Keeping Your Patients On Track

It’s common to assume that when a patient attends physiotherapy, they want to do what-ever is necessary to get better. In the management of acute and serious injury or post-surgical this is often the case. But what happens in the management of chronic injuries or the physical injuries related to obesity, lack of exercise, diabetes and other chronic illnesses? Physiotherapists are increasingly seeing patients that fall into these categories. Patients that fall into the category of managing chronic injuries often have varying degrees of enthusiasm for education and a rehabilitation program.

As clinicians it can be extremely frustrating to manage patients who say they want improvement, but their compliance doesn’t reflect their desire for outcome they say they want. In this article I will present three things to consider when engaging the more challenging patients in education. These include:

1. Consulting Styles
2. Psychological Reactance
3. The Influence of Habit

Consulting Styles

Having an expectation that the patient should be the one to adjust behaviour can lead to frustration at best or at worse, a sense of hopelessness on the part of the clinician.
If the clinician can consider taking on the responsibility to adjust their consulting style with the resistant patient, there is a reasonable chance that this same patient will respond differently. But what do you need to do to adjust your consulting style?

The Impact of Adjusting Consulting Styles William Miller and Stephen Rollnick (1) found that there were three distinctive consulting styles that are effective in managing the different emotional states patients can present in. They are:  Directive, Guiding and Following. Susan Hargreaves (2) described two styles of consulting she found when reviewing private practice techniques. They are: Dominant and Affiliative. Her Dominant style is the same as Miller’s Directive and her Affiliative style is the same as Guiding. I will refer to Miller’s wording in this article. Summary of Each Style

Directive:

• Implies an uneven relationship- knowledge, expertise, authority or power
• The patient has a problem and you know how to solve it and what to do
• Cornerstone of current education
• Patients often expect it but it renders them passive in their recovery
• Done well- timed appropriately, personally relevant, clear and compassionate
• Done poorly- it can leave the patient feeling unheard and dissatisfied

NOT USEFUL WHEN BEHAVIOURAL CHANGE IS NEEDED

Guiding:

• The clinician knows what’s possible and can offer alternatives
• “I can help you solve this for yourself”
• An acceptance that the patient is the expert on themselves
• It requires letting go of some control but not a lack of influence
• It is goal-directed but guides the patient to consider how and why they might want to pursue a
goal
• Aims to evoke ambivalence
• Actively seeks to evoke the patient’s own argument for change

REQUIRES ATTENTIVE LISTENING SKILLS

Following

• It is easy and often used with a distressed patient
• It is often used at the beginning of a consultation
• There is no agenda other than to understand the world through another’s eyes
• When used well it allows the patient to tell their story and what’s important to them
• When used poorly it is time consuming and non-specific

Clinicians typically have a default style of consulting and never considered the value of adjusting. Commonly the default style for most clinicians is ‘Directive’ as this is the way they have been taught. That is to assess the problem and tell the patient what they need to do to get the improvement they’re looking for. A ‘Directive’ style of consulting works extremely well in the management of acute injury and with highly motivated patients. It starts to become less effective as long-term rehabilitation progresses or in the management of chronic injury or illness. Here patients have often been told by others what to do or are aware of what they need to do but struggle to take action. Miller’s ‘Following’ style is most effective in the management of patients in a highly emotional state. These emotions may include but are not limited to anger, frustration, sadness, hopelessness or depression. With these patients time is well spent early to understand what has caused or contributed to the strong emotion, before any thought is given to providing education.

The initial aim is to modify somewhat the presenting emotion before continuing with management. The main difference between ‘Guiding’ and ‘Directive’ is the former style is aimed at eliciting from the patient what they can commit to and how they are doing to put the agreed plan into place. This is in contrast to telling the patient what to do and expecting them to comply. Lack of action is often not a lack of information but a lack of consideration of why they might want to do the exercises and how they will manage to fit them in.

Psychological Reactance

Thinking of all the reasons why not to change is a natural response to being told what to do. It’s called ‘psychological reactance’ (3). Hence telling patients what they need to do especially if this advice requires behaviour change is often met with resistance. As the clinician tells the patient what they need to do they will either be verbalising or thinking of all they reasons why they can’t implement the suggested changes. The clinician will be met wit excuses as to why the agreed plan has not been followed when they come in for the next treatment. This situation is unhelpful to both parties. To avoid psychological reactance the clinician needs to ask questions that have the patient
thinking into the future. These questions include:

• “Why might you want to…. (insert desired behaviour)?
• “What needs to happen for you to fit these exercises in?”
• “How might you get these exercises done?”

In each question the patient will considering the day or week ahead and how they will implement the changes required. ‘Might’ is a powerful word in asking these questions as it implies that the patient doesn’t need to do anything. The choice is up to them. “Might” takes away the pressure of having to change. How will this benefit the clinician?
By assuming the patient is the expert on themselves your role is modified to that of a coach or mentor rather than and educator. Honest answers to these questions can help both parties be realistic about treatment outcomes. Also the time frame for these to be achieved when taking into consideration the commitment the patient is prepared to make.

The Influence of Habit

When providing patients with information how often do you consider the influence of habit? Motivation, guidance or education may get your patient started, but habit will determine whether the new behaviour will be sustained. When seeking treatment, it is logical to assume that the patient is going to have to implement some form of behaviour change. From the patient that’s never exercised before to athletes who exercise regularly but now find they have to do remedial exercise. In both cases change is
required. To increase the success rate of education and rehabilitation, know your patient’s current and previous habits. If your patient has never exercised or had a really bad experience with exercise, your first role may be in helping them create a new habit that will be effective. It’s imperative that you support the patient in creating the habit rather than telling them what to do. Habits that work for you or others may not necessarily work for every patient. If your patient exercised in the past but not recently, then find out what worked well for them. You can use this strategy to reform a habit that will help them be successful now. If your patient exercises regularly your challenge will be to get them thinking about how they will implement new exercises into an already packed program. Persuading this patient to adapt their program can be as challenging as helping a patient create a new habit. Physiotherapists have been taught to assess, diagnose, treat and give advice. This system works extremely well for the highly motivated patient. With the increase in management of more chronic conditions this system may need some adjusting on the part of the clinician to better engage these more resistant patients.
The challenge is on the clinician to adapt to the changing demands of clinical practice rather than expecting the patient to change previously entrenched behaviour just because they are seeking medical support.

If you are willing to adjust the way you consult with various patients and acknowledge that the patient is the expert on themselves, you may well succeed in helping them where others have failed.

Bibliography

1 “Motivational Interviewing” William R. Miller and Stephen Rollnick
2 “The Relevance Of Non-Verbal Skills In Physiotherapy” Susan Hargreaves. The Australian
Journal of Physiotherapy. Vol. 28, No. 4, August 1982
3 “Understanding Psychological Reactance: New Developments and Findings. Christina Steindl,
Eva Jonas, et al. Zeitschrift für Psychologie 2015; Vol. 223(4):205–214

Blog by Annette Tonkin – Thinking Physio