9

Patient Education

Facilitating Behavior Change

Margaret M. Plack, PT, DPT, EdD and Maryanne Driscoll, PhD

CHAPTER OBJECTIVES

After reading this chapter, the reader will be prepared to:

• Appreciate the role of the physical therapist in patient education and in facilitating behavior change.
  
• Assess a patient’s readiness to change.
  
• Identify potential barriers to adherence.
  
• Assess a patient’s health beliefs and explanatory model.
  
• Select effective patient education strategies to meet the unique needs of each patient.
  
• Create effective patient education materials.
  
• Use a 5-step model of behavior counseling to facilitate and maintain behavior change.
  
• Select an appropriate approach to patient education based on a patient’s health beliefs, explanatory model, learning style, literacy level, and readiness to change.
  
• Teach your patient to access valid and reliable health information.

As we described in the introduction to this text, we, as health care providers, teach every day; it is integral to what we do. Thus far, we have discussed teaching in the context of the classroom and in the context of professional and community presentations. However, perhaps the most important aspect of our role as teachers or educators is teaching our patients and their families. While our goal in all teaching-learning situations is to help our learners learn, in the context of patient care, learning becomes that much more critical. Our goal is to ensure that our patients are fully educated about their dysfunction so that they can make informed choices, be effective advocates for themselves and others, become valuable partners in the therapeutic process, and remain actively engaged in their own health and wellness.

In this chapter, we examine the complexities of patient education. We describe the importance of education from a number of perspectives and explore the many factors that need to be considered in designing effective learning experiences for your patients. Before you can begin any educational sessions with your patients, it is important for you to assess their readiness to learn, both physically and emotionally. To do so, we link back to adult learning principles and to motivation theory. We then describe the importance of placing your patients at the center of the decision-making process, and how you can negotiate shared meaning using explanatory models.

After developing goals that meet your patients’ needs, we discuss strategies and processes to optimize motivation and facilitate behavior change by understanding your patients’ health beliefs. We explore the stages of change and suggest different strategies for teaching and learning to help move your patient along the continuum of behavior change. We examine some of the factors (including comorbid conditions) that may facilitate or hinder adherence, and we present the communities of practice framework to help you identify supports that may facilitate adherence in your patients. As low literacy is quite prevalent in the United States, we also provide you with strategies to assess your patients’ literacy levels and mechanisms to design educational materials that will be optimally accessible to your patients. Finally, we provide you with a mechanism to facilitate the long-term maintenance of behavior change in your patients using behavioral counseling strategies. Throughout, we use a communities of practice framework to problem solve strategies to support your patients and to optimize their success in the rehabilitation and wellness process.

The second edition of Guide to Physical Therapist Practice1 describes the following 5 elements of patient/client management that lead to optimal outcomes: examination, evaluation, diagnosis, prognosis, and intervention. Intervention is defined as “purposeful and skilled interaction of the physical therapist with the patient/client and, if appropriate, with other individuals involved in the care of the patient/client, using various physical therapy procedures and techniques to produce changes in the condition that is consistent with the diagnosis and prognosis.”¹ The text further differentiates 3 types of intervention as follows: (1) procedural interventions; (2) coordination, communication, and documentation; and (3) patient/client related instruction. Patient/client instruction is described as¹:

Patient education is much more than instructing patients on exercises and therapeutic interventions. It includes education about illness, resources, healthy lifestyles, and the like. By now, you also know that educating your patients is much more than simply telling them what they should or should not do.

PATIENT EDUCATION: WHY IS IT IMPORTANT?

Patient education is clearly an integral part of what we do as physical therapists. It is what extends the therapy session beyond the 30 to 45 minutes that you might spend with your patient, and can help to optimize patient outcomes. Patient education is necessary to promote adherence to exercise programs, facilitate changes in behaviors, and cultivate healthy lifestyles in our patients.

