A relatively newer concept that’s emerged in rehab in the last 10-11 years, thanks in part to people like Peter and Kieran O’Sullivan, is that of belief change in clients. It is a tricky area that straddles traditional rehabilitation and psychology that can be effective and sometimes very necessary to move certain clients forward.

In this article I discuss nuggets I use and recommend to help with the process of belief change in clients.

Before we do that – Here are additional resources for those who want to take a dive into similar topics and Biopsychosocial Rehab in general.

A framework for optimising the patient interview & clinical outcomes
Know Pain: A Practical Guide to Persistent Pain Therapy (I’m biased towards this one as I did Mike Stewart’s course in person in 2019)

Nugget #1: Accept the fact that belief change can be hard

Belief change can range from things as simple as quickly getting someone to realize that a bit of activity – even when having pain – is OK to something as complex as major maladaptive beliefs about the body that are very rigidly kept by the client even when they’ve gotten a lot of advice to the contrary from friends, family members, and providers. Sometimes these beliefs don’t even objectively match what is going on from a symptom or physical examination perspective.

As I told a pupil of mine – we don’t learn in physio school that there’s a person attached to the injured body part(s) that you are trying to rehab. We each have our own background knowledge, culture, beliefs and expectations that influence our own beliefs and expectations.

Peter O’Sullivan in a recent interview (1) stated that, even though his videos make it look like belief & behaviour change are easy and happen just with a snap of a finger, behaviour and belief change both often take a fair amount of time. Clients need to be ready to make those changes and in some cases clients are not.

It is also tricky as we’re really the first generation of clinicians doing this on a large scale. It’s not like rotator cuff exercise where we have thousands of cases and dozens of exercises to use as prior reference. We will make mistakes and that’s part of the game.

When I see a client that isn’t successful despite putting in a fair amount of time and effort to the process, quite often it’s not the size of the tear or the amount of arthritis that’s the big barrier to recovery but rather other factors such as clients:

Expecting a quick fix
Not being confident in themselves, the rehab approach, or their bodies
Having poor coping mechanisms with pain and taking counterproductive steps as a result (i.e. excessive amounts of rehab exercise, bouncing from provider to provider in a short period, looking up a lot of stuff on the internet, or just freaking out when they don’t get better right away)
Not being ready to change their beliefs or behaviours

Accepting that it’s hard and that there are times you may make mistakes and not succeed is probably the most important part of the process.

Nugget #2: Time management

Discussions on belief change are not the kind of the thing you want to do during the last five minutes of a therapy session before you start to get set up for your next client. These are definitely the kind of discussions you need to have at or near the start of a session.

Also – the kind of clients who need a lot more psychologically informed therapy, belief change, reassurance, education, etc are ones that should be booked for an ABSOLUTE BARE MINIMUM of 30 minutes in a session. I’m sorry – 10-15 minutes just don’t cut it.

Nugget #3: Slow down

This is an issue I see a lot of clinicians do, and also catch myself doing, and that is simply going too fast. There can be a lot of reasons for that including:

Being in a busy clinic and feeling under a time crunch
Feeling time pressure to “move it along” for fear that
- Clients may run out of benefits
- OR clients may feel unhappy because they’re not making progress or they’re not getting enough hands on treatment
Not feeling comfortable with behaviour change and wanting to move onto the exercise, manual therapy and modalities that many therapists are brought up on.

Those are certainly valid concerns however:

Most clients appreciate, especially in this world where clients get interrupted quickly by health professionals (2), being listened to thoroughly.
There are some clients who are going to be dead set on a quick fix and may take a while to be mentally ready to make that shift. I find that these clients often need to try and fail a few times before realizing this themselves.
There are some clients that want things an exact way and will not be happy regardless of what you do. It is what it is.

The big trick is to slow yourself down. I find, especially on many days of back to back clients, it’s nice to do a few seconds of deep breathing before going into a potentially more challenging client interaction.

Nugget #4: Listen actively and reflectively

This is pretty straight forward and has been covered in a lot of different resources both in and out of rehab so I’m not going to spend a ton of time on this.

Nugget #5: Acknowledge where their prior beliefs came from & validate them

Quite often you may very well have had the same beliefs as your client at one point or another (i.e. hurt always meaning damage, pain being solely due to