I recently ran into trouble with a patient who agreed to goals during the initial assessment, but made little progress. What I didn’t realize was that I was missing a crucial step: assessing readiness to change.
Free DIRECT downloads: Assess readiness to change and set goals (cheat sheet) and the Readiness Scale (assessment tool). (Email subscribers get free access to all the resources in the Free Subscription Library.)
Outline:
- The trouble with my patient.
- The five stages of change.
- Assessment of readiness to change.
- 10 questions to assess readiness and set goals.
- What would you like to see changed in your life?
- Is it OK to talk about your memory?
- What would be different about your life if your memory were better?
- How would things be better if you worked on your memory?
- What’s the best/worst thing that could happen if you participated in speech therapy?
- On a scale from 1 to 10, how confident are you that you could improve your memory?
- What would make you feel more confident about working on your memory?
- On a scale from 1 to 10, how ready are you to improve your memory?
- Would you like my opinion about how I think I can help?
- I wonder what it would be like if we practiced strategies to improve your memory. Would you like to try?
- MedBridge course on motivational interviewing and health coaching.
- Related Eat, Speak, & Think posts.
- Are you ready to assess readiness to change?
The trouble with my patient
I recently worked with a patient who didn’t achieve nearly as much as I’d expected. During the evaluation, I used collaborative goal-setting to identify very specific goals that she wanted to achieve. Little did I know that she wasn’t ready to make changes and likely agreed with the goals out of politeness.
At the second session, I jumped right into teaching strategies and how to apply them to her real-world activities. But she seemed resistant. She asked lots of questions, was slow to try out things that I suggested, and tried to start unrelated conversations. And she didn’t implement most of my recommendations between sessions.
During this time, I was writing about collaborative goal setting, and I happened find a related course on MedBridge which helped me to realize where I had gone wrong with this patient.
As a result, I backed off teaching and began exploring her hesitation.It turns out that she didn’t believe she could change how she did things. She didn’t believe that she could improve her memory. She agreed to therapy because she knew she was having trouble. However, because she didn’t really believe she could improve, she didn’t do most of the work.
It took three weeks for us to reach the point where she was trying anything outside of therapy. If I had thought to investigate her readiness to change and find out what was holding her back from the start, we probably would have made better progress.
The five stages of change
The five stages of change come from the transtheoretical model of change (TTM). TTM is a research-based model that can be used to predict whether a person is likely to achieve their goals. It’s a way to conceptualize the path that a person follows in making changes and provides tools to assist them.
The stages are:
- Pre-contemplation.
- Contemplation.
- Preparation.
- Action.
- Maintenance.
Pre-contemplation
People in the pre-contemplation stage aren’t even thinking about making changes in their life. Perhaps they don’t recognize that they have a problem. They may think that a change won’t help. Or maybe they don’t think it’s possible to change.
Motivational interviewing can help increase awareness that a change could improve their lives, and that it’s possible for them to change. You may not see immediate results, but this could plant the seed for future change.
Contemplation
People in the contemplation stage are open to the idea that it’s possible for them to make changes in their lives. They may be ready to move on to the next stage, but are unsure how. Or they may be concerned about the cost of making changes.
Motivational interviewing is helpful in clarifying their understanding of their difficulties, addressing concerns, setting motivating and realistic goals, and building rapport and trust with the therapist.
Preparation
In the preparation stage, people are getting ready to make changes. They believe that the benefits of making a change outweigh the costs. And they intend to start making changes in the near future.
In speech therapy, this may include completing standardized assessments, finalizing goals, signing up for computer-based programs, gathering materials, or negotiating how therapy will be structured.
Action
During the action stage, our patients are actively engaged in learning strategies and doing exercises. They’re applying what they’re learning and providing feedback to you.
During this time, we’re preparing our patients to continue taking action after discharge so that they can maintain gains from therapy.
Perhaps they’re learning how to set and achieve their own goals, such as with intensive home exercise programs with aphasia.
We may be developing a home exercise program that can be continued indefinitely.
Or maybe we’re helping out patients develop a routine to make the new behaviors a habit.
Maintenance
The maintenance stage occurs when people have reached their goals, and they do whatever is necessary to maintain those gains. Our patients (or their families) take full responsibility for putting into action the discharge plan we co-created.
Assessment of readiness to change
Ideally, we’d like to help people move into the action stage as quickly as possible. Skilled intervention is a limited resource, and may become even more limited with PDGM going into effect. Assessing readiness to change should help us be more efficient, in conjunction with collaborative goal-setting.
