This blog has emerged from a range of sources and an interest in how physiotherapists can utilise coaching skills into patient care. It also considers how this can then develop into day to day practice with teams and the wider health-care community.
Debates surrounding the “Hate exercise, Love activity” campaign driven by the CSP, as well as the concept of exercising through pain and around the theoretical proposals of “windows of opportunity” have also made us consider the links between coaching, motivation and the other issues surrounding these discussions.
This discussion stems from an interest in “self-determination theory” (SDT). SDT can be traced to humanistic psychology that emphasises an individual’s effort toward self-actualisation, which is the point where the realisation of a persons potential transpires. It is formed via the premise that as long as the basic psychological needs of an individual are met then a natural “growth” will occur. SDT also relates to how people perceive their locus or control, which is the extent to which an individual views their own behaviour, perceived by internal factors (interests, values and identities), is in relation to external factors such as other people’s demands and regulation through the environment.
As clinicians who wish to help our patients, we are in a constant flux with respect to helping an individual move towards self-actualisation. SDT theory argues that as humans we require three basic psychological needs to be met; autonomy, competence and relatedness and when these needs are satisfied, then self-regulation creates a sense of well-being and engagement toward their goals.
Autonomy can be described as being in control, competence is the need to be effective and relatedness is the need to feel valued and connected with others. It is also suggested that if self-regulation is not achieved then individuals may develop patterns of behaviour that offer short-term benefit but may not realise their long term goals or achievements. These patterns of behaviour may manifest through feelings of fear, guilt or through the pursuit of an external reward.
In physiotherapy we may have to be aware of unwittingly developing these feelings in our patients, such examples may include:
“You must do your exercises to help you, if you don’t, how can you ever expect to get better!”– Fear
“It is your responsibility to do these exercises! If you don’t then we cannot help you”– Guilt
“If you do these exercises, we can show you have tried, then we can justify asking for a scan, because we have moved through the right process”– External Reward
So, how does this relate to many of the discussions around exercise or activity, having a “window of opportunity”, or pushing into pain?
Importantly (Gagne and Deci 2005) & (Spence and Oades 2011) speak of a vital fourth motivation, integrated motivation, where the individual experiences fun and enjoyment from a goal that was extrinsically set.
These concepts, we propose, link to the exercise prescription we offer patients. It suggests that the first three motivations (fear, guilt, external reward) will not lead to the three required; the need for autonomy, competence and relatedness and therefore will not lead to internal motivation. An integrated approach, i.e. finding what the individual enjoys (internal reward) and make it relatable to their goals, and then motivation led by the individual is far more likely to happen.
So, asking a patient to stand in a room on their own, repeatedly doing a movement over and over again, experiencing pain based upon the premise that it may help, could be conflicted. The reason that it could be conflicted is that on the one hand, the movements may build power, strength, endurance, flexibility, however on the other, unless it leads to a feeling of control, effectiveness and connecting to others then the chances of the physiological changes observed in studies having any long term benefit is compromised. Of course, if the exercise can be experienced to offer these three needs, irrespective of the pain experienced, and manifest in a sense of reward, then the result is likely to be more successful. So, the context, meaning and relevance of the exercise must be acknowledged and accepted, and of course it might be a starting point, so we are not suggesting that individual exercise plans are wrong, far from it, rather what we are saying is that they need to meet the psychological needs as well as physiological aims.
Therefore, when developing an exercise programme, the activity and its environment as well as the motivation and choice for the individual will need to be taken into account in order to meet these psychological needs. This may improve compliance and become an integrated part of life, rather than be regarded as a treatment. This is far more likely to create a sense of self-actualisation and reach a person’s full potential.
So perhaps, the “hate exercise, love activity” concept is really just a real world self-determination theory model that allows therapists to be wider and more person-centred in their exercise prescription. The development of social prescribing parallels this and we may see a shift from gyms, and weights to parks, bikes, and rambling (for some of course), as self-actualisation can absolutely come from the gym and heavy exercise, but in the right group and social context.
The term “window of opportunity” is so often linked to hands-on treatment, and is actually in our opinion, a far wider and deeper concept. It is when changes in behaviours or beliefs lead to the individual having the support to meet their psychological needs. It is when a humanistic coaching approach opens up the opportunity for change through the clinician-patient relationship. The window is never opened unless a humanistic coaching process is initiated, and so irrespective of our treatments and their proposed effects, it must be built upon a coached approach to the care episode.
Developing the environment for change requires taking others perspectives into account, acknowledging their feelings, minimising pressure and offering choice that make sense to the patient within their community. There is no reason why a short term pain relieving intervention offered in the appropriate context should not help this, however, we must remember that, although these treatment offer pain reduction, it is the appropriate psychological responses surrounding this that offer the chance for change. The short term period of pain relief is described as neuro-modulationand it is suggests that one’s self is separate from our physiological being, and of course that is not the case, so perhaps we offer the opportunity for people to modulate themselves, alter the pain experience, and affect beliefs; we therefore, don’t specifically modulate nervous systems!
Good quality physiotherapy offers autonomy, and as such opens a psychological window that offers this opportunity, and as the “window” remains open the growth towards competence can begin. With the development of competence (this could be confidence in a movement, increased integration of activity, improved engagement in tasks) the key is to then create the social support that offers the individual fun, enjoyment and the opportunity to feel valued (this could be increased social interaction, returning to work, or perhaps joining a club).
So, in summary we propose that some patients refer to activity as part of their normal life and we can see why, conceptually and psychologically, linking recovery to activity and not a pre-determined view of exercise can build upon SDT theory. When patients are active, then they are of course exercising, but they are not limited by external goals such as repetitions, time and weight, they are influenced by internal integration such as enjoyment, interaction and fun and this perhaps is why the campaign developed this way.
External limited exercise prescription is a vital approach to recovery for numerous patients but perhaps it should be underpinned by SDT theory which may lead to the development of improved personalised exercise plans and improved outcomes.
Many of these concepts can be applied in our working environments and from coaching managers, athletes and staff we can utilise similar concepts across environments.
Neil will be talking about this and more at PhysioUK19 so if you are going, we hope to see you there!
Neil Langridge, NHS Consultant Physiotherapist
Matthew Low, NHS Consultant Physiotherapist