The Use of Therapeutic Communication

Changing established habits and making changes to lifestyle choices, in order to better wellbeing, can be quite difficult, thus simply providing advice to patients in order to achieve that healthier lifestyle usually presents obstacles such as resistance, inaction and enduring poor health (Watkins, 2018). Advice such as exercise and dieting, keeping up with correct medication and routine follow-ups are examples of health promoting behaviours that can prevent complications and enhance wellbeing (Dellasega, Gabbay, Durdock, & Martinez-King, 2010). Nonetheless, it is important for health care professionals to intervene in order to encourage patients to engage in and take beneficial precautions to better health behaviours.

Motivational interviewing (MI), originally developed for use with people struggling with addictive behaviours (e.g. drug and alcohol), is now used for a variety of health issues. It has evolved from person centred therapy and now aims to encourage the individual to recognise the need for change and to take specific action to progress in that change (Dellasega, Gabbay, Durdock, & Martinez-King, 2010). Furthermore, patients are always encouraged to explore their own beliefs and values that they may hold towards or against a behaviour that they desire to change. Motivational interviewing specifically emphasises the importance of considering each person’s distinct perspectives when discussing a treatment plan (Dellasega, Gabbay, Durdock, & Martinez-King, 2010).

Through the use of therapeutic communication and rapport building, health care professionals are able to empower patients to strive and make those behaviour changes. Motivational interviewing is purely an approach that actively engages patients and draws on their primary motivation for change. The following will identify specific components of motivational interviewing which are used to help patients change their health behaviours. It will consider Alistair’s case and link to how the Transtheoretical Model of Change can be used to support him. It will do this by describing and using the Stages of Change Cycle to his care.

Establish Rapport & Setting the Agenda

Pre-contemplation & Contemplation Building rapport between the interviewer and the patient is an important step to make the patient feel comfortable and relaxed. This is so the interviewer can reach a level of trust which allows the patient to accept and process any suggestions and processes. This further establishes a comfortable environment that favours examining issues and eliciting personal reasons for change. It is important for the interviewer to consider the patient’s own perspectives, values and feelings, following with an accepting attitude. This, however, does not undermine approval or agreement, ambivalence is expected and thus this must also be recognised (Substance Abuse and Mental Health Services Administration , 1999).

In the stage of pre-contemplation patients do not take action as of yet and are unaware that their current behaviours, habits or lifestyle choices may be negatively affecting their health. Within this stage the patient is focusing on the “what if’s” of the idea of change instead of the pros. In the case of Alistair, he belong in this stage as he is concerned and has initiated the thought of change. Contemplation, however, is where the patient intends to take action to bettering their behaviour, yet they may still be ambivalent (LaMorte, 2018). Assessing Readiness to Change & Sharpening the Focus: Determination A study conducted by the Australian Bureau of Statistics collected data from 2014-15 regarding obesity rate in Australia. It showed that within the adult population (18 and over) alone there are 63.4% of that population who are overweight or obese (Australian Bureau of Statistics , 2015).

It was also found that the rates of obesity increase with age with four in five men - mid-40s and over – being overweight in 2014-15. With obese patients it is important to discuss specific interventions. With patients in orthopaedic conditions, obesity is a common condition and is increasing. Not only does it affect the health care system and the body itself, it is also a huge set-back for individual care of the patient and affects bone and joint health (American Academy of Orthopaedic Surgeons , 2015). It is important to assess the patient’s motivation for change and develop an understanding as to where they stand with the idea. There may be a plan of action in place that is beneficial to supporting behavioural change. In regard to Alistair, a dietary intervention would be a beneficial action plan in order to achieve a long-term goal of weight loss. This is allowing Alistair to become aware of the negative lifestyle and confront it with discrepancy (LaMorte, 2018).

Alistair should also be encouraged with self-efficacy so that he and the interviewer believe that he is capable of his goal. Identifying Ambivalence & Eliciting Self-Motivating Statements: Action Ambivalence is where a patient may experience mixed feelings about their plan to change their behaviour and may claim that their problems aren’t at all that serious (LaMorte, 2018). Lacking motivation can manifest this feeling and therefore must be acknowledged. The concept of ambivalence can be the positive or negative appraisal of the behavioural change and should be identified early (Sipilä, 2017) . Once Alistair is set and acknowledges that through his action plan he will achieve weight loss, he must be fully engaged in the process of change. Alistair must be helped to understand that his everyday life may be a lot better once he fulfils the change in his behaviour. Miller and Rollnick identified four different types of self-motivating statement including:

• Cognitive Recognition,
• Affective Expression of Concern,
• Direct or Implicit Intention to Change Behaviour
• Optimism About one’s Ability to Change (LaMorte, 2018).

These statements exemplify the different self-motivational statements that can be recognise. Patient’s must be encouraged through the thought process of change and once the patient is using self-motivational statements it will become evident that they have made progress. Handling Resistance & Shifting the Focus: Maintenance Once the therapeutic process is well underway, resistance may present. If resistance appears, this could be as result of lack of motivation by the patient or the approach is simply not working for the patient themselves (LaMorte, 2018). The patient may present with unusual behavioural patterns; arguing, ignoring, interrupting denying (Australian Institute of Professional Counsellors , 2015).

As the patient may feel resistant to the change, it is important to maintain their personal control and choice over their specific problem and keep reminding that resistance (much like other feelings) is very normal. To further assist with resistance, shifting focus off barriers or certain obstacles may help prevent future relapse into resistance. Self-motivation is highly important in changing behaviour, habit or lifestyle. As an interviewer it is possible to provide Alistair with tips and skills to help and guide him through his journey of bettering his health. Interviewers can talk to their patients about any barriers and worries they may have; however, it is up to the patient himself to take onboard the advice and implement it into his life. It is very much so up to the patient to keep up the maintenance of building behavioural change. The maintenance stage tends to be the stage where the person isn’t working as hard as they were in the previous (action) stage, they are however confident and willing to continue and work toward preventing relapse (Zimmerman, Olsen, & Bosworth, 2000).

Conclusion

In conclusion, the above has discussed the five different Stages of the Change Model including Pre-contemplation, Contemplation, Determination, Action and Maintenance. The stages have been referred back to Alistair who is worried about his weight and his upcoming Total Knee Replacement (TKR). A motivational interviewer could suggest a dietary intervention and ask Alistair about his concern and how he thinks he could manage his problem. It is important to remember that “relapse” may occur within any stage between Determination, Action and Maintenance even though it is normal for developmental progress to fall through it must still be encouraged that the patient talks about what went wrong and how they believe they could prevent it from happening again. Motivational interviewing can provide patients with moral tips and tricks to assist them in improving their health, as aforementioned, self-motivation will encourage Alistair to keep fighting and finding his own path.