questions do not elicit a particular answer or
limit patient to say either yes or no. These questions
help to explore the history of patient for further
information, to clarify and encourage patient to talk.

e.g. “what brings you to the hospital?” Or “Kaisay

Aana Hua” or even “Jee Kahiye Kya Hua”or “how
does this affect you?”
Avoid following questions

▪ Leading questions

A “Leading Question” is when you ask a

question that sneakily “injects” the answer you
want.

▪ “why” questions
Requesting Clarification

Counselor needs to be sure he/she understands

what client is saying. It requires a client to repeat
or elaborate.

E.g.

◼ “please help me understand this…”

◼ “can you please repeat yourself”

 Funneling

◼ This technique involves starting with general

questions, and then drilling down to a more specific
point in each. Usually, this will involve asking for
more and more detail at each level.
◼ Tip:

◼ When using funnel questioning, start with closed

questions. As you progress through the tunnel, start
using more open questions.
Reflection of Feelings

▪ Responding to the other person by reflecting

the thoughts and feelings you heard in his or
her words, tone of voice, body posture, and
gestures.
Empathy

◼ Empathy is the art of seeing the world as

someone else sees it. When you have empathy,
it means you can understand what a person is
feeling in a given moment, and understand why
other people's actions made sense to them.
 Paraphrasing and Summarising

It refers to the process of repeating the last few words

the patient said and summarising what the patient has
communicated so far.

E.g.

◼ “So you’re saying that …?”

◼ “If I understand you right, you’re saying that …?”

◼ “… you believe that …?”

◼ “… you feel that …?”

Principles of Effective Communication

◼ When angry, separate yourself.

◼ Attack the problem, not the person

◼ Communicate your feelings assertively

◼ Work to develop common agreement, create

win-win situation.

◼ Never jump to conclusion

➢ Try to be non-judgemental

➢ Listen without interruption (active

listening)

➢ Interpret non-verbal cues

➢ Be empathetic towards others

➢ Thank the person for listening.

Counseling
 Definition:

“A talking therapy that consists of a single

conversation or a series of conversations, taking
place between a psychologist and client.”
 “Counselling is a process where an
individual, couple or family meet with a trained
professional counsellor to talk about issues and
problems that they are facing in their lives”.
Counselling is not:

◼ Giving advice.
◼ Being judgemental.
◼ Attempting to sort out the problems of the
client.
◼ Expecting or encouraging a client to behave as
the counsellor would behave if confronted with
a similar problem in their own life.
◼ Getting emotionally involved with the client.
◼ Looking at a client’s problems from your own
perspective, based on your own value system.
The Role of a Counselor
◼ Help the client to develop their own
understanding of the situation.

◼ They will enable the client to explore aspects of

their life and feelings, by talking openly and
freely.

◼ Talking to a counsellor gives clients the

opportunity to express difficult feelings such as
anger, resentment, guilt and fear in a
confidential environment.
Traits of a Counselor
◼ Unconditional positive regard
◼ Rapport building
◼ Good communication skills
◼ Clarity
◼ Reflection
◼ Empathetic (to ‘feel with’)
◼ Here and now thinking
◼ Active listening
Basic Counseling Skills

◼ Confidentiality

◼ Rapport Building

◼ Empathy

◼ Active listening

◼ Verbal and non-verbal techniques

◼ Empathy
Informational Care
Informational Care (IC)
◼ 3 Ds
◼ Disease, Drug, & Doctor

◼ Seven Essentials in IC

◼ Seven Questions a Patient Needs Answered

in an IC Session
Handling Difficult Patients
and Their Families
◼ Long and meaningless discussion with doctor
◼ Waste precious time
◼ Ask for undue favors
◼ Unprofessional demands
◼ Manipulate the doctor
◼ Become rude and angry when things do not
go their way
◼ Non-compliant
◼ Medically Unexplained Symptoms
◼ Drug users
Management
◼ Understanding of Biopsychosocial Model
◼ Training in principles of effective
communication
◼ Use of relaxation techniques to calm down
◼ Avoid being personal – unconditioned
positive regard
◼ Allow expression of anger and feelings
◼ Offer referral
◼ Use humor
◼ Involve family members
Breaking The Bad News
◼ If physicians lack proper training, breaking bad

news can lead to negative consequences for

patients, families and physicians/doctors.

