In my previous blog, The Soft Skills - Part 1 of 3, I discussed the importance of helping patients build self-efficacy. For anyone who might have missed it, the general conclusion there was that feelings of self-efficacy toward certain activities or behaviours increases the likelihood of participating in those activities or behaviours (makes sense, right?). Knowing that helps us orient our interventions toward not just the physical, but the psycho-emotional side of treatment.
It’s safe to say that self-efficacy does not exist in a vacuum; there are a number of other variables at play. In keeping with this theme, the second part of this series focuses on helping patients build (and/or maintain) motivation.
Self Determination Theory (SDT), one of the most widely accepted theories of motivation, suggests that motivation isn’t black or white, extrinsic or intrinsic, but rather it exists on a continuum. People aren’t “amotivated” or “motivated”, they’re likely somewhere in between. You might be thinking “So what? What difference does the type of motivation really make, so long as they’re motivated?”. You raise a valid point, at least in the short term. But if we’re looking to make lasting, long-term change, then the type of motivation plays a significant role.
The table above provides a nice breakdown of the SDT Continuum. I’ve made it a clickable link for any of you go-getters who really want to soak it in, but for the rest of us “meat and potatoes”-types, I’ll keep it brief;
- Extrinsic motivation (EM) isn’t necessarily bad, but there are sub-types of it that are definitely less good (see: External and Introjected Regulation). These can be extremely motivating, but will likely involve negative emotions and will not withstand the test of time.
E.g. Patient A comes to you with LBP and explains that they need to get better ASAP because the pain is causing them to miss work, their employer is upset with them, and they’re losing wages and have bills to pay.
- Identified Regulation and Integrated Regulation are better versions of Extrinsic Motivation where people value the activity or have integrated it into their current values; they’re motivated because they’ve identified the activity as personally important or have integrated this activity and its outcomes to be congruent with their current values or needs
E.g. Patient B comes to you with LBP and explains that they need to get better because their pain is impeding their exercise routine and although they don’t really enjoy exercising, they know it’s important for their health (something they value)
- Intrinsic Motivation (IM) is the most powerful version of motivation in that it is linked to inherent satisfaction and enjoyment, making it the most enduring and resilient form.
E.g. Patient C comes to you with LBP and explains that they need to get better because she loves spending time hiking the local trails and hasn’t been able to do so since the pain began.
Patient A, Patient B, and Patient C are all motivated to get better, however Patient A’s motivation will last only as long as their pain does, Patient B’s motivation will persevere only as long as they continue to value their health, but Patient C’s motivation is likely to endure as it is linked to something of great inherent satisfaction or value for them.
Our goal as practitioners isn’t necessarily to have all of our patients be like Patient C, but rather it’s to help move patients along this continuum toward more self-determined forms of regulation. The question is... how?!
Well, Self Determination Theory posits that human motivation is based on the satisfaction of 3 universal needs;
Autonomy: The need to perceive our behaviours and thoughts as freely chosen
Competence: The need to perceive our behavior and interactions as effective; to believe that we can and will succeed (thank you, self-efficacy theory)
Relatedness: The need to perceive that we are connected to those around us; that we belong
The idea being that, the degree to which these needs are met when engaging in (or contemplating) a certain behaviour or activity will determine what type of motivation drives that behaviour. The more they’re met, the more self-determined the type of motivation.
So, if we apply this theory to Physical Therapy, how can you create an environment for your patients that supports these needs, thereby facilitating more self-determined forms of motivation and all the good things that come with it? Well, if we look at some of the literature from the exercise psychology world, we can pull out a few good suggestions.
To foster Autonomy:
- Offer choice
- If they have multiple complaints, ask which one they’d like to address first (even if it’s as simple as right hip vs. left hip)
- When prescribing exercises, offer options and let them choose which one they prefer
- Demonstrate that their opinion matters
- Emphasize that they can ask questions at any point
- Encourage them to communicate how they’re feeling
- Explain what you’re going to do and WHY before you do it
- Ask them if they have any questions, check-in often
- Integrate their values
- Get creative with exercises; make them relatable to their “why” (e.g. your patient is a badminton player with a shoulder issue, have them bring in their racquet to do ROM exercises rather than just using a theraband)
- When you prescribe an exercise, explain how it relates to their goal (e.g. a plank will help strengthen your trunk which will support lifting and quick athletic movement)
- Exercise caution when using deadlines and/or evaluations
- These often create external pressure that is characteristic of extrinsic motivation
To foster Competence:
- Give positive feedback, avoid negative feedback (or at least frame it in a constructive way).
- Use optimistic, solution-focused language. Use words that heal.
- Break down complex tasks to allow for small successes.
- Set appropriate difficulty levels; challenging enough to engage, but not so challenging that they don’t succeed
- Remember the 4 main sources of self-efficacy; previous experience, vicarious learning, verbal persuasion, and physiological states, and integrate them into your session (see “The Soft Skills - Part 1 of 3: Helping Patients Build Self-Efficacy”)
To foster Relatedness:
- Take the time and put in the effort to develop therapeutic alliance
- Use “we” in place of “you”; send the message that you’re in this together
- Create opportunities for supportive social connections
- E.g. Create a ‘goals board’ for your patients and post it somewhere people will see it. It can (and probably should) be anonymous, but will demonstrate that there is a group of people working on similar goals
- Celebrate successes together; a big “great job!”, high five, or gesture of congratulations can go a long way
- Follow up with patients between visits; a quick call or email to check-in demonstrates care and thoughtfulness
There you have it; yet another crash course in psychological theory and its application in the world of Physical Therapy. Hopefully you were able to sift through all the psychobabble and hone in on the true clinical pearls. Once again, you’re encouraged to take all that good stuff you learned in school and from experience and convert these ideas from good to great. As always, be genuine, trust your patients’ expertise, and know that a strong therapeutic alliance goes a long way.
Stay tuned for The Soft Skills - Part 3 of 3: Motivational Interviewing.