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[Physio Explained] Behaviour change secrets every Physio should know with Serena Simmons

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In this episode with Serena Simmons, we discuss behaviour change, and in particular why Physios can have trouble with patient compliance. We discuss:

  • Why doesn’t everybody change? 
  • Exploring the WHY in why patients don’t do their exercises
  • Why is psychology missing from physiotherapy education? 
  • Why understanding our own psychology is as important as understanding our patients

👉🏻 Learn more about Physio Network’s Practicals here - https://physio.network/podcast-simmons

Serena has over 30 years of experience working in the field of psychology. She has also been a Senior Psychology lecturer at Nottingham Trent University (UK), for the last 19 years and has engaged in private practice in psychological consultancy and private teaching for over 13 years. She now runs her own successful Positive Psychology Consultancy, The Psychology School (www.thepsychologyschool.co), which specialises in Behaviour Change & Peak Performance which she teaches predominantly in Healthcare settings all over the world.  

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Our host is @James_Armstrong_Physio from Physio Network

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SPEAKER_01:

what's really empowering about the work and about psychology is when you are just showing up to support someone and you're doing it beautifully you are there as expert but you're also handing over that responsibility in a really beautiful way you're supporting someone but really it's up to them to change and either they will want to do that or they won't

SPEAKER_02:

Welcome to another episode of the PhysioExplain podcast. Today we're diving into the fascinating but often overlooked world of behaviour change with expert psychologist Serena Simmons. Serena brings over 30 years of experience working in psychology and is a chartered psychologist, a member of the British Psychological Society and part of its special group in coaching psychology. She's spent nearly two decades as a senior psychology lecturer at Nottingham Trent University and has over 13 years of experience in private practice delivering psychological consultancy and teaching. Serena now runs the Psychology School, a global consultancy specialising in behaviour change and peak performance, working extensively in healthcare to help clinicians and teams understand the psychological roots of human behaviour in both patients and themselves. She's also widely recognised for her work in forensic psychology, particularly in the profiling of serial murder. Having worked in high security settings like HM prison services and Her expertise has featured major media outlets, newspapers and documentaries across Apple TV, Amazon, Sky, Virgin, Now and many UK terrestrial channels. In this episode, we explore why not everyone changes, why psychology is often missing from practitioner training and why understanding our own psychology is just as important as understanding our patients. This is a powerful conversation and any clinician wanting to deepen their practice will get an awful lot from this. I'm James Armstrong and this is Physio Explained. Serena, welcome to the Physio Explained podcast. It's great to have you on.

SPEAKER_01:

It's so lovely to be here finally. It feels like we booked this in ages ago and now the day has come. So thank you very much for inviting me.

SPEAKER_02:

Definitely. It's flown by and it seems like a long time chatting before this about loads about what we should have probably recorded for the episode. So hopefully that's going to come through because it's been already fantastic and really interesting talking to you about this topic, which is not always seen by many physios as the hot topic. topic the one that they want to go and see that course on or the really kind of sexy part of physiotherapy and I think I want to try and change that today I think we can maybe look at different ways that people can approach this and you've got some really good ideas.

SPEAKER_01:

Thank you for saying that and acknowledging that because it feels like that I don't bring really cool kit with me when I go and do my training I don't have any dry needles I don't have really cool weights and bands I just turn up and it's very different the pace is very different and yeah I think it takes a very particular kind of practitioner to want to engage with it actually.

SPEAKER_02:

Definitely and we're talking about behaviour change and I think sometimes you could argue it's that element that we maybe get drawn to later on in our clinical experience when we start to realise just how crucial this element of skill set if you like is to our practice and our patients.

SPEAKER_01:

Yeah definitely and I think what I said before about it takes a particular kind of practitioner I think that's part of it is I think you're clearly curiosity about behaviour change comes with time. I think that when you go and study, when any of us go and study the thing that we're passionate about, you want to do the thing. And if someone tells you you're not going to do the thing, you're like, why am I doing this? And why are they making me do this other stuff? And I think psychology would feel like that if it was incorporated into a degree. And I have heard some physios say, actually, they did have some psychology in their training, but they didn't really want to know about it at that time. It didn't feel relevant to them. at that stage.

