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| This article is currently under review and may not be up to date. Please come back soon to see the finished work! ({{REVISIONDAY}}/{{REVISIONMONTH}}/{{REVISIONYEAR}})
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| '''Original Editor '''- [[User:Robyn Holton|Robyn Holton]], [[User:Frank Ryan|Frank Ryan]], [[User:Shawn Swartz|Shawn Swartz]], [[User:Elaine McDermott|Elaine McDermott]], [[User:Noel McLoughlin|Noel McLoughlin]], [[User:Zeeshan Mundhas|Zeeshan Mundhas]] part of [[Current and Emerging Roles in Physiotherapy Practice|Queen Margaret University's Current and Emerging Roles in Physiotherapy Practice Project]] | | '''Original Editor '''- [[User:Robyn Holton|Robyn Holton]], [[User:Frank Ryan|Frank Ryan]], [[User:Shawn Swartz|Shawn Swartz]], [[User:Elaine McDermott|Elaine McDermott]], [[User:Noel McLoughlin|Noel McLoughlin]], [[User:Zeeshan Mundhas|Zeeshan Mundhas]] part of [[Current and Emerging Roles in Physiotherapy Practice|Queen Margaret University's Current and Emerging Roles in Physiotherapy Practice Project]] |
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| * Environment - Provide the patient with an area that is private and away from noise and interruptions | | * Environment - Provide the patient with an area that is private and away from noise and interruptions |
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| | == Communicating Sensitive Issues == |
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| == Communication When Addressing Persistent Pain Complaints == | |
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| === Introduction ===
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| Acute pain conditions have a very good rate of healing, but health care systems still find that a large portion of these patients go on to experience persistent pain and maladaptive behaviours .<ref name="Darlow et al. 2013" />,<ref name="Croft et al. 1998">Croft, P., Macfarlane, G., Papageorgiou, A., Thomas, E. and Silman, A. (1998). Outcome of low back pain in general practice: a prospective study. BMJ, 316(7141), pp.1356-1359.</ref> As a result Persistent Pain conditions place a huge strain on the healthcare system and economy .<ref name="Darlow et al. 2013" /> Modern pain research tells us that often patient beliefs play a huge role in the transition from acute pain to chronicity. By better understanding patient beliefs and positively influencing them with reassurance and compassion we can better manage patients perception of pain .<ref name="Darlow et al. 2013">Darlow, B., Dowell, A., Baxter, G., Mathieson, F., Perry, M. and Dean, S. (2013). The Enduring Impact of What Clinicians Say to People With Low Back Pain. The Annals of Family Medicine, 11(6), pp.527-534.</ref>,<ref name="Butler & Moseley 2003">Butler, D. and Moseley, G. (2003). Explain pain. Adelaide: Noigroup Publications.</ref><br>We know from nursing literature that pain is the most common reason for an individual to seek medical advice .<ref name="Nair & Peate 2012">Nair, M. and Peate, I. (2012). Fundamentals of Applied Pathophysiology. Chicester: Wiley.</ref> At times Healthcare Professionals can negatively impact patients beliefs about pain. It is common that some patients feel that their stories haven’t been listened to and consequently their pain is not validated .<ref name="Yelland 2011">Yelland, M. (2011). What do patients really want?. International Musculoskeletal Medicine, 33(1), pp.1-2.</ref><br>
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| === What is Pain? ===
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| Many believe pain is a simple sensation that you get after, lets say “closing the car door on your finger”. It’s easy to understand in a structural model of reasoning, which believes that the more pain you get the more tissue damage you are causing. Although it is not as simple as this, and much of the persistent pain that physiotherapists see on a everyday basis would not be adequately addressed by this model of thinking. Recent authors have indicated that pain could be a measure of potential threat rather than an indication of tissue health.<ref name="Moseley 2003" /><br> Lorimer Moseley’s 2007 paper “Reconceptualising Pain According to Modern Pain Science” suggests that :<ref name="Moseley 2007">Moseley, G. (2007). Reconceptualising pain according to modern pain science. Phys. Ther. Rev., 12(3), pp.169-178.</ref><br> [[Image:TABLE5pain.png|center|600x300px]]
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| If we look at the work of Louis Gifford and the Mature Organism Model <ref name="Gifford 1998" />(1998) we see that when we get a input nociceptive stimuli the nerve impulse travels to the brain and is sampled against a number of different factors such as:<br>
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| [[Image:Table 6. Pain Factors.png|border|center]]After the brain scrutinises all these unconscious pieces of information it asks itself, “How dangerous is this really?” Pain is a good thing and tries to protect our tissues, we as physiotherapists need to monitor if pain is adaptive or maladaptive .<ref name="Stewart 2014">Stewart, M. (2014). The Road To Pain Reconceptualisation: Do Metaphors Help Or Hinder The Journey?. Journal of the Physiotherapy Pain Association, Winter(36), pp.24-31.</ref><br>
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| [[Image:MatureOModel picture.png|border|center]]<ref name="Gifford 1998">Gifford L (Ed) (1998) Topical Issues in Pain 1: Whiplash – science and management. Fear avoidance beliefs and behaviour. CNS Press Falmouth.</ref><br>
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| === Every Chronic Pain Was Once Acute ===
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| As pain carries on the patient may become more anxious, stressed, helpless, sedentary, further reinforcing the brain’s choice to cause pain.<ref name="Moseley 2003">Moseley, G. (2003). A pain neuromatrix approach to patients with chronic pain. Manual Therapy, 8(3), pp.130-140.</ref>,<ref name="Gifford 2000">Gifford L S (Ed) (2000) Topical Issues in Pain 2: Biopsychosocial assessment. Relationships and pain. L. S. Gifford. Falmouth, CNS Press</ref>We often see a fire alarm that goes off from a piece of burning toast similarly our bodies alarm system can malfunction in much the same way if the body becomes hypersensitive..<br>More and more research is starting to look at pain as a disorder rather than a symptom. <ref name="Bourke 2014">Bourke, J. (2014). The story of pain. London Oxford University Press.</ref> Just as asthma, diabetes or epileptic patients are educated on the mechanisms of their disease and how their actions could make their condition better or worse. Persistent pain patients should be socratically introduced to their condition by facilitating dialogical critical thinking in a similar manner .<ref name="Yelland 2011" /><br>Often it can be easier to address peoples lack of care for their pain when patients have co-morbidities because physiotherapists are able to compare how poorly their pain is being managed. If we take a moment to look at Diabetes and persistent pain through the same lense, and imagine that doctors had a patient coming in every 3 days for an insulin injection and an overnight stay because they weren't managing their diabetes correctly there would be a problem. In a physiotherapy setting if a patient was coming into your clinic every 3 days for some manual therapy to decrease their pain while they otherwise poorly manage their condition, this would not be right. Some therapists are content with that, We shouldn’t be…!<br>
