"No" Is Not A Failure - Thinking Physio

“No” Is Not A Failure

“No” is a pause, a nudge, and a chance for the patient to articulate what they do want.

You’ve completed what you think is the hard work by assessing and diagnosing the problem your patient has presented with.

You’ve listened to what they want to achieve by coming to see you and created a treatment plan that will help them achieve the goals they want.

Why is it then that so many patients fail to comply with the plan that’s been created?

Why also, do so many clinicians struggle to present a treatment plan that solves the patient’s problem early on in the management cycle?

The reality is that the assessment and diagnosis of a problem often proves a lot easier than engaging your patient in plan you’ve created.

With the assessment and diagnosis you are in control but when you deliver your plan, the patient is now in control of doing the work and implementing it.

The planing phase of rehabilitation is the comfortable stage for the patient. Sitting in with you has your patient feeling as if they have finally committed to doing something about their problem and you will provide the solution they need.

They haven’t had to take any action yet!

If you fall into the trap of telling your patient what they need to do or should be doing you are likely to elicit ‘Psychological Reactance.”

If you’re lucky they will verbally tell you all the reasons why they can’t comply with the plan. If you’re not so lucky they will be telling themselves those reasons and you will find out the next time you see them when you hear their excuses for not following the plan.

You will recognise psychological reactance when your patient is arguing for the status quo. That is, they don’t have to make the changes you’ve suggested.

A more effective way of engaging in behaviour change is to enter into a negotiation.

RECOGNISING WHEN YOU ARE IN A NEGOTIATION

When ever you say “I need you to…”, “I want you to…” or “I’d like you to…”, you are involved in a negotiation.

The successful implementation of a treatment plan should always be a negotiation rather than you dictating what the patient should be doing.

Unfortunately early in my career I often told my patients what they needed to do to get better. It was usually a one way conversation after I had assessed them with me advising them on what they should be doing to get the outcome they said they wanted. My advice was given with compassion and a willingness on my part to help my patients as much as I could. But it was still advice rather than a negotiation.

I would often get very frustrated by the excuses that they came back with. I didn’t consider negotiation as I thought my role was to be the expert and they had come for my advice.

They had, but I had miscalculated how much people don’t like to be told what to do.

THINKING DIFFERENTLY ABOUT TREATMENT PLANS

I’d like to propose a paradigm shift by you aiming to get your patient to say “No” to your plan rather than say “Yes”.

I read about this concept in Chris Voss’ book “Never Split The Difference” and I believe it’s a game changer for successfully negotiating the implementation of a treatment plan. Especially in chronic care management.

When your focus is on getting your patient to agree to the plan Voss suggests you will get one of three types of “Yes” and they are as follows:

Counterfeit- they say “Yes” but mean “No”, the dirty “Yes”. An escape route but no intention to follow through. We’ve all been in a situation where we agree just to shut the other person up and then go about doing what we were going to do anyway
Confirmation- an affirmation with no promise of action. This is commonly what you will get from your patient because they are not thinking about the consequences of what they are agreeing to
Commitment- leads to action taking. This type of ”Yes” from my experience is a lot rarer than you think

Patients often agree with health professionals to a change of behaviour with regards to their health and fitness, but more than 90% don’t go on to make those changes even when their life is at stake let alone managing an injury.

What if instead, your aim is to get your patient to say “No” to your plan. Now you’re in a position to begin your negotiation.

“No’s” can be a gateway to “Yes”.

“No’s” can provide time for both parties to pivot, adjust and reexamine and create an environment for a “Yes” that matters. It is often where the real negotiation begins.

Your invitation to say “No” can bring down barriers and allow for beneficial communication. So aim to get it early in the management phase when you present your plan.

“No” is not failure. “No” is a word that opens a path forward.

Give your patient the right to say “No” from the outset so that the negotiating environment becomes more constructive and collaborative. By allowing them to tell you what they don’t like about your plan from the outset, you fulfil their need to stay in control. Control is something that those in the health system often feel as if they lose.

