[Physio Explained] Communication skills every physio needs with Dr Alison Sim

In this episode, we discuss everything about therapeutic alliance and motivational interviewing. We explore: 

• The power of communication
• How to build alliance in the first few minutes of an appointment
• How to approach resistance to behaviour change 
• Skills from motivational interviewing we can apply immediately
• Cognitive Behavioural Therapy (CBT) strategies within Physiotherapy practice

Want to learn more about communication and optimise patient behaviour change? Alison Sim recently did a brilliant Masterclass with us called “More than Words: Communication Tools for Treating People in Pain" where she goes into further depth on this topic. 

👉🏻 You can watch her class now with our 7-day free trial: https://physio.network/masterclass-sim

Dr Alison Sim (PhD) is an osteopath, educator, and researcher specialising in pain management and early intervention following injury. She has worked clinically for over 20 years and teaches communication and behaviour change skills to allied health professionals across Australia. Alison’s research focuses on distress, risk screening, and compensable injury recovery. Alison enjoys helping improve clinician - patient interactions and supporting practitioners to integrate evidence-based communication strategies into everyday care.

If you like the podcast, it would mean the world if you're happy to leave us a rating or a review. It really helps!

Our host is @Sarah.yule from Physio Network

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Transcript

SPEAKER_02 0:05

Cognitive behavioural therapy is essentially just recognizing that the thoughts that we have drive our behaviour and also our emotions. And so tapping into those kind of that three-way triangle can help us to then obviously influence behaviour, and behaviour is what we're interested in as clinicians, isn't it? But also people's worries. So we know that if people are really worried about their pain, that will ultimately influence what they do and how they think about themselves and their condition.

SPEAKER_01 0:36

Have you ever found yourself giving clear, evidence-based advice? Yet perhaps nothing seems to shift? Or perhaps you felt that you're saying all the right things in your consults, but the behaviour change isn't happening. If that sounds familiar, today's episode is going to land deeply. We're diving into the topic of communication for better outcomes with Dr. Alison Sim, osteopath, educator and researcher specialising in pain management and early intervention following injury. Alison has worked clinically for over 20 years and teaches communication and behaviour change skills to allied health professionals across Australia. Her research focuses on distress, risk screening, and recovery-in-compensable injury settings, giving her a uniquely practical lens on how communication shapes outcomes. She's incredibly passionate about improving clinician-patient interactions and helping practitioners integrate evidence-based communication strategies into everyday care. And she has created a masterclass with Physio Network titled Beyond the Symptoms, Communicating for Better Outcomes, which we'll be unpacking today. You're going to love today's episode with plenty of clinical gems. I'm Sarah Yule, and this is Physio Explained. Well, hello to you, Alison. Thanks so much for joining us today on the podcast. Thanks, Sarah. Thanks for having me along. Well, we'll launch straight into it. Now, we're talking all things therapeutic alliance today and motivational interviewing, and you describe it as a genuine clinical tool rather than just a nice to have. Can you explore why it's so powerful from a science and an outcomes perspective clinically?

