What is your most precious resource? What do you guard with all your heart, steward with utmost wisdom, and seek to multiply? I think many of us would agree with Steve Jobs when he said,
“My favorite things in life don’t cost any money. It’s really clear that the most precious resource we all have is time.”
Time. Personally, I never seem to have enough of it. The weekends end too quickly, my kids seem to be hurdling toward adulthood while I’m still in middle-school-mom-mode, and my documentation time routinely evaporates into some mysterious black hole while I’m at the office. From a logistical standpoint, time is a very finite asset, and I struggle to juggle it effectively.
From time to time (pun somewhat intended), this brings up a dilemma. What should I do when I carefully and respectfully deduce that the patient with persistent pain before me is completely unready for change? What do I do when my honest appraisal of their rehab potential is poor?
I’m pretty sure we’ve all seen a time-drain scenario in the clinic. It’s the patient who comes to our office against their will because their doctor told them they had to attend therapy in order to have their prescription refilled. It’s the patient who is staunch in their assessment of their situation: “therapy will not help me; I’ve seen my bulging disc on the MRI; I need surgery.” It’s the patient who is simply uninterested in change, and who certainly doesn’t believe in the tools we therapists are peddling.
One could make the argument that everybody deserves a chance, and that all patients deserve our very best effort. After all, the patient before us is clearly suffering. They are in PAIN. They have been in pain for a long time, and no one seems to be able to help them. Their lives have been turned upside down and they are in a place they never intended to be. They are a fellow human being, deserving of respect, dignity and empathy.
Furthermore, those of us in the therapy world who have been fortunate enough to gain a modern understanding of the neuroscience of pain have the skills and knowledge that could actually help them, if they would only buy in and do their part. We know how to teach patients about pain, how to get them moving with a moderate cardiovascular exercise program, how to help them regulate their sleep, and how to encourage them towards their goals. We have a host of other skills and techniques that have helped hundreds of patients over the years. We CAN help them! They are in the right place! They deserve our very best. They deserve our time and effort…right?
In the late 1990s, James Prochaska and Carlo Di Clemente of the University of Rhode Island gifted the psychology community with a model that is worthwhile for the rehab world to study: The Stages of Change Model (Prochaska and Velicer 1997; Prochaska and Velicer 1998).
Stage of Change
|Pre-contemplation (not ready)||· Not currently considering change
· “Ignorance is bliss”
|Contemplation (getting ready)||· Ambivalent about change
· “Sitting on the fence” / “Snoopers”
· Not considering change in the next month
|Preparation (ready)||· Some experience with change and are trying to change
· “Testing the waters”
· Planning to act within 1 month
|Action||· Practicing new behavior for 3-6 months|
|Maintenance||· Continued commitment to sustaining new behavior
· Post 6 months to 5 years
|Relapse||· Resumption of old behaviors
· “Fall from grace”
This model has broad application to all matters of behavior change, from battling addictions to working toward goals for health and fitness. When it comes to chronic pain, it is clear that behavior change on the part of the patient is critical. The complexity of the pain process virtually eliminates any reasonable expectation that someone else can “fix” a patient’s pain. The patient simply must engage in behaviors that harness neuroplasticity and reshape the neuro-endocrine-immune system into a more resilient state.
This brings us back to the dilemma at hand: what do we do with a patient who is NOT READY to participate in their own recovery? How many visits do we spend with them? How much of our most precious resource do we allocate to them?
Consider the research Prochaska and Norcross shared in 2001 in Psychotherapy: For “Pre-contemplators” educated on necessary behavior changes who remain pre-contemplators after one month, there is a 3% success rate for the desired behavior being achieved. For those pre-contemplators who are able to shift into the contemplation phase within a month, there is a 7% chance for success. On the other hand, among those individuals educated while in the contemplation stage, if they remain contemplators after 1 month, they have a 20% chance of achieving behavior change. And encouragingly, for those contemplators who are able to shift to preparation stage after one month, there is a 40% chance for success.
Scales and tools from the world of motivational interviewing, such as the readiness to change ruler can help us in determining where someone is at in their readiness to change. Certainly, we never want to underestimate our patients. If we can identify those who are ready to do the hard work involved in moving beyond pain, we can help people on a whole different level.
Timing truly is crucial. The right (i.e. ready) patient connecting with right therapist at the right time can be a game-changer. And this goes both ways: A patient who is ready being assigned to a therapist that doesn’t yet understand pain science may be at a strong disadvantage for success. Where we are at in our own professional journey makes a difference. How many of us, knowing what we know now about pain science, wish we could climb into Marty McFly’s DeLorean and go back in time to better serve those prime candidates for pain neuroscience education we’ve had along the way? The moral of the story: let’s be ready and invest deeply into those patients who are also ready.
So, I’d love to hear your perspective on this. What is the wise therapist to do? What does walking the tightrope of honesty, compassion, boundaries and responsibility look like in terms of time spent with patients? How many visits? How much effort? If we want to have longevity in this crazy yet beautiful world of helping people navigate through some of the darkest seasons of their lives, do we owe it to ourselves to cut some ties quickly, or do we invest equally in each person who walks through our door, because under all of that negativity, anger and skepticism, there still lies a hurting human being?
Jessie Podolak is a member of the ISPI faculty and owns a private, direct-pay practice in Eau Claire, Wisconsin where she specializes in treating patients with complex pain issues, orthopedic injuries and running injuries.