Benefits of assessing readiness to change
Assessing readiness to change isn’t just about helping you determine if your patient is a candidate for therapy.
It’s also about supporting your patient’s sense of self-efficacy, to help them understand that they have the power to take an active role in improving their own lives.
Assessing readiness to change will:
- Build trust and rapport.
- Exposes limiting beliefs that may slow down therapy.
- Help your patient take an active role in their own rehabilitation.
- Allow you to develop goals that are meaningful to your patient.
- Improve the chances that therapy will result in real change.
A useful tool to supplement your intuition
Sometimes it’s easy to tell when someone’s just not ready to participate in therapy. They deny difficulties, express disinterest, or avoid conversation about their problem areas.
Other times, it’s not so easy to tell. Some people will tell you what they think you want to hear, regardless of what they believe.
Even when a person is open to participating in therapy, they may have limiting beliefs that can slow their progress. Or they may have concerns you may not think to talk about.
How to assess readiness to change
As you can see from this post, I’m just beginning to assess readiness to change in my patients in a more direct way. What I’ve done here is list the 10 questions I think will be most helpful in my practice and explained why.
The MedBridge course included a useful exercise in writing interview questions, which helped me generate some of the questions below. I’ve already been using a few of these questions as part of my collaborative goal-setting process.
10 questions to assess readiness and set goals
You can pick and choose which questions to ask, depending on how things are going with your patient. Two questions use a rating scale (from 1 to 10). I’ve made a free Readiness Scale you can download. Or you likely already have a pain scale in your bag, which you can likely use.
Although I’ve written these questions about memory, you can modify them to target any communication or cognitive-communication skill. Not all of our patients can answer these questions, but you can modify accordingly. You can also ask these questions of your patient’s family, with your patient’s permission.
1. What would you like to see changed in your life?
This question is open-ended and doesn’t even target the areas that we treat. I love to open the floor by allowing my patient to talk about whatever is bothering them the most. This allows you to:
- Find out what matters most to your patient.
- Hear them talk about their main concerns.
- Assist them with finding solutions or refer them to the right person.
- Gain insight into how you may address their problems in a meaningful way in therapy.
Asking open-ended questions and listening to the response is a great way to build rapport and trust. I know from experience that if my patient is worried about something, it’s likely to impact our work together.
Sometimes just listening is enough to relieve some anxiety, at least for awhile. But even better if you can help in some concrete way.
2. Is it OK to talk about your memory?
Sometimes we know from our patient’s history that memory is an issue, but they haven’t brought it up. In this case, it’s helpful to ask permission to talk about it. It’s a sign of respect and sends the message that we’ll only talk about the things they’re comfortable talking about.
I’ve never had a patient outright say “no”, but I’ve had patients tell me that their memory is fine or deflect. In these situations, I’ll switch to asking about something else, like swallowing or communication.
Then after a few minutes, I’ll mention that many people I know have some trouble with X (whatever specific thing they’re having trouble with). I’ll say that my job is to help people improve X, and I’ll ask if they’ve noticed any changes in that area.
This serves to normalize the problem. It sends the message that it’s a common problem, and that it’s possible to improve the situation.
If they still answer that they’re not having trouble, then I’ll ask a different question. By this point, I avoid using the word “memory”, since some people get nervous about admitting to memory problems, thinking it might mean they have dementia. I’ll keep probing until we find something specific to talk about.
Or I may ask permission to talk to their spouse or adult child to “see if they’ve noticed anything.” My patient may accept what their family says, or I may learn that therapy will consist of educating and training the caregiver.
3. What would be different about your life if your memory were better?
This question allows your patient to think about what changes they’d like to see in their life. It’s very similar to the first question, except this one is constrained to memory.
It’s a “magic wand” type of question, meaning that there’s no pressure on our patient to imagine that they’d have to do anything to have a better memory.
The point is to allow your patient to focus on the final outcome and what that would look like for them.
4. How would things be better if you worked on your memory?
Like Question 3, this question is meant to help your patient daydream about possibilities they care about.
In this case, it puts your patient in an active role and supports an attitude of agency. It sends the message that your patient has a choice to take action on a problem that is bothering them.
I choose between asking Question 3 and Question 4 based on how motivated my patient seems to be at the time.
5. What’s the best/worst thing that could happen if you participate in speech therapy?
This is a great question for people who are in the contemplative stage. If they’re open to the idea of therapy but have concerns, they’ll be able to answer this pair of questions.
Maybe your patient isn’t thrilled about adding yet another therapy to their busy schedule. Will the investment be worth it?