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| [http://giffordsachesandpains.files.wordpress.com/2013/06/biopsychosocial-part2.pdf '''Further reading Louis Gifford (2000) Shopping Basket Approach''']<br>
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| === Neuroscience Education ===
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| According to Louw et al. (2011) Neuroscience education is a cognitive based intervention that aims at reducing pain and maladaptive behaviours by guiding patients to grasp understanding of the mechanisms underpinning their pain experience.<ref name="Louw et al. 2011">Louw, A., Diener, I., Butler, D. and Puentedura, E. (2011). The Effect of Neuroscience Education on Pain, Disability, Anxiety, and Stress in Chronic Musculoskeletal Pain. Archives of Physical Medicine and Rehabilitation, 92(12), pp.2041-2056.</ref><br>This semi complex information needs to be delivered to the patient in a way that is clear and easy to understand. Language and other communication techniques such as drawings,pictures, videos, workbooks can aid patient learning. Research shows that traditionally clinicians tend to underestimate patients ability to understand complex pain, when in fact patients are very interested in learning about their pain .<ref name="Louw et al. 2011" /><br>Multiple studies have shown that Neuroscience Education combined with graded exercise is in line with the best evidence available for treating persistent pain.<ref name="Louw et al. 2011" /> Resulting in decreased fear, pain, cognition and physical performance, increased pain thresholds during exercises, and reduced brain activity(especially the amygdala) that is usually involved with pain.<ref name="Louw et al. 2011" /><ref name="Veinante et al. 2013">Veinante, P., Yalcin, I. and Barrot, M. (2013). The amygdala between sensation and affect: a role in pain. J Mol Psychiatry, 1(1), p.9.</ref><br>
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| <br> | | Primary care providers and particularly physiotherapists are often faced with sensitve issues within their daily practice. One example is dealing with obesity and encouraging patients to take a more active approach in the management of obesity<ref name="Stafford et al.2002">Stafford RS, Farhat JH, Misra B, Schoenfeld DA. National patterns of physician activities related to obesity management. Archives of Family Medicine. 2000 Jul 1;9(7):631.</ref>. However physiotherapists have encountered many challenges related to addressing obesity with patients<ref name="Alexander et al 2007" />. Given that obesity is becoming an epidemic in many nations throughout the world, the need to understand how, when and with whom to have these discussions which becomes essential in order to provide effective care for obese patients. There is a growing need for the training of physiotherapists in areas such as weight loss counseling in order to reduce the barriers encountered when discussing obesity <ref name="Alexander et al 2007">Alexander SC, Østbye T, Pollak KI, Gradison M, Bastian LA, Brouwer RJ. Physicians' beliefs about discussing obesity: results from focus groups. American Journal of Health Promotion. 2007 Jul;21(6):498-500.</ref>. |
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| [[Image:B2GG JFCEAAi7S1.png large.png|border|center|570x428px|Figure from Mike Stewart MCSP SRP PG Cert(Clin Ed) http://knowpain.co.uk/]]
| | Wadden & Didie<ref name="Wadden and Didie 2003)">Wadden TA, Didie E. What's in a name? Patients’ preferred terms for describing obesity. Obesity Research. 2003 Sep;11(9):1140-6.</ref> reported that patients observed the terms obesity and fatness to be very undesirable descriptors used by their physicians when discussing their body weight. Other terms such as large size, heaviness and excess fat were also highlighted as undesirable. The use of these terms by physicians can be interpreted as offensive or hurtful by the patient and lead to a breakdown in communication.<br>The study reported that weight was the most favourably rated term to be used by physicians as it is easily understood and non judgemental. Another term which was viewed as favourably, as it was non judgemental was BMI, however it is found to be not universally known. |
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| Figure from Mike Stewart MCSP SRP PG Cert(Clin Ed): '''Know Pain''' http://knowpain.co.uk/<br>
| | Johnson<ref name="Johnson 2002" /> reported that some patients preferred to be described as plus sized, large or even fat. By embracing these terms these patients are motivated to remove the negativity and stigma related to them.<br>Wadden and Didie<ref name="Wadden and Didie 2003">Wadden TA, Didie E. What's in a name? Patients’ preferred terms for describing obesity. Obesity Research. 2003 Sep;11(9):1140-6.</ref> reported the most beneficial approach would be to ask the patient how they feel and their thoughts towards their weight. Using this approach the physiotherapist should seek the patients consent and come to an agreement to address and discuss the issue. Caution should be taken to avoid reiterating the hazards obesity has to the patients health. Wadden et al<ref name="Wadden et al 2000">Wadden TA, Anderson DA, Foster GD, Bennett A, Steinberg C, Sarwer DB. Obese women's perceptions of their physicians' weight management attitudes and practices. Archives of Family Medicine. 2000 Sep 1;9(9):854.</ref>, reported obese patients often experience a feeling that care providers seldom understand how much they suffer with their weight issues. Utilising the conversation approach also allows the physiotherapist to show respect and empathy to the patient by focusing on the positive steps they may have taken previously to tackle the issue. <br> |
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| === Explaining Pain: How to Do it in Under Ten Minutes ===
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| === Clinical Example: Osteoarthritis ===
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| When explaining a condition such as osteoarthritis to a patient we must consider what their viewpoint of the condition must be. Osteoarthritis is a condition of cartilage degeneration, subchondral bone stiffening and active new bone formation<ref name="Heuts et al" />. <br>Osteoarthritis is a complex sensory and emotional experience. An individual’s psychological characteristics and immediate psychological contest in which pain is experienced both influence their perception of pain<ref name="Hunter et al" />.
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| Research has utilised qualitative methods and focus groups to establish the patient’s point of view. A common theme that is emerging is that patients are sometimes dissatisfied with the overall level of understanding, help and information that is given to them by healthcare professionals<ref name="Hill et al" />. Patients also expressed concern that there was a lack of understanding by healthcare professionals as to the impact that osteoarthritis can have on an individual’s life<ref name="Hill et al" />.
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| As physiotherapists, we must be aware of current and alternative treatments for OA (hydrotherapy, acupuncture etc) as contradictory information being given to the patient from different sources may lead to confusion as to what exactly they should be doing<ref name="Hill et al" />. <br>
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| Somers et al<ref name="Somers et al" />highlights that patients may adopt certain attitudes towards pain; Patients who are pain catastrophizing tend to focus on and magnify their pain sensations. This group of patients tend to feel helpless in the face of pain. Patients who adopt this stance report higher levels of pain, have higher levels of psychological and physical disability.
