"I know I am ready to give feedback when I'm ready to listen, ask questions, and accept that I may not fully understand the issue" - Brené Brown
You will be hard-pressed to find a clinical practice guideline that does not recommend patient education; it is one of the cornerstones of the field of healthcare. Education comes in many different forms and levels of effectiveness. If you have an MD behind your name, chances are, anyone over the age of 60 treats your word as the law that cannot be refuted. Conversely, for people under 30, your MD carries weight than that random post they saw on their newsfeed 3 weeks ago (DPT likely doesn’t even register as worthy of consideration).
There are many areas of patient education to tackle. What are the best methods of delivery, how long and how frequent (yes, we will return to the spacing effect), when is it used in isolation and when is it an adjunct treatment? While many forms of education are beneficial, we will struggle immensely if we expect patients to cling to every word we utter and change their behavior the moment they walk out the clinic door.
What is motivational interviewing?
Motivational interviewing is a “person-centered method of guiding to elicit and strengthen personal motivation for change”.[1] Essentially, it is the art of responding to your patient rather than vomiting information. The communication is empathic and person-centered with special attention focused on the patient’s own verbalized motivations for change. If a patient is not seeking change, every treatment session will be an uphill battle. Note seeking change in behavior and seeking results – such as being pain-free – are not the same thing. The key is to have the patient voice the arguments for change rather than the clinician. When done correctly, the results are promising.
Studies have shown motivational interviewing significantly improves retention and motivation for change six months post plan of care.[2] The improvements have been demonstrated in a variety of patient populations as well, including patients seeking care for cardiovascular rehabilitation, diabetes management, dietary change, hypertension, illicit drug use, infection risk reduction, management of chronic mental disorders, problem drinking, problem gambling, smoking, exercise/activity level, and concomitant mental and substance use disorders.2 Furthermore, the outcomes are even greater when motivational interviewing is paired with another active treatment.
Promote 'change talk' and discourage 'sustain talk'
So how is it done? An integral component to promoting behavioral change is having patients verbalize arguments for change, which is referred to as “change talk”. Depending on the patient and attempted behavior change, the amount, intensity, and sequence of change talk can vary. On the flip side, when a patient utilizes “sustain talk” they are strengthening the current behavior. The goal is to increase change talk while minimizing sustain talk. Here are some examples:
Sustain talk: Every time I try exercising, I hurt more. I have tried all the recommendations you gave; I’ve heard it all before. Exercise simply doesn’t work for me.
Change talk: It would be nice to have more energy and be able to go on walks with my dog again. I guess I can set aside 5 minutes a day for the exercises you suggested.
Small wins are still wins, and you can build off them. Bear in mind, your frequency of change talk, as the clinician, of verbalizing one or the other does not yield nearly the same results. You must get your patient to verbalize the change. The behavior change you are seeking will be directly related to the patient’s change talk during a treatment session, and inversely related to sustain talk. After all, the purpose of patient education is for behavior change as opposed to a list of ‘fun facts’ that allow you to check the patient education box. So how do we enhance change talk?
There are several components of motivation needed for change: desire, ability, reasons, need, and commitment.[2] The strength of these components can reliably predict the strength of the commitment but not the actual change. Basically, they prime the individual for change. Motivational interviewing can extract statements from a patient that express desire, ability, reasons, and need for change which in turn strengthens the commitment to change. With respect to change-talk, “action-oriented” speech has stronger correlations with follow-through and maintenance of the targeted behavior change.[3]
Patient education should have a plan and a structure, similar to exercise. Frequency, intensity, and mode all vary depending on the readiness of the patient. Additionally, it is not a linear progression. If you find a patient is using more sustain talk and less “action-oriented” change talk, you may need to take a step back and re-evaluate the situation.
Resistant to change is common, don't force It
So, what happens if a patient has no interest in changing? How do you increase the odds of change talk occurring? Glad you asked. It is an answer that is used frequently and is at the heart of any successful treatment intervention: the patient-therapist relationship. A key to the therapeutic alliance is the therapist’s empathic thinking skillset. Often times a patient may feel judged, frustrated, trapped, or incapable of change. If we develop cookie-cutter strategies, attempt bulldozing through the session and forcing down education, or ignore the individual concerns of each patient, we will struggle to transfer any knowledge or change behavior in the slightest. If patients are to fully explore the possibility of change and develop sound strategies, they require an atmosphere of safety and acceptance. This is accomplished through accurate empathy, congruence, and positive regard in every session and every encounter.