SPEAKER_02:

Yeah, absolutely. Definitely. We talked again off air. I want to try and draw this back because this is really interesting about what behaviour changes or what we're talking about when we're talking about behaviour change in the bigger picture in terms about how important it is. Can you talk on that at all?

SPEAKER_01:

Yeah, I think there's a misconception that behaviour change is like just a set of tools that you can learn or use. It's almost like when I train off and talk about, I think people think there's maybe like a change button, you know, as a joke, obviously, that we could just do these things one plus one will equal two and so often being someone who works in the area of behavior change people will often call upon me to do things like training in goal setting or training in motivation or training in motivational interviewing and these are all things that people have heard about and they're tools and some of them are brilliant tools and I'm a huge advocate for motivational interviewing for example but they're not the whole picture and I think that's the misconception for me is people think it's just these things and if I know how to goal set and I can enhance my communication and know how to motivate someone that I will help change their behavior. And I would just say it's a lot more subtle than that. And I think the broader psychology of a human is really relevant to that conversation. And I think it's some of those really quite fundamental things about how humans think and behave and how they feel is the unlock. It might be very automatic to think that we go to the tools, as I said before, but we are thinking beings I think what we first have to appreciate before we jump to those tools is just considering how someone is thinking. But more than that, we are actually feeling beings at our core. And so if you consider just for a moment that the person sat in front of you, as you are, are first and foremost a feeling being. So in other words, if I say something to you, you actually have a feeling before you bring the thought to mind. That's actually what we're working with. But simply put, it's that somatic being. So we are somatic first and foremost. So I think one of the unlocks for me is having a deeper understanding of those processes first. So how we impact how someone feels when they show up and how will we then impact their thinking because it's impacting them on a feeling level and a thinking level. So those two things first in that order is going to give us those unlocks down the line when we start to use the tools to change their behavior. And I think it's understanding that better that helps us work with people. We're humans and that's how we work. We work on that feeling basis. typically your feelings happen so quickly because we feel things all the time that we're not necessarily tuned into that so what we do is we then have the thoughts that come with it and the thoughts are sometimes really maladaptive and don't help us and so that's what you'll often hear you'll either hear the things that they're saying that are maybe their story around why they're not doing the exercises or maybe they don't really know themselves and so they again they just slip into compliance and tell you what you want them to hear so that's the thing that you hear in clinic and these are all kind of responses that someone has maybe because they are struggling but they haven't had time to process while they're sat in front of you why they're struggling with that and so again you just jumping in with tools doesn't necessarily help so it's those more subtle conversations to bring someone's attention to what they're really thinking what they're really feeling and how that's the unlock again I keep talking about this unlock it's those things those conversations that help someone basically figure out for themselves why they're struggling because sometimes they don't know. And

SPEAKER_02:

I'm just thinking of lots of patients I've seen whereby they know they're not doing the exercises or whatever it might be, but they're not linking that reaction, that thought to the feeling that's driving that lack of adherence, if that makes sense. You said the fear, they don't link the fact that because they're a bit afraid of it is why they're not doing it, maybe.

SPEAKER_01:

The other thing about that somatic response is they might not even be aware of it. So what I'm saying is there will be a feeling first, but they may be very unaware of the feeling. And it might be, for example, because they're used to just telling their story. So when you say to them, why haven't you done the exercises? It just evokes the thing that they've always said when they felt cornered. Yes. And again, that's the psychology. It's, you know, maybe if they were the kid that didn't do their homework and now they're still the adult that's not doing the exercises, you'll just see them slip into the same modes that they had slipped into before.

SPEAKER_02:

Almost like a protective mechanism.

SPEAKER_01:

It is. It's often that, you know, as we all know, that kind of fight-flight form of response that we have so you will just see those old patterns play out which again for me is why it doesn't come back to just strategizing and using a tool or say well hey then what are your goals because that's again not going to evoke a true authentic response from somebody because they are already maybe in that place of I'm not really going to do it I'm just going to be compliant while I'm sat here and so ultimately what we're saying is because this is about behavior change and essentially we often are seeing that struggle with adherence. There's a lot of things that we can do as practitioners to bring what I would always call the observer to the conversation where you have those deeper conversations. Again, we're not telling you to go out of scope of practice, but you just learn to have conversations that allow someone to kind of figure that out.