SPEAKER_02 2:11

The reason I frame it like that is to help people conceptualize just how important it is because it often comes back to our identity as therapists and how we see ourselves and our role. And science and evidence often does motivate us. So that's why I often bring in the idea of that this is the best use of evidence that you can kind of put your intention and your time towards. And that gives us two things. One is the amount of time that we might give to it within a consult, but it also might direct our CPD as well. So thinking about what do we spend our time on, what's most important, what's going to give us the most bang for our buck. And that's why I think the science of therapeutic alliance gives us this really nice story. So it tells us that it doesn't matter quite so much what you do in the consult, particularly whether it's in the settings of highly distressed patients or things like chronic pain, where your outcomes are often quite small anyway. So we're not making those huge or very fast gains. And we're often asking people to do really hard things. We're asking them to perhaps move in the face of pain, which can be quite frightening, even when we've done a good job of reassuring them. So this there's beautiful science that says that the outcomes that we get are that are most predicted by the therapeutic alliance. So that is the connection between the patient and the clinician and the patient. So rated both ways. And when we think about it, that makes an awful lot of sense. So again, if you think about being in that situation where you need to trust someone and they're asking you to do hard things, you're far more likely to do those things if you believe the person and if you feel connected to them. Whereas if you perhaps don't feel that connection to them, you're less likely to engage. So the reason we frame it like that is because when we're going into a consult and we're seeing ourselves as these kind of activity-based clinicians. So whether we're doing hands-on or whether we're seeing ourselves as exercise or those often modality-focused approaches is how we see ourselves. And it's often how we patients see us as well. But what we have to keep in mind is that the science tells that this is valuable. And so therefore, if we can take that breath and take that pause to recognize, particularly as I say, in those distressed patients, that this is worth putting the time aside for. It might slow us from rushing to get to things that we think might be more important. But actually, the science says it's probably more valuable to invest in. It's kind of just trying to marry up that clash that we'll often have between the desire to get on and tick boxes and get through our examination and get to treatment. That's what patients want. That's what they're coming in for, that's what they expect. But at the same time, if there's complexity there, we're really better off investing in relaxing into it and investing in understanding the patient's story and understanding what's going on for them.

SPEAKER_01 4:55

And I'm curious, in that pause, rather than rushing through, in your experience, what are the most underrated ways clinicians can actually build alliance, particularly in the first couple of minutes of an appointment? And what are we actually doing with that time we're spent pausing?

SPEAKER_02 5:12

It's a great question. I think if you get a sense that you're looking at some at a presentation that is a little bit more complex. So perhaps where there is chronicity or where there is high levels of distress, things like where there's compensation, where there's likely to be lots of competing factors and lots of often distress in that setting. Where we're picking up in that story early that this might be more complex and taking that beat, one of the things that we might do is to set the scene is to actually take that pause and say, this sounds like it's quite complex, or it sounds like this has been quite intrusive to your life, or it sounds like it's having a really big impact on you, or life's become really small, something like that. So once you're starting to hear that's going on, we could jump in there and introduce that pause. And then maybe by setting the scene something along the lines of it sounds like this is not going to be something that you expect to be a quick fix and that we might have to invest some time into. And I'm wondering if we spent a bit more time today getting to really understand your story. And that way you know that whatever we do next is coming from a place of me really understanding what's going on for you. And that didn't help set the scene so that the patient is also comfortable to sit back and take that time, particularly if they're describing things like failed intervention. So you might reflect on the fact, but you told me that these things haven't worked. I'm getting a sense that if we rush down the track and do that again, that it's unlikely to work, we might be better off to take this bigger picture approach or slow things down a little bit and invest. I always use the words to invest this time to really understand what's going on for you. And I'll often say things like, that way you know that when I'm setting up a program for you or I'm I'm setting up a treatment plan for you, I'm coming from a place of really understanding what's going on for you. And it's not just a one size fits all approach. And most patients will kind of come along for that ride, particularly if they're if they have had lots of failed treatments or lots of bad experiences.

SPEAKER_01 7:06

And I'd imagine that process of active listening, the validation, the agenda setting, and the framing of that is a nice antidote to the reality being that often in the private practice and the public health setting, we're we're often under time pressure. And so that sounds like it'd be a repeatable communication strategy that would strengthen that therapeutic alliance whilst also working in a busy setting.

SPEAKER_02 7:32

I think you're right, because being in that private practice, we also have to remember that patients come in with an expectation. And if we don't meet those expectations, that in itself will break rapport. So I guess having that moment to discuss expectations, to say, does that sound like a reasonable approach to you? Is that is that kind of what you're expecting today? Or so just having a bit of time to discuss that can make sure that you're both on the same footing. But the time pressures are real and they're real for everybody. To not acknowledge that is kind of living in la la land. We have to balance both. So we need to kind of maximize the time that we've got, but also then value that sometimes the talking and the listening is really highly valuable and becomes a foundation that once that's really solid, whatever you put on top of it is more likely to stick or more likely to be effective.

