Exploring the Three Key Styles of Consulting Utilised by Physiotherapists

Patients’ lack of treatment plan implementation is often not due to a lack of information. So who needs to make the adjustments when adherence is not working?

Clinical practitioners often assume that patients who attend physiotherapy are motivated to improve their health. This is frequently the case in the management of acute and serious injuries, or in post-surgical visits, but not always in chronic care management.

Physical therapists are increasingly seeing patients with chronic injuries, or injuries associated with obesity, diabetes, lack of exercise, and other chronic illnesses.

A variety of degrees of enthusiasm are often present among these patients regarding education and rehabilitation programs. What happens in the management of these conditions?

Managing patients who claim to want improvement but whose compliance does not reflect their desire for an improved outcome can be extremely frustrating for clinicians.

In order to engage resistant patients, clinicians should consider three factors:

1. Consulting styles
2. Psychological reactance
3. Habitual behaviour

Consulting Styles

Clinicians may experience frustration or a sense of hopelessness when expecting the patient to adjust behaviour.

Clinicians who are willing to adjust their consulting style when they encounter resistant patients are likely to see more positive outcomes.

So, what are the options for adjusting your consulting style?

A comparison of various consulting styles and their effects

Three distinct consulting styles have been identified by Stephen Rollnick and William Miller[1] as effective in managing the various emotional states in which patients present: directive, guiding, and following.

A study by Susan Hargreaves[2] (1982) identified two types of consulting: dominant and affiliate. The dominant style corresponds to Miller and Rollnick's directive style, while the affiliative style corresponds to Miller and Rollnick's guiding style. In this article, I will use Miller and Rollnick's terms.

An overview of each style

There is a tendency for clinicians to have a default style of consulting and rarely consider the value of adjusting.

Directive Style

• Most health education today is based on this principle
• Implies an unequal relationship: the clinician has superior knowledge, expertise, authority, or power
• It is the clinician's responsibility to assist the patient in resolving a 'problem'
• There is a tendency for patients to expect it, but it renders them passive in their recovery process
• As long as it is delivered correctly and at the appropriate time, it can be personally relevant, clear, and compassionate
• If done incorrectly, it can leave the patient feeling unheard and unsatisfied
• When behaviour needs to be changed, it is not useful

It is common for clinicians to adopt a directive style of care as their default - it is the way they have been trained. The health care professional assesses the problem and tells the patient what needs to be done in order to achieve the desired outcome.

In the management of acute injury, with highly motivated patients and often with the elderly, a directive style of consulting is exceptionally effective.

During long-term rehabilitation and the management of chronic injuries or illnesses, it becomes less effective. Most of the time, patients in these situations have been instructed what to do by others, or are aware of what they need to do but find it difficult to follow through.

Guiding Style

• A clinician is aware of what is possible and can provide a range of options
• The clinician must let go of some control, but still maintain influence (e.g., I can assist you in finding a solution to your problem)
• Implies that the patient is the 'expert' on himself or herself
• This approach is goal-directed, but encourages patients to consider how and why they may wish to pursue their goals
• Attempts to evoke ambivalence
• Attempts to elicit the patient's own arguments for change
• It requires the ability to listen attentively

In contrast to a directive approach, a guiding approach seeks to elicit from the patient a plan of action that they can commit to, as well as how they will implement the plan. It is quite different from telling patients what to do and expecting them to follow through with it.

Lack of action among patients is often not due to a lack of information, but rather to a lack of consideration of why they might want to do the exercises and how they will be able to fit them into their schedules.

Following Style

• Often used with distressed patients
• Often useful at the beginning of a consultation
• Has no agenda other than to gain a better understanding of the world through the eyes of another
• Patients can tell their story and express what is important to them when it is used effectively
• Poorly used, it can be time consuming and non-specific.

Miller and Rollnick's following style is most effective when treating patients who are in a highly emotional state. These emotions include anger, frustration, sadness, hopelessness, and depression, among others. Spending time with these patients and understanding what has caused or contributed to their strong emotion is recommended before continuing with the consultation or providing them with educational information.?

Prior to pursuing management, it is necessary to modify the presenting emotion somewhat otherwise the patient will not feel heard and not hear what you are saying. Internally, they are still in the strong emotion.

In my next newsletter I will take a look at point 2- ‘psychological reactance’ from the perspective of the physiotherapist.

[1] Miller, W. R. & Rollnick, S. (2012). Motivational Interviewing: Helping People Change. New York:?Guildford Press

[2] Hargreaves, S. (1982). “The Relevance Of Non-Verbal Skills In Physiotherapy”. The Australian?Journal of Physiotherapy, 28(4)