SPEAKER_02:

Yeah. And that's really hard. You mentioned there, we talked before about is this definite knowing that we need to be better at taking people through behaviour change, but also recognising a scope of practice as a physiotherapy is where does that line sit in terms of what we're capable of doing with our skill sets and the training that we may or may not have had and that's really hard as well.

SPEAKER_01:

It is really hard I really feel for my physios because often I see as I said you know the ones that are really passionate about learning more and wanting to understand this better because they see the benefit that it will have on their practice and I do personally think that it should be a standard part of all training that you get some psychology so going back to what I right back at the start about what we can learn in terms of basic human psychology around how people feel, how they think, how they make decisions, how we better communicate, how people's communication is maybe their own communication is lacking because they can't voice their true feelings. Sometimes we need to have more subtle conversations to help someone figure that stuff out for themselves and that will open up a whole world of change because no one's ever spent time to have those conversations while at the same time as you've said really importantly staying within your scope of practice because this isn't about becoming psychologists or counsellors I think there's sometimes a fear of you know if I learn this are you trying to make me do psychology what am I going to unravel with this person who sat in front of me and so I think the other part of learning psychology is to learn a little bit about mental health so that you can signpost and I think that really is the sweet spot is it's not about unlocking someone and opening a lid on something and then going oh my god I have to deal with it. I think if you learn psychology and behavior detection strategies in the right way, what you're able to do is to navigate really beautifully a conversation which helps someone bring attention to themselves around why they are doing something or they're not doing something. And if you see something that you know they need more help with, that you can have that conversation to signpost them.

UNKNOWN:

Music

SPEAKER_00:

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SPEAKER_03:

Yeah.

SPEAKER_02:

And then having knowledge of what that signposting might look like in your local area, which can be really hard sometimes as well. So we talked about in our sort of plan for this about the fact that not everyone will change. And when you say that, because obviously we want to help everyone. And I think certainly when you're sort of relatively newly qualified as a physiotherapist, there's a genuine thought that we will. And there's a lot of pressure I think we put on ourselves to change everyone and make these wonderful changes to everyone. But you're saying there that actually potentially there's a, kind of an okay you might not get there with everyone is that right?

SPEAKER_01:

Yeah definitely I think this is a really empowering thing to remember is again going back to that you're dealing with a human and I always say human beings are pesky and if they don't want to do something they won't do it and so I keep talking about this observer and what I mean by that just to explain that very briefly but in a little bit more detail because often the human beings work on autopilot we run most of our life through this kind of routine and habits and we don't really think about what we're doing a lot of the time so if think about your day you will do it on autopilot you know a lot of the stuff that you do you just do you drive to work in the same way you go to the office in the same way and that means that maybe how you're responding to things in your environment you do and navigate in the same way as well so the example I gave before for example about someone who struggles to do the thing that's being asked of them that person that didn't do their homework at school and now are not doing the exercises they may be just used to giving this reason for not doing them just to get people off their back and that might just just be second nature to them just to say the thing that they've always said because it gets people off their back in some way. But the work that you can do and the conversations that you can have can at least bring someone's attention to how they're behaving and that's the observer. And I think it's really beautiful to think about we can all change our lives if we just observe what we are doing ourselves a little more. So just notice what we're doing, notice how we're thinking, notice how we're feeling. That's a mindful practice. I think what we're doing trying to bring that mindfulness into our work and I think ultimately where you can get to if you navigate a really beautiful conversation with someone is you get to the place where either they can problem solve themselves how they will do the thing or they will be able to tell you they're not going to do it because they don't want to as an adult it's their right to say no and I think we forget when your job is to help someone you want to help them as you've said what's really empowering about the work and about psychology is when you are just showing up to support someone and you're doing it beautifully you are there as expert but you're also handing over that responsibility in a really beautiful way you're supporting someone but really it's up to them to change and either they will want to do that or they won't or it won't be the right time you know don't underestimate someone saying they don't want to do it if you've had a really amazing conversation where they've thought about it and they've been able to observe those feelings and those thoughts a bit more they would think that doesn't have an impact they're might just come back later when they're ready. I think us as practitioners not taking all the responsibility for someone and obviously we haven't got time to cover that today but there's a lot of really beautiful work around looking at this from a psychodynamic perspective because you know we don't want to slip into parent-child mode. We're looking at two adults having an interaction so it's not your responsibility to help someone change and I think that's really important to know.

