Effective Communication in Physical Therapy Interviews: Techniques and Guidelines, Exams of Physiotherapy

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Interviewing in Physical Therapy

JANICE J. CROFT, MS

An important responsibility of a physical therapist is to create a communicative atmosphere with his patients so that information can be readily offered and received. The interview is an effective method for gathering information, estab- lishing rapport, and encouraging constructive planning, all of which are impor- tant in creating an atmosphere that facilitates communication. Guidelines for effective attitude formation, questioning, and responding within the context of physical therapy are discussed.

Key Words: Communication, Counseling, Interpersonal relations.

Establishing and maintaining good interpersonal relations and applying communication and counsel- ing skills with patients are responsibilities of a com- petent physical therapist.^1 Meaningful, well-devel- oped interpersonal relationships must exist in order for the therapist to be effective when obtaining infor- mation from, instilling confidence in, instructing, or motivating a patient. One medium through which any relationship may be initiated, developed, and sustained is the inter- view.^2 An interview is a purposeful conversation, a basic process of communication in which two or more persons interact to achieve some goal.^3 The interview between a physical therapist and a patient in a ther- apeutic relationship can serve varied purposes, whether it be for establishing rapport, releasing ten- sions, providing information, encouraging construc- tive planning or direction, or encouraging the pa- tient's self-understanding.^4 The purpose of this article is to present the neces- sary conditions, the basic principles, and the structure of an effective interview, which includes some basic techniques of questioning and responding that are useful in patient-therapist interactions.

OPTIMAL CONDITIONS FOR EFFECTIVE INTERVIEWING

The Environment

The external atmosphere of the interview environ- ment contains psychological and physiological factors

that influence communication flow.^5 The ideal setting for an interview is a private room, or one not over- whelmingly noisy or distracting. A room void of bright lights or clutter, which inhibit patient-therapist eye contact, and one that allows for complete freedom from interruptions is most conducive to free-flowing communication. The seating arrangements during the interview should be, if at all possible, the choice of the patient. Seats should be arranged so that the patient need not always look at the therapist directly. If the patient has the choice of eye contact during the interview, he can control some of its intenseness. One can imagine the discomfort a patient senses while lying supine on a mat, looking directly upward at the therapist. The timing of the interview is also important in promoting continuity of conversation and a sense of patient trust in the therapist. It is very difficult, for example, for the patient to continue talking through various interruptions of the therapist's being called away to the telephone. The patient can obtain a sense of being important and a feeling of trust toward the therapist much more easily with 10 uninterrupted minutes of discussion than with a half hour of seg- mented thoughts. Because an isolated corner of the room must suffice in the typical physical therapy clinic and because the time must be begged, borrowed, or stolen, lack of a proper place and enough time must usually be com- pensated for by what may seem to be minor details. For example, you may demonstrate to the patient that you are concerned about what he is telling you by 1) looking at him, and not around the room, 2) creating a relaxing atmosphere by your gestures of comforta- bleness, and not glancing at your watch every few minutes as if there were something else you really should be doing at this time, and 3) if an unforeseen

Mrs. Croft is Supervisor and Clinical Education Coordinator, Methodist Hospital, PO Box 1367, 1604 N Capitol Ave, Indianapolis, IN 46206 (USA). This article was submitted March 22, 1978, and accepted December 31, 1979.

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interruption does occur during the interview, by mak- ing everyone involved (including the patient) aware that your priority at that time is the patient and that any problems will be dealt with after the interview.

Attitudes

The physical therapist brings into any relationship his own predetermined attitudes and prejudices. He is a human being who frequently and unconsciously imposes his own feelings and attitudes upon others. These prejudices and attitudes need to be kept under control if they are not to influence the content and outcome of the interview. Researchers have deter- mined that respondents react to the expectations of the interviewer as well as to the content of the ques- tions the interviewer asks.^5 That is to say, the patient will respond not only to the question asked but to the attitudes the physical therapist relays through his tone of voice, gestures, and body language. In the case of the physical therapist who looks at his watch every few minutes, the patient will probably think the ther- apist has more important tasks to do and will begin to answer questions rather abruptly, if at all! Or, if the physical therapist begins an interview with the question "Where is your pain?" the patient may immediately think that the therapist expects him to have pain, thereby influencing his answer. The therapist can, however, express positive and productive attitudes during patient interaction. These attitudes demonstrate empathy, or the awareness and acceptance of the feelings and attitudes being expe- rienced and expressed by the patient.^4 '^6 When the therapist uses empathy and active listening in the conversation, the patient can feel he is free from judgment and evaluation and that his expressed atti- tudes are being understood. The therapist does not need to accept each patient's beliefs and values as his own in order to be empathetic toward that patient. What is important is that the patient has something to say that is important to him at that time. The therapist, then, needs to convey to the patient that nothing at the moment is more im- portant to him than listening to and helping the patient as much as possible. In order to convey this feeling of understanding to the patient, the therapist must be 1) aware of his own feelings and 2) aware that these are not necessarily congruent with the feelings of others. Therefore, the way in which the therapist views himself and his own attitudes affects whether he can react in a productive or empathetic manner to the attitudes of the patient. The more he knows about himself, the better he can understand, evaluate, and control his behavior, and the better he can understand, evaluate, and appreciate

the behavior of others.^7 Rogers speculates that the degree to which one can create relationships that facilitate the growth of others is a measure of the growth the person has achieved in himself.^8 This personal growth is demonstrated by being acceptant toward his own feelings, being secure enough to allow others to be separate individuals, encouraging self- awareness, and keeping relationships free from judg- ment and evaluation.