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| The second stance is patients who have pain related fear. They have a fear of physical activity as a result of feeling vulnerable to pain during activity. This group are more likely to engage in avoidance behaviours such as avoiding movement<ref name="Somers et al" />. <br>We as physiotherapists must remember that OA patients with a fear of engaging in painful movements may be hesitant to engage in physical activity. This can contribute to a vicious cycle of a more restricted and a physically inactive lifestyle which will lead to increased pain and disability<ref name="Somers et al">SOMERS, T.J., KEEFE, F.J., PELLS, J.J., DIXON, K.E., WATERS, S.J., RIORDAN, P.A., BLUMENTHAL, J.A., MCKEE, D.C., LACAILLE, L. and TUCKER, J.M., 2009. Pain catastrophizing and pain-related fear in osteoarthritis patients: relationships to pain and disability. Journal of Pain and Symptom Management. , vol. 37, no. 5, pp. 863-872.</ref>
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| Hendry et al<ref name="Hendry et al">HENDRY, M., WILLIAMS, N.H., MARKLAND, D., WILKINSON, C. and MADDISON, P., 2006. Why should we exercise when our knees hurt? A qualitative study of primary care patients with osteoarthritis of the knee. Family Practice. Oct, vol. 23, no. 5, pp. 558-567.</ref>conducted qualitative research on primary care patients with OA. They found that personal experience, aetiology of arthritis and motivational factors all influenced compliance rates towards physical activity. Some patients believed that their joint problems were a direct result of heavy physical activity<ref name="Hill et al">HILL, S., DZIEDZIC, K.S. and NIO ONG, B., 2011. Patients' perceptions of the treatment and management of hand osteoarthritis: a focus group enquiry. Disability and Rehabilitation. , vol. 33, no. 19-20, pp. 1866-1872.</ref>. This is where we as clinicians must be aware that patients may present questions such as;
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| '''‘why should we exercise when our knees hurt?’'''
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| In the same study patients were asking;
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| '''‘if it is wear and tear on the bone, is it helping to do all this exercise, walking and that?’'''
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| As physiotherapists we must be careful with our choice of words, phrases such as ‘wear and tear’ may be misinterpreted by some patients and lead to further maladaptive behaviour. Grime et al<ref name="Grime et al" />established that an ongoing concern of musculoskeletal professionals is that the use of this ‘wear and tear’ explanation often leads to decreased physical activity to avoid further ‘wearing of the joint’.
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| A unique approach adopted by a number of patients in the same study by Grime et al<ref name="Grime et al">GRIME, J., RICHARDSON, J.C. and ONG, B.N., 2010. Perceptions of joint pain and feeling well in older people who reported being healthy: a qualitative study. British Journal of General Practice. , vol. 60, no. 577, pp. 597-603.</ref>was the ‘use it or lose it’ approach. This simply put was use the joint or lose your functional ability. As physiotherapists we could utilise a similar approach to get our patients to comply with the physical exercise that we have prescribed as an intervention. Through effective communication we can increase a patient’s self efficacy and reduce their level of physical disability<ref name="Hunter et al" />. Patients with higher self efficacy for pain control had higher thresholds for pain stimuli<ref name="Hunter et al">HUNTER, D.J., MCDOUGALL, J.J. and KEEFE, F.J., 2009. The symptoms of osteoarthritis and the genesis of pain. Medical Clinics of North America. , vol. 93, no. 1, pp. 83-100.</ref>. Can we as physiotherapists use this to our advantage to increase patient’s compliance to exercise?
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| Exercise has been shown to have a positive effect on functional ability in patients with OA<ref name="Heuts et al" />. We as physiotherapists must consider the role of pain related fear in patients with OA and investigate different treatment approaches to combat this behaviour<ref name="Heuts et al">HEUTS, P.H., VLAEYEN, J.W., ROELOFS, J., DE BIE, R.A., ARETZ, K., VAN WEEL, C. and VAN SCHAYCK, O.C., 2004. Pain-related fear and daily functioning in patients with osteoarthritis. Pain. , vol. 110, no. 1, pp. 228-235.</ref>.<br>
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| [[Image:Avoidance model 2.PNG|border|right|300x300px]]
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| Scopaz et al<ref name="Scopaz et al" />suggests psychological factors such as anxiety, fear and depression may also be related to physical function in patients with OA of the knee.
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| Further to this, a model of fear avoidance suggests that patients can either be adaptive and non-adaptive in their approach to their pain and functional ability<ref name="Scopaz et al" />
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| This model indicates that anxiety + fear avoidance beliefs are significant predictors of self report physical function in patients with knee OA<ref name="Scopaz et al">SCOPAZ, K.A., PIVA, S.R., WISNIEWSKI, S. and FITZGERALD, G.K., 2009. Relationships of fear, anxiety, and depression with physical function in patients with knee osteoarthritis. Archives of Physical Medicine and Rehabilitation. , vol. 90, no. 11, pp. 1866-1873.</ref>.
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| Following on from this, we may also consider the avoidance model presented by Dekker et al<ref name="Dekker et al">DEKKER, J., TOLA, P., AUFDEMKAMPE, G. and WINCKERS, M., 1993. Negative affect, pain and disability in osteoarthritis patients: the mediating role of muscle weakness. Behaviour Research and Therapy. , vol. 31, no. 2, pp. 203-206.</ref>(right).<br>
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| This model indicates that a decreased muscle strength as a result of activity avoidance leads to activity limitations<ref name="Holla et al">HOLLA, J.F., VAN DER LEEDEN, M., KNOL, D.L., PETER, W.F., ROORDA, L.D., LEMS, W.F., WESSELING, J., STEULTJENS, M.P. and DEKKER, J., 2012. Avoidance of activities in early symptomatic knee osteoarthritis: results from the CHECK cohort. Annals of Behavioral Medicine. , vol. 44, no. 1, pp. 33-42.</ref>.
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| === Recommendations ===
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| '<nowiki/>''What can us as physiotherapists do to combat these beliefs that may be instilled in patients?'<nowiki/>'''''<br> '''
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| Table 7 highlights some useful techniques when managing patients with OA.
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| [[Image:Table 7 recommendations.PNG|center|600x300px]]
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| <u>'''Further Reading:'''</u>
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| [http://www.biomedcentral.com/content/pdf/1471-2474-7-48.pdf '''Further reading on the importance of appropriate and effective communication in the treatment of OA can be found in this article by Rosemann et al (2006). ''']''' ''' <br>
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| [https://lirias.kuleuven.be/bitstream/123456789/26202/1/johan1.pdf '''Leeuw et al (2007) paper highlighting further information about pain catastrophizing and activity avoidance.''']
