Dr. Ellen Csepe // #TechniqueThursday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, ICE Older Adult Division faculty member Ellen Csepe demonstrates an example of using motivational interviewing techniques when discussing weight loss with a patient.

Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog.

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EPISODE TRANSCRIPTION

ELLEN CSEPE Welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. My name is Ellen Csepe. I'm a physical therapist. I'm bringing to you live the Technique Thursday and we're going to talk about motivational interviewing today. I'm joined by my co-worker Rachel Jordan. She and I are both physical therapists in Littleton, Colorado. And today what you can expect out of our episode is we're going to talk about what motivational interviewing is, what to look for in our kind of, um, reenacted interview between a patient and a provider and then we're going to kind of sum it up and bring it back home talking about how this case went at the end of the day. So we had an awesome discussion about weight management with one of our patients in the clinic within the last few weeks and I really wanted to share that with you guys. We used motivational interviewing strategies to talk about weight management and truly it was a slam dunk. So today we'll kind of start talking about what motivational interviewing is. So motivational interviewing is basically a counseling technique where we talk about where we invoke out of a patient their own wisdom and their own ideas on how to solve their problems rather than barking at them and telling them what to do. Motivational interviewing is a really powerful technique for providers to really treat patients first like people, then like patients, all while showing them that you genuinely care. This is an excellent strategy to talk about weight, which can be a hugely uncomfortable topic for some providers and patients. So this discussion that we had went super well. Rachel's going to be the patient. I'll be the provider. And what I'd like you to look for in our discussion are four key topics that kind of illustrate the spirit of motivational interviewing. And so those four key topics that really kind of reflect the spirit of motivational interviewing are partnership, acceptance, compassion, and empowerment. So think of it this way, partnership. I want Rachel to leave our session knowing that she has somebody who really, really cares in her corner. Partnership. Acceptance. I'm not gonna look down the end of my nose at Rachel while she's struggling. I'm in her corner and I'm cheering for her. Acceptance. Compassion. I recognize that weight management is really, really hard. From a biomechanical level, from a neuroendocrine level, Weight management is super difficult. So compassion. I see her struggle and I care. And then empowerment. I want Rachel leaving our session like she just won a game of elementary school dodgeball. I want her leaving this session feeling like she has got it made. I want her to leave here feeling like she has a plan, like she's on top. So again, partnership, acceptance, compassion, and empowerment. So we'll go ahead and get into character. So Rachel, I understand that your doctor sent you over to us to kind of check out your ankle. It looks like you had an ankle surgery, but it looks like it's going pretty well. Tell me a little bit more. RACHEL Yeah, I had the ankle surgery not too long ago. I repaired my deltoid ligament. Overall, the ankle's doing pretty well, but ever since, I've had a lot of falls and I'm having a lot of pain and weakness because I keep falling. And, you know, I really think it's a lot to do with my weight, that's why I keep falling.

ELLEN It sounds like you're thinking that your weight has been an issue for you in the past. Is this the first time that you've kind of talked about this with a health care provider?

RACHEL I've talked a little bit about it with my primary care doctor, but she doesn't really seem to take interest in having a conversation about it. I've asked her about the GLP medications that just came out, because they also have diabetes. She doesn't really seem interested in prescribing them and I just don't feel like I'm really feeling hurt when I go into the doctor.

ELLEN That is really frustrating and it sounds to me like you're ready to make some changes. Like you're really eager to change your weight because you know that that's going to be a real stepping stone for you to be healthier in the future. Well, we can definitely talk more about that. So tell me a little bit more about what your history of managing your weight has looked like in the past. How can I help you?

RACHEL Yeah, about 17 years ago I had gastric bypass surgery. But ever since, I've pretty much gained all the weight back. And so I'm just really frustrated because nothing has really worked. I've tried all the diets and that's been pretty unsuccessful in losing weight. I'm just feeling really hopeless about how to even go about that or what to do.

ELLEN I am so sorry, and I just want you to know you're not the only person. Weight is really hard to manage long-term, and obesity is a chronic disease. Did you know that everything in your biology, after you lose weight, fights to get it back? Your body doesn't know the difference between intentional weight loss and starvation. So I hope you know that you're not the only one. And it can be really hard, but those new medications could be really helpful. It sounds like that's a goal for you, and that's something you've been interested in trying.

RACHEL Yeah, I'm definitely interested. I just feel at this point I just need to do something because I'm unable to play with my grandchildren right now because I'm scared of falling and I can't get off the floor because I feel like I'm just really heavy and things. So I'm kind of feeling down about that.

ELLEN So it sounds like you're feeling down about that and you're feeling kind of hopeless. Tell me a little bit more about what steps you're taking to manage your mobility. It sounds like It's the weight, but it's also your ability to balance, your strength. All of those things have kind of been keeping you back for the past few years. Tell me more. Are you doing any exercise participation right now?

