How Physiotherapists Can Work With Ambivalent Patients

Any behavioural change has a component of ambivalence

Physiotherapists frequently report their frustration at listening to the range of excuses from patients who haven’t stuck to their treatment plans.  Apart from the obvious impact on patient recovery, it also leaves physios at a loss to work out why some of their patients seem to be so resistant to change.

One of the reasons could be that patients are feeling ambivalent about what they are being asked to do.

What is ambivalence?

Ambivalence comes from two Latin words – ambi (‘both’) and valens (‘influential’ or ‘powerful’) – and involves strong feelings and motivations that draw a person in two different directions simultaneously.

To put it simply, ambivalence is about wanting two incompatible things at the same time. This conflict can feel extremely confusing and uncomfortable.

We all experience ambivalence at different times, and in various aspects of our lives.

Here are some common examples:

  • We really want to lose weight but we also love the types of food we eat.
  • We want to get an early start to the day but we also enjoy staying in bed in the morning.
  • We want to get away from work earlier but always feel the need to stay to complete another task.
  • We want to spend more time reading, but we can’t miss our favourite TV shows.

Any behavioural change has a component of ambivalence, because of the strong pull from two directions: what we want in the future, and what we are doing now.

When your patients struggle to comply with treatment plans, it often means they are struggling with ambivalence. They want to get better but they also want to continue with their current activities (or lack of activity).

How to recognise ambivalence

  • When you suggest something and the patient responds with ‘Yes, but…’,  you are dealing with ambivalence. ‘Yes’ signals a willingness to follow your suggestion; the ‘but’ statement reveals the pull from another direction.
  • Similarly, when patients continuously make excuses, listen for the conflicting direction in which they are being pulled.
  • When patients are managing chronic conditions poorly, it’s often because they have become stuck in a state of ambivalence.
  • Patients who do well for a while and then relapse, because they are neglecting their ongoing home maintenance exercises, might also be struggling with uncomfortable feelings of ambivalence.

How to challenge patients’ ambivalence

As you have probably observed, just because patients know they must, or have good reasons to do your exercises, and even though they say they can, or want to do them, doesn’t mean that they will.

Whenever patients enter the medical world there’s a pretty good chance a clinician will ask or expect them to do something they don’t normally do. This means they will have to devote some time to it, give up something, or adjust their behaviour in some way.

They are ambivalent – pulled between doing what’s necessary to get better and staying the same.

This is frustrating for you and not helpful to your patients.

Try:

  • Listening to the ‘but’ statements and excuses they make for not doing the agreed tasks.
  • Then ask open questions related to each excuse.

Here are a few common excuses, and how you might respond:

Client:   I forgot to do the exercises.

You:      What needs to happen for you to remember to do your exercises?

Client:   I don’t have time to fit the exercises in.

You:      What needs to change for you to fit these exercises in?

Client:   I can’t do this exercise. It hurts too much.

You:      What part of the exercise causes you pain?

In all of your questions, your aim is to help your patients find solutions. This is a more effective approach than telling them what they should be doing.

Ideally, your patients will start to think about possibilities, rather than simply agree to your requests and then possibly do nothing.

Working with your patients’ current level of motivation

When you hear language that indicates your patient is struggling with ambivalence – wanting to take action to get better but stuck in their current behaviour – your aim is to elicit any speech that favours change.

Although many patients are ready to make those adjustments, many are not. Their excuses might indicate they are not fully persuaded of the need to make certain changes in their lives.

It’s important you are aware of the extent of your patients’ willingness to implement change.

Aim to work with your patients at their current level of motivation.

If your options ask for more than they are willing to implement, then change is unlikely. Instead, you will probably be met with resistance in the form of excuses and the ‘Yes, but…’ syndrome.

If this happens, ask yourself whether your demands push your patients above their level of motivation.

And if that is the case, you might need to find out exactly what your patients feel motivated to do at this stage, and review your expectations accordingly.

This is much more constructive, for them and for you, as it will reduce ambivalence and resistance, and eliminate the need for excuses.

In summary:

  • In discussion with your patients, listen for language that indicates ambivalence or unwillingness.
  • Refrain from telling patients what they should do.
  • Ask open questions to help them come up with potential solutions.
  • Listen to what they say, so you can provide them with clinical options that fit their needs and their current level of motivation.

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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