I’m going to start off with one of those “no shit, Sherlock” type of statements, but stay with me. After we have ruled out any reasons of need for immediate referral or indications that our care would not be appropriate, we next start looking for opportunities to make a positive change. To make this work we need to know what change will be meaningful and relevant to the person who’s seeking our help. We are not looking for any change that can be made. We are looking for a change that will make a meaningful impact to their particular issue (No shit, Sherlock!).
But, how do we decide what is a meaningful change? We can decide for the person and this might be reasonable. After all, we’ve gone through all this fancy and expensive education to gain access to all of this useful knowledge about problems and solutions. Shouldn’t we just tell the patient what they need?
Oh, if only it were that easy! This is what many try to do and leads to hearing or thinking the all too common saying of “you can lead a horse to water but you can’t make him drink.” If only the patient would do what we tell them they would get better! It’s so frustrating!! Of course some people will do what you tell them get better. But those aren’t the patients that cause us to lose sleep or spend our valuable personal time wondering why we couldn’t get our message across.
Here’s the insight: It’s better if the change is their idea.
1) Elicit a specific and measurable prediction about the problem from the patient.
Our first therapeutic task is going to be to assist the patient to describe their issue at the level of an outcome that they fear or worry about, to a degree specific enough that it can be checked or measured. We want to help them formulate their issue in the form of a prediction. We don’t want to dictate their problem to them.
Why is this important? In my last post I talked about some of the problems with trying to disconfirm a maladaptive belief. Beliefs are slippery. They are very difficult to pin down and therefore very difficult to change and are very prone to bias. We have confirmation bias working against us here and if we try to change a belief by just presenting contrary evidence we might even make things worse through the backfire effect! This is why we need them to come up with the prediction (instead of it being dictated to them) and it needs to be specific enough that it can be shown to be wrong (much more on this in the next installment). This is consistent with the concepts and processes of expectancy violation.
Our assistance will likely be needed and here is where some motivational interviewing skills come in very handy. In motivational interviewing the questions asked are open ended, allowing the patient to describe the issue in their terms. Reflective statements are used to draw out more detail in a non-threatening manner AND to reframe statements into something that may be useable in terms of a prediction and/or more adaptive.
There are many ways that we may accomplish getting to specific predictions. It could be as simple as asking “Can you show me how high you feel that you can safely lift your arm?” You can take your trusty goniometer off your Batman utility belt and get a measurement that gives you a specific (even if non-verbal) prediction of “I am not safe to flex my shoulder past 95 degrees.” You might want to get into some specifics about what they fear will happen if they move higher than this and how they knew that this was all the higher they could safety go. But either way, you’ve now got a measureable prediction to refute.
A more complex interaction could be as detailed as the following:
What is the outcome that you fear? (open ended question)
I won’t be able to go back to work as a drywaller.
What will bring about this outcome (unable to work)? (open ended question)
Not being able to lift my hand over my head or having to get a shoulder surgery.
How far can you lift the arm safely?
Demonstrates raising the arm to 90 degrees of shoulder flexion.
If you lift your arm past that point bad things happen (Reflective statement).
Yes, it hurts. It’s weak.
And that’s got you worried about needing a shoulder surgery or something that will keep you from being able to lift the hand long term (Reflective statement).
Yes, I’ve read that this type of pain and weakness may mean that there’s a rotator cuff tear or something. If that’s the case, if it’s damaged, then it’s not going to get better without getting it fixed.
I see. So you’re worried that something is wrong that won’t improve without surgery and the things about the shoulder that make you think that this may be the case is the pain and weakness when raising the arm past this point (mimics 90 degrees). (Summarizing statement)
This creates a detailed picture of the expectation and it gives us very measurable prediction!
From the patient’s perspective, If the shoulder is damaged, there will be pain and weakness that won’t improve above 90 degrees of shoulder flexion.
These are the problems from the patient’s perspective. But, you can also see how important the back and forth of the interaction was in getting to the point of some specifics. Now we are left with a specific prediction in the terms of why it is important to the patient (continuing to work).
We are now set up nicely to move to our next step, which will be to attempt to refute or falsify this prediction through experimentation. This will be the focus of the next post.