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| == Sensitive Issues: Obesity ==
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| === Introduction ===
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| Primary care providers and particularly physiotherapists are being encouraged to provide a more active approach in the management of obesity<ref name="Stafford et al.2002">STAFFORD, R.S., FARHAT, J.H., MISRA, B. and SCHOENFELD, D.A. (2000). National patterns of physician activities related to obesity management. Archives of Family Medicine, vol 9 issue 7, pp.631-638.</ref>. However physiotherapists have encountered many challenges related to addressing obesity with patients<ref name="Alexander et al 2007" />. Given that obesity is becoming an epidemic in many nations throughout the world, the need to understand how, when and with whom to have these discussions which becomes essential in order to provide effective care for obese patients. There is a growing need for the training of physiotherapists in areas such as weight loss counseling in order to reduce the barriers encountered when discussing obesity <ref name="Alexander et al 2007">ALEXANDER, S.C, ØSTBYE, T., POLLAK, K.I, GRADISON, M., BASTIAN, L.A. and BROUWER, R.J.K. (2007) Physicians' Beliefs about Discussing Obesity: Results from Focus Groups. American Journal of Health Promotion, 2007, vol. 21 issue 6, pp. 498-500</ref>.<br>Wadden & Didie<ref name="Wadden and Didie 2003)">WADDEN, T.A. and DIDIE, E. (2003). What's in a Name? Patients' preferred terms for describing obesity. Obesity Research, vol 11 issue 9, pp.1140-1146.</ref> reported that patients observed the terms obesity and fatness to be very undesirable descriptors used by their physicians when discussing their body weight. Other terms such as large size, heaviness and excess fat were also highlighted as undesirable. The use of these terms by physicians can be interpreted as offensive or hurtful by the patient and lead to a breakdown in communication.<br>The study reported that weight was the most favourably rated term to be used by physicians as it is easily understood and non judgemental. Another term which was viewed as favourably, as it was non judgemental was BMI, however it is found to be not universally known.<br>Johnson<ref name="Johnson 2002" /> reported that some patients preferred to be described as plus sized, large or even fat. By embracing these terms these patients are motivated to remove the negativity and stigma related to them.<br>Wadden and Didie<ref name="Wadden and Didie 2003">WADDEN, T.A. and DIDIE, E. (2003). What's in a Name? Patients' preferred terms for describing obesity. Obesity Research, vol 11 issue 9, pp.1140-1146.</ref> reported the most beneficial approach would be to ask the patient how they feel and their thoughts towards their weight. Using this approach the physiotherapist should seek the patients consent and come to an agreement to address and discuss the issue. Caution should be taken to avoid reiterating the hazards obesity has to the patients health. Wadden et al<ref name="Wadden et al 2000">WADDEN, T.A., ANDERSEN, R.A. AND FOSTER, G.D., BENNET, A., STEINBERG, C. and SARWER, D.B. (2000). Obese Women's Perceptions of Their Physicians' Weight Management Attitudes and Practices. Archives of Family Medicine, vol 9 issue 7, pp.854-860.</ref>, reported obese patients often experience a feeling that care providers seldom understand how much they suffer with their weight issues. Utilising the conversation approach also allows the physiotherapist to show respect and empathy to the patient by focusing on the positive steps they may have taken previously to tackle the issue. <br>
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| === The Issue With "Calling It As It Is" === | | === The Issue With "Calling It As It Is" === |
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| This approach fails to avoid the degrading and offensive terms, used by the public, and causes more negative effects than beneficial effects <ref name="Johnson 2002" />. It is a challenge for obese individuals to understand the medical implication of these terms as they cannot separate them from the degrading aspects of the terms used by the public.Using a confrontational approach instead of a discussion with the patient is far more likely to negatively affect the patient’s moral, feelings and confidence. Johnson<ref name="Johnson 2002">JOHNSON, C. (2002). Obesity, Weight Management and Self-Esteem. In: Wadden, T.A. and Stunkard, A.J Handbook of Obesity Treatment. New York, NY: Guilford Press, pp.480-493.</ref> reports that care providers who approach the issue by attempting to 'break through the patient’s denial of their weight issues, are more likely abolishing the patients trust and their motivation to return for future sessions and care. This is the most common outcome when individuals are advised to battle their obesity by losing weight, to avoid the ominous medical consequences. <br>More desirable and beneficial outcomes can be achieved through the use of motivational interviewing and discussions with patients in need of weight management compared to a confrontational approach <ref name="Miller and Rolnick 2002">MILLER, W.R. and ROLNICK, S. (2002). Motivational Interviewing: Preparing People for Change. New York, NY: Guilford Press.</ref><ref name="Wadden and Didie 2003" />.<br> | | This approach fails to avoid the degrading and offensive terms, used by the public, and causes more negative effects than beneficial effects <ref name="Johnson 2002" />. It is a challenge for obese individuals to understand the medical implication of these terms as they cannot separate them from the degrading aspects of the terms used by the public.Using a confrontational approach instead of a discussion with the patient is far more likely to negatively affect the patient’s moral, feelings and confidence. Johnson<ref name="Johnson 2002">Johnson, C. Obesity, Weight Management and Self-Esteem. In: Wadden, T.A. and Stunkard, A.J Handbook of Obesity Treatment. 2002. New York, NY: Guilford Press, pp.480-493.</ref> reports that care providers who approach the issue by attempting to 'break through the patient’s denial of their weight issues, are more likely abolishing the patients trust and their motivation to return for future sessions and care. This is the most common outcome when individuals are advised to battle their obesity by losing weight, to avoid the ominous medical consequences. <br>More desirable and beneficial outcomes can be achieved through the use of motivational interviewing and discussions with patients in need of weight management compared to a confrontational approach <ref name="Miller and Rolnick 2002">Miller WR, Rollnick S. Motivational interviewing: Preparing people for change. Book Review.</ref><ref name="Wadden and Didie 2003" />.<br> |
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| === Teaching Tools === | | === Teaching Tools === |
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| <u>'''Further Reading:'''</u>
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| [http://books.google.co.uk/books?hl=en&lr&id=JuRZ2ERqlx0C&oi=fnd&pg=PA3&dq=wadden+and+stunkard+handbook+of+obesity&ots=1J92v4xZ7J&sig=aqoK0YMBR6ou3OyIvzTba1H1fS8#v=onepage&q=wadden%20and%20stunkard%20handbook%20of%20obesity&f=false Handbook of Obesity]
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| [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3310899/pdf/nihms350665.pdf Patients preferred terms for describing their obesity]
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| == Motivational Interviewing == | | == Motivational Interviewing == |
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| === Introduction === | | Evidence has shown that patient-centred approaches to health care consultations are more effective than the traditional advice giving, especially when lifestyle and behaviour change are part of the treatment<ref name=":0">Britt E, Hudson SM, Blampied NM. Motivational interviewing in health settings: a review. Patient education and counseling. 2004 May 1;53(2):147-55.</ref>. |
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| Evidence has shown that patient-centred approaches to health care consultations are more effective than the traditional advice giving, especially when lifestyle and behaviour change are part of the treatment<ref>BRITT, E, HUDSON, S., BLAMPIED, N. 2004. Motivational interviewing in health care settings: a review. Patient Education and Counseling. 53, pp. 147-155</ref>.
| | In the past, healthcare practitioners encouraged patients to change their lifestyle habits through provision of direct advice about behaviour change<ref name=":1">Rollnick S, Butler CC, Kinnersley P, Gregory J, Mash B. Motivational interviewing. Bmj. 2010 Apr 27;340:c1900.</ref>. However, this has proven to be unsuccessful, as evidence show success rates of only 5-10%<ref>Rollnick S, Kinnersley P, Stott N. Methods of helping patients with behaviour change. British Medical Journal. 1993 Jul 17;307(6897):188-90.</ref> . Additionally, this can put a strain on the patient-therapist relationship with the patient perceiving this style as being lectured on their lifestyle choices<ref>Stott NC, Pill RM. ‘Advise yes, dictate no’. Patients’ views on health promotion in the consultation. Family Practice. 1990 Jun 1;7(2):125-31.</ref>. |
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| In the past, healthcare practitioners encouraged patients to change their lifestyle habits through provision of direct advice about behaviour change<ref>ROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246</ref>. However, this has proven to be unsuccessful, as evidence show success rates of only 5-10%<ref>ROLLNICK, S., KINNERSLEY, P., STOTT, N. 1993. Methods of helping patients with behaviour change. BMJ. 307, p. 188-90</ref> . Additionally, this can put a strain on the patient-therapist relationship with the patient perceiving this style as being lectured on their lifestyle choices<ref>STOTT, NCH., PILL, RM. 1990. “Advice yes, dictate no”: a patients views on health promotion in consultation. Fam Pract. 7, 125-31</ref>.
