Following up from Part 1 of Motivational Interviewing in Rehab, we’ve provided some extra detail at a time where adherence can falter and some recovery strategies might be needed!
The Principles and The How to of Motivationally Interviewing
Motivational Interviewing is:
“A directive, patient-centred counselling style for eliciting behaviour change by helping patients to explore and resolve ambivalence.”- Rollnick and Miller (1993)
Motivational Interviewing utilises various techniques to foster a conversation that should empower the recipient to change. The conversation explores the benefits of implementing changes versus staying the same and prompts them to devise their own solutions to barriers. Within Wellness Coaching both the “Importance” and “Confidence” level of the client’s goal needs to be 8 or more out of 10 to be worthwhile. It is important to maintain empathy and a non-judgemental attitude, remembering that ambivalence is normal. Cognitive dissonance and discrepancies between their goals, values and current behaviour can be respectfully addressed, without provoking an argument.
Let the patient tell youthey need to change – “People believe what they hear themselves say”
Some techniques used include: Open-ended questions (questions that cannot be answered by simply “yes” or “no”), eliciting self-motivational statements (spoken confidence from the client), provision of Affirmations and Encouragement, and practice of Active Listening (Paraphrase, Summarise, Reflect, Clarify).
The Difference in Rehab! 🔍
Motivational Interviewing in Rehab is slightly different, and Motivational Interviewing in Rehab makes all the difference!
Firstly, we often don’t have the luxury to wait for their Confidence and Importance rating to be high enough (as encouraged in Wellness Coaching). This could be due to claim durations or costs, or simply best practise; knowing that early intervention rehabilitative results are superior for returning to work promptly and has consistently been shown to be healthier for the client[i].
In the Rehab setting[ii], clients are coming to us for our expertise as health providers. Yes, we need to empower them, and prompt them to come up with solutions, but we also need to appropriately provide education. Remember, given that they may have come to us thinking we would fix them, the Motivational Interviewing approach might be a shock to some, learning that they themselves need to do most of the work, changing their lifestyle and habits. So, we need to break this to them compassionately.
It’s also important to know when to refer out to an appropriate professional such as a Psychologist or Counsellor. Working in rehab, opposed to “general/healthy population,” there is a higher risk of mental illnesses. You can practice MI all you want with someone, but if they are unmotivated due to underlying depression or anxiety for example, you won’t get far. (Check out the Resource List for more info).
Specialised Health’s Top Tips for Motivational Interviewing in Rehab
CreateSMARTgoals and make them meaningful, i.e. Connect with THEIR WHY
When setting goals and working towards them, start small. Break down the ultimate goal into smaller and sooner ones. This makes the task more achievable while increasing their self-efficacy.
In the Rehab world it can be easy to focus purely on the overarching rehab or return to work goals, however personal goals are just as important!
The Importance of Personal Goals in Rehab
Most, if not all, of us are working in this space because we want to see improvements in people’s lives. Helping clients achieve meaningful, personal goals makes us feel good!
From a pragmatic view, working towards personal goals assists in achieving other rehab goals such as return to work or ADLs. This is because clients may be more attached to their goals, therefore more motivated, with higher adherence to the rehab program. Achievement of personal goals will result in an increase in function, impacting overall functional capacity related to the rehab goal.
#2 Be aware of potential reasons for lack of adherence
Low adherence can be frustrating for us all, but it is important to be mindful of the reasons. When you uncover the reasons, you can better address them. It could be lack of knowledge of the condition, prognosis or the claim process, but may also be due to anxiety and overwhelm causing avoidance. It may also be an informed decision they have chosen, for example choosing the quick, enjoyable activities of the present over the tasks that would benefit their future
#3 Build Trust and Rapport
Without genuine trust and a decent rapport you are unlikely to receive honest exploration of barriers or reports of adherence.
#4 Be Respectful in Education
Acknowledge that you have the specialised knowledge, but they have the real world, lived experience – outside of a clinic. Respect their experience and understanding. If you do have a similar experience, or have “seen clients with this before”, remember that everyone experiences situations differently, coming from various biopsychosocial compilations.
A respectful strategy for providing education is the Elicit-Provide-Elicit Cycle
- Elicit: Understand what the patient already knows and what they would like to know, request permission to educate
- Provide: Educate using neutral language
- Elicit: Check their understanding of what you said. Preferably in their own words.
Remember: Not everyone has the same learning style as you.Try to provide various formats (verbal, written, visual). Also note that stress and anxiety decrease absorption of new information. Do not be disappointed if you need to repeat the education, and again, be aware if you are over-loading your subject.
#5 Be Mindful
Be Mindful of yourself and others. Are you talking too much? Are they listening? Is it personally applicable to them? Are you having a conversation or providing a lecture? Are you or the client becoming overwhelmed or emotional?
#6 Work with the Rehab Team
The Rehab Team could be Exercise Physiologists, OT’s, Rehab Consultants, Psychologists, Case Managers, Injury Management Advisors and GPs. Work together to provide consistent messages, work towards the same goal, determine lack of rapport/trust (it may not be obvious to us in our optimism to see things working), and brain storm various support strategies.
As EPs, being on the ground we are rewarded after setting small challenges, encouraging attempts, and seeing their surprise when they perform what they were afraid of! This builds their confidence for the change. We love sharing our wins because it always comes as a result of a great team working together!
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Comment or Message us! – Let us know what you think of our 6 Top Tips. Did we miss anything?
Exercise Physiologist and Content Manager
- Latchford (2010), A Brief Guide to Motivational Interviewing, Department of Clinical & Health Psychology, St James’ University Hospita
- Arnetz B, Early workplace intervention for employees with musculoskeletal-related absenteeism: a prospective controlled intervention study, J Occup Environ Med.2003 May;45(5):499-506.
- My opinion/experience
- ROLLING WITH RESISTANCE https://health.mo.gov/living/healthcondiseases/chronic/wisewoman/pdf/MIRollingwithResistance.pdf
- GUIDE TO MI
- DECISIONAL BALANCE TOOL https://motivationalinterviewing.org/sites/default/files/decisionalbalance.pdf
- TECHNIQUES http://tucollaborative.org/wp-content/uploads/2017/04/Motivational-Interviewing-Techniques-for-RTs.pdf
- K10 QUESTIONNAIRE FOE DEPRESSOIN/ANXIETY