SPEAKER_01 8:23

And I suppose ascertaining what they expect from the session allows you to frame any interventions and target it at their priority for the day.

SPEAKER_02 8:34

I think that's a really good point, yeah, is is perhaps exploring what were you expecting or what were you hoping to get out of this consult today and seeing if you can meet somewhere in the middle with that. And I think for most patients, they they really do want that examination, they want some certainty and they often want a plan. And I think again, vocalizing that if people have been a bit lost and they've had failed treatments or they've had not so great experiences with clinicians, to kind of acknowledge that it does sound like perhaps you you're missing a bit of a plan, and that might be something that we could work towards. And these are the steps that we would take to get to that. We may not get to that definitive plan in today's session, but we might get there down the track.

SPEAKER_00 9:14

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SPEAKER_01 9:42

I think that's a really, really great summary with some great tools. So let's talk about motivational interviewing, which you've sort of alluded to with some of these questions and eliciting answers. Looking at the videos of motivational interviewing, it's an absolute art form that we presumably practice our whole careers. But many clinicians will recognize resistance to behaviour change, but perhaps don't know how to respond well with what to and or what to do with that information. So, what are some of the early signs of resistance from a patient perspective? And what does a skilled motivational interviewing informed response sound like?

SPEAKER_02 10:22

I think what what we're listening for with a motivational interviewing approach. And if we just take a step back and kind of introduce the concept, it's a slightly different shift from a more didactic way of interacting with patients. That is often what we're taught as undergrads. And there's a reason for that, and it and that's because it helps us to be safe. So we cover everything that we need to cover, to be thorough, and it gives us a bit of structure. And so often what that direction is is it pushes us into closed questioning so that we kind of control the consult for safety and time and thoroughness and all of those kind of things. That's the way that we operate. It's it becomes a bit of a habit as well. So when we challenge that with introducing concepts of motivational interviewing, which is kind of moving in the opposite direction, it's kind of allowing the patient to come in with a desire to do something different and tapping into that a little bit more rather than relying on a clinician being all-knowing and having all the right ideas and telling a person that, kind of tapping into what might work for them, what do they want, and allowing their own motivation to drive that. So, what we're listening for in that first instance to see if motivational interviewing is something that might be a worthwhile pursuit for this patient, is we're listening for contemplation. So often people will be describing like reasons to change and reasons not to change. So things that they might be interested in. And that's kind of what we're listening for. When we're hearing the opposite, which is what your question was, which is the resistance, often it's people being earbutting, is often how we would describe it, or having that kind of back and forward conversation where a clinician's proposing something and a patient has all the reasons why that isn't going to work for them. So for motivational interviewing, what we're doing is we're listening for that. That's kind of what we're hearing as being ambivalence. And we want to nudge it in one particular direction if we're using motivational interviewing approaches, which is to kind of roll over the resistance bits and not highlight them quite so much and zoom in on the reasons that a person wants to change and create some structure around that. And the good thing about motivational interviewing as an as a clinical entity is it's very structured and therefore it's relatively easy to learn. You can kind of use bits of it at a time, or you can use cheat sheets and flow charts and things like that to keep it moving. And then I guess just further to your question is when you're hearing resistance, there's probably a really good skill for clinicians around knowing when not to push into that resistance. So if someone is really kind of pre-contemplative where that particular change is not important to them right now and it's not something that they're probably ever going to adopt, regardless of what technique you use, whether it's motivational interviewing or whether you come at them with heavy stats and kind of threats, it's knowing to kind of identify those and say, this is probably not the right time. This is not a great use of my time for this person, and it's not likely to be successful for them. So it might be something that we park, even if it feels important to you as a clinician.

SPEAKER_01 13:25

It's such an important thing to differentiate, isn't it? For the clinicians listening, if there were to be one component, I know this is probably a very hard question, but one skill from motivational interviewing that they can apply tomorrow, what do you think would move the needle the most in their consults?

