The Language of Change: From ‘Obstacles’ to ‘Friction’ in Rehabilitation Conversations

Introduction: The Power of Words in Therapeutic Dialogues

Language is the medium through which we express our thoughts, convey our intentions, and foster change. In therapeutic settings, especially within the realm of physiotherapy, the words we choose can either pave the way for a patient’s progress or inadvertently contribute to resistance. 

Let’s embark on a reflective journey informed by the insights of both motivational interviewing and habit formation science, as we explore the subtle yet significant difference between the words ‘obstacle’ and ‘friction.’

Understanding Resistance: The Traditional Viewpoint

In the journey of rehabilitation, resistance often appears as a formidable opponent. Clinicians, grounded in traditional models, might talk about ‘overcoming obstacles’ in treatment plans. The term ‘obstacle’ inherently suggests a hurdle that is static and substantial. An ‘obstacle’ stands in the way, demanding to be removed or surmounted. This conceptualisation, while intuitive, might inadvertently instil a sense of struggle within the mind of the patient.

The Dual Nature of Friction: Navigating Behavioural Choices

Wendy Wood’s concept of ‘friction’ in her book “Good Habits: Bad Habits” extends beyond the simplification of a barrier; it is a dual-force that can be adjusted both to deter unwanted behaviours and to encourage beneficial ones. 

To limit undesirable behaviour choices, ‘friction’ can be increased by introducing elements that make the negative behaviour less convenient or less appealing. For instance, a physiotherapist might work with a patient to rearrange the home environment so that engaging in harmful postures or activities requires more effort — perhaps by moving frequently used items away from areas where the patient tends to stay seated to encourage the them to move avoiding sitting for long periods which may exacerbate back pain.

This method, rooted in the science of habit formation, makes the unwanted behaviour harder to sustain, thus reducing its impact.

Conversely, decreasing ‘friction’ can make positive behaviours easier and more accessible. In the rehabilitation context, this might involve simplifying exercise routines, reducing the number of steps to get started, or aligning the exercises with activities that the patient already enjoys or does routinely. 

These strategic manipulations of ‘friction,’ drawing from Wood’s work, recognise the profound impact the environment and routine have on behaviour, providing clinicians with practical tools for shaping healthier habits.

Shifting Perspectives: The Notion of ‘Friction’

Wendy Wood’s enlightening work proposes a paradigm shift. She encourages us to replace the term ‘obstacle’ with ‘friction.’ Friction implies a force that resists motion—it is not an immovable barrier but rather a variable that can be adjusted. 

In rehabilitation, ‘friction’ can manifest in the form of environmental factors, emotional states, thoughts, behaviours/habits or cognitive beliefs that make the desired behaviour either more or less challenging.

Motivational Interviewing: Facilitating Change through Language

Motivational interviewing (MI), a collaborative conversation style developed by William Miller, is about evoking and harnessing the client’s own motivation for change. In MI, the focus is on empathy and the exploration of ambivalence, creating a space where ‘friction’ can be navigated and modified through the patient’s own insights.

Clinical Example: Changing the Dialogue

Imagine a patient recovering from a knee injury, who is not adhering to their exercise regimen. Traditional dialogue might identify ‘lack of motivation’ as an obstacle. In contrast, an MI-informed clinician might explore what ‘friction’ the patient is experiencing—perhaps it’s pain during exercises, or difficulty in scheduling them into a busy day. By identifying and discussing the ‘friction,’ both clinician and patient can collaboratively find ways to reduce it, such as adjusting the exercise intensity or finding more suitable times for the regimen.

Case Study: Addressing ‘Friction’ in Making a Follow Up Appointment

A common example of ‘friction’ is making a follow up appointment. If the patient has frequently been kept waiting, then they may be more hesitant to make the next appointment, especially if it requires fitting into other commitments in their day.

Conversely, if the clinician is always on time, the patient is less likely to be hesitate in making the next appointment as they will feel confident that they will be seen on time and get to their next commitment without being unduly stressed or anxious.

From ‘Obstacle’ to ‘Friction’: Reframing the Approach

Incorporating the concept of ‘friction’ into clinical practice involves reframing how we view obstacles. They are not walls to be knocked down, but rather slopes to be navigated with care. This reframing allows for a more nuanced approach to each patient’s unique situation.

Implementing Change: Practical Takeaways

1. Reflective Listening to Identify Friction

Listen carefully to what your patients have to say with regards to struggles they may be having. Explore the the language they are using to uncover the ‘friction’ in their narratives that can be decreased rather than talk about obstacles to be overcome. 

2. Collaborative Strategy Development

To encourage a new desired behaviour, work with patient to develop strategies that minimise ‘friction.’ For example, if a patient finds it hard to remember exercises, together you could discuss what they need to do to remember to do their exercises. Only offer your suggestions and no more than three, when the patient doesn’t have any ideas. Then allow them to choose the one that they believe will work for them. Or your suggestions may prompt a better some ideas of their own.

3. Empowerment through Autonomy

Encourage patients to take charge of their rehabilitation journey. Facilitate the exploration of their own solutions to the ‘friction’ they face, thereby fostering a sense of autonomy and commitment to change.

Conclusion: The Path to Sustainable Change

The shift from ‘obstacle’ to ‘friction’ is not merely semantic—it is a profound change in how we perceive the challenges in the therapeutic process. 

As clinicians, by adopting this language of ‘friction’ rather than ‘obstacle’ we can transform the landscape of resistance into an opportunity for growth and development. In doing so, we empower our patients to glide more smoothly along the path of recovery, making the changes they enact not just possible but sustainable.

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