◼ Bad news, “any news that drastically and

negatively alters the patient’s view of his or her
future”
 SPIKES

◼ The SPIKES model was first published in The

Oncologist in 2000 as a protocol for delivering
bad news to cancer patients.

◼ Since then, it has been adopted more widely

and used by clinicians in various circumstances
to communicate difficult news to patients in a
way that is clear, supportive and
compassionate.
Six Steps of SPIKES

➢ S – Set Up

➢ P – Perception

➢ I – Invitation

➢ K - Knowledge

➢ E - Empathy

➢ S – Strategy And Summarizing

S - Set up (Seating and
Setting)
◼ Think about what you want to say in advance.
◼ You may wish to suggest to the patient that they are
accompanied by a friend or relative.
◼ Make sure there is enough seating in the room, and turn
off or mute any electronic devices so that the patient has
your full attention.
◼ Establish rapport with the patient and maintain eye
contact.
◼ Allow enough time for the patient and/or their relative to
express their emotions and ask questions.
P – Perception

Ask: aap apni bemari k baray main kya jante hain?

◼ Use open-ended questions to determine the patient's
understanding of their condition. This will help you tailor the
way you deliver the information and where you begin.

◼ Check that the patient is able and willing to hear what you
will say. They may give you an opening to start the
discussion, or they may try to avoid hearing what you are
saying.
I - Invitation

Ask: aap bemari k baray main kya janna chahain gay?

◼ Most patients will indicate that they want full information,

but some may shun information as a coping mechanism.
◼ If patients do not want to hear details, you can offer to
answer any questions in the future or speak to their
family or friend.
◼ Use language appropriate to the patient's level of
understanding. It can help to reflect the patient's words
and body language.
◼ Avoid unnecessary jargon and euphemisms,
which could impair the patient's
comprehension and create a barrier to
communication.

◼ Be sensitive to how the patient is reacting,

and provide information at an appropriate
pace.
K - Knowledge

Ask What have you understood?

◼ Warning the patient that you have bad news
may reduce the shock of disclosure.
◼ Give the patient and their friend/relative
enough time and space to absorb the
information and ask questions.
◼ Give the patient information regarding next
steps, such as follow-up appointments. The
patient should also be told who will be in
charge of their care and how they can contact
them.
◼ Reassure the patient of ongoing support. This
will help them to cope and feel less isolated.

◼ The patient and relative/friend may differ in how

much information they want or require. If you
sense a disparity, check that the patient is
happy for you to speak to their friend/relative
separately
E - Empathy
◼ Don't make assumptions about what the patient
might be feeling. Encourage them to express
their concerns, and respect their wishes about
how much information they are prepared to
hear.
◼ Observe and validate the patient's emotions
and give them enough time and space to
express their reactions.
◼ Remember that all patients are different.
S - Summarize

◼ Make sure the patient has understood by

asking them to briefly summarise the main
points of the conversation. Encourage them to
express their concerns.
◼ Provide reading material for the patient to
absorb when they are ready.
◼ Suggest that the patient note down any
questions they'd like to ask you at your next
meeting, so you can be sure you are
appropriately exploring their understanding.
CRISIS INTERVENTION
Definition of Crisis

◼ “A crisis involves a disruption of an individual's

normal or stable state”.

◼ “A crisis can refer to any situation in which the

individual perceives sudden loss of his/her
ability to use effective problem solving and
coping skills”.
Cont…
A crisis may cause a person to lose their ability
to cope with stress, trauma, grief, guilt, shame,
or any other dilemma causing them to lose their
mental balance, or even relapse back into
substance abuse.
Crisis are usually categorized as being either situational
or maturational
◼ Situational crisis:

It involves an unexpected event that is usually

beyond the individual's control. e.g. Natural disasters,
loss of a job, physical or sexual assault, and death of
a loved one.
◼ Maturational crisis:

It occurs when a person is unable to cope

with the natural process of development, usually
occur at times of transition, such as when the first
child is born, when a child reaches adolescence, and
when the head-of-the household retires.
What is Crisis Intervention?

A crisis intervention refers to the methods

used to offer immediate, short-term help to
individuals who experience an event that
produces mental, emotional, physical, and
behavioral distress or problems.
Purpose

◼ To reduce the intensity of an individual's

emotional, mental, physical and behavioral
reactions to a crisis.

