Managing Patient Anxiety In Clinical Practice

What is said is often not what is heard.

You would be aware of people who seem ‘unflappable’. In a crisis, they can appear calm on the outside, when inside they want to shout or scream. For many people, however, the body’s interpretation of a ‘crisis’ becomes skewed, and leads them to ‘flip out’ over even trivial or inconsequential situations.

It is likely that a number of your patients will experience some form of anxiety when dealing with injury, management or impending surgery. Even those who might be ‘unflappable’ in other situations may feel especially vulnerable as a result of being incapacitated. It isn’t easy for some people to put their future into the hands of another person they don’t know well.

Many will deal with the situation easily, but for those who don’t cope so well, their anxiety can have a significant influence on treatment outcomes. You need to know how to manage it.

What are the effects of patient anxiety?

Patients’ anxiety narrows their attention span. You might give them things to do, or explain what’s happening, and they will come back without remembering a single thing you said.

It also affects the information they give you. It might be distorted or generalised. It is even possible that information that would be of use to you is completely deleted from their memory.

Anxiety also distorts the perception of pain. What patients might tolerate in a relaxed state becomes intolerable when they are anxious. An anxious state can even be misinterpreted as lack of motivation.

Because of this, the ability to manage anxiety is rapidly becoming a necessity in clinical practice.

How to manage patient anxiety

Here are two tools that you can use in everyday clinical practice.

Think about how you deliver the message ‘This is going to hurt’

It’s always assumed we need to inform patients about the treatment they will undergo. I also believed that if something was going to hurt, then we ought to tell them.

I didn’t realise that, in many cases, this is likely to increase patients’ perception of the pain if they were in an anxious state. There is ample evidence that this is the case.

Next time you go for treatment, and a clinician tells you it will hurt – even if the comment is a common one, like ‘This will sting a little’ or ‘You’ll feel a little pin prick’, be aware of what happens in your brain. If you focus on the upcoming procedure, you will begin to understand what’s happening at an unconscious level. It’s REALLY interesting.

There are the stoic patients, of course, who will say they don’t feel anything, but most patients are ‘primed’ for the pain they are about to experience.

There is a dilemma. Should you be totally honest and gain informed consent, and get a worse response than if you had said nothing? Knowing that the response will be worse if your patient is already in a semi anxious state because anxiety is known to increase the perception of pain.

Be aware that anxious patients will perceive most things you do in an altered way. So what can you do?

Here are two simple statements clinicians might make, but there’s a difference that has a profound effect on patients’ perception.

Here they are:

A. ‘Some people experience discomfort with this procedure but many don’t’

B. ‘Most people don’t feel much discomfort with this procedure but some people do‘

Both statements say some people have found the procedure a little painful and others haven’t, but the word order makes a big difference.

The mind naturally focuses on the part of the sentence that follows the word ‘but’.

When you deliver the message and end with ‘but many don’t’ (statement A), patients focuses on the fact that what you’re going to do doesn’t cause discomfort for many people. The reverse is true when you use statement B.

The order in which you deliver information can solve the dilemma. You can be honest, and get informed consent, without precipitating an exaggerated response.

By being thoughtful about how you deliver information, you have control over where the mind focuses attention, and reduce any anxiety patients might have.

The next time you need to warn patients about possibly painful procedures, think about your message and how you deliver the information. It will have an effect on the response you get.

2. Be aware that stress influences what patients hear

Have you ever noticed that when you’re in a stressful situation, your attention and focus are narrowed? Stress influences what people hear, feel and see; it’s important therefore, to be aware of your patients’ stress levels.

Stress activates the survival part of the brain – the more primitive part of the brain that is most concerned with how to get out of the current situation alive. The prefrontal cortex, or reasoning part of the brain, is less engaged.

Stress distorts, deletes and generalises information that is being processed. What is said is often not what is heard.

What causes you stress might be very different from what others find stressful. That’s why it’s important you avoid making judgments or assumptions about what can cause stress in your patients.

Where possible, try to get a snapshot of your patients’ current level of stress or perceived stress. When you must deliver important information, and you know an individual might be under stress, take steps to make sure your message is understood correctly.

This might involve asking them to tell you what they understand from what you’ve said. You could also suggest they have a partner or friend present while you are explaining things.

How beliefs can influence the brain

Patients can also distort, delete and generalise information through beliefs.

Think about the brain as a camera. Information comes in through the ‘lens’, which for the brain is via seeing, hearing, feeling, taste and smell.

Just like a camera has filters to alter an image, beliefs can filter information going into the brain, changing how people experience the world.

Some beliefs ‘filters ‘ you might have heard your patients express are:

‘I’ll never get back to the way I was’
‘I’ve got a disc injury so I’ll never get better’
‘Physios always hurt’
‘Nobody’s been able to help me, so what are you going to do that’s different’
‘I’ll never get rid of this pain’
‘My leg (arm) will never be the same’
‘You can’t help me’

When patients say these things, either to you or to themselves, they are also blocking out any possibilities that would be in contrast with the filters they are using.