| | Patients can also feel that the therapist is not considering the personal implications the change may have on their life, as they are just placing emphasis on the future benefits and not recognising the initial struggle the patient may have to go through<ref name=":0" />. Such an encounter can risk the patient becoming resistant to change or further increasing their resistance to change<ref>Miller WR, Rollnick S. Motivational interviewing: Helping people change. Guilford press; 2012 Sep 1.</ref>. This resistance to change was seen as a personality trait that could only be dealt with by direct confrontation which potentially placed a further strain on the patient-therapist relationship <ref>Miller WR. Motivational interviewing: III. On the ethics of motivational intervention. Behavioural and Cognitive Psychotherapy. 1994 Apr;22(2):111-23.</ref>. |
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| Patients can also feel that the therapist is not considering the personal implications the change may have on their life, as they are just placing emphasis on the future benefits and not recognising the initial struggle the patient may have to go through<ref>BRITT, E, HUDSON, S., BLAMPIED, N. 2004. Motivational interviewing in health care settings: a review. Patient Education and Counseling. 53, pp. 147-155</ref>. Such an encounter can risk the patient becoming resistant to change or further increasing their resistance to change<ref>MILLER, WR., ROLLNICK, SR. 1991. Motivational Interviewing: preparing people to change behaviour. New York: Guilford Press</ref>. This resistance to change was seen as a personality trait that could only be dealt with by direct confrontation which potentially placed a further strain on the patient-therapist relationship <ref>MILLER WR. 1994. Motivational Interviewing. III. On the ethics of motivational interviewing. Behav Cogn Psychol. 22. 111-23</ref>.
| | Research has shown that patient-centred approaches have better outcomes in terms of patient involvement and compliance<ref name=":0" /> <ref>Ockene JK, Kristeller J, Goldberg R, Amick TL, Pekow PS, Hosmer D, Quirk M, Kalan K. Increasing the efficacy of physician-delivered smoking interventions. Journal of General Internal Medicine. 1991 Jan 1;6(1):1-8.</ref>. The key feature to these approaches is that the patient actively engages in discussing a solution for their problem<ref name="Emmons & Rollnick">Emmons KM, Rollnick S. Motivational interviewing in health care settings: opportunities and limitations. American journal of preventive medicine. 2001 Jan 1;20(1):68-74.</ref>. |
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| Research has shown that patient-centred approaches have better outcomes in terms of patient involvement and compliance<ref>BRITT, E, HUDSON, S., BLAMPIED, N. 2004. Motivational interviewing in health care settings: a review. Patient Education and Counseling. 53, pp. 147-155</ref> <ref>OCKENE, J., KRISTELLER, J., GOLDBERG, R., AMICK, T., PEKOW, P., HOSMER, D. 1991. Increasing the efficacy of physician-delivered smoking interventions: a randomised control trial. J Gen Intern Med. 6, 1-8</ref>. The key feature to these approaches is that the patient actively engages in discussing a solution for their problem<ref name="Emmons & Rollnick">EMMONS, K., ROLLNICK S. 2001. Motivational Interviewing in Health care settings. Opportunities and Limitations. Am J Prev Med. 20 (1) 68-76</ref>.<br>[[Motivational Interviewing]] (MI) is based off Miller & Rollnick’s (1991)<ref>MILLER, WR., ROLLNICK, SR. 1991. Motivational Interviewing: preparing people to change behaviour. New York: Guilford Press</ref> experience with treatment for problem drinkers and is becoming increasingly popular in healthcare settings. The model views motivation as a state of readiness to change rather than a personality trait<ref>ROLLNICK, S., MILLER, WR., BUTLER, C. 2008. Motivational Interviewing in health care: helping patients change behaviour. Guilford Press</ref>. As such, motivation can fluctuate over time and between situations. It can also be encouraged to go in a particular direction. By taking this view , a patient’s resistance to change is no longer seen as a trait of the person but rather something that is open to change<ref>ROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246</ref>. Therefore, the main focus of MI is to facilitate behaviour change by helping the patient explore and resolve their ambivalence to the change<ref>ROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246</ref>.
| | [[Motivational Interviewing]] (MI) is based off Miller & Rollnick’s (1991)<ref>Miller, WR., Rollnick, SR. 1991. Motivational Interviewing: preparing people to change behaviour. New York: Guilford Press</ref> experience with treatment for problem drinkers and is becoming increasingly popular in healthcare settings. The model views motivation as a state of readiness to change rather than a personality trait<ref name=":2">Rollnick S, Miller WR, Butler C. Motivational interviewing in health care: helping patients change behavior. Guilford Press; 2008.</ref>. As such, motivation can fluctuate over time and between situations. It can also be encouraged to go in a particular direction. By taking this view , a patient’s resistance to change is no longer seen as a trait of the person but rather something that is open to change<ref name=":1" />. Therefore, the main focus of MI is to facilitate behaviour change by helping the patient explore and resolve their ambivalence to the change<ref name=":1" />. |
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| While MI is patient centred and focuses on what the patient wants, thinks and feels, it differs slightly from other patient-centred approaches as it is directive<ref>BRITT, E, HUDSON, S., BLAMPIED, N. 2004. Motivational interviewing in health care settings: a review. Patient Education and Counseling. 53, pp. 147-155</ref>. In using MI there is the clear goal of exploring the patient’s resistance to change in such a way that the patient is likely to change their behaviour in the desired direction<ref>BRITT, E, HUDSON, S., BLAMPIED, N. 2004. Motivational interviewing in health care settings: a review. Patient Education and Counseling. 53, pp. 147-155</ref>. <br>The focus of Motivational Interviewing is to: | | While MI is patient centred and focuses on what the patient wants, thinks and feels, it differs slightly from other patient-centred approaches as it is directive<ref name=":0" />. In using MI there is the clear goal of exploring the patient’s resistance to change in such a way that the patient is likely to change their behaviour in the desired direction<ref name=":0" />. <br>The focus of Motivational Interviewing is to: |
| * Assist the patient in examining their expectations about the consequences of engaging in their behaviour. | | * Assist the patient in examining their expectations about the consequences of engaging in their behaviour. |
| * Influence their perceptions of their personal control over the behaviour through use of specific techniques and skills.<br><ref>ROLLNICK, S., MILLER, WR., BUTLER, C. 2008. Motivational Interviewing in health care: helping patients change behaviour. Guilford Press</ref>. | | * Influence their perceptions of their personal control over the behaviour through use of specific techniques and skills.<ref name=":2" />. |
| A benefit to this approach is that time can be saved by avoiding unproductive discussion by using rapid engagement to focus on the changes that make a difference<ref>ROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246</ref>. | | A benefit to this approach is that time can be saved by avoiding unproductive discussion by using rapid engagement to focus on the changes that make a difference<ref name=":1" />. For more on this topic see [[Motivational Interviewing]] |
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| === Theoretical Basis ===
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| Motivational Interviewing is not based on any one specific theory as Miller drew from different aspects of social psychology using processes such as attribution, cognitive dissonance, and self efficacy<ref name="Britt et al" />, as well as empathetic processes from Rodgers (1991)<ref name="M & R 1991">MILLER, WR., ROLLNICK, SR. 1991. Motivational Interviewing: preparing people to change behaviour. New York: Guilford Press</ref> . As interest in applying the model to healthcare setting increased, it was further elaborated and developed by Millner & Rollnick (1995)<ref name="R & M 1995">ROLLNICK, SR., MILLER, WR. 1995. What is motivational interviewing? Behav Cogn Psychol. 23, 325-34</ref><br> <br>MI has been linked to the transtheoretical model of change, with the model providing the framework with which to understand the change process and MI providing the means of facilitating that change<ref name="Sobell et al">SOBELL, LC., TONEATTO, T., SOBELL, MB. 1994. Behavioural assessment and treatment planning for alcohol tobacco and other drug problems: current status with an emphasis on clinical applications. Behav. THER. 25, 533-80</ref>.