◼ To help individuals return to their level of

functioning before the crisis.
 Roberts’ Seven-Stage
Crisis Intervention Model
 Roberts’ Seven-Stage Crisis
Intervention Model
1) Plan and conduct a thorough biopsychosocial and
lethality/imminent danger assessment.
2) Make psychological contact and rapidly establish the
collaborative relationship.
3) Identify the major problems, including what precipitated
the crisis.
4) Encourage an exploration of feelings and emotions.
5) Generate and explore alternatives and new coping
strategies.
6) Restore functioning through implementation of an action
plan.
7) Plan follow-up and booster sessions.
Disaster Management
Conflict Resolution
What is Conflict?

“Conflict is a state where two forces oppose

each other”.

“Difference in opinion or some kind of

disagreement between two or more parties”.
Conflict is a process that begins when one party

perceives that another has negatively affected or

is about to negatively affect, something that the

first party cares about.

◼ It arises in situations where individuals and
groups are not getting what they want or need.

◼ It includes: marital conflict, conflict among

colleagues, the attendant of a patient and the
nursing staff, medical students on a clinical
rotation in conflict with hospital staff, or the
college administration etc.
Causes of conflict in healthcare settings

◼ Assumptions are being made

e.g. the doctor assumes patient knows that his

absence is due to his academic commitments like
attending meetings or conferences. The patient
instead is not aware of the activity and not
understand its importance.
◼ Knowledge is minimal

e.g. the family has inadequate information about the

procedures, treatment, hospital rules and regulation.

◼ Expectations are too high

e.g. the patient believes that he/she should fully

recover after treatment.
◼ Needs and wants are not being met

e.g. a patient is dissatisfied with food, bedding or

facilities in ward.

◼ Values are being tested

e.g. a female patient reluctant to allow a male

student to examine her.
◼ Personality, race, gender, or social class
differences exist

e.g. a trainee nurse may have a low tolerance level and

take offence of an innocent remark by a patient; a visitor
or medical student or the janitorial staff goes on a strike
for being poorly paid.
Techniques of Conflict Resolution
There are two views on conflicts or the so called
differences in opinion between people.

▪ The traditional view says “conflicts are bad and should

be totally discouraged”.

▪ The new modern view says “conflicts can be

constructive and good and different ways of thinking
should be encouraged to get multiple ideas and
solutions to problems in hand”.
 1. Problem Solving / Collaboration / Confronting

▪ People involved in the conflict come forward to

discuss the problem at hand with a very open mind.

▪ They focus on resolving the conflict and finding the

best alternative/ solution for the team.

▪ They keep aside personal emotions, their sole

intention is finding best for the team.

▪ This leads to a win-win kind of an outcome.

▪ Here everyone collaborates.

2. Compromising/Reconciling

▪ Certain conflicts involve parties to think of a middle

path, wherein, both parties decide to give up
something and identify a resolution.

▪ This kind of solution will be temporary for that moment

and are not long lasting solution.

▪ This leads to lose-lose kind of an outcome as both

parties may feel they have lost something.
3. Withdrawing/Avoiding

▪ In some situations, one of the parties in the conflict

may decide to retract from the discussion and allows
going with the other person’s opinion.

▪ Or some situation, one of the parties may decide to

completely avoid the conflict by maintaining silence.

▪ This works well in situation where one of the parties
in the conflict is emotionally charged up or is angry.

▪ Hence avoiding any conflict resolution provides a

“cooling off” period to the people involved so that
they can later come back for meaningful resolution.
4. Forcing/Competing

▪ In some situations, a person with authority and power

can force his/her opinion and resolves the conflict
without giving any chance to the other party/person.

▪ This leads to a win-lose kind of an outcome.

▪ Someone may end up feeling as a loser while the
other person with authority may feel as a winner.

▪ This technique can be used if we see the conflicts

are unnecessary and mostly destructive for the
team.
5. Smoothing/Accommodating

▪ One of the parties can take charge and tries to smooth

the surrounding.

▪ This is a technique which is used when the atmosphere

seems to be filled with apprehension/distrust among
the parties involved and no one is coming forward for
resolving the conflict.
▪ Use nice words, emphasize on the points of
agreements and play down on the points of
disagreements.

▪ This can work as catalyst to break the discomfort

between the involved parties by creating a feeling of
trust and encourages them to come forward and
resolve the conflict.