Standards from The Joint Commission (the organization that accredits health care organizations) require all accredited inpatient facilities to have a multidisciplinary program of patient and family education.^2–4 The Joint Commission’s educational criteria mandate that patient education be grounded in sound educational principles and based on the patient’s needs and readiness to learn; it should be ongoing, systematic, interactive, and individualized to the patient’s learning preferences and educational level. The Joint Commission’s standards mandate facilities to have policies and procedures that delineate good patient-centered educational practices, including the following:

• Assessing patient/family needs
  
• Considering individual differences
  
• Having a written plan that addresses the needs of the patient
  
• Providing relevant information and skills
  
• Using a variety of educational tools
  
• Actively engaging the patient and caregiver in the process
  
• Evaluating the learning achieved

Not only does The Joint Commission mandate the use of good pedagogical practices, but it goes further to mandate that patient education include information about diagnosis, treatment, safe use of medications, drug interactions and reactions, nutrition counseling, diet, oral health, rehabilitation needs and techniques to maximize independence, pain and pain management, community resources, and postdischarge treatment.²

The American Hospital Association’s Patients’ Bill of Rights, which was more recently replaced by the Patient Care Partnership: Understanding Expectations, Rights and Responsibilities, also notes that it is the patient’s responsibility to be a partner in the decision-making process. For it to be an effective partnership, patients must be informed about treatment and expected outcomes, including risks and benefits, sources of follow-up care, and training in self-help.^2–4 Medicare also requires patient education to be part of the documented plan of care, as does the Commission on Accreditation of Rehabilitation Facilities, currently known as CARF International.^2,4,5

In physical therapy specifically, as noted earlier, the Guide to Physical Therapist Practice, which sets the standard for good practice in physical therapy, includes patient-/client-related instruction as an integral component of the patient-client management model.¹ A Normative Model of Physical Therapist Professional Education also provides the following sample objectives as expected outcomes of all entry-level physical therapist education curricula: “Demonstrate and document effective patient/client education” and “Employ patient/client-specific instructional strategies.”⁶ To ensure that this happens, the Commission on Accreditation in Physical Therapy Education (CAPTE) accreditation criteria includes Standard 7D27h in its 2015 Standards and Required Elements for Accreditation of Physical Therapist Education Programs which reads, “Competently perform physical therapy interventions to achieve patient/client goals and outcomes. Interventions include: Patient/Client Education.”⁷ Based on these standards and guidelines, it is clear that patient education is a valued activity in health care.

Finally, and perhaps most importantly, given the changes in health care today, patients have a limited number of therapy sessions available to them. The ultimate goal in health care is to empower and motivate patients to manage their own health. Patient education provides a mechanism for therapists to optimize patient adherence and extend necessary interventions beyond the limited time available in therapy. The more informed your patients are about their own health and how to manage their illnesses, the more prepared they are to become effective partners in making health care decisions and the more likely they are to follow through on home exercise programs (HEPs) and adhere to best practices in health and wellness.

PATIENT EDUCATION: WHAT DO YOU NEED TO CONSIDER IN PREPARING TO TEACH?

Traditionally, patient education has consisted of telling the patient what you expect, demonstrating it, and then having them do it (ie, tell, show, do). From there, health practitioners simply expected patients to follow their instructions and recommendations. By now, you are well aware that teaching is much more complex than show and tell. Educators must assess their learner’s needs and develop effective strategies that meet those needs.

In physical therapy, we assess our patients from the biopsychosocial perspective. That is, we consider not only biology, but also environmental (physical, social, and psychologic), lifestyle, and behavioral factors. From there, we develop effective intervention strategies to meet the needs of our patients and clients. Just as we select interventions based on solid rationale and best evidence, similarly, it is important that we select patient education strategies based on solid rationale and best evidence. Having a solid rationale for selecting the appropriate teaching strategy requires you to know the educational theories available upon which to build your strategies. A complete exploration of educational theory is beyond the scope of this text; we will instead focus on the following 2 major educational theories commonly used in patient education: behaviorism and constructivism.

Behaviorism is among the more traditional theories in education. Proponents of the behaviorist approach to learning focus on observable human behaviors and seek to shape those behaviors by reinforcing effective behaviors and extinguishing ineffective behaviors.^8,9 Behavioral theorists believe that learning occurs through stimulus, response, and conditioning activities. The role of the teacher is to create an environment that facilitates behavior change. Behavioral theorists break down the learning task into its component parts (ie, small steps). Each small step is reinforced using positive reinforcement to facilitate learning or behavior change. Adherents of the behaviorist approach rely primarily on drill, practice, and reinforcement.

1. Lock her brakes.
   
2. Unbuckle her seat belt.
   
3. Place the cane on her right side (slightly in front and to the side of the right armrest).
   
4. Move her buttocks forward toward the front of the chair seat.
   
5. Position her feet flat on the floor with your right foot slightly behind your left foot.
   
6. Place her right hand on the armrest of the wheelchair.
   
7. Lean her body forward and push up with your right arm and leg, letting your left arm and leg help as much as possible.
   