“No” protects and benefits both parties in the conversation. “No” is a pause, a nudge, and a chance for the patient to articulate what they do want.

Voss suggest that those who fear a “No” response, become the hostage of “Yes”. It puts pressure on you and your patient.

By giving your patient the permission to say “No”, or tell you what they don’t like, you can:

Calm emotions in those who are fearful of change or not being in control
Improve effective decision making from both perspectives
Allow your patient to really consider your plan
Give yourself time to elaborate and adjust the plan if necessary
Allow for real issues that have not been considered to be brought forward
Protect yourself from having to get the plan right from the beginning. You may understand the presenting condition but you rarely are fully aware of your patient’s day to day commitments
Help both you and your patient to feel safe with regards to decisions and emotionally comfortable

“No” is not rejection or manifestation of stubbornness nor the end of a conversation, rather it has other meanings that you may have been previously blind to like:

I’m not yet ready to agree
You are making me feel uncomfortable
I’m feeling uncomfortable with the change, the commitment, or the challenge/situation I’m in
I don’t fully understand the commitment you’re suggesting
I don’t think I can afford it
I want something else
I need more information
I want to talk it over with someone else

All of these meanings can be discussed in the safety and comfort of a “No” response.

HOW TO GET A “NO” YOU CAN WORK WITH

To improve compliancy your goal is to persuade from the patient’s perspective, not yours.

You cannot control others but you can influence as long as you are prepared to inhabit their world by seeing, hearing and feeling what they want.

To try and understand the other’s point of you rather than making assumptions, you can get there by asking for a “No”. For many clinicians this is easier than standing in the shoes of the patient.

By using a question that prompts or resembles a “No”, it is an opportunity for your patient to become engaged and think about what you have delivered. For those managing chronic conditions it may be the first time they have really considered what they are committing to.

By aiming for an early agreement, patients that are resistant to change are more likely to get defensive, and wary. They are also unlikely to have considered all the consequences of the commitment they are about to embark on.

With these patients you will probably get the ‘Confirmation yes’.

Here are some suggestion that might help you allow your patient to say “No”:

“Because I don’t fully know what’s going on in your life, tell me what doesn’t work for you in this plan.”

“Based on what we’ve discusses, this is my suggestion for your treatment plan. What about it don’t you like/approve of?”

“This is the plan I’ve come up with to help you achieve your goal. Tell me what you don’t like about it.”

“This is the plan and for it to fit into your life, tell me where I might have gone wrong/what you don’t like/be honest with me and say what’s not going to work for you.”

“This is my first version of your treatment plan. Tell me how I can improve it to best suit you.”

These are all versions of allowing the patient to say “No” to the first version of your treatment plan. You can adapt the plan accordingly depending on the response you get.

USING A “NO” RESPONSE WITH A DIFFICULT PATIENT

Using this same philosophy, here are some ideas when dealing with a difficult patient when you’re not getting anywhere and they are non-compliant:

“Do you want me to give up on treating you?”

You’re aiming for a “No” response to which you can follow up with:

“What do you want me to do?” Or “What do you want from me instead?”

Your aim is to give the control back to the patient and allow them to define the next move.

You could also mislabel an emotion by saying something that’s totally wrong.

Examples:

“It seems like you’re really eager to give up on treatment”

“It seems like you’d prefer to see another physio.”

“It seems like you are really frustrated with me”

Response- “No, that’s not it. This is it…”

In each instance you give the patient the opportunity to tell you what is the real issue for them to which you can respond and move on to an acceptable outcome.

Triggering “No” peels away the plastic falsehood of “Yes” and gets you to what really matters.

Ultimately your aim is to get to an agreement with regards to your plan because it solves the patient’s problem. They want to get better and you want to help them achieve the goals they want. You just don’t want this too early in the negotiation.

Use the suggestions I’ve offered and adapt them to suit your natural communication style. It might just be quite liberating encouraging a “No”. I know this concept would have helped me especially early in my career.

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…