Wellfie Wednesday Tip #62: It Starts with a Conversation

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     Happy #WellfieWednesday everyone! In today’s tip, @AaronPerezPT is back with more change talk. His two previous posts discussed #ScienceSecretsToHealth and #SixSourcesOfInfluence. The major takeaways from those were:

  • Knowledge alone does not translate to behavior change
  • Behavior change is hard partly due to the many factors that influence our behaviors

     There is plenty of hope though. Although knowledge alone is unlikely to transform behavior, Knowledge is still powerful. For example, low health literacy is associated with poorer health outcomes and worse healthcare utilization. Furthermore, creating a comprehensive change plan that addresses the six sources of influence makes the chance of success with behavior change 10x more likely.  So, helping others with behavior change is still very possible and worthwhile. And it starts with a conversation.

Motivational Interviewing (M.I.)

     I’m no expert at motivational interviewing. Actually, at a mere two years into my career, I’m not an expert at anything. Nevertheless, I’m grateful for having learned a little bit about M.I. over the past year. I truly believe in the power of this awesome skill. And today, I’d like to share some of that with you.

Start with WHY (Importance)

     Behavior change discussions can be challenging, but they can also be crucial. I don’t find many of my patients coming to see me as a physical therapist expect to have behavior change discussions. This can make broaching these conversations all the more challenging, and yet all the more enjoyable and effective. One strategy in motivational interviewing is to find out why, without asking “Why…?” Also, it’s good to use open ended questions. This is easier said than done. So, it’s helpful to have some go-to questions.

“If could do one thing this year to make it the best year ever, what would it be?”

     I have to credit my friend/boss @mikerjrpts for that one. I love this question for a couple reasons. First, it’s a BIG question. It’s really asking the patient to reflect on what is really important in their life. Importance is one of the ingredients of readiness. Secondly, it’s unexpected. Sometimes, patients will struggle to come up with an answer. That’s perfectly fine. By just asking the question, I hope I’m changing the patient’s expectations. I hope they are surprised. I hope they think that this healthcare experience will be something unlike any other. That can be very important for patients who have seen multiple healthcare providers without much improvement, and therefore come in with negative expectations. I’ve also been surprised by some answers. For instance, I recall one patient with shoulder pain answering “To quit smoking for good.” It’s hard to imagine a more impactful response and behavior to address. 

     The most vital part of motivational interviewing is listening. Ideally, you won’t have to broach the topic. The patient may do so themselves. Listen for change talk. These are words or phrases that highlight a patient’s desire for change. Then, reflect back to the patient what you are hearing. Be curious, not critical. Also, avoid should statements. Don’t “should” on your patients. That would stink.

The Scale Game

     After exploring motivations and determining a goal, it can be useful to have the patient rate the importance of their goal. Or play what I call, “The Scale Game.” Ask, “On a scale of 0 to 10, 0 being not important at all, and 10 being the most important thing in your life, how important is this goal to you right now?” I’ve never had a patient say zero, and it seems unlikely they would since they self-identified the goal. There are strategies if they do say zero. But, for the sake of brevity, I’m going to break one of the principles of M.I. and assume the patient says any number 1-10. My follow question then is, “That’s great. What makes it ___fill in with number patient said___ and not 0?” The objective here is to have them reflect on their motivations in relation to competing desires. Take note of any pros and cons the patient identifies.

Great, now HOW? (Confidence)

     The second ingredient to readiness is confidence. As mentioned earlier, knowledge alone is not enough to change behavior. We need skills too. A supportive environment is also tremendously helpful, but that’s another post for another time. Let’s imagine the patient has self-identified a goal. And that goal is really important to them. Now, the question is, “On a scale of 0 to 10, how confident are you that you will be able to accomplish your goal?” Again, let’s commit a cardinal sin of M.I. and assume they answer any number other than zero. If you’re following along, you know what’s next. The follow-up questions is, “Fantastic. What makes it ___fill in with number patient said___ and not 0?” The objective here is to have them reflect on their ability to accomplish their goal. Make note of any barriers and facilitators that the patient identifies.

Don’t Be a Hero.

     The last step in M.I. is to summarize the conversation succinctly and clearly, ideally using the patient’s words. Again, this is much easier said than done. It may help to break it up into steps. Start with the status quo, or the default future if no change is made. Follow with the expressed motivations for change, both pros and cons. Finish with identified barriers and facilitators to success. Then ask, “So, where does that leave you?” In other words, allow the patient to analyze the data and make a decision. Is it time to change? Maybe so, maybe no. Either way, it’s okay.

     Let’s again assume the patient is ready to change. Now what? Here is another excellent opportunity to empower the patient. Encourage them to create their own solutions. They will be more likely to follow through with them when they do. More often than not, the person most excited about your idea is you. So, let the patient be the hero. One way to do this is to ask, “Given all we’ve discussed, what do you think is one thing you can do starting today to help you make progress towards your goal?” This is my favorite way to prescribe home exercises, which don’t always have to be home exercises. I recall one patient answering, “I’m going grocery shopping once I leave here.” Maybe she was already planning on that though ¯\_(ツ)_/¯.

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Summary

Do’s of M.I.:

  • Ask open-ended questions
  • Listen intently and reflectively
  • Be genuinely curious
  • Empower the patient

Don’ts of M.I.:

I strongly believe M.I. is a worthwhile skill to continually refine because it:  

  • Enhances therapeutic alliance
  • Improves patient expectations
  • Empowers the patient / boosts self-efficacy

I think we can all agree these are things we strive for in every patient interaction regardless of specialty or setting.

     I hope one take away from this post is that motivational interviewing is a nuanced conversation that can take significant time to do well. For that reason, I believe it is one of the most vital skills a physical therapist can have. Not only for the reasons listed above, but because we have the number one asset, time. Chronic disease is the leading physical and financial global health burden. It is largely preventable and even reversible through lifestyle intervention. This solution requires behavior change. Change is hard. And it starts with a conversation. 

     As always, thanks for all of the #WellfieWednesday support. And be sure to tag the WW crew members in your post (@PBernerSPT, @Eric_in_AmERICa, @AaronPerezPT, @DianaKlatt) and keep the wave of healthy change going!

- WW Crew