Are we helping or hindering engagement in health self-management? Common practices that feed patient resistance

In my many years of counselling I’ve often used the phrase “you teach people how to treat you”. What this means is that we set people’s expectations around what is appropriate behaviour, what is not ok and what is ok, by the way we communicate, express ourselves and behave around them.

This is no less relevant in the interaction between the client or patient and the health care practitioner. We influence the role the client takes, their expectations of how to behave in the healthcare setting, and how engaged they become in managing their own health by the way we communicate with them. Our communication with clients is both overt, through our words and actions, and subtle, such as the messages we convey through our attire or expression or even the setup of the room.

In a world where up to 80% of people don’t follow their health recommendations and 50% don’t even take medication consistently let alone changing lifestyle health choices (which is much harder to do!), there is an obvious need to get people taking more ownership and responsibility for their health outcomes. We need to be enabling people to self-manage their health. However, the traditional role of a health care practitioner works against this aim and actively hinders engagement in health self-management.

The traditional care model places the practitioner as an authority figure; the ‘expert’ whose role it is to prescribe treatment and give advice (tell people what to do). While this is appropriate and works well in an acute care context, it doesn’t work well in the context of chronic care, preventative care, rehabilitation, or any context where it is what happens outside of the consultation room that makes the greatest impact. Unfortunately, education and telling people what to do just isn’t effective, as evidenced by research from the World Health Organisation (2003).

When the practitioner controls the decisions and positions the patient as the layman who is reliant upon the health system, they thwart the patient’s key psychological needs for autonomy, relatedness and competence. These are the drivers of self-regulation. So we can find ourselves blaming patients for not taking ownership of their health management, but we’re not always giving them the tools to do so. It’s a bit unfair, really.

Hence, over the last decade or so we have seen the rise of patient-centred care. What patient-centred care means is that patients take an active role in their healthcare. The communication in a patient-centred role is vastly different, in that there is a clear message that while the practitioner has expertise in health conditions and recommendations, it is the client who is the expert in their own lives and is ultimately in control of the actions they take and the outcomes they get. The role of a patient-centred practitioner is to guide, support, collaborate and partner with the client to empower them to take action that improves their condition. The College of the Family Physicians of Canada provided a good comparison of the two models.

When patients are more involved in their care there are positive outcomes, both to the patient as well as health system utilization. Reductions in re-admission rates, medication error, and complications are all improvements associated with a patient-centred approach.

While patient-centred care has now been around for many years and is accepted as standard practice, keeping our overt and subtle communication in line with this paradigm can be a challenge. Particularly in a system still so enmeshed with the ideology that the ‘Dr knows best’ and that providing education is the most effective behaviour change tool, we need to be mindful of how our communication teaches the client how to treat us and their own health management.

Health practitioners will always need to impart knowledge and provide education. That’s a given. But there is such a powerful difference between doing this in a way that makes someone feel disempowered, less than, or bereft of choice, and doing it in a way that makes them feel that their opinions and preferences matter, and that they are listened to and respected.

When we teach them that they have choice and control in decision-making, that they and only they have the power to heal themselves, and demonstrate that we are on their ‘team’ as an equal, then we have the ingredients for active engagement in health self-management.

And here’s the funny thing about resistance: when a client no longer perceives they are being ‘told what to do’, they no longer have anything to resist against.

How do you use verbal and non-verbal communication to help your clients take ownership for their health and engage in self-management?

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