This means they will not recognise improvements, or ways in which your treatment might be different from other experiences they’ve had. They are more likely to find fault or challenge what you are doing.

How do you deal with these beliefs?

Just like you can change filters on a camera, it is possible to challenge a belief filter. Your aim is to have patients question the beliefs they have.

You do this by saying things like:

‘How do you know this?’
‘What evidence do you need to see that you are improving?’
‘Who told you this?’
‘So nobody’s ever recovered from a back injury before?’
‘How can I help you see that it is possible to improve?’

These questions are challenging what are often entrenched beliefs. To ask them, or similar questions, you must have a great rapport with your patient. You must also ask them with a sense of curiosity, rather than confrontation. To challenge a belief your question must be an open one, which allows patients to think about what they have said.

When you begin this process, look for signs that the patient is thinking about your question, and only persist with further questions if you can sense some willingness on the part of the patient to consider that their current belief might not be correct.

How to recognise ‘deletions’ in patient statements

When making comparisons in a statement, the patient leaves out the comparator – for example, ‘The treatment was good (or bad)’: Compared with what?
Patients might leave out information about a person, object or event – for example, ‘I feel so down’: About what, specifically?
They make unreferenced statements – for example, ‘That doesn’t matter’: What, specifically, doesn’t matter?

Deletions are often used in communication, and it isn’t necessary to challenge every single one. You might need to challenge a statement that has deletions in it however, so you can better understand what the other person means.

To help you recognise deletions, I have made a list below. Look at each statement and think about what has been deleted and how you might clarify what the statement really means.

Unreferenced Statements

‘People push me around’
‘They don’t know what they are doing’
‘It’s a nasty looking thing, isn’t it’
‘Everybody feels that way sometimes’
‘It doesn’t work any more’

Making Comparisons

‘That treatment is more dangerous’
‘This is more like it’
‘This is the most efficient way’
‘John is the best’
‘She’s the toughest’

Simple Deletions

‘All the time’
‘Never again, until next year’
‘We left it all behind’
‘It won’t do’
‘It’s all scrambled’

How to recognise the three forms of generalisation that patients might use

1. Necessity

There is a number of ways we make generalisations in conversation. Here are a couple of common generalisations you might come across when consulting with your patients.

In conversation, patients commonly use words that indicate necessity, especially when considering home exercise programs. Examples are:

Should
Ought
Must
Have to

These words imply that there is a generalisation about the requirement to do or abstain from doing something. Often people who say these things haven’t thought about what would happen if they made a different decision.

You can help your patients decide whether the action they are considering is what they want to do. If it is they will change their language to ‘will’, ‘want to’, going to’.

You can challenge comments above this with:

‘What would happen if you didn’t do that?’

‘Suppose you did something else, what would happen?’

Your aim is to have patients think about the generalisations they are making and be specific about whether they want to do the behaviour in question.

2. Possibility

A second form of generalisation clinicians often hear is the use of words that reference possibility. These are words such as:

Can’t
Impossible
Unable

You can challenge comments like this with:

‘What would happen if you did?’

‘What stops you?’

‘Suppose you do?’

‘What part of this can’t you do?’

3. Universal Qualifiers

This third type of generalisation is very common. Examples are:

Always
Never
Every
All

A simple way of challenging comments that include these words is to repeat the statement to the speaker, in a questioning tone. You do this by using an upward inflection at the end of the sentence.

By doing this you are alerting them to the fixed nature of their comment, and questioning its accuracy. This might open the conversation up to other considerations.

Remember, to challenge generalisations, you must have great rapport, in order to allow patients to think about their comments and not feel threatened by your response.

How patients distort information

When information comes into the brain it is often distorted and this can be done in four ways:

Making assumptions
Mind reading
Making cause-effect links
Giving meaning to something that is not true

Distorting information is a very common cause of miscommunication between patient and practitioner. When listening to you, your patients can distort what you’re saying in any of these four ways. When listening to your patients’ history, you might also distort what they are saying in exactly the same ways.

Here are a few ways you can challenge the most common distortions.

Assumptions:

‘Are you saying…?’
‘Are you assuming that…?’
‘Do I take it that…?’

Mind reading (use with rapport):

‘How do you know that?’
‘How do you know that means X?’
‘What specifically do you mean by that?’

When you hear an assumption or a possible mind read, try challenging the comment with one of the above statements or questions, assuming you have exceptional rapport with the patient.

As you can see, there are many ways for what we see, hear and feel to be altered in the brain. It is normal for the brain to distort, delete and generalise information. It does this so as not to be overwhelmed by the volume of potential information it is receiving.

The challenge for you, the clinician, is to determine whether the distortions, deletions or generalisations are adversely affecting communication, especially in the anxious patient. If they are then it is up to you to clarify what is being said and understood.

Misunderstanding is often the result of failing to clarify or understand the context of a message.

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.

Please share this article with a colleague you care about…