Patients’ lack of action is often not due to lack of information. Information whether it be correct or misleading can be sourced in numerous ways. So who needs to make the adjustments when compliance is not working?
It’s common for clinicians to assume that patients who go to see a health practitioner want to do whatever is necessary to improve their situation. In the management of acute and serious injury, or in post-surgical visits, this is often true.
However, increasingly, clinicians are seeing patients with chronic injuries, or physical injuries related to obesity, diabetes, lack of exercise, and other chronic illnesses.
These patients often have varying degrees of enthusiasm for education and for rehabilitation programs. Wanting to get improvement and doing what is necessary to get that improvement are often poles apart. What happens in the management of injuries or illness when the patient is struggling to adhere to recommendations?
Clinicians find it extremely frustrating to manage patients who say they want improvement but whose compliance doesn’t reflect their desire for the outcome they claim to want. This dilemma in what the patient is doing versus what they need to do was an ongoing struggle for me when working as a clinician.
When managing more challenging patients and challenging conditions, and particularly when attempting to engage them in education, clinicians might consider these three things: (1) adapting consulting styles, (2) recognising psychological reactance, and (3) the influence of habit on behaviour.
Consulting Styles
The expectation that the patient should be the one to adjust behaviour can lead, at best, to frustration or to a sense of hopelessness on the part of the clinician.
If clinicians are prepared to take on the responsibility of adjusting their consulting style when they encounter resistant patients, there is a reasonable chance that these patients will respond differently.
William Miller, the co-founder of Motivational Interviewing once said:
“A lack of motivation is a therapist’s problem, not the patient’s problem.”
This statement will be a huge paradigm shift for many clinicians, as it was for me. For those who are prepared to make the shift, they will make available to themselves a number of options to help them help their patients. One of those options is adjusting your style of consulting.
So, what does it mean to adjust your consulting style?
Various Consulting Styles And Their Impact
William Miller and Stephen Rollnick have found three distinctive consulting styles that have proved effective in managing the different emotional states in which patients present: directive, guiding and following.
Susan Hargreaves (1982) found two styles of consulting, which she described as: ‘dominant’ and ‘affiliative’. The dominant style is the same as Miller and Rollnick’s directive style and the affiliative style corresponds with Miller and Rollnick’s guiding style. I will refer to Miller and Rollnick’s terms in this article.
Summary Of Each Style
Clinicians typically have a default style of consulting and rarely consider the value of adjusting.
Directive Style
• is the cornerstone of current education
• implies an uneven relationship: the clinician has the knowledge, expertise, authority or power
• the patient has a ‘problem’, which the clinician knows how to solve
• patients often expect it, but it renders them passive in their recovery
• done well, and timed appropriately, it can be personally relevant, clear and compassionate
• done poorly, it can leave the patient feeling unheard and dissatisfied
• it is not useful when there is a need for behavioural change.
For many clinicians a directive style is the default – the way they have been taught. They assess the problem and tell patients what they need to do to get the improvement they are looking for.
A directive style of consulting works extremely well in the management of acute injury, with highly motivated patients and often with the elderly.
It becomes less effective as long-term rehabilitation progresses, and in the management of chronic injury or illness. In these cases, patients have often been told what to do by others, or they are aware of what they need to do but struggle to take action.
Guiding Style
• the clinician knows what is possible and can offer a range of alternatives
• requires the clinician to let go of some control, but still retain influence – (eg, I can help you solve this for yourself)
• implies acceptance that patients are the ‘experts’ on themselves
• is goal-directed, but guides patients to consider how, when and why they might want to pursue their goals
• aims to evoke ambivalence, a common cause of a lack of action
• actively seeks to evoke each patient’s own argument for change, thereby resolving the ambivalence
• requires attentive listening skills.
A guiding style contrasts with a directive style mainly because it aims to elicit from the patients a plan they can commit to, and how they will put the agreed plan in place. This is quite different from telling patients what to do and expecting them to follow those directions.
Patients’ lack of action is often not due to lack of information, but rather because they have not considered why they might want to do the exercises and how or when they will manage to fit them in.
