- Behavior change is the number one thing that physical therapists are trying to intervene on when working with patients
- Patients come with beliefs about what is contributing to what they are experiencing as well as what will help them improve
- Attacking those beliefs can lead to defensiveness and a withdrawal of trust in you as a provider
- Shining light on the means with which patients arrived at a belief is potentially a more productive way of having a conversation around unhelpful beliefs and behaviors
There are few things more difficult than successfully changing someone else’s behavior. Anyone who’s worked in the musculoskeletal field knows that the name of the game is behavior change. People on the outside looking in are certain that there is a special mix of stretches or a combination of rub down and TENS unit placement that can get patients over the finish line without them really needing to do anything themselves. What this leads to is an unfortunately facing of reality for those who have not been to physical therapy before. The reality is that we are and always will be mainly focused on altering behaviors that may be negatively contributing to what a patient is experiencing.
One thing that needs to be understood fully is that patient behavior is influenced by the beliefs they hold about their presentation and context. The patients always come into the clinic with a preconception about how things are, and the task of the physical therapist is to identify the behaviors that may be contributing to their presentation and guide them towards alternatives.
Most of the trouble is that meddling someone’s beliefs is a delicate process. It can’t be forced; change must come from within. If there is an attempt to force a belief in one direction, there is the opportunity of whats called the backfire effect to kick in. Then not only does the person not see your point of view, but they now are even more convinced of their stance than they were before.
While we can provide education and information as authorities in our field, the real change happens when the patient is ready to embrace it. Change of beliefs and behavior does not simply happen by presenting someone with “good” information. We as people are under the impression that if we simply share the information that helped us see the light, whatever that light may be, it will be enough to sway anyone else receiving this good word to see the same light we did in the same fashion. This lacks account of all of the complex difference between our reality and theirs.
Conventionally an argument is centered around a claim, or a few claims. Someone makes a claim or chooses to challenge another person’s stance on something and then chaos ensues. When someone makes a claim (a belief of theirs) and we choose to challenge that claim (that belief), we are effectively saying you are wrong. There have been entire books written about the disgust humans have for being wrong, and the mental gymnastics they will go through to avoid actually believing or acknowledging that they are wrong. It’s easy to see how this sort of discussion can degrade quickly. I’m certain you can think of times that you have personally had a conversation go in this direction. As we come up on the holidays, consider some of the conversations that occur around things like politics and the state of the world while having thanksgiving dinner with your relatives if you’re coming up short on personal examples.
Let’s look at an example: a patient claims that too much protein is bad for their kidneys. This belief alters the way they interaction with food intake, possibly setting themselves up for a less than successful recovery plan. In a topic rebuttal, we might try to persuade them that they are mistaken and that they should believe that taking in 1.6-2.4g of protein per kg of bodyweight is a great idea. We end up with a he-said-she-said situation in which rapport is side stepped for a small win that nobody receives.
This is where we pivot towards a technique rebuttal. Instead of arguing the claim directly, we shift the focus to the technique or method they used to come to believe that claim. By examining the process that led to a belief, we can gently shed light on its origins. We may ask about the sources they relied on to reach that claim and evaluate their credibility. The goal is not to prove them wrong but to make them aware of their thought process. This “meta-cognition” turns someone’s finger back at themselves so that they can be the one deciding if they themselves were diligent in the process of arriving at that claim.
What Do We Do With Technique Rebuttals?
Understanding that patients are coming to you with preconceived notions that are likely different than yours can help you know what direction to start out in. Simply taking the time during a patient interview to assess what they believe to be contributing to their presentation as well as what they believe will help them can take almost all of the guess work out. At that point we can decide if using a technique rebuttal to challenge myths and encourage the adoption of healthier habits is appropriate or not. If so, try these steps outlined in the Street Epistemology series:
- Ask yourself, “why do I want them to change their mind?”
- Build rapport
- Ask for a (fact based) claim
- Confirm/repeat the claim (in your own words)
- Clarify definitions
- Ask for a confidence level rating/weigh certainty
- Explore reasoning (pick the most common [there may be many])
- Ask what method have they used to justify the quality of their reason(s)
- Summarize and repeat
- Wrap up
I highly recommend watching some of Anthony’s videos linked above to get an idea of the power of technique rebuttals.
Behavior change in patients is a complex journey, but the technique rebuttal offers a more effective approach than traditional topic rebuttals. As physical therapists, it’s our job to guide our patients gently toward healthier beliefs and behaviors. By shifting our focus from attacking beliefs to understanding the pathways taken to arrive at them them, we can help our patients turn inward and potentially make the necessary changes for a healthier lifestyle.