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| [[Image:Trans Model.png|center|400x300px|Transtheoretical Model/ Stages of Change]]
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| MI differs from other patient centred approaches as it includes the concept of readiness to change<ref name="Rollnick 1993">ROLLNICK, S., KINNERSLEY, P., STOTT, N. 1993. Methods of helping patients with behaviour change. BMJ. 307, p. 188-90</ref>. This concept can help to explain why direct advice-giving alone can be limited in effectiveness. If the patient is not ready to change then the advice is unlikely to be acted upon<ref name="R & M 1995">ROLLNICK, SR., MILLER, WR. 1995. What is motivational interviewing? Behav Cogn Psychol. 23, 325-34</ref>. Due to this, behaviour change does not have to be the only goal of the healthcare professional. They can aim to increase a patient’s readiness to change through using MI<ref name="Emmons & Rollnick">EMMONS, K., ROLLNICK S. 2001. Motivational Interviewing in Health care settings. Opportunities and Limitations. Am J Prev Med. 20 (1) 68-76</ref>. Using this concept means that interventions can be tailored appropriately to suit the degree of readiness to change of a patient, increase greater parity between the PT and patient agenda<ref name="Rollnick 1999">ROLLNICK, S., MASON, P., BUTLER, C. 1999. Health Behaviour Change: a guide for practitioners. Churchill Livingstone</ref>. This potentially;
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| *Decreases patient resistance
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| *Increases effectiveness of the intervention
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| *Strengthens the patient-physic relationship
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| <ref name="Emmons & Rollnick">EMMONS, K., ROLLNICK S. 2001. Motivational Interviewing in Health care settings. Opportunities and Limitations. Am J Prev Med. 20 (1) 68-76</ref>.<br>
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| <br>The principles of MI are closely related to those of cognitive dissonance<ref name="Britt et al" />. MI focuses on resolving ambivalence by focusing on inconsistencies<ref name="Emmons & Rollnick">EMMONS, K., ROLLNICK S. 2001. Motivational Interviewing in Health care settings. Opportunities and Limitations. Am J Prev Med. 20 (1) 68-76</ref> . This is creating dissonance. Techniques used in MI, such as reflection and summarizing, function to develop cognitive dissonance<ref name="M & R 2002">MILLER, WR., ROLLNICK, S. 2002. Motivational Interviewing: preparing people for change. 2nd edition. Guilford Press</ref>. It produces as dissonant state by focusing on the ambivalence and then controls the direction chosen for the dissonance resolution through skilful and practiced use if the MI techniques<ref name="Britt et al" />.<br>
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| === Principles of MI ===
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| MI is based on the following principles (See right):[[Image:5GenPrinciples.jpg|right|400x500px]]<br>
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| An empathetic conversational style is fundamental<ref name="R & M 1995">ROLLNICK, SR., MILLER, WR. 1995. What is motivational interviewing? Behav Cogn Psychol. 23, 325-34</ref>. The PT's attitude must be one of acceptance and they must view resistance to change as normal<ref name="Rollnick 2010">ROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246</ref>. Using this empathetic style the PT can create and amplify any discrepancy between the patients present behaviour and their goals in such a way that the patient can present an argument for change<ref name="Britt et al" />. Argumentation between the patient and PT should be avoided as it is counterproductive and only serves to increase resistance to change and damage the patient PT relationship<ref name="R & M 1995">ROLLNICK, SR., MILLER, WR. 1995. What is motivational interviewing? Behav Cogn Psychol. 23, 325-34</ref><ref name="Rollnick 2008">ROLLNICK, S., MILLER, WR., BUTLER, C. 2008. Motivational Interviewing in health care: helping patients change behaviour. Guilford Press</ref>. The consultation is carried out in a facilitative way where the relationship between the PT and patient is seen more as a partnership instead of an expert/client<ref name="Rollnick 2010" />. The patient is viewed as a valuable resource to finding a solution to their problem and they are responsible for choosing and carrying out personal change<ref name="Rollnick 2010" /> <ref name="Britt et al" />. In order for this to be effective the patient must have a belief in themselves and their ability to change<ref name="M & R 2002">MILLER, WR., ROLLNICK, S. 2002. Motivational Interviewing: preparing people for change. 2nd edition. Guilford Press</ref> . As such, the PT must encourage, support and build self efficacy<ref name="Britt et al" /> <ref name="Rollnick 2010" />.
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| <br>There is one key distinction between Motivational Interviewing and other patient centred approaches. MI is not viewed as a technique which is applied to patients, but rather an interpersonal style which is shaped by guiding principles of what triggers behaviour change processes<ref name="Rollnick 2010" />. The spirit of adhering to the method involves allowing patients to express their own arguments to change and the PT to accept these<ref name="Emmons & Rollnick">EMMONS, K., ROLLNICK S. 2001. Motivational Interviewing in Health care settings. Opportunities and Limitations. Am J Prev Med. 20 (1) 68-76</ref>. MI is an individually tailored client centred method which changes to suit each individual ensuring that effectiveness is increased<ref name="M & R 2002">MILLER, WR., ROLLNICK, S. 2002. Motivational Interviewing: preparing people for change. 2nd edition. Guilford Press</ref> <ref name="Rollnick 2010" />. As such, there is no set structure to MI as a too tightly structured model will fail to honour the uniqueness of the individual, their views and their issues<ref name="Rollnick 2010" /><ref name="Rollnick 2008" />. However there is a range of techniques that can be used interchangeably to effectively carry out MI<ref name="R & M 1995">ROLLNICK, SR., MILLER, WR. 1995. What is motivational interviewing? Behav Cogn Psychol. 23, 325-34</ref>.<br>
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| === MI Techniques ===
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| It is the patient’s task to articulate and resolve their resistance to change<ref>ROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246</ref> <ref>ROLLNICK, SR., MILLER, WR. 1995. What is motivational interviewing? Behav Cogn Psychol. 23, 325-34</ref>. It is the therapist’s task to expect and recognise resistance and to be directive in helping the patient recognise and resolve this resistance<ref>ROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246</ref>. This can be done through the use of MI specific trainable techniques<ref>ROLLNICK, SR., MILLER, WR. 1995. What is motivational interviewing? Behav Cogn Psychol. 23, 325-34</ref>.<br>There are 3 elements to the technical aspects of MI
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| #Client centred counselling skills based on Rogerson counselling
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| #Reflective Listening statements, directive questions and strategies for eliciting internal motivation from the patient. These are in the form of self motivating statements from the patient as is encourages them to examine their resistance to change and make their own decision about why and how to proceed.