8. Grab her cane with your right hand and stand fully upright.
   
9. Maintain her balance before she starts walking.10

You will then work with Mrs. G to determine which of these steps is most challenging for her. You may then have her practice just that component of the transfer until she can perform it safely, efficiently, and effectively. At that point, you might chunk the tasks so that there are fewer steps for Mrs. G to remember. Finally, you would be sure to put it together as a whole. This approach is consistent with the part-to-whole strategy previously discussed in Chapter 8. The behaviorist approach is especially effective for discrete tasks with patients who prefer a sequential and detailed plan for learning or require a very structured environment, such as patients who have sustained traumatic brain injury.^9,11,12

Constructivism is an approach to learning whereby learners actively make sense of their experiences based on their own values, beliefs, knowledge, skills, and prior learning.¹³ Constructivists believe that all tasks are context-dependent and that each task should be viewed as a whole. Proponents of the constructivist approach believe that tasks should not be broken down into discrete components by the teacher to be mastered individually by the learner; rather, the learner must actively engage in problem solving (ie, how best to accomplish the task within the context of how and when the learner actually needs to perform that task). Constructivists do not view the teacher as the expert or authority, but rather, as a facilitator. Instruction is learner-focused rather than teacher-directed. The role of the teacher is to facilitate the learner’s own problem-solving ability.¹⁴

The constructivist approach to teaching and learning comes from Dewey’s work on learning from experience. Educators draw on the patient’s own experiences and let them solve problems in ways that work best for him or her. In using this approach, you would engage your patient in authentic activities in realistic settings. Your role as the therapist is to set up an environment that is safe for experimentation and risk taking. As the therapist, you would not tell your patient what to do, but rather, support him or her by creating a safe environment for him or her to try different strategies and ultimately to figure out which strategy works best for that particular patient.

For example, rather than breaking the task of transferring from the wheelchair to standing into its component parts, you might prepare the room for your patient by placing the wheelchair in a safe spot away from the crowded gym and then stand by for safety purposes. You might then have your patient strategize on how she would approach the task of getting up from the wheelchair. This would allow your patient to draw on some of her own past experiences in determining how best to complete the task. Clearly, this approach requires that the patient be able to participate cognitively and physically in the problem-solving process. If this is not the case, such as when the patient has significant sensory or cognitive limitations, the patient educator may use the more structured, behaviorist approach.

As a patient educator, it is important for you to understand the various theoretical approaches available so that you can select the approach that is most congruent with the given situation/task and with your patient’s learning preference. Just as it is important for you to have solid rationale for the types of assessments or treatment interventions you select, it is equally important for you to have a clear rationale for the educational approach you select with your patient. In selecting the appropriate educational approach, it is important to consider the following:

• Your patient’s cognitive, sensory, emotional, and physical capabilities
  
• Your patient’s experience, beliefs, knowledge, skill, and learning style
  
• The task itself
  
• The environment

For your educational session to be effective, your patient must be both ready and willing (ie, motivated) to participate. In Chapter 1 we discussed how adults generally bring with them a readiness to learn. However, we also know that each person is an individual with different life stressors and different personal motivators.¹⁵ Readiness means that your patient is both emotionally and physically able to participate in the teaching-learning situation. Motivation means that your patient has some drive to act.¹⁵ If your patient is not ready or willing, you will have to adjust your strategies to ensure that the educational session occurs at a time when he or she is more available to participate. This concept of physical and emotional readiness takes on even greater importance in physical therapy, where active engagement is essential and where we often work with patients with neurologic, cognitive, psychologic, and/or communication disorders. A more detailed discussion of educational strategies for use with special populations is provided later in this chapter.

Having the drive, willingness, and motivation to participate on a basic level includes both intrinsic and extrinsic motivation.¹⁵ You may have a patient who is intrinsically motivated because he or she finds the activity personally valuable, interesting, and perhaps enjoyable. On the other hand, you may have a patient who is extrinsically motivated because of guilt, coercion, or some other outside pressure. For example, your patient may be doing his or her exercises solely to please his or her spouse or therapist. Finally, you may have a patient who is not motivated to participate at all. It should be noted that external and internal motivation are not dichotomous; rather, they are on a continuum.^16,17 Our goal is to help move our patients along this continuum toward intrinsic motivation to optimize their learning, retention, and follow-through. Although we cannot intrinsically motivate our patients, we can provide certain social and environmental conditions in the teaching-learning situation that may facilitate a level of intrinsic motivation. Ryan and Deci¹⁵ suggest 3 major factors that may help our patients to develop intrinsic motivation. Patients are more likely to be intrinsically motivated if they feel a sense of the following:

1. Connectedness, which can come from a sense of being trusted, respected, and cared for by the therapist.
   
2. Self-efficacy, or a feeling of competence, which can occur when patients have sufficient knowledge and skill to perform the expected activities.
   
