Engagement with Treatment
Non-compliance is a key problem for PFMT – undermining its potential benefits.
It involves:
- Non-attendance.
- Non-adherence.
- Non-concordance.
Reasons for Non-engagement
Sub-optimal outcomes due to poor engagement across many treatments:
- Pharmacotherapy discontinuation = 80-90% (D’Souza et al., 2008; Krueger et al., 2005).
- Physiotherapy discontinuation = 40-50% (Khan et al., 2013); 30% (POGP survey 2020).
Intervention to Improve Engagement
In our 2016 paper (Osborne et al., 2016), we tested a psychological support intervention with an RCT:
- The intervention focused on supporting patient engagement with PFMT, not on improving psychological state, and could be delivered by any health professional.
- Can be an individual or a group-based programme – can be short (10min) or long (30min).
- 67 PFMT patients undergoing 6 group PFMT sessions (approx. 7-8 per group).
- Participants completed HADS to assess psychological distress.
- 31 patients in mild-moderate range for depression and anxiety were randomly divided into:
- PFMT only (n = 15).
- PFMT + Motivational Interviewing and Values Support (n = 16).
- MIVS group received 3 x 20min psychological group sessions (2nd, 3rd, 4th PFMT session).
- 90% of MIVS group, but only 60 of PFMT only group completed treatment.
Practical steps and procedures to support patients during physiotherapy
- Focus on patient motivation and values.
- Use principles of motivating change.
- Use principles of identifying what the patients want to achieve for themselves (values).
- Use a diary system to record goals and successes – this serves as reinforcement:
- Patients record times they practised targeted behaviours and achievements
- These can be shared and discussed in the group.
Questions that elicit self-motivated ‘Reasons to Change’
- Tell me some reasons why you might want to do this.
- Tell me some things you wouldn’t like if you didn’t change.
- Tell me some reasons why you may not want to change (fears, barriers).
- How might your life be different if you changed?
- What benefits might there be if you changed?
- How does this affect your life?
- What are some of the negative things about not changing?
Summary of important life values
- Values are intrinsically reinforcing for people.
- Behaviours congruent with values will be performed long after treatment finishes.
- Try to make results of PFMT treatment match values.
- In our 207a (Osborne et al) paper, and in our 2020 (Reed et al.) paper, we examined life values associated PFMT with engagement.
- Relationships with family and friends are a very important aspect of patients lives.
- Health values, work/achievement values, and spiritual values predict attendance.
Questions identifying individual values
When were you happiest?
- What were you doing?
- Were you with other people?
- What other factors contributed to your happiness?
When were you most proud?
- Why were you proud?
- Did other people share your pride?
- What other factors contributed to your feelings of pride?
When were you most fulfilled and satisfied?
- What need or desire was fulfilled?
- How and why did the experience give your life meaning?
- What other factors contributed to your feelings of fulfilment?
Try a values discussion exercise
There are several excellent tools to download to help clarify and highlight values:
Values discussion questions:
https://www.therapistaid.com/therapy-worksheet/values-discussion-questions/values/adults
Values exploration exercises:
https://www.therapistaid.com/worksheets/exploring-values.pdf
Values self-exploration:
https://www.therapistaid.com/worksheets/values-self-exploration.pdf
The Motivation Ladder
- After goals decided, the patient makes ‘motivation success’ ladder.
- Practical tool assisting goal-achievement by giving an objective representation of processes needed.
- Add to ‘representation’ (drawing, physical object) of the ladder – each rung labelled, and only added, when sub-goal achieved.
Further Goal Exploration Exercises
There are several excellent tools to download to help clarify and highlight values:
Goal Exploration:
https://www.therapistaid.com/worksheets/goal-exploration.pdf
Goal Breakdown:
https://www.therapistaid.com/worksheets/goal-breakdown.pdf
Goal Planning:
https://www.therapistaid.com/worksheets/goal-planning.pdf
Supporting Behaviours – Reinforcement
- Many patients do not notice when they achieve something.
- Depression makes patients focus on negatives, not positives.
- Achievement of goals has to be highlighted.
- Patients have to do this themselves:
- Self-efficacy.
- Social reinforcement.
‘Three good things’ exercise (promotes self-efficacy)
- Write down some things that went well (give events titles).
- Items can be small or large in importance.
- Provide explanations of why they went well – write down what happened, what was said by you and others.
- Include how events made you feel, at the time, and later.
- Explain what you think caused the events – focus on targeted behaviours to be encouraged.
- Create a physical record by writing them down – it is not enough to do this in your head.
- Do this exercise as part of a routine – daily or weekly.
‘Three good things’ tools
There are several excellent tools to download to help thinking about positives:
Three good things recording chart:
https://www.therapistaid.com/worksheets/gratitude-journal-three-good-things.pdf
Behaviour chart to record events:
https://www.therapistaid.com/worksheets/behavior-chart.pdf
Social reinforcement
- Patient records motivate patients and create a sense of self-efficacy.
- It gives a record of how things went between sessions – so goals can be adjusted.
- It gives a chance to bolster rewards socially!
- It works well in groups – so long as there is no pressure to share.