Finding the Entry Point of Change
When a person has a problem that they want to change, why do some change and others don’t? Let’s be honest. Most New Year’s resolutions have failed by now. It happens time and time again. It is difficult to turn even the best of intentions at the start into long term behavioral change and long term results.
This concept comes up often in the physical therapy setting. The foundation of rehabilitation is creating change. If a patient is not ready to change, this can create a clash in the dynamic between therapist and patient. In turn, this inhibits reaching the patient’s goals, or stops them from doing PT completely. How can a physical therapist determine the best strategy to connect with patients to create lasting change and results?
The Transtheoretical Model of Change was developed by two scientists, James Prochaska and Carlo Di Clemente, during their research into smoking cessation. They developed a classification system of six stages which would determine a smoker’s likelihood of being able to quit smoking. The determining factor of the ability to change behavior is the level of readiness, or assessing where a person is psychologically when thinking about change. I pulled a description of each stage from Boston University Medical Center:
Precontemplation – In this stage, people do not intend to take action in the foreseeable future (defined as within the next 6 months). People are often unaware that their behavior is problematic or produces negative consequences. People in this stage often underestimate the pros of changing behavior and place too much emphasis on the cons of changing behavior.
Contemplation – In this stage, people are intending to start the healthy behavior in the foreseeable future (defined as within the next 6 months). People recognize that their behavior may be problematic, and a more thoughtful and practical consideration of the pros and cons of changing the behavior takes place, with equal emphasis placed on both. Even with this recognition, people may still feel ambivalent toward changing their behavior.
Preparation – In this stage, people are ready to take action within the next 30 days. People start to take small steps toward the behavior change, and they believe changing their behavior can lead to a healthier life.
Action – In this stage, people have recently changed their behavior (defined as within the last 6 months) and intend to keep moving forward with that behavior change. People may exhibit this by modifying their problem behavior or acquiring new healthy behaviors.
Maintenance – In this stage, people have sustained their behavior change for a while (defined as more than 6 months) and intend to maintain the behavior change going forward. People in this stage work to prevent relapse to earlier stages.
Termination – In this stage, people have no desire to return to their unhealthy behaviors and are sure they will not relapse. Since this is rarely reached, and people tend to stay in the maintenance stage, this stage is often not considered in health promotion programs.
A patient will progress (or regress) through these stages as they seek to make positive change in their lives. Usually the changes they want to see in our world of physical therapy are eliminating pain, improving function, or coming back from an injury to doing the things they love again. Candidates for physical therapy that walk into the office are going to be in stage 1-3. This is because hopefully the action (step 4) that they will take is to start physical therapy and become a member of the action stage. It is crucial to recognize a patient’s initial stage and communicate with them appropriately based on their state of readiness.
The Precontemplation Patient: This person does not know why they are in therapy besides their doctor told them to show up at this specific date and time. They do not have an ability to recognize their own contributions to their situation, and they do not think that there is a problem. For example, there could be a patient who has a desk job but doesn’t get up at all during the day, and does not think that is contributing to their neck pain. Another example is a person who loves running and does it every day but now has an overuse injury. Even though the running program needs to be modified and tweaked with a PT program, the person sticks to their guns about their training methods and refuses to change. These are going to be the toughest eggs to crack. Moving a person from precontemplation to contemplation is anecdotally the biggest challenge.
I find the principle that helps most in this stage is don’t force treatment if the person is not ready. This doesn’t happen often, but at the end of the day we have to recognize that maybe this patient could benefit from therapy, but it’s just not the right timing. You never know what other life factors are at play that are causing the resistance to change. Sometimes it’s a stressful family situation, work stress, financial stress, or relationship stresses. These are all outside factors that can be too distracting to be able to contemplate change. Sometimes the best move is to wish the person well and follow up at a later time.
Alos, don’t try to get from precontemplation to action all at once. It is enough to just get them to think about it. If you come on too strongly with trying to book an appointment or jump into treatment, they may shy away because it’s too much at once. Instead of going for a call to action at first, provide some educational materials about their condition. Share your social media accounts so they can see what you are about. Invite them to a lecture you have coming up. If you have a newsletter, encourage them to sign up for your newsletter. This begins to build the trust in you as a clinician, and also helps them to come to the realization that you can help them.
The Contemplation Patient: Now you’ve got them thinking about change, or the person was already thinking about it and has walked into your clinic to inquire about your services. Here we need to take the person from contemplation to preparation, which is setting up an appointment. This is generally where most of a clinic’s marketing will fall, as these are typical strategies to create new patients.