SPEAKER_02 13:43

I would suggest the most simple thing would be to switch from closed to open questions a little bit more. And that doesn't mean a complete switch over, but it just means asking more of those curious, exploring questions where you don't necessarily know what the answer's going to be. And that is quite different to what we would be normally doing in clinic where we're asking yes and no questions and quite black looking for those black and white answers. It's kind of asking the open question, zipping it and allowing that person to ponder and then come back to you with their answers that you don't necessarily know where that's going to go.

SPEAKER_01 14:14

Two ears, one mouth. Yeah, exactly. Leader curiosity. Yeah, yeah. Okay, so moving now into the next portion that you've also spoken about in your masterclass is this whole concept of applying CBT principles in clinical practice. I might try to give just a little summary of what it is. And then also I'm curious as what basic CBT-informed strategies do you think all of us as physios and clinicians should feel confident in using in the clinical room or clinical setting tomorrow?

SPEAKER_02 14:49

So I think cognitive behavioral therapy is essentially just recognizing that the thoughts that we have drive our behavior and also our emotions. And so tapping into those kind of that three-way triangle can help us to then obviously influence behavior. And behavior is what we're interested in as clinicians, isn't it? But also people's worries. So we know that if people are really worried about their pain, that will ultimately influence what they do and how they think about them themselves and their condition. Most of us are doing it anyway. So sometimes it's just about tapping into things a little bit more directly. And so what the way we'd kind of suggest is that people go looking for the emotions, because that's often a way to tap into it. So it might be something right. It sounds to me like you're really worried about how your ankle's going to go with the upcoming Christmas period or whatever it might be. And can you tell me more about that? So I think identifying the emotions is a really nice way to keep it focused. And then allowing that open question to elicit what's going on for that person. And then with a cognitive behavioral therapy approach, what we're doing is getting people to challenge their own thoughts around that. So asking them open questions around that. So that sounds really interesting, and I'm sure that is quite upsetting for you. What's happened in the past? So you might you might get them to challenge things about how real is this thought? Does it align with what's happened in the past, what's most likely to happen? What might you tell a friend, those kind of things. So really just kind of almost put those thoughts under a microscope and fact-check them a little bit. And again, it's a way to empower the person to be able to take a bit of ownership over that so that we're not coming in and either reassuring for them where that may not feel real, or you know, we're kind of using our own external facts and things like that. It's it's allowing people to answer those questions for themselves.

SPEAKER_01 16:43

And I suppose there can even be merit in attempting to identify an emotion, even if we get it slightly wrong, because it probably prompts reflection from the patient to say, no, I'm not frustrated, I'm this. Yeah.

SPEAKER_02 16:55

That's definitely one of the things that we really try and highlight is that having a go and looking for the emotion, and even if you get it wrong, is fantastic because the empathy that the person is going to perceive from that is that this person cares. They're thinking about this more deeply, they're exploring this, and that makes you feel good. That makes you feel like, yeah, this person's really on my team. So you're absolutely right there. I think look for the emotion and don't worry if you get it wrong, take a punt.

SPEAKER_01 17:23

Last bit of advice. If there's one thing we can all do tomorrow, you've mentioned curiosity. Is there anything else we should take into the rooms tomorrow?

SPEAKER_02 17:32

Trust in the science that says this is likely to be helpful. And remember that making change. So if we're looking to integrate some of these things, it's tricky. It's hard, especially if it's changing the way we've done things forever and for a long time. So be gentle with yourself and start with little bits at a time.

SPEAKER_01 17:51

Great advice. Well, Alison, thank you so much for coming on the podcast today. We really appreciate all of your wisdom. Thanks, Sarah. It's been wonderful. Thanks for your time. And if this episode has reminded you that communication is treatment, not something separate from it, then Alison's masterclass Beyond the Symptoms goes even deeper. So you can check it out via the link in the show notes with a free trial to Physio Network. So thank you for joining us.