During my observations and on my OT fieldworks, there are always clients who don’t want to do therapy. They come in all shapes, sizes, and ages, and trying to get them to participate in treatment can be like pulling teeth. It seems like no matter what you say or what you do, they are determined to remain in bed or in their rooms.
Earlier this summer I was working with a 93 year old woman in a SNF. She had a severe cough that racked her body as she lay in her hospital bed, complaining of various aches and pains. When I first asked if she would come to the therapy gym for an occupational therapy session “to build up her strength,” she refused to get out of bed and said repeatedly that she didn’t feel well. After a few minutes of my coaxing and her refusal, I was going to just give up. But then, in an effort to simply get her talking (and with the hopes of leading the conversation in a therapy-related direction) I started asking her questions about what she did for a living. It turns out that she had been a hairdresser for over half of her life, and that she spent almost all of those years standing on her feet and doing hair! Using this new knowledge of a valued occupation as motivation, I asked her if she could stand up for me so we could get to her wheelchair and visit the beauty shop that was just around the corner in the SNF. She agreed, and off we went!
During our nearly hour-long session, I also learned that she loved gardening and being outside and that she had been raised on a farm. As I wheeled her outside in the sunshine, she pointed out the different types of plants growing around the building, and smiled as she told me about her childhood spent on her family farm. From the minute I helped her into the chair to the minute we got back in bed, she didn’t cough once. (For the record, it wasn’t just a leisurely stroll; she had a wheelchair positioning goal!)
This encounter was a lesson in the motivating power of occupation and how introducing meaning into a treatment can take an unsuccessful session in a totally different direction. And while many of the strategies below have been helpful to me as I’ve worked with clients of varying ages and in various settings, it’s important to note that none of them will work if you haven’t laid a good foundation for treatment. Specifically, if you are working toward goals that are not meaningful, relevant, or achievable, you’ll just be wasting your time and theirs.
Remember that occupation = motivation. Your goals for a client should always be client-centered and occupation-focused. If you have a hard time getting clients to participate in your treatment sessions, take a look at your goals or intervention approach and revise to ensure that each one focuses on enabling a client to maximize participation in or return to meaningful occupation and incorporates occupation.
Once you’ve engaged in a process of self-reflection related to your goals and intervention approach, use the tips below to help motivate those “difficult” clients!
- Explain yourself. Many OT clients see multiple healthcare professionals who may ask them to do very similar things. Ask your client if he understands why you want to work with him, and then explain the goals of his individualized OT treatment plan. Many clients don’t know the difference between OT, PT, nursing, etc., and a clear elevator speech about how OT can improve health, well-being, and safety can help drive home the importance of their participation in treatment.
- Ask around. Many clients have worked with multiple therapists or providers in a facility. By talking to people who know a client well, such as family, caregivers, and other rehab staff, you can learn about the things he finds motivating or interesting and use this knowledge to encourage participation during your sessions.
- Read all about it. A thorough review of a client’s medical chart, therapy notes, occupational profile, and other documents can help you identify motivating tasks, cues, or treatment approaches as well as health conditions that may impact motivation, mood, or affect. Carefully reading a client’s chart/documentation will give you many clues about how to encourage participation or why an individual is not participating.
- Break the ice. Before you start making requests, make conversation! To many sick or injured people, an occupational therapist is just another person encroaching upon their personal space and making a bunch of strange requests. Spend time building rapport and establishing a positive relationship with a client before asking them to complete therapeutic activities.
- Establish highly-motivating goals. Using person-centered assessments like the COPM can give you information not only about a client’s ability to perform certain tasks, but also about what is important to him and what he would like to work on. Even without a formal assessment, you can simply ask a client to state his goals for therapy. A person will almost certainly be motivated to participate in a therapy program he helped develop!
- Understand why the answer is NO. Is this person refusing because she is…afraid of falling? In pain? Depressed? Confused about what you want her to do? Getting answers to these questions can give you a good idea of why the client doesn’t want to do therapy, and what you can do to encourage participation (i.e. provide reassurance, clarification, etc.)
- Meet them where they’re at (literally!) For some clients, leaving their room to participate in what may be a physically demanding treatment is just too much. Be prepared to work with a client wherever you can get him to participate, whether it’s sitting up in bed, at the edge of the bed, or in a chair. It may take a little creative thinking and flexibility, but treatment can take place almost anywhere!
- Ask, don’t tell. People often aren’t motivated to do activities they didn’t choose. Instead of telling a client what you are going to do during a session, whenever possible you should ask what he would like to work on. Enter a session with a general plan, but offer a choice between various activities to give a client a sense of agency and control and increase their motivation to participate. Note: This may not work well with clients who are very young or have poor cognition or memory.
- Check the clock. If you are trying to work with a client at an inconvenient time – early in the morning, after a meal or medical treatment, or during nap time, it’s likely that he will refuse. Whenever possible, ask clients what times they are not busy and/or feeling their best and try to schedule therapy at these times.
- Switch settings. Not practice settings – just the treatment setting! If the weather is nice, offer to treat the client outside (as appropriate) or simply go to a different area of the building to work. A change of background can often inspire a change of heart!
- Be their biggest fan. Instead of (or in addition to) identifying issues to be fixed or goals that remain unmet, celebrate your client’s progress with every session. This study concluded that “a lack of positive feedback” was an important factor related to non-compliance, so the importance of providing positive feedback about a client’s performance to encourage participation and develop positive rapport shouldn’t be overlooked.
- Compromise. By “starting small” or agreeing to limit what you do during a session, you can make a task appear more manageable and your client may be more likely to participate. A person may not be motivated to walk a full lap around the floor, but you may be able to convince him to walk outside his room and come back, which is still something! And once he’s up and moving, you may be able to convince him to do more.
- Set a clear goal. Identify a concrete task for the treatment session and explain its importance. For example, instead of just saying “Let’s walk,” try saying “I want you to walk 100 feet so you won’t be as tired when you’re at the store.” By outlining a numeric goal and its purpose, you create a solid “stopping point” for the treatment that a client can look forward to.
- Call for backup. Getting friends, family, or caregivers involved can be a great way to motivate clients. By saying “Let’s show your husband what we’ve been working on” or saying “I want your nurse to see how well you’re doing!” you can put a little positive pressure on the client to participate and get the added benefit of sharing their hard work with the world! (Note: Be careful who you ask to observe, as some people may do more harm than good for a client’s motivation or behavior during a session!)
- Focus on the future. Having a future-oriented discussion with a client can help him see how participating in or refusing treatment will affect his health. Encourage participation by explaining what your client will be able to do after therapy (Ex. “These exercises will help you perform wheelchair transfers more easily.”). You can also inform the person about what could happen if they do not participate (Ex. “If you don’t do these range of motion exercises, you will develop contractures and lose the ability to use that hand.”)
- Rule out mental health issues. If a client is unmotivated to participate for unclear reasons, consider making a referral for mental health services; many OT clients experience psychological distress as well as physical challenges. Familiarize yourself with the signs of clinical depression and use a quick screen like the Beck Depression Inventory or PHQ-9 to collect evidence and make a referral if necessary. Once a person’s mental health condition is managed, you may find that they are more willing to participate in treatment.
Finally, it is important to recognize when No means NO. Ultimately it is a client’s choice about whether or not he wants to participate in therapy. If after your best efforts a client continues to refuse, respect his wishes and try to reschedule for another time.
I hope you found these tips helpful, and remember that you can’t spell mOTivation without OT! 😀
These articles provide evidence-based information about occupation as motivation and factors affecting client motivation.