3. Autonomy, which can come from feeling that the activities are personally meaningful and valuable.

To meet these 3 basic needs and facilitate movement toward autonomous and intrinsic motivation, it is critical for us to take a supportive, nonjudgmental stance. Many of our patients are adult learners, so our goal is to work collaboratively to understand their goals and values, provide information and choice, and enable them to take responsibility for their own learning and performance. It is important that we provide a safe, comfortable, nonjudgmental environment where we do not try to control or pressure our patients, but rather recognize their self-concept and support them as they make decisions about their own care. This is consistent with the self-determination theory of behavior change.¹⁶

Keeping in mind the factors of autonomy, relatedness, and competence proposed by Ryan and Deci,¹⁵ there are a number of practical strategies that we can use to facilitate more intrinsic motivation. Because autonomy refers to a person choosing to do an activity because he or she values or enjoys doing it, it is important to ask a patient about specific activities that he or she enjoys doing. Remember, particularly when working with adult learners, that relevance is critical. Inquire about interests, leisure activities, and hobbies. Discuss personal goals for physical therapy. Finally, make explicit how specific exercises relate to the patient’s personal goals and interests inside and outside of physical therapy sessions.

Finally, to help a patient feel a sense of connectedness or relatedness, the physical therapist needs to demonstrate respect and caring, to practice what Streight17 refers to as intentional sensitivity. Because the learner/patient needs to feel supported, safe, and cared for, the environment should be organized, and we can consciously provide verbal and nonverbal feedback in a caring and empathic manner.

Our role as health care provides goes beyond just telling our patients what to do. Our role is to facilitate the behavior changes needed to maximize their function, prevent future injuries, and optimize their health. Behavior change is more likely to persist if it is internally motivated.

Although our ultimate goal is to help our patients assume responsibility for their own health, we may need to modify this expectation, depending on where the patient is in the rehabilitation process and what associated cognitive and/or emotional factors may be present. Early on, there may be significant comorbid physical, cognitive, and/or emotional factors (eg, delirium, confusion, fatigue, medical complications), which can interfere with the patient’s readiness to participate.¹¹ Rather than focusing on your patient’s ability to adhere to a given program, your role may be to seek and provide additional external supports that will enable your patient to overcome these barriers to participation.

During the later or more chronic phase of rehabilitation, patients may experience loss of function, changes in their medical condition, or the need for assistive devices, all of which require effective coping skills if they are to complete their rehabilitation successfully. Developing self-efficacy and problem-solving skills to optimize independence and function are an essential component of your patient education at this point. As a physical therapist, it will be important for you to modify your educational approach based on your patient’s needs, capabilities, and comorbid factors. Depending on what phase of recovery your patient is in, you may need to assume more or less responsibility for encouraging and managing your patient’s abilities to participate in, and adhere to, the therapeutic plan.¹¹ Regardless of the phase of the rehabilitation process, obtaining patient cooperation and motivation is critical to optimizing health and function. We cannot just take it for granted that just because we tell our patients or their family members or care providers to do something for the patient’s own good, they will. Nor can we assume that a patient who is not fully participating in the therapeutic process lacks motivation. Rather, our role is to assess the readiness of our patients to participate on a continuous basis and to modify our approach as necessary.

Our goal is to motivate our patients by influencing their beliefs, their attitudes, and, ultimately, their behaviors. Motivation fluctuates and often can be influenced.18 We are more likely to influence behavior if we first take time to understand our patients’ and their family members’/caregivers’ perceptions of their illnesses. Patients make sense of their illnesses based on their experiences. Their culture, experience, support systems, and social networks shape their beliefs and their view of the illness. As a result, they develop explanations for what happened to them and for the type of medical care that they think they need (including home remedies and alternative therapies). Our patients develop explanatory models to help them make sense of their illness experience.¹⁹ These explanatory models guide what our patients will and will not do and how they view therapy itself. Explanatory models are similar to illness perception, or how patients represent their illness. These illness perceptions are the result of the patient’s past experiences, his or her interpretation of the symptoms, and what he or she has and has not been told about the health condition.²⁰ This representation can include factors such as the cause, identity, consequences, and symptoms of the illness; what they understand about the illness; how manageable the illness is; whether it is curable; the timeline or trajectory of the illness; and their reaction to the illness.²¹ These explanatory models or illness representations may influence the patient’s readiness to participate in the therapy session. For example, if your patient believes that rest is the best medicine, he or she might not engage in any exercises that you prescribe or return to work-related activities, but rather, he or she might decide to stay home on bed rest until his or her pain is gone, which, in fact, might lead to further disability. On the other hand, if he or she believes in no pain, no gain, she might overdo the activities that you prescribe and actually injure him- or herself even more.²² By taking the time to elicit our patients’ explanatory models, we can begin to understand the following:

