Physiotherapy, physical therapy – the name itself is deceiving.
It sets up a misconception. Physiotherapists help with physical problems (muscle injuries and such) using physical modalities (massage and exercise, for instance).
Using a physical approach will work sometimes (with varying degrees of success). But other times, physical therapy will miss the mark completely.
We, as physiotherapists must do two things (continually) to address the physical fallacy:
- Set (or, reset) expectations – We’ll need to use our ‘expected’ skills to win the patient over. Then, once we’ve established rapport we must gradually explore what the patient knows about physiotherapy. Then, we must gradually fill in their blind spots
- Upgrade our non-physical skills – It’s important that we broaden our expertise and bulk up our ‘soft’ skills. This means looking towards and learning from fields like psychology
What motivates you?
Motivational interviewing is one such technique that would be an excellent addition to any physiotherapists tool kit. So, what is it?
An approach that helps patients explore and restore their mixed feelings towards behaviour change
Motivational interviewing is based on the ‘stages of change’ model:
Where to start?
Firstly, the method that we take with a patient varies depending on where they’re at. Let’s take a person who is in the ‘contemplating‘ stage:
Contemplating person: “I know that exercise is important. But I don’t think it will help with my back pain. I’ve had it for so long.”
Physio: “It’s great that you recognise the importance of movement. You’re right – it’s so beneficial. I’m interested to know what you believe to be the benefits of exercise.”
CP: “Well, I know that it can help to make you fitter and stronger. Obviously, there’s the enjoyment factor too – depending on how you choose to exercise.”
P: “That’s great insight. It makes your body more resilient, as you said. So, would you say that even without it helping your back pain, exercise would have a positive effect on your health and life?”
CP: “Huh. I guess I didn’t think about it that way. But yeah, it probably would. Plus, I’ve been missing golf so much. Not just the sport but spending time with my buddies too.”
Pros and cons
The motivational interviewing process is about facilitating introspection. Why are they behaving that way? What do they gain (short term rewards)? What do they lose (long term benefits)?
Using the example above, let’s explore what the contemplating person could gain and lose from their non-exercise approach to managing their pain:
Physio: “I’m interested in what you get out of not exercising for your health and back pain. What are the benefits for you?”
Contemplating person: “Hmm. To start with, there’s less exercise soreness! The type you get after not doing something for a while.
Also, exercising or playing a game of golf takes time.
And, I don’t know… It makes me feel like I’m not in charge of my back pain. It sort of takes the responsibility off me. It sounds kind of silly now that I think about it.”
P: “So, you get less exercise pain, more time and less responsibility by not exercising. What do you think you lose by not exercising often?”
CP: “I haven’t thought about that. I think I try to drown it out.
Less exercise makes me feel less healthy, I probably won’t live the longest and my back pain will stay the same”
Food for thought
Now, the contemplating patient has more to think about.
The ‘benefits’ of his current approach are rather trivial. And conversely, he’s losing out on a lot.
He has pointed out to himself the flaws in his thinking which will drive more contemplation. He’s now more open to strategies and suggestions to get back to exercise.
What do we need?
Skills for effective motivational interviewing:
Understand the patient’s frame of reference
Where are they on the ‘stages of change’ model? Are they pre-contemplating or contemplating?
Questioning their beliefs can help reveal this. If we asked a patient about their exericse thoughts and they responded with:
“It’s useless. Exercise has only made me feel worse.”
Then, they’re in the pre-contemplating phase. We can use this knowledge to tailor our next question (“So, you’ve had some bad experiences with exercise. Tell me about them.”)
Reaffirm when a patient makes a positive statement about change.
When the contemplating patient mentioned that, ‘Exercise is important,” make it clear that it’s an accurate statement that you agree with. It will strengthen their belief. The patient will start asking, “If exercise is so important, why don’t I do it?”
Dampen and redirect unhelpful beliefs
There are two ways to tip a patient’s beliefs towards a more positive outlook. By boosting their exisitng positive beliefs (‘amplifying positivity’) and by tempering their negativity.
Don’t use confrontation here (it will backfire!). Instead, try to make them see the holes in their current unhelpful beliefs. This is what the physio did when discussing the downsides of exercise with the contemplating patient.
“And, I don’t know… It makes me feel like I’m not in charge of my back pain. It sort of takes the responsibility off me. It sounds kind of silly now that I think about it.”
Now, the contemplating patient can see that his belief about exercise and back pain is nonsensical. He’s not far from changing his perspective.
How do I apply this?
The table below is a guide for how to tailor your approach based on where your patient’s sits in the stages of change:
|Pre-contemplation||– Increase their doubt by challenging (be subtle!) their existing beliefs|
– Increase their perception of the risks with their current behaviour
|Contemplation||– Explore their mixed feelings towards change and make them look for alternatives in their ways of thinking|
– Address the pros of changing and the cons of not changing
– Build their confidence through affirmation of positive statements
|Determination/action||– Set a goal and develop a realistic plan to achieve the goal|
|Maintenance||– Identify (and put into place) strategies to prevent relapse|
|Relapse||– Discuss that a relapse is a learning opportunity|
– Re-affirm why they made changes in the first place. Remind them of the rewards of change and the costs of not changing
Is this working?
How do we know if our motivational interviewing is working? Below are a few signals to look out for:
- A low level of resistance from the patient (i.e. a general openness to the questioning and conversation)
- A greater amount of helpful statements (‘I want to change’) relative to unhelpful statements (“I don’t want to change”)
On the contrary, the signs below tell us what we’re doing is not working:
- Anger and aggression from the patient
- Avoiding or re-directing of the motivational interviewing questions
- The patient tries to control the session
You’re right in thinking that motivational interviewing will work with some of your patients and not with others.
You’re also right in thinking that this article only touches the surface of this technique. The aim of this post is to make it clear that:
- We must build on our psychological skill set
- Motivational interviewing is one way to do this
- Motivational interviewing is not a set series of questions. Rather, it is a framework that let’s you understand your patient’s beliefs (and how they’re impacting on their behaviour)
- Then, questioning your patient in a way that makes them look within themselves to uncover (and, eventually, correct) faulty thoughts (and, therefore, behaviours)
What are your thoughts on motivational interviewing? Is it something you’ve tried? Did you succeed or fail? What did you find worked and didn’t?
Leave a comment below!