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| #Strategies for ensuring client resistance are minimized. <br><ref>MILLER, WR., ROLLNICK, S. 2002. Motivational Interviewing: preparing people for change. 2nd edition. Guilford Press</ref>
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| Motivational Interviewing has been modified for use in healthcare settings<ref>ROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246</ref>. This is mainly to overcome issues surrounding time constraints, as intervention effectiveness increases with contact time<ref>MILLER, R., ROSE, G. 2009. Towards a theory of motivational interviewing. Am psych. 64, 527-37</ref>, yet a general first PT appointment will last 40 minutes. Models have been developed to deliver 30 minute interventions based on a framework. One such framework is Brief Motivational Interviewing (BMI)<ref>ROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246</ref>. This is a set menu of techniques which follow the spirit and practice of MI. It has been designed for use in a 40 minute single session in a primary healthcare setting<ref>ROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246</ref>.
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| <br>A very clear distinction is made between the practitioners job, which is providing facts, and the patients role which is the personal interpretation of how those facts apply to them<ref>MILLER, R., ROSE, G. 2009. Towards a theory of motivational interviewing. Am psych. 64, 527-37</ref><ref>ROLLNICK, S., MILLER, WR., BUTLER, C. 2008. Motivational Interviewing in health care: helping patients change behaviour. Guilford Press</ref>. This influences the decision making process by actively engaging the client in the evaluation of their lifestyle and behaviour and can potentially promote a change in the balance of positive and negative aspects to change relating to their behaviour<ref>MILLER, WR., ROLLNICK, S. 2002. Motivational Interviewing: preparing people for change. 2nd edition. Guilford Press</ref>. Traditionally the PT would be seen in the role of an expert and the advice given and the interpretation would be delivered by the PT in one message<ref>BRITT, E, HUDSON, S., BLAMPIED, N. 2004. Motivational interviewing in health care settings: a review. Patient Education and Counseling. 53, pp. 147-155</ref>. With using MI, the patient is in the role of the expert as they must decide how the facts are interpreted and whether it is relevant to their situation<ref>MILLER, WR., ROLLNICK, S. 2002. Motivational Interviewing: preparing people for change. 2nd edition. Guilford Press</ref>.
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| <br>The PT uses reflective listening in seeking to further understand the patient’s point of views<ref>MILLER, WR., ROLLNICK, S. 2002. Motivational Interviewing: preparing people for change. 2nd edition. Guilford Press</ref>. Through expressing acceptance and affirming the patients freedom of choice and self determination, they can monitor and influence the patient’s readiness to change<ref>ROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246</ref>. However, care must be taken not to jump ahead of the patient or take over the decision making as this can lead to increased patient resistance<ref>EMMONS, K., ROLLNICK S. 2001. Motivational Interviewing in Health care settings. Opportunities and Limitations. Am J Prev Med. 20 (1) 68-76</ref>. Advice must not be given without the patient’s permission and when given, it is always accompanied by encouragement to the patient to make their own choices<ref>ROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246</ref>. It is also the patient’s decision as to where to take the consultation<ref>ROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246</ref>. The PT should encourage this through use of agenda setting to help structure the discussion so that it is meaningful and important to the patient<ref>ROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246</ref>.
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| <br>Personal dissonance is a strategy commonly used in motivational interviewing<ref>ROLLNICK, S., MILLER, WR., BUTLER, C. 2008. Motivational Interviewing in health care: helping patients change behaviour. Guilford Press</ref>. Its aim is to create dissonance between the patient’s positive image of themselves and their negative image of themselves <ref>BRITT, E, HUDSON, S., BLAMPIED, N. 2004. Motivational interviewing in health care settings: a review. Patient Education and Counseling. 53, pp. 147-155</ref>. They are encouraged to outline the positives in remaining how they are, followed by the negatives. The PT should encourage them to talk about specific individualised problems and concerns they have about their own behaviour. The strategy concludes with a summary which highlights both the problems and concerns and the positive benefits as outlined by the patient. Following this the patient can be encouraged to weigh up the pros and con's of behaviour change. The PT can assist with support and influence the patient’s readiness to change through this discussion<ref>MILLER, WR., ROLLNICK, S. 2002. Motivational Interviewing: preparing people for change. 2nd edition. Guilford Press</ref>.<br>These strategies are not used in isolation or in a set way<ref>ROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246</ref>. All techniques are used alongside each other in a way which is unique to each individual and problem<ref>ROLLNICK, S., MILLER, WR., BUTLER, C. 2008. Motivational Interviewing in health care: helping patients change behaviour. Guilford Press</ref> . MI should not be thought of as a quick fix method or clever technique used to get patients to do something they do not want to<ref>BRITT, E, HUDSON, S., BLAMPIED, N. 2004. Motivational interviewing in health care settings: a review. Patient Education and Counseling. 53, pp. 147-155</ref>. It is something that is done with and for them<ref>ROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246</ref>. If the patient responds positively and becomes active in the change discussion this can be viewed as positive feedback<ref>ROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246</ref> . However, resistance is a signal to change strategy<ref>ROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246</ref>. The resistance should be acknowledged by the PT and they should encourage the patient to further explore this resistance with a view to shift the patient’s perception<ref>ROLLNICK, S., BUTLER, C., KINNERSLEY, P., GREGORY, J., MASH, B. 2010. Motivational Interviewing. BMJ, 340, pp. 1242-1246</ref>.[[Image:Table 8 - What to avoid in MI.png|right|500x400px]]<br>
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| === Summary ===
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| MI involves helping patients to say why and how they might change based on the use of a guiding style. A guiding style is used to engage patients, clarify their strengths and aspirations, evoke their own motivations for change and promote autonomy of decision making.<br>PT's should practise a guiding rather than a direct style, develop strategies to elicit the patient’s own motivation to change and refine their listening skills and respond by encouraging the patient to participate in change talk.