• What they believe caused their disease or injury
  
• What their reaction has been to the disease (ie, illness experience)
  
• What they believe will cure their disease
  
• Their personal preferences
  
• Their valued activities
  
• Their expectations of their role as a patient in the recovery process
  
• Their expectations of your role as a therapist involved in their recovery process

It is also important to understand your patient’s expectations about recovery. For example, if your patient believes that his or her back pain should be gone in 7 to 10 days and it is not, he or she may become disheartened and demotivated to continue the prescribed exercises and activities.22 The more we know about our patient’s beliefs and values, the more equipped we are to provide the best and most individualized care for each patient.

It is important to remember that both patients and health care providers have explanatory models. As a health care provider, you will likely have your own thoughts about the mechanism of your patient’s injury and about which interventions will be most effective. You will base your beliefs on what and how you were taught, your own search of current evidence, and your own personal experiences with other patients. As therapists, we think we know the following:

• What caused the impairment or illness
  
• What the patient needs
  
• How the disease should be treated
  
• What the long-term consequences might be

Our own explanatory model will very much influence our clinical decision making and what and how we choose to explain the health condition to our patients.^23,24 In addition, sometimes we even develop a plan of care for our patients based on our own explanatory models. However, unless we consider the patient’s and family member’s/caregiver’s explanatory models and use them in developing the most appropriate plan of care, we may fail to motivate or get “buy in” from our patient. While it is possible for us to extrinsically motivate our patients during the treatment session, they will not become intrinsically motivated to maintain a particular activity or behavior change unless they value the activity. As a result, despite being best practice, our plan may not be successful. For example, we might believe that the cause of our patient’s low back dysfunction is biomechanical in nature but, in fact, our patient is actually afraid to move because he or she does not want to feel pain. If we solely approach this patient’s care from our own belief system (ie, explanatory model), we might recommend manual therapy and exercise. However, if the patient is afraid to move and believes that rest is what will work for him or her, then our approach would likely not be effective.

As therapists, it is important that we not rely solely on our own personal meaning-making process; rather, we must develop a shared understanding with our patients, which requires dialogue. Your initial dialogue with your patient should be to elicit information about his or her explanatory model because it is important to understand how your patient and his or her family experience a particular disease state, as this will guide his or her behaviors and so, too, must it guide your actions and your plan of care.

If your patient’s limitations prevent him or her from being fully involved in this process, it would be important to engage family members or care providers and seek additional supports to overcome barriers to participation and to ensure that your patient’s voice is considered. So, the first step in patient education is determine who is the key learner, which might not always be the patient, particularly if your patient is elderly, very young, or has some cognitive impairments or comorbidities. The key learner might be that person most likely to help your patient follow through on his or her HEP. To determine who should be part of the education session, you might ask your patient the following questions:

• “Is there someone at home who will be helping you with the exercises?”
  
• “Who will be taking you to therapy?”
  
• “Is there someone else you would like me to talk to about your therapy sessions?”

Only once you have identified who your learner or learners are, can you begin your patient education.

When students enter the clinical setting, a learning triad is developed (ie, student, clinical instructor [CI], community), and each member of that community is essential in the learning process. Similarly, with patients, a triads develop that includes the patient, the therapist, and the therapeutic community, and the patient’s own family, community, or network (Figure 9-1). With patients, the community extends beyond the health care setting to include spouses, significant others, immediate family, extended family members, members of their social network, and spiritual advisors and the like. Just as members of the health care community help to facilitate student learning, members of the patient’s community may help to facilitate your understanding of your patient and may be equally instrumental in helping you educate, motivate, and facilitate change in your patient. Further, just as barriers and supports can emerge from all aspects of the student’s learning triad, similarly, barriers and supports can emerge from all aspects of the patient’s learning triad. To be effective in enhancing your patient’s adherence to the therapeutic plan, it is important to consider the potential barriers and supports with every patient.