RACHEL No, I don't really like to exercise. I've tried some stuff in the past, but I just don't enjoy it and I feel kind of uncomfortable because I don't know what to do. And I think I just might hurt myself if I try to go.

ELLEN That is totally understandable. And I'm sure every exercise attempt that you've had in the past has been to lose weight. Am I right about that? Yeah. And I mean, if you've been unsuccessful in losing weight, I bet exercise could be, feel really like a wasted cause and a lost cause. Yeah. So let's, um, I'd love to challenge how you see exercise because really exercise shouldn't be about punishing your body for what it isn't. It should be helping empower you to do what you want to do. For example, I know that you love playing with your grandkids. Lunges are a really great way to get up and down from the ground. So if you think about it that way, I'm not exercising just arbitrarily to lose weight, but I'm training for grandma duty.

RACHEL That's what I really want to look for.

ELLEN That's a really great point. It sounds to me like you're ready to make some changes. I have a few ideas that I can offer to you and I want you to tell me what you think. I have a few primary care doctors that I know are really on board with prescribing GLP-1 medications when it's appropriate. If you'd like, I'm happy to send you their names and you can check them out and tell me what you think. Yeah, I think that'd be great. It sounds like your foot is doing great. That's kind of on the back burner of what's important to us. Why don't you and I look at kind of creating an exercise program. to see if we can match what you care about to functional things that you can do in the gym. And if you don't like going to the gym, I can give you a lot of other options, too, to do these exercises at home and still feel like you're really getting a great workout. OK.

RACHEL Yeah, I don't say I don't really like going to the gym, but I used to do a swim class, like swim aerobics, and I loved that. That's great. I felt comfortable and, you know, I didn't feel the weight on me.

ELLEN Yeah, feeling weightless in the pool, there's nothing like it. And I know, I saw in your intake that you're a scuba diver. I am, I love to scuba dive. That is so cool. I definitely want to get you back into the open water. I bet you love scuba diving for that same reason, just feeling weightless and like you're floating. We've got to get you back into the water. And I know if you felt better about your balance and your mobility, those things would be way more confident. You'd be way more confident in those things. Am I right about that?

RACHEL Yeah. Last time I tried to go scuba diving, I actually took a fall before and wasn't able to go because I hit my head. Oh man. And I just ever since haven't really tried again because I've just been a little discouraged about it.

ELLEN Oh, I totally get that. That would discourage me too. And it sounds like if you and I have a plan to not just go to the gym mindlessly, but to really say, I'm working for a pragmatic goal to be able to get up and down from the ground, to be able to lift all my equipment, to be able to play with my grandkids. That's far more meaningful than going to the gym to bust out cardio.

RACHEL i really feel good about this. I agree. I've never really thought of exercise that way.

ELLEN Oh, well I'm so glad that we can kind of reframe how you see exercise because truly exercise isn't punishing you, it's enabling your body to do all the wonderful things that it can do.

RACHEL This is awesome. I'm really excited about this. I feel like I have a little bit of hope now that I might be able to play with my grandchildren.

ELLEN Well, I hope you know I'm on your team and weight loss and weight management are really tough. And I hope you know that I'm in your corner and I'm here to help you figure this out.

RACHEL I really appreciate that. I feel like I finally felt heard today.

ELLEN Oh good. So that was almost exactly the conversation that we had in the clinic within the past week. It was a slam dunk. And if I can kind of illustrate how this went further, She came in for an ankle surgery, a deltoid ligament repair, but by the end of the session she left here feeling super positive about the strategies that we discussed. to help manage her weight. And kind of the happy ending to this story is that the patient did get on those medications with her doctor after switching doctors. Her doctor was super old school. She started working with a new doctor and it went super well. It was the perfect medication for her to use. She started exercising regularly at home and she was able to get up and down off of the ground with some skilled training. from our team within a few weeks of this surgery. So I kind of just want to illustrate that this motivational interviewing can be hugely impactful for your patients and in your practice to talk about uncomfortable subjects like weight. The things that we really wanted to look for in our discussion were partnership. Rachel knew that after our session, she and I were on the same team. I was here to help her. Acceptance. I didn't look down the end of my nose and say, well, eat too much and that's why you have obesity or you don't exercise and that's why you're struggling with your weight. She knew that I accepted her for who she is and I saw her journey. So compassion. She knew that I had compassion for this struggle. She knew that I wasn't judging her. I genuinely cared because I genuinely do. empowerment. She left our session having a plan, having a goal, knowing exactly what she was going to do to manage her weight in the future. So thank you guys for joining us on today's Technique Thursday. I'm so glad that you could be here with us and I hope that these motivational interviewing strategies were helpful for you in the clinic. Have a great morning.

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