Readiness to change in clients with persistent pain

What is ‘readiness to change’?

One of the things we want to assess when meeting a new client for the first time is ‘readiness to change’.  This is based on the transtheoretical model (Prochaska & DiClemente, 1983) proposing that when changing behaviour, we move through a series of stages– rather than changing in an all or nothing way.  Certain principles and processes of change work best at each stage to reduce resistance, facilitate progress and prevent relapse.  One way of using this model is through a communication model called Motivational Interviewing.

For the best chance of success, get alongside our clients and ask them where they are at….

It stands to reason then, that if we want to help our clients change their behaviour – perhaps increasing their activity, or practising skills which help them manage distress – we need to know where they are at in this cycle of change.  Are we really listening to what our clients are saying?  Can we ask open questions? It is a collaborative way of working, and if we agree that someone is not in the ‘preparation’ or ‘action’ phase, there is very little point in giving them a leaflet of exercises to do!  (We could argue that is always a waste of time, but that’s another blog post).

Healthcare professionals expect people to be in the ‘action phase’

All too often in healthcare, we expect people to be in the ‘action’ phase.  If they aren’t, they may be labelled as unwilling, difficult or malingering.

We might start by asking, what would change, or a good outcome, look like to you?  Sometimes, my agenda for change will be very different to the client’s.  Perhaps their goal is to look at a purely traditional medical model to manage pain, whereas our agenda might be to help self manage pain. 

MDT pain management is often offered a long way down the road in someone’s pain journey, sometimes after being offered scans, different diagnoses and hopes of cure.  It is no wonder people are often in the precontemplative or contemplative phases (i.e. not ready, or just starting to think about getting ready) to access this support.  Why would you consider changing YOUR behaviour, if you had been on a traditional medicine trajectory – be ‘done to’, rather than involved in your rehabilitation?

How can we be more helpful as health professionals?

Assessing beliefs around pain as a first step is an absolute must.  Just this week I have spoken to several clients who say ‘I know something is wrong, even if the doctor cannot find it’, ‘no one has explained why my knee is clicking’, ‘I have been told my knee cap is the wrong shape from the accident – but my other knee is the same’. 

Listening with curiosity and asking permission to offer suggestions can be helpful.  Have you ever been ‘told off’ by your GP for being overweight, drinking too much alcohol or smoking?  Did it help motivate you to change? Usually, it has the opposite effect.  Think of behaviour change discussions as ‘a dance not a wrestle’ – when we meet resistance, we roll with it.

Pain affects frontal lobe activation and therefore affects our ability to learn.  This might also be misinterpreted as lack of interest or motivation.  We have to remember this when working with clients with pain – recaps, writing things down and repetition can all be helpful to consolidate those messages we are sharing. 

Timing, particularly during litigation, can be a really tricky thing to navigate.  The client may not feel ready to engage with rehabilitation, but the case needs to progress.  Timing is everything, and sometimes we will all have had to consider that intervention may be more beneficial post litigation.

Sometimes, significant mental health difficulties such as Post Traumatic Stress Disorder (PTSD) will stand in the way of someone having the readiness to change other behaviours.  We need to carefully consider the order of intervention, which is amazing if you are part of an MDT, where you have all the information in one place and can lay the options out for the client.

Finally, it is helpful to explore both importance of changing with a client, but also how confident they are to change.  Sometimes change feels very important, but they have lost confidence in their ability to make changes, or do not have a support structure in place to carry out change.  Motivation to change is not an all or nothing concept – if we watch out for ‘change talk’, we might start to hear the client’s motivating factors – and this is a great place to start.

Top tips to try today

  • As a first step, explore what the person we are working with believes is causing their pain.
  • Asking for permission to share information, rather than bombarding. 
  • Recap, consolidate, and keep checking in – are we on the same page?
  • Roll with the resistance – communicating is a dance, not a wrestle.  Notice if you are pulled in by wanting to ‘fix’ and if this is feeling helpful or unhelpful.
  • Explore both importance of changing a behaviour, and their confidence to change it.  You often learn something interesting doing this.
  • Watch out for change talk.  ‘I hate exercises, they make my pain worse….but I want to be able to play with my children’.
  • Never forget the power of sowing seeds of change – the client may not be ready now, but they may remember these seeds, and they start to germinate in the darkness.

Photo by Ravi Roshan on Unsplash

Our team of professionals are well versed in how tricky change can be when you have pain.  Say hello at