To help your patient break through resistance to exercise you will need to notice and reverse unproductive distorted thinking.

We spend a large part of our lives distorting information. We do this to create a thinking process that suits our natural tendency towards negativity or being optimistic.

Patients who are particularly resistant to treatment options and self maintenance may very well distort what information they see, hear or feel. This can have an adverse influence on the choices they will make on a daily basis.

They may be unwittingly limiting themselves to trying new experiences. Even those that will help them recover from injury or illness.

Feelings of helplessness, sadness, or loss of hope being start with a seed of negative thought.

Understanding the Types of Cognitive Distortions

Cognitive biases are ways our brain likes to distort reality so the world we experience aligns with our mindset. They can include irrational thoughts and perspectives we unintentionally accept as reality.

Below are eight simplified categories of cognitive distortions that your challenging patients may display. As you begin to recognise them, so you can begin to challenge them with the aim of expanding your patient’s thinking.

Black-or-white thinking

Black-or-white thinking only allows for one of the extremes. As an example, the patient is either in pain or not in pain. Or they are either completely fixed or the same as they’ve always been.

Overgeneralisation

This distortion is similar to black-or-white thinking, but it’s more broad. For example, if one treatment didn’t work, then your patient may say “Physio is not going to work for me.” It’s overgeneralising treatment effects and outcomes.

Negative filters

Negative thinking is similar to the two above. But having a negative filter is like wearing the opposite to rose-coloured glasses where everything looks dark and negative. It may be a result of previously poor treatment outcomes but there are plenty of other causes for negative filters.

If a clinician didn’t help in the past, then the start of a new relationship with a different clinician gets darkened with a negative hue.

Discrediting the positive

Discrediting the positive is when the patient’s brain distorts the positive to fit a negative reasoning. For example, some patient’s self-talk is that they will never get better, even though you recognise and compliment them on how well they are progressing.

Their mind will have to figure out a way to distort the positive to fit the negative thinking. They can do this by saying something like:

“They’re just being nice to encourage me. They don’t really mean it” or “They have to say that so I will feel better.”

Jumping to conclusions – fortune telling

‘Fortune telling’ can be heard as “I know I’ll never get back to the way I was.” Treatment outcome is not set in stone, but since it is distorted in the patient’s mind, it becomes truth. The patient is sitting there thinking they are predicting the future when they have no idea of what the future has in store.

The binocular effect

The binocular effect is like looking through either side of binoculars. There is the side that magnifies, making a situation or comment appear bigger than it needs to be. Then there’s looking through the side that minimises, downplaying a comment or situation, by making it smaller than it is.

The “I feel, therefore it must be true” distortion

This distortion is a reasoning that just because they feel a certain emotion, it’s automatically validated and must be true. Feelings have a way of being wrong but feeling right. The patient may feel like giving up, but the truth is that they still have hope. They might not feel like doing exercises, but by doing them they feel better. 

It’s highly unlikely that patients are ever going to ‘feel like’ doing exercises. Helping them understand this may guide them towards making better choices.

Even when the don’t feel like it!

“Should” statements

These are subtle expectations that patients put on themselves.

Examples:

• “I should do my stretches.”
• “I shouldn’t sit at my desk for so long, because my back pain will get worse.”
• “I should get to my Pilates class.”
• “I should get in for more treatment.”

When the patient doesn’t live up to the ‘should’ statements, they feel bad, like they’ve failed.

Steps To Challenge Assumptions

As you begin to understand what distortions are, you will be able to listen for them during your consultations. 

Make a note of any repetitive comments that fit the distortions above. Distortions are likely to be a patterns of thinking and communication. To help your patient move forward, you may need to challenge this thinking.

Your initial consultation is rarely the best time to challenge distortions. You have too many other  important pieces of information to gather. 

It’s also imperative to be in exceptional rapport before challenging a person’s thinking. You may need time to build this rapport so that your patient feels safe with you from an emotional point of view. 

They also need to trust you completely before they will ever consider expanding their thinking.

Prepare yourself in advance

Write down the distortion you would like to challenge for example, “I’ll never get any better.” This sets a rule for the patient to not do any exercise. Why should they do any exercises if they believe they will never get any better. Exercises are now waste of time.

Prepare yourself with how you are going to challenge this comment. You could ask:

• “How do you know?”
• “Is it possible that you might get just a little better?”
• “Why do you bother coming in for treatment?”

The answers will help you understand how your patient came to have this distortion and will guide you as to the next question.

You can counter negative comments with facts to help the patient consider possibilities. Taking this next step is best used when the patient is starting to consider that it is possible to make some improvements.

Ask the patient if they know or have heard of any other person that has a similar injury and has made progress. If they agree that they have, this fact further challenges the distortion they have had in the past.

The aim is to elicit possibilities.

As your patient considers the challenge to their comments, they may begin to realise how they have been limiting their progress purely from the way they talk to themselves and others.

By expanding their thinking, your patient is more likely to consider the benefits of positive choices you have offered them.

Two Words of Caution: 

1. Thinking differently, that is more positive may be difficult for some people. Persist and don’t give up. 

Persist slowly and allow for processing time between treatments. Some patients have been in a negative, distorted thinking process for a number of years. It may be hard for them to change their thinking quickly.

As you persist you may give your patient that little bit of hope they need to make the small choices on a daily basis that will contribute to their recovery.

2. Challenge thinking with open questions. This will make it necessary for your patient to give you more than a ‘yes’ or ‘no’ answer. The more you understand how the patient came to have the thinking they have, the better you are able to help them.

To learn more about motivational tools through effective communication download my eBook

“Improving Patient Motivation In Physiotherapy”

I wrote this eBook in response to the most common question I get asked and that is “How do I motivate my patients?”

If you would like to fine-tune your communication skills when working with resistant patients, you might consider working with a coach or mentor.

Or perhaps your staff would benefit from training in this area.

Contact us, and find out more about what we can offer you.

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