SPEAKER_02:

Yeah that's a really key thing you just said there and it's something I've tried to do more and more is turn those skills of clinical relationships into just two human beings rather than a physiotherapist and your patient they're not your as if there's some sort of ownership of them to you and actually it's just two human beings and if you can try and bring that onto that same level I think we've probably all been there where we've had that really brilliant relationship or interaction with the patient we thought that's worked really well and I think personally it tends to be those ones where you've just had a really good conversation with someone on the same level

SPEAKER_01:

I love that I think one of the key things I would say is if you can retain your curiosity that's a really beautiful thing i'm a big believer in remaining curious remaining playful in your approach problem solving things together you definitely have your expertise and there's a real art to retaining that expertise and guiding someone and empowering them to change versus oh my god it's my responsibility they're sat in front of me i have to know what's wrong with them i have to be able to give them all the right things i have to motivate them i have to make them better in And again, a lot of the work I do is a little bit of a Trojan horse because I look at your psychology as much as the patient's psychology when I train. Because if you're slipping into those patterns and you're taking too much responsibility, why are you doing that?

SPEAKER_02:

Yeah, yeah.

SPEAKER_01:

And how is that manifesting in your practice? So I think that's the bit that people forget is actually all of the work starts with you. So

SPEAKER_02:

listeners listening to this, what would your sort of first takeaway or whatever you want to call them be to physios listening to this who may or may not be interested in taking this further, what would you say to someone? This is something I'd say, or you would say, go away and have a look at this or go away and look at this or start being interested in this.

SPEAKER_01:

I'm biased, obviously, so I love psychology. So I just feel like if anyone, if you do anything, I'm not saying me, but if you go and do any learning in psychology about humans and human beings and how they make decisions, it's fascinating. So that's going to help you feel differently. But I would flip the script and look at yourself and look at how you're showing up. To make sense of that for yourself is to have that reflective practice yourself. How am I showing up? What kind of patients are triggering me? You're allowed to be triggered. You're allowed to be pissed off. You're allowed to be angry. You're allowed to find things frustrating. If you notice that you want to rescue everyone, i.e. you feel like you have to fix everyone, land on that for a bit longer and look at why. A lot of it starts with that self-reflection. And I think you have to do the work. It's another reason I'm really passionate about physios getting the right support, because I actually think that all physios should have clinical supervision. So you get to go and talk to someone and I think some do but I think having it as you know more of a standardized package of support where you get to go on offload to someone you get to figure out the things that you're struggling with in your communication so that you're supported in that because you see a lot of trauma you see a lot of mental health issues you are having these really deep difficult conversations and so actually my takeaway would be get support yourself and retain that curiosity in your practice I think the more supported you feel the more curious and playful you can be because you have the space to think

SPEAKER_02:

we've definitely run out of time we knew this was going to be a hard one to fit in the physio explained format but it's been a really good introduction if anything and I think certainly obviously I'd kind of back you in the fact that I think go away and have a explore this more and there's some really different type of tips that you've given us Serena in terms of what our listeners can go away and think about and do and there's no doubt in my mind we need to get you back on in a longer format on our physio disgust I'm putting it out there straight away because I think it'd be really useful to dive into a bit more with you Serena because it's a big topic and there's always one of those topics where there's lots of avenues that we can go down and today we've been a bit restricted but there's definitely some tips there that people can take away so thank you so much for your time

SPEAKER_01:

thank you so much for having me and thank you for letting me have a little rant because I do get passionate about it so I appreciate it thank

SPEAKER_02:

you that's exactly who we were onto this podcast. That's brilliant. Serena, thank you so much. We'll catch you up another time.