Following Style
• is easy and often used with a distressed or highly emotional patient
• is often helpful at the beginning of a consultation
• has no agenda other than to understand the world through another’s eyes
when used well, it allows patients to tell their story and talk about what’s important to them
• when used poorly, it is time consuming and non-specific.
Miller and Rollnick’s following style is most effective in the management of patients in a highly emotional state. These emotions include, but are not limited to, anger, frustration, sadness, hopelessness and depression. It is advisable to spend time with these patients and understand what has caused or contributed to their strong emotions, before thinking about providing education.
Patients or for that manner, anyone in an highly emotional state will not hear what you are saying.
There is a saying which goes:
“You said, I heard.”
The difference in what is being heard by the patient is being filtered by the emotion. This can lead to a communication breakdown.
The initial aim is to modify the presenting emotion somewhat, before continuing with management.
Psychological Reactance
A natural response to being told what to do is to think of all the reasons not to make any changes. This is called psychological reactance . Therefore, when clinicians tell patients what they need to do, especially if the advice requires behavioural change, they are often met with resistance.
Even as they are hearing what they need to do, patients either verbalise, or think of, all the reasons why they can’t implement the suggested changes. Then, when they come in for the next treatment, they give clinicians the excuses as to why they have not followed the agreed plan. This situation is unhelpful to both parties.
To avoid psychological reactance the clinician would benefit from asking questions that lead patients to think into the future.
Some examples are:
• why might you want to (insert desired behaviour)?
• imagine you (insert desired behavior), what would the positive outcomes be?
• what needs to happen for you to fit these exercises in?
• how might you get these exercises done?
Each question requires patients to consider some time into the future, how they will implement the changes required and why it might be important to them.
‘Might’ is a powerful word to include in these questions. It implies that patients don’t have to do anything; the choice is theirs. ‘Might’ takes away the pressure of having to change.
How do these questions benefit the clinician?
By assuming patients are the experts on themselves, the clinician’s role is modified to that of a coach or mentor, rather than an educator. Honest answers to these questions can help both parties be realistic about treatment outcomes. They also establish a time frame for outcomes to be achieved, taking into consideration the commitment the patient is prepared to make.
These questions also go some way to minimise the influence of psychological reactance
The Influence Of Habit
When you provide patients with management recommendations, how often do you consider the influence of habit? Motivation, guidance or education might get your patient started, but habit will determine whether or not the new behaviour will be sustained.
When patients seek treatment it is logical to assume they must implement some form of behavioural change. Whether they are patients who have never done what you are asking before, or athletes who regularly train but now find they have to do remedial work, some change is required.
To increase the success rate of education and rehabilitation, it’s important to know your patients’ current and previous habits. If they have never performed your recommendation before, or had a really bad experience with it, your first role might be to help them create new and effective habits. It’s imperative that you support patients as they create the habit, rather than tell them what to do. Habits that work for you, or for others, might not necessarily work for every patient.
If patients have exercised in the past, but not recently, then find out what previously worked well for them. You can use this strategy to reform a habit that will help them be successful now.
For patients who exercise regularly, your challenge will be to get them thinking about how they will incorporate new exercises into an already packed program. Persuading this type of patient to adapt an existing program can be as challenging as helping a patient create a new habit.
Clinicians are taught to assess, diagnose, treat and give advice. This system works extremely well for the highly motivated patient. With the increase in management needed for more chronic conditions, clinicians might need to make adjustments to this system, so as to engage resistant patients more effectively.
The clinician’s challenge is to adapt to the changing demands of clinical practice rather than expect the patient to change previously entrenched behaviours, just because they are seeking medical support.
If you are willing to adjust the way you consult with various patients, and to acknowledge that patients really are the experts on themselves, you might well succeed in helping them where others have failed.
1 Miller, W. R. & Rollnick, S. (2012). Motivational Interviewing: Helping People Change. New York: Guildford Press
2 Hargreaves, S. (1982). “The Relevance Of Non-Verbal Skills In Physiotherapy”. The Australian Journal of Physiotherapy, 28(4)
3 Steindl, C., Jonas, E. et al. (2015). “Understanding Psychological Reactance: New Developments and Findings”. Zeitschrift für Psychologie, 223(4), 205–214