In attempting to understand a patient’s explanatory model fully, Kleinman et al19 developed 8 questions that you can ask (Table 9-1). Realize that, by asking these questions, your goal is to understand your patient’s beliefs, so it is important to suspend judgment and actively listen. This is not the time to educate your patient; rather, this is a time for you to become educated about your patient. You want to ask the question and be sure to listen to what your patient tells you so that you can understand your patient’s perspective fully. It is also a good time for you to check your own assumptions and compare your personal explanatory model with your patient’s explanatory model.

At one time, the dominant explanatory model for physical therapists was one of a biomedical model. In the biomedical model, the belief is that a pathology exists, which results in impairments and functional limitations; an intervention will fix the impairments and possibly the pathology; and the therapist is at the center of the decision-making process. As noted in the earlier example of low back pain, this focus alone can lead to a disconnect between the patient and the practitioner. Practitioners using a biomedical model focus on the physiological state of dysfunction (ie, disease) and may miss how the individual experiences that disease (ie, illness). As practitioners, we may fully understand the pathology, but we can never fully know how the patient experiences that pathology and, in fact, each patient might experience the pathology differently. We now recognize this disconnect and the important influence that culture and experience have on an individual’s attitudes and beliefs toward disease, rehabilitation, and recovery. We no longer simply look at pathology and impairments, but rather, our focus has changed to one of a biopsychosocial model.25 As practitioners, we move beyond pathology and impairments (ie, the disease state) to fully consider the patients illness experience (ie, participation restrictions, environmental factors, personal factors; Figure 9-2). This places the patient at the core of the decision-making process and makes the negotiation of shared meaning even more critical to effective clinical care.

A good example of the importance of considering the biopsychosocial model rather than a pure biomedical model is pain. Many of our patients experience pain, and there is ongoing research related to psychologically informed decision making and management of patients with low back pain in particular and pain in general.^22,26–28 Many factors influence how we experience pain, including our attention to the pain, our interpretation of the pain, our own beliefs, our attitudes, our coping mechanisms, the consequences of the pain, and other contextual and environmental factors.²² Clear linkages in the literature have been made among pain, disability, and response to treatment.²⁷ As described previously, our health beliefs and explanatory model very much influence how we experience pain. Some of the psychologic factors that may contribute to increased pain perception and potentially impact a patient’s transition from acute to chronic pain include fear avoidance beliefs, catastrophizing, perceived control over pain, self-efficacy, anxiety, and depression. Some refer to these psychologic factors that might suggest increased risk for persistent pain, poor recovery, and disability as yellow flags.^26,29 Important to note is that these psychologic factors can often be as influential as biomechanical factors in the experience of pain. Incorporating psychologic factors into your treatment plan has been shown to have a positive impact on recovery and outcomes.³⁰ Of even greater importance is the fact that, as physical therapists, we can address not only the biomechanical issues, but also many of the psychosocial issues. Of course, depending on the severity of the psychologic factor, a multidisciplinary approach might be necessary and you may need to refer your patient to a pain specialist or psychologist for additional supports. In Table 9-2, we provide some common psychosocial factors that influence pain and recovery, along with some examples of how you might approach patient care.^22,26

One of the challenges of incorporating psychosocial factors into your treatment plan is being able to fully assess these contextual factors. Assessment tools and outcome measures are available, but utilizing some of the strategies that we have already discussed, such as exploring health beliefs and explanatory models, will give you a good place to start. Once you have identified the presence of some of these yellow flags, you then have to identify the best approach to treatment. Given that pain perception is multifactorial, there is no gold-standard approach. Only when we understand both our patients and our own explanatory models fully from the biopsychosocial perspective can we begin to negotiate the plan of care that best meets their personal, beliefs, values, needs, and goals, and addresses any potential contextual factors (eg, psychosocial and environmental) that may be influencing your patient’s recovery process.

It is important that our goals are patient-centered, and to ensure that they are we must engage our patients, to the extent possible, in the decision-making process. In the negotiation process, we may need to clarify any misperceptions or misunderstandings that our patients might hold regarding the disease process (eg, cause of the problem, length of the course of treatment). Providing complete and accurate information will enable our patients to engage more fully in the therapeutic relationship and in developing an effective plan of care. By engaging our patients (or a family member if the patient has significant limitations) in the process, together we can identify the best plan of care. This plan is not always necessarily the one that will have the greatest impact on the disease process, but rather, the one that has the greatest impact, on the illness experience. Recognize, also, that if our patients are involved in the decision-making process to the greatest extent possible, they will have greater autonomy over the resultant plan of care, which may lead to enhanced adherence.

