A Whole Brain® approach to adherence: From adherence to growth

Johan Olwagen

Physiotherapists play a critical role in patient recovery. Despite their dedication, ability to operate under adversity and their resilience, they are still confronted by patients who do not adhere to the treatment regimes. Whilst this is true for all health care professions, physiotherapists have the added reputation of “hurting” patients, or even requiring of them to do the impossible. Add to this the other occupational hazards, such as stress, burnout, compassion fatigue, long hours, and more recently COVID-19. Yet from an ethical point of view, we expect of them
to do well and act in the best interest of their patients.

Several factors have been identified as contributing to the lack of adherence related to:

  • The patient
    • Socio-demographic and socio-economic factors.
    • Poor social support.
    • Perceived ability to take ownership and ability to accommodate exercises.
    • Internal Locus of Control and motivation.
    • Etc.
  • The treatment & the context
    • Treatment exacerbates the pain the experience.
    • Perceived difficulty of the exercises.
    • Beliefs about the efficacy of the treatment.
    • Etc.
  • The physiotherapist
    • Characteristics and behavioural profile of the physiotherapist.
    • The nature of the relationship.
    • Communication.
    • Etc.

The challenge for physiotherapists is to decide what they have control over and what not, and how this will help them improve adherence. Herrmann’s Whole Brain® thinking preference approach seems to offer one way of helping therapists determine their own approach, but also what the patient might need from them. Thus, the approach, through its use of the metaphorical 4
Quadrant thinking preferences, helps physiotherapists to decide how they are actually approaching the patient vs. what the patient might need. In understanding the clues patients leave, the model can also help improve the communication between therapist and patient:

  • The Analytical-problem solving Quadrant, where the focus is on diagnosis, goals and, ultimately, getting results.
  • The Structured-organised Quadrant, where the focus is on practical implementation and follow-through.
  • The Relational-engaging Quadrant, where the relationship with & empathy for the patient is paramount.
  • The Big picture-creative quadrant, where the focus is on finding alternative solutions and thinking out the box.

Where therapist and patient are of a like mind, e.g., providing information, setting goals and a “let’s-get-on-with-it” adherence may be more easily achieved. The same mind-set from the therapist, when the client needs engagement, interaction, a desire to express their fears and concerns, may in fact exacerbate the patient’s non-adherence.

Similarly, a patient who has a need for a step-by-step breakdown of the treatment plan, who wants something on paper to take home and to refresh their memories, might find it difficult to follow, and even remember, the conceptual-creative therapist, who talks about options and possibilities. This is true especially in a hospital context, where the patient’s mental resources are already depleted. Therapists may become somewhat irritated by these patients who would rather play it safe and need constant monitoring and follow-up. Conversely, the therapist
who has a structured, planned and organised approach might see some patients as slapdash, all talk and no action.

Research done in a South African context identifies the typical Whole Brain® profile of physiotherapists and indicates that often it tends to be more goal and task focused. This has implications for patient interaction, engagement and empathy for patients’ challenges, as well as working with patients to find alternative solutions that may be more conducive to their needs and ensure greater flexibility around adherence.

Thus: Understanding their own and the patient’s strengths, hot buttons and blind spots, could also help physiotherapists to identify more appropriate ways to engage with the client around the total treatment plan, and both implicitly and explicitly the issue of adherence.

Physiotherapists must ensure they are agile in their thinking and able to shift mental gears to accommodate the wide range of patients they are dealing with. In addressing their own underlying concerns about being authentic, understanding the hot buttons, concerns and thinking biases of patients will go a long way to overcome adherence issues. Considering the Whole Brain® model as a mental framework to address these concerns will prove of value to physiotherapists in changing patient behaviours.

Why don’t you join us and learn more about your own approach and how to use the Whole Brain® model in your practice to the benefit of your patients.

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