BASIC PRINCIPLES

Within the practice of physical therapy, all patients, even of those with the same diagnoses, are usually treated individually. Although each patient is an in- dividual, some basic principles can be used as guide- lines in every interview.^9 Some of the techniques for these principles will be discussed in the section on Interview Structures. The principles are

1. Help the patient begin talking.
2. Establish rapport. The initial interview with a patient usually serves to establish rapport and develop an understanding of the patient's per- ception of the problem.
3. Pay attention to the patient. a) Have the therapist seated in a comfortable, relaxed position so he can more readily talk to the patient. In contrast, a tense, hurried physical therapist is less likely to pay atten- tion, which is easily communicated to the patient. b) Use eye contact effectively. A physical ther- apist who looks at the wall and out the window does not focus on the patient, which communicates to the patient that the thera- pist is not listening. A fixed gaze is also undesirable, inasmuch as it is likely to make the patient uncomfortable.
4. Ask questions.
5. Respond to and summarize feelings.
6. Clarify the patient's statements.
7. Close the interview by summarization.

INTERVIEW STRUCTURE

Opening

Within the first few minutes of contact, the thera- pist must effectively manifest support, listening, em- pathy, and reassurance, all of which play important parts in establishing patient rapport. The therapist must remember that the patient is a person who probably no longer feels totally self-sufficient in car- ing for himself and feels the need for help. He is an individual finding himself playing the role of a pa-

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tient, to which he may or may not have adjusted. The person comes to this new role with past experiences, ideas, and fears built upon his social, cultural, and economic background. The therapist must take time to introduce himself to, listen to, and observe this patient in an effort to search out his personal attitudes, insecurities, and needs. An atmosphere that facilitates patient conversation is therefore necessary for further interviewing. The effectiveness of this atmosphere lies in the supportive, motivational, and reassuring capa- bilities of the physical therapist.

Questioning

Effective questioning in an interview can assist in reducing the patient's anxiety and in obtaining useful information. Basically, questions must be purposeful, simple, logical, open-ended ones that obtain an an- swer reflecting the patient's feelings and reactions.^3 Questions are needed when information is required or needs clarification and when a topic needs to be explored. The open-ended question is very effective because the patient must offer specific or general information and cannot answer yes or no. Open- ended questions or statements such as "How did it happen?" "Tell me about it!" and "What can you remember about it?" allow the patient to express his feelings, reactions, and emotions rather than to rei- terate objective findings that are probably docu- mented in his medical chart. The opening question of the interview must be stated so as to establish the main topic of the session, help the patient start talking, allow the patient a feeling of being qualified to answer, and perhaps demonstrate the therapist's sympathetic understand- ing of the problem.^5 A question such as "How do you feel about your progress so far in physical therapy, Mr. Jones?" enables the patient to make qualitative remarks and shows that the therapist is concerned with the patient's feelings. Further questions or implied questions can be em- ployed for different purposes: 1) to explore ("Tell me more about it!" or "Would you describe it more fully?"), 2) to encourage the patient ("Go on" or "And then?"), 3) to focus on a particular aspect of the interview ("This seems worth looking at more closely" or "Maybe we should spend a little more time discussing this"), 4) to attempt to translate the patient's words into feelings ("Are you saying that you feel... ?" or "Are you telling me that you feel

... ?"), and 5) to confront the patient ("You look unhappy!" or "You sound like you aren't pleased with the results of your treatment program"). Double questions, ones that ask two questions at one time, should be avoided. They limit the patient

to answering one question at a time. For example, "Are you managing your crutches better today, Mr. Jones, and how is your shoulder feeling today?" confuses the patient because he doesn't know which question to answer first. The questions might suggest to him that neither one of these topics is deemed worthy of being discussed separately. Probes, questions that elicit information in addition to that given in the first response to a general question, must be used cautiously, so as not to appear threaten- ing to the patient.^7 Examples of probes are "Anything else?" "What else are you thinking of?" "Why is that?" or "I don't quite see what you mean." Probes may be used when the patient's answer to a question is irrelevant, unclear, or incomplete, or when the therapist is not certain the patient is telling the truth.