Negotiation of shared meaning is an ongoing process. Just as you learned the importance of asking questions to facilitate reflection and enhance learning, questions are equally—if not more—important in helping you understand your patients. Kleinman et al’s19 8 critical questions are a springboard to help you begin to understand your patient’s illness experience. However, it is only the beginning. It is helpful to ask questions of your patients and family members throughout the process. For patients with cognitive or communication limitations, family members or caregivers may be able to provide you with important and helpful information.

It is also important to remember that, as patients learn more and experience therapy longer, their explanatory models may change, as may their goals and motivations. Questions can help ensure that the plan of care initially established remains consistent with your patient’s evolving needs. Questions such as the following may be helpful throughout the process:

• What is limiting you most from participating in your usual activities?
  
• What activity would you most like to do that you currently cannot?
  
• What do you see as your biggest barrier to following your exercise regime?
  
• Do you have anyone who can help you with your exercises?
  
• How confident are you in performing your exercises on your own?
  
• Do you think these exercises will help you to recover or return to the activities you want to do?
  
• Have you experienced any changes in your overall health recently?
  
• Have you had any prior experience in physical therapy or in doing other physical exercise?

FACILITATING BEHAVIOR CHANGE BY UNDERSTANDING HEALTH BELIEFS

Once you more fully understand how your patient experiences his or her illness, you can begin to facilitate change. However, change will be difficult if your patient does not believe the following³¹:

• That there are consequences to continuing his or her current behavior or that the consequences are not significant.
  
• That the benefits to change outweigh the costs.
  
• That he or she has the potential to change.

Miller and Rollnick³² describe this as ready, willing, and able, which is slightly different from how Ryan and Deci¹⁵ use these terms, as described earlier. Miller and Rollnick³² explain that your patient is ready when he or she indicates that change is a priority for him or her, willing when change is important to your patient, and able when your patient is confident in his or her ability to change. To determine whether our patients are ready, willing, and able to change, we need to understand their beliefs about health, wellness, and therapeutic intervention. We can develop a better understanding of our patients’ belief by using the Health Belief Model. Psychologists in the United States Public Health Service (PHS)³¹ developed this model in an attempt to understand why a program that provided free access to health promotion and prevention activities failed. Despite the availability of free chest X-rays to detect tuberculosis, few individuals accessed the service. After studying this phenomenon, the United States PHS identified a number of factors that influenced the decision-making process and motivated individuals to change. It suggests that, to facilitate behavior change in our patients, we must first engage our patients in conversation about those factors noted in Table 9-3.

What follows is an example of how a patient’s health beliefs might influence behavior change. You are working with overweight teens at risk for such health-related issues as obesity, diabetes, and heart disease. Teens often may not believe that they are susceptible to disease, and, if they do, they may not recognize the significance of the potential consequences of obesity. They may recognize that they are overweight and that it is harder to exercise, but not believe that being overweight can lead to heart disease or stroke in the future. They also may not believe that benefits of exercise outweigh the time, hard work, and energy it takes to engage in a diet and exercise regimen. They may have tried many fad diets that have failed and, so, do not believe that they have the potential to lose weight. Finally, if their social network consists of other overweight teens, there may be nothing prompting them to change. Educating these young teens about the consequences of obesity and helping to modify their health beliefs toward obesity is the first step. We must then begin to motivate them to take action in changing their behaviors.

To facilitate change, our patients must first be motivated to change. Lorish and Gale³³ promote the use of a behavioral change conversation to help us begin to understand our patient’s motivation. That is, they encourage us to engage our patients in a dialogue to understand their assumptions about their own susceptibility to disease, whether change is possible and, if so, whether it will make a difference, and the cost-benefit of the needed change. During this dialogue, as a therapist, you will also provide expert information, resources, and prompts to facilitate action.