Or maybe they are concerned that they won’t be able to do the therapy exercises. Memory is such an abstract concept that it can be intimidating to people. And no one likes to fail.
There are likely many other reasons why your patient may be hesitant about speech therapy.
This question can help them weigh the pros and cons. As an example:
- The best thing about participating in speech therapy might be that they can remember things better and be less frustrated and embarrassed.
- The worst thing might be that therapy doesn’t help. If they can’t do the exercises, then it might mean they have dementia. (A common fear, in my experience.)
If you can address their concerns, they may decide to fully participate in speech therapy with an open mind.
6. On a scale from 1 to 10, how confident are you that you could improve your memory?
Ask your patient to show you their confidence level on a scale from 1 to 10, with 1 meaning not at all confident and 10 meaning very confident. Download the Readiness Scale I made, or use your pain scale, or simply draw a line on a piece of paper.
If they’re not very confident, see Question 7.
7. What would make you feel more confident about working on your memory?
If your patient isn’t especially confident (perhaps 1 – 7 on the scale), you can ask open-ended questions to explore why. For instance, you can ask Question 7 and allow your patient to tell you what they feel they need. Or you may ask other open-ended questions.
If your patient is able to express why they’re not strongly confident about participating in therapy, it will allow you to address the issue and make the experience more positive.
8. On a scale from 1 to 10, how ready are you to improve your memory?
You can ask your patient to answer, where 1 means not at all ready and 10 means very ready.
It’s possible to be very confident that you can change, and still not be ready to make those changes.
I have worked with people who wanted to improve their memory and felt like they could do it, but weren’t ready.
Usually, the reason has to do with more urgent health problems. I do remember one person who postponed therapy because she couldn’t concentrate in the weeks leading up to her granddaughter’s wedding!
If your patient answers between 1 and 7, you can ask open-ended questions to find out why they’re not ready. You may be able to address their concerns, or you may defer therapy until they’re ready.
9. Would you like my opinion about how I think I can help?
This is another permission question. The MedBridge course pointed out that giving our opinion or ideas for the plan of care before our patient is ready can be a negative factor in outcomes.
By asking permission, we’re again sending the message that we’re a team. I’m not dictating how the sessions will be run, and I’m not imposing my decision on my patient.
Instead, I’m informing them that I’m willing to share my expertise with them and giving them the choice.
10. I wonder what it would be like if we practiced strategies to improve your memory. Would you like to try?
This is a great question for people who are willing to participate, but are still a little hesitant. It’s more inviting than “I’m going to teach you some memory strategies, and then we’ll try them out” which is how I usually start off.
MedBridge course on motivational interviewing and health coaching
I recommend the following course, which helped me realize what went wrong with my patient.
Tracey Collins wasn’t the most enthusiastic speaker I’ve ever listened to, but the information was clearly organized and the exercise she had us do was very helpful. I think it’s worth taking her seminar.
Patient-Centered Care: Motivational Interviewing and Health Coaching* by Tracy L. Collins, PT, PhD, MBA, GCS.
*This is an affiliate link. At no extra cost to you, you can help keep Eat, Speak, & Think sustainable if you subscribe through this link or use the code EatSpeakThink. Learn more about the discount.
Related Eat, Speak, & Think posts
- How to plan cognitive therapy with 6 questions.
- Goal Attainment Scaling tutorial.
- Collaborative goal-setting to identify meaningful cognitive goals.
- 7 tips to benefit your home health patients and minimize your workload.
- Treating cognition in the real world.
Are you ready to assess readiness to change?
So how ready are you to assess readiness to change in your patients, on a scale from 1 to 10? Have I convinced you that it might make therapy go a little more smoothly? Please comment below!
Free DIRECT downloads: Assess readiness to change and set goals (cheat sheet) and the Readiness Scale (assessment tool). (Email subscribers get free access to all the resources in the Free Subscription Library.)
Featured image by BBH Singapore on Unsplash.
Lisa earned her M.A. in Speech-Language Pathology from the University of Maryland, College Park and her M.A. in Linguistics from the University of California, San Diego.
She participated in research studies with the National Institute on Deafness and other Communication Disorders (NIDCD) and the University of Maryland in the areas of aphasia, Parkinson’s Disease, epilepsy, and fluency disorders.
Lisa has been working as a medical speech-language pathologist since 2008. She has a strong passion for evidence-based assessment and therapy, having earned five ASHA Awards for Professional Participation in Continuing Education.
She launched EatSpeakThink.com in June 2018 to help other clinicians be more successful working in home health, as well as to provide strategies and resources to people living with problems eating, speaking, or thinking.
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