Responding

Because of the frequency and intensity of therapist- patient verbal and nonverbal interaction, each ther- apist must consider the potential therapeutic or de- structive power of his every response. An effective response is one that fulfills one or more of these processes: clarification, reflection, interpretation, fa- cilitation, or silence. Clarification is the process by which the therapist tells the patient the observations and perceptions he is receiving from what the patient presents. Clarifying may reassure the patient that he is communicating something that is understandable to the physical ther- apist.^10 For example, statements such as "I think I understand what you're saying" or "I'm not sure I follow you" will show the patient that the therapist is interested in and concerned with what the patient has said. Goldin and associates suggest that the major psychodynamically oriented role of the physical ther- apist is that of clarifier.^10 Reflection is the process of bringing to the surface and expressing in words the patient's attitudes and feelings.^7 When a patient states, "I just can't take this any longer—therapy isn't helping me at all!" a re- sponse such as "You feel fed up right now!" or "You think you've gone as far as you can in therapy?" will allow the patient to reflect on what he has said, in order for the therapist to hear what the patient really meant for him to hear. Interpretation is explaining or inferring that which is not immediately explicit. The therapist must search beneath the surface to understand more than the superficial significance of the patient's remarks. The patient's remarks need to be interpreted not only on a cognitive level, but also on an emotional level.^11 At

this time, the therapist must separate the frames of

reference of both the patient and himself. For exam-

Volume 60 / Number 8, August 1980 1035

pie, when the therapist interprets what he has under-

stood from the patient's communication, he is re-

sponding to the patient. However, when the therapist

interprets the information in terms of his own frame

of reference and within his own ideas, he is respond-

ing to himself and expects the patient to react as he

would react himself. In order to clarify a patient's

statement such as "I can't talk to you, or anyone else

about it!" one might reply "You seem to think that

nobody understands you!" Thus, the patient can

either clarify what he meant to say or specify what he

really wanted the listener to get out of his statement.

Facilitation is the act of encouraging the patient to

say more. Statements such as "Go on," "I see," "How

are things?" or "I'd like to hear more about it" all

demonstrate, if stated with interest and sensitivity,

that the therapist wants to hear more of what the

patient has to say.

Silence is also considered to be a communication

or a response.^4 Here, the therapist can capitalize on

observing the patient's nonverbal signs, which can

relate to his feelings of anger, anxiety, fear, or sadness.

Silence allows the patient to reflect on past statements,

think about new ideas, consider alternative directions

to pursue, or avoid a topic. If the patient's eyes are

looking from one object to another, he is probably

trying to avoid the topic of discussion. However, if

the patient's eyes are fixed, without being focused, he

is probably thinking. Silence can stimulate the patient

to initiate conversation, but silences longer than 30

seconds may be unproductive.^9

Summarizing

The final stages of an interview or patient interac-

tion can be just as dynamic and as important to the

success of the interview as the opening remarks. It

may be fruitful to summarize the patient's basic re-

marks in order to determine if the therapist's percep-

tions and the patient's intents are congruent. More

importantly, the next step to be taken in the thera-

peutic process should be discussed, such as referral to

other resources, further discussion in following ses-

sions, or implementation of plans for action. The

decision, although strived for through interaction by

both participants in the process, should be primarily

that of the patient. The therapist's inclination to solve

the patient's problems, offer advice, and approve or

disapprove of ideas suggested by the patient must be

controlled.

SUMMARY

An important responsibility of the physical thera-

pist is to create an open, communicative atmosphere

whereby information can be readily offered and re-

ceived. An effective tool in obtaining information is

the interview. When the appropriate techniques,

questions, and responses are employed, both the pa-

tient and the therapist reap the benefits.

REFERENCES

1. Competencies in Physical Therapy: An Analysis of Practice. **San Diego, Courseware, Inc, 1977

2. Engel GL, Morgan WL: Interviewing the Patient. London,** **W.B. Saunders Co, Ltd, 1973, p 26
3. Wickes RJ: Counseling Strategies and Intervention Tech-** niques for the Human Services. Philadelphia, J.B. Lippincott **Co, 1977, pp 1-
4. Froelich RE, Bishop FM: Clinical Interviewing Skills, ed 3. St.** **Louis, C.V. Mosby Co, 1977, pp 3, 13
5. Kahn RL, Cannell CF: The Dynamics of Interviewing. New** **York, John Wiley & Sons, Inc, 1965, pp 12-
6. Rogers CR: Counseling and Psychotherapy. Cambridge, MA,**

Houghton Mifflin Co, 1942, pp 86-

7. Benjamin A: The Helping Interview, ed 2. Boston, Houghton **Mifflin Co, 1969, pp 1 -

8. Rogers CR: On Becoming a Person. Boston, Houghton Mifflin Co, 1969, pp 50-
9. Brown JH, Brown CS: Systematic Counseling: A Guide for the Practitioner. Champaign, IL, Research Press Co, 1977, pp 21-
10. Goldin GJ, Leventhal NA, Luzzi MH: The physical therapist as "therapist." Phys Ther 54:484-488, 1974
11. Ramsden EL: Interpersonal communication in physical ther- apy. Phys Ther 48:1130-1132, 1968**

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