Traditional patient education approaches operate in an authoritative and educational framework with a predominant one-way communication. Patients express their issues (and maybe their goals) and the clinician tells them what changes need to be made (which are often incomplete and ignoring lifestyle concerns, such as diet). Even if your patient education is fully comprehensive and addresses every possible concern contributing to the patient’s current condition and goals, a one-way communication style will have little effect. The beauty of motivational interviewing is that it places responsibility on the patient to change their behavior and facilitates patient reflection. The simple act of establishing autonomy free of guilt and judgment frees the patient, and significantly increases the likelihood of a joint effort to create change. Clinicians can use open-ended questions and reflective listening to empathize and affirm the patient’s strengths, resources, and achievements, which will enhance the patient’s belief they can change.[1]
Tell me if you have heard this before: You need to listen to you patients
Not that we have a theoretical framework in place, how do we apply MI? For the purpose of this post, I’m focusing on big picture items, as there are many strategies – such as rolling with resistance – that can be used.
While there are several ways motivational interviewing proponents may construct a single session or plan of care, I like to use the three core tasks of explore, guide, and choose.[4] During the “explore” phase, focus on open-ended questions, listening, shared goal setting, building trust, and double-sided reflections. As you start employing motivational interviewing into your repertoire, realize open-ended questions are your greatest ally. However, open-ended questions are nearly useless without another critical skillset: listening.
There are few ways to torpedo a relationship quicker than failing to listen to someone. A powerful tool in the explore phase is reflective listening, in which the clinician demonstrates they have heard and are trying to understand the patient, affirm the patient’s thoughts and feelings without judgment, and help the patient continue the process of self-discovery. You will then move into the “guide” phase.
Your goal as a clinician is to elicit change talk through guiding the conversation. While there are many strategies for this, a simple one is to ask the patient to consider life with and without change and build a discrepancy between the patients’ current actions and his or her goals and values. If they want to improve strength and endurance, what are the actions needed and what are the actions being performed currently? A crucial caveat is to NOT shame or judge the individual under any circumstance. This is a BIG no-no.
So you're telling there's a chance
Now, if you want to gauge the patient’s progress, you can use a confidence ruler. Basically, you are asking the patient to express their confidence in their ability to execute the discussed change. Here is a simple way of applying the confidence rulers:
“On a scale from zero to ten, with ten being the highest, how important is it to you to change [insert target behavior]?”
“On a scale from zero to ten, with ten being the highest and assuming you want to change this behavior, how confident are you that you could [insert target behavior]?”
“Why did you not choose a lower number, like…?
“What might it take to get you to a higher number, like…?”
Boom! That easy. And last, but not least, we have the “choose” phase.
The primary objectives include assisting the patient in identifying a goal(s), building an action plan, anticipating barriers, and agreeing on a plan tracking change.
Resist the urge to give advice
As I wrap up, I want to highlight a couple of areas clinicians often stumble and create setbacks (or even lose the relationship altogether). The first common mistake to avoid is pushing forward regardless of the patient’s readiness for change. You may have used all the strategies under the sun and performed admirably. The simple fact is the patient’s readiness trumps all.
Studies continually demonstrate drops in commitment level and poor outcomes when a therapist pushes ahead regardless of the patient’s feedback or readiness to change. As stated before, the progression is frequently undulating, and a skilled clinician acknowledges and responds to the within and between session fluctuations.
The second frequent misstep is allowing the advice monster to rear its ugly head. This can apply to many facets of education (mentoring, student internships, coaching, etc.), but for now, I will focus on patient education. If you are seeking to effectively employ motivational interviewing in your treatments, then you must master your ability to suppress the instinct to immediately dazzle patients with your vast knowledge and provide premature advice. Patients are biased, and they often ask what they think the clinician wants to hear or the direction they want the conversation to go. Additionally, immediate advice and telling someone what to do may lead to resistance or pseudo-commitment.[1] Instead, dive deeper and ask the patient their thoughts on the question. Have them provide answers and only provide your advice as a last resort, once you can safely weed out the bias and know the patient has a genuine desire for an answer.
Communication is a skill and it takes practice
I have expressed this in many previous posts and will continue to in the future, this takes practice. When picturing practice with respect to rehabilitation, we often draw up images of tasks utilizing our hands (e.g. manual therapy and assessments). As we continue to dive into the literature and review new material, it has become more evident that the ability to facilitate lifestyle behavior change is a vital skillset of a clinician.
Education and exercise are typically large components of a plan of care and require practice themselves. However, if a patient is going to sustain improvements gained throughout a plan of care, or even achieve those changes in the first place, they must develop behavior changes. Whether it be exercise, sleep, nutrition, or stress management, you and your patients will likely find significantly more successful if you are able to employ motivational interviewing and develop a truly collaborative approach to treatment.
References
Resnicow KM, F. Motivational Interviewing: moving from why to how with autonomy support. International Journal of Behavioral Nutrition and Physical Activity. 2012;9(19):1-9.
Miller WR, Rose GS. Toward a theory of motivational interviewing. Am Psychol. 2009;64(6):527-537.
Gaume J, Gmel G, Daeppen JB. Brief alcohol interventions: do counsellors' and patients' communication characteristics predict change? Alcohol Alcohol. 2008;43(1):62-69.
Rollnick S, Miller W, Butler C. Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York: Guilford Publications; 2008.
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