It is imperative for the patient to know, like, and trust you as a clinician. Individualized consults with prospective patients are a way to show them what you bring to the table that is different, and lay the groundwork of how you would get from point A to point B of achieving the desired change. Tell them your credentials and specialties. Allow the patient to walk through the facility and point out the different pieces of equipment, giving examples of how it is utilized for that person’s condition. Take away any doubts that you are the person to help.
Sometimes, the barriers during contemplation are not clinical. Mainly, this is going to be cost and time. People will hesitate if they think therapy is going to be too expensive, or if they think that they do not have time during the week due to competing interests. These patients are different from the precontemplative patient because they recognize they have a problem to solve and are inquiring, but need to eliminate these barriers in order to take action. In these scenarios, I try to help prospective patients understand the bigger picture of investing in a course of physical therapy. I connect how a temporary investment on working on these problems will lead to the ability to not only meet goals, but have self management strategies to manage flare ups so that they don’t end up in the same boat again. I frame the typical length of stay based off of their condition, and estimate what the cost of that course of care would be versus the value of the goals that they want to achieve. It’s taking a step back and seeing more perspective on how prioritizing PT for a specific length of time will help in the long run. Seeing it as a finite length of time with a fixed price helps create buy in as opposed to vague parameters that may create fear.
The Preparation Patient: This person has decided they are ready and want to take action. This is a true opportunity to set up a patient for success before they even walk in on their first day. Create systems that are seamless for scheduling with a warm welcome from the front desk and any staff that they encounter. The first impression of a clinic happens on the first phone call, no matter who it is that answers the phone. Once the appointment is scheduled, send prep emails of tips on how to prepare for the first day, including paperwork, what to wear, what to bring, what questions to ask, etc. The person should be ready and excited to go on arrival on day 1. The more confident they are going in, the more likely they will stay compliant through their treatment.
The Action Patient: This is the physical therapy part! Do your thing and the patient should experience the excellent results of your clinical care. Set goals of the change that you are trying to make for the patient, and break down each week as a piece of working towards that goal.
The Maintenance Patient: This stage tends to get lost in physical therapy care, but I don’t believe the job is done until we get here. This is where not only the patient has achieved their change, but they also have the self management strategies to maintain their change once therapy is over. This can include home exercise programs, desk ergonomic tips, sport specific tips, sleeping tips, etc. This is anything that the patient can do themselves to give themselves the best chance of being healthy. As much as we like our patients, no one wants to see them come in again for the same exact issue over and over.
To summarize, the psychological framework presented in the transtheoretical model can overlap significantly with how we approach our communication with patients. In a study that just came out in the January 2021 edition of the Journal of Orthopedic Physical Therapy practice, the stages of change were studied in a population of veterans with chronic pain admitted to physical therapy. Based on a questionnaire, each patient chart was bucketed into one of the stages of change in the transtheoretical model. The authors did not find a significant difference in the incidence of diagnosis of psychological distress, nor in the self-reported functional measure scores between the stages. However, the authors did note a higher incidence of pain catastrophizing in the precontemplation stage. Pain catastrophizing is marked by rumination, feeling hopeless, and magnifying the pain to extreme levels. This indicates that even through the rates of actual psychological diagnoses and actual physical disability did not significantly vary amongst the groups, the precontemplation group was negatively impacted because of how that group perceived their situation.
What can we take away from this? I believe this study demonstrates the importance of recognizing stages of change. You can have a patient that comes in with shoulder pain that physically looks and sounds the same as all the other patients with shoulder pain, but if you are not considering the state of change you may miss the mark for that person if the approach of communication and education is not right. When we meet a patient for the first time, they can give us hints of where they fall in the spectrum of change readiness. If we are equipped to recognize these different states of readiness, then we can give our patients the best chance of success of lasting change and meeting their goals.
Boston University School of Public Health. (2019, 9 9). Behavorial Change Models. Retrieved 1 2021, 2, from The Transtheoretical Model (Stages of Change): https://sphweb.bumc.bu.edu/otlt/mph-
Evans, E., Bialosky, J., & Barry, A. (2021). Functional Disability, Catastrophizing, and the Stange of Change in Veterans with Chronic Pain. Orthopedic Physical Therapy Practice , 33 (1), 6-11.
Physiopedia. (2, 1 2021). Physiopedia. Retrieved 1 2021, 2, from Pain Catastrophizing Scale: https://www.physio-pedia.com/Pain_Catastrophizing_Scale