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| == How Best to Implement MI ==
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| === Useful Questions ===
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| [[File:Table_9_-_useful_questions_in_MI.png]]<br>
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| </div> | | </div> |
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| === Practice Using a Guiding Style === | | == Conclusion == |
| <div> | | <div> |
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| [[File:Table_10.png|400x400px]]
| | Communication is more than just what we say, it matters how we say it too. It is important that communication is good, clear and compassionate in a healthcare setting. The style in which we communicate may differ between individual patients due to learning styles, literacy levels or the level of understanding the patient has of their condition and the anxiety they may present with. |
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| The PT should take the stance of an informed guide, collaborate with patients, emphasise the patients role in decision making and facilitate their self efficacy and motivation<ref name="M & R 2002">MILLER, WR., ROLLNICK, S. 2002. Motivational Interviewing: preparing people for change. 2nd edition. Guilford Press</ref><ref name="Rollnick 2010" />. The PT controls the structure of the consultation and provided information when requested but the patient is responsible for leading the change discussion and providing any solutions to problems<ref name="Rollnick 2010" />.
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| <br> Using 3 core skills, the guiding style can successfully draw out the patients views and ideas:
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| <u>'''Asking'''</u>- open ended questions encourage the patient to consider why and how they might change their behaviour.
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| '''<u>Listening</u>''' to the patients experience- use reflective listening statements or brief summaries. This shows empathy and encourages the patient to elaborate further as well as it being the best way to respond to and understand resistance.
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| <u>'''Informing-'''</u> ask permission from the patient before providing information and then discuss the patients views of the implications of the advice.<br> <ref name="M & R 2002">MILLER, WR., ROLLNICK, S. 2002. Motivational Interviewing: preparing people for change. 2nd edition. Guilford Press</ref><ref name="Britt et al" /><ref name="Rollnick 2010" />
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| === Develop Useful Strategies ===
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| ==== Agenda Setting: Deciding What to Change ====
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| Instead of imposing your priority on patients, the PT invites them to select an issue which they feel most ready to tackle<ref name="Rollnick 2010" /> <br>
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| ==== Pros and Cons: Deciding Why to Change ====
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| Asking the patient their views on the pro's and cons of keeping their behaviour the same can be helpful in influencing their readiness to change. The next step would be to discuss with them if change was a possibility and how they could bring it about<ref name="Rollnick 2010" />. [[Image:Table 11.png|right|400x300px]]<br>
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| ==== Assess Importance and Confidence ====
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| For this method to be successful the PT needs to spend their time where it is most needed. Patients who are unconvinced of the benefit of change or their ability to change are less likely to change their behaviour. The following line of questioning has been shown to be successful in MI in helping patients to quit smoking<ref name="Rollnick 2010" />
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| [[Image:Table 12.png|center]]<br>
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| ==== Exchange Information ====
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| Miller et al (1994)<ref name="Miller 1994">MILLER WR. 1994. Motivational Interviewing. III. On the ethics of motivational interviewing. Behav Cogn Psychol. 22. 111-23</ref> have shown that the most successful way of exchanging information with the patient is by using the elicit-provide-elicit strategy. This is where the patient clarifies the personal implications of the information which is provided to them by the PT<ref name="Rollnick 2010" />.[[Image:Table 13.png|center|300x200px]]
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| <br>
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| <span> </span> <br>
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| ==== Setting Goals ====
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| Patients should [[Goal Setting in Rehabilitation|set their own goals]], as this will increase motivation to work towards change. Questioning styles such as the following can be used to encourage the patient to come up with practical solutions as well as offering suggestions in a way which will not increase resistance<ref name="Rollnick 2010" />
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| [[File:Table_14.png|400x400px]]<br>
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| === Skillfully Respond to, and Change, Patients Language ===
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| A PT can further enhance their MI skills by paying attention to the language used by patients<ref name="Miller & Rose">MILLER, R., ROSE, G. 2009. Towards a theory of motivational interviewing. Am psych. 64, 527-37</ref>. Patients either use change talk about how or why they might change (I want to, I should exercise etc.). Or the opposite (I’ve never been able to lose weight etc.). The PT can chose whether to encourage the patient to use change talk or not but studies believe that readiness to change is more likely to be enhanced and the subsequent change is more likely to take place when change talk is used<ref name="Miller & Rose">MILLER, R., ROSE, G. 2009. Towards a theory of motivational interviewing. Am psych. 64, 527-37</ref>.
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| === Challenges Faced by Physiotherapists Using MI ===
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| Practice, training, supervision and feedback on performance will increase the PT's ability and confidence in using efficient questioning that suits both their own personality, that of their patient and the setting<ref name="Rollnick 2010" />.<br>The hardest challenge most PT's will face is using the guiding style and empathetic attitude as this requires the PT to ignore the tendency to identify and solve the problems for the patient<ref name="Britt et al">BRITT, E, HUDSON, S., BLAMPIED, N. 2004. Motivational interviewing in health care settings: a review. Patient Education and Counseling. 53, pp. 147-155</ref><ref name="Rollnick 2008" />. This can make PT's feel like they do not have control of the session<ref name="Rollnick 2010" />, but they can still retain control of the direction of the session while giving the control of the what, why and how to change to the patient<ref name="M & R 2002">MILLER, WR., ROLLNICK, S. 2002. Motivational Interviewing: preparing people for change. 2nd edition. Guilford Press</ref><ref name="Rollnick 2010" />. The PT can still offer advice and expertise but in a way that is collaborative with the patient’s views and emphasising that the patient makes the final decision on what they will do<ref name="Rollnick 2010" />.<br>
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| === Examples in Practice ===
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| The videos below show a healthcare professional attempting to embark on a conversation about quitting smoking with a patient. This is a scenario very applicable to physiotherapists, especially those working in a respiratory area. The first video shows the traditional advice giving approach, while the second shows the implementation of motivational interviewing techniques. {{#ev:youtube|80XyNE89eCs|700}} {{#ev:youtube|URiKA7CKtfc|700}}
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| <u>'''Further Reading:'''</u><br>
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| [http://motivationalinterviewing.org/ Motivational Interviewing WebSite]
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| [https://www.physio-pedia.com/Motivational_Interviewing Motivational Interviewing on Physiopedia]
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| == Conclusion ==
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| This resource tool was made as a guide for newly qualified physiotherapists and other healthcare professionals interested in improving their communication skills or expanding their knowledge of effective communication tools. It highlights the importance of good, clear, compassionate communication in a healthcare setting, as well as how communication style may differ between individual patients due to learning styles, literacy levels or the level of understanding the patient has of their condition and the anxiety they may present with. It focuses on certain techniques that physiotherapists can adapt to deal with a broad range of conditions. It offers suggestions and links to further relevant readings to enhance learning and to give the reader the opportunity to explore further relevant tools.
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| Users are encouraged to practice these communication techniques regularly and to reflect on their own practice to best develop their communication skills and to discover what works best for them.
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| == References == | | == References == |
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| [[Category:Rehabilitation Foundations]] | | [[Category:Rehabilitation Foundations]] |
| [[Category:Mental Health]] | | [[Category:Mental Health]] |
| [[Category:Effective Communication]] | | [[Category:Communication]] |
| [[Category:Current and Emerging Roles in Physiotherapy Practice]] | | [[Category:Current and Emerging Roles in Physiotherapy Practice]] |
| [[Category:Queen Margaret University Project]] | | [[Category:Queen Margaret University Project]] |