We can never really know what will motivate our patients sufficiently to enable behavior change to occur, but determining those motivating factors will be critical to facilitating change. For example, you may think that it is sufficient to explain the potential health-related risks of obesity to teens, but if an overweight teen does not believe that he or she is susceptible to heart disease or diabetes, an explanation may not be sufficient to facilitate a change in his or her behavior. Perhaps what will motivate that person is information about a healthy teen program in his or her neighborhood. He or she may see others exercising and may meet individuals who have been successful with their weight loss and exercise programs. The patient may suddenly care more about his or her appearance and physical abilities. He or she may begin to view him- or herself as having the potential to change and view his or her new relationships as important. For the patient, the benefit of fitting in with his or her new peers and maintaining his or her new relationships may outweigh the energy it takes to participate in a weight loss and exercise regimen. It is important to remember that motivating factors may be non–health related and health related. By engaging your patient in the behavior change conversation, you can begin to determine the factors that will be most effective in facilitating behavior change in that particular patient.

Think back to the Stop and Reflect activity presented earlier when we asked you to consider a time when you wanted to make a change in your behavior. Do you remember how difficult it was to change your behavior or your lifestyle? You may very well work with patients who know that they need to change their behaviors because they are at risk for a disease with significant consequences, who recognize that the benefits outweigh the barriers to change, and who know that they have the ability to change; yet, they are not ready to make the change. If a person is not ready to change, that change will not occur. In facilitating change, it is important that we assess our patient’s readiness to change so that we can match our strategies to our patients’ needs.

Prochaska and DiClemente34 and Prochaska et al³⁵ studied addictive behaviors, particularly in smokers who were in the process of quitting. They described the transtheoretical model of change, which has 5 stages individuals move through as they progress through the change process:

1. Precontemplative: No thought of change
   
2. Contemplative: Thinking about changing
   
3. Preparation: Preparing to change
   
4. Action: Implementing the change
   
5. Maintenance: Maintaining the change

These stages, and how individuals experience them, may vary depending on the behavior they are trying to change. For example, there may be differences between those trying to quit smoking and those trying to incorporate exercise into their daily lives. These stages may not occur in a step-wise systematic fashion either. Individuals may enter the change process at any stage. Furthermore, individuals may experience relapses, or backward movement, at any stage in the change process.

As therapists, we will also select very different strategies for patient education, depending on our patients’ readiness or stage of change. For example, you are working with a patient who is obese and prediabetic and he or she tells you that he or she is too busy and too tired at the end of the long work day to consider exercise. You would likely consider him or her to be in the precontemplative stage. Before you can expect the patient to adhere to an exercise program, your best strategy might be to discuss the Health Belief Model and possibly to work to influence a change in his or her beliefs by providing information about consequences of continued inactivity. Use the motivational interviewing strategies and the 5 Rs, which we will discuss later in this chapter. If you are successful, he or she may tell you at the next session that he or she has given some thought to what you said and would like to consider an exercise plan, but just does not have 30 to 45 minutes to fit into his or her day. At this point, you would consider the patient to be in the contemplative stage. Your best strategy now might be to brainstorm and problem solve some of his or her barriers to participation and look for alternative solutions. At the next session, the patient tells you that he or she has decided to begin a walking regime during his or her lunch hour every day. The individual has cleared his or her schedule and is asking your advice on the type of sneakers that he or she should purchase. At this point, you realize that your patient has moved to the preparation stage, and your strategy might be to provide positive reinforcement, provide information about shoe wear and how to monitor his or her heart rate, and help him or her to establish realistic goals for the upcoming weeks. Finally, the big day comes and the patient starts the exercise regime during lunch. He or she has reached the action stage, and, now, ongoing reinforcement and support is necessary. You also want to continue to problem solve barriers, provide alternatives related to valued activities, identify rewards for adherence (eg, noted weight loss, decreased windedness on stairs), and remind your patient of the benefits of adherence and the risks of nonadherence. You see your patient again 2 weeks later, and you ask whether he or she is still walking every day. He or she tells you that it was impossible to keep up with the schedule; his or her lunch hours were busy, and, so, the patient became frustrated and just quit walking. He or she indicates that he or she would really like to continue the walking program, but it is just not working. Your patient has relapsed into the contemplative stage. Your best strategy might be to work with him or her to develop realistic goals (eg, walking twice/week during lunch and once on the weekend) and to help him or her move back into the action stage by using your motivational interviewing strategies and the 5 Rs. This is a cyclic process with the ultimate goal being to reach the maintenance stage, in which your patient is able to follow his or her exercise regime routinely and consistently. Even during the maintenance stage, patients/clients need ongoing reinforcement and problem solving to prevent relapse. Table 9-4 provides a list of questions that you can ask your patients/clients to determine where they are in the process of change, along with goals for each stage and potential educational strategies to consider while working with patients and clients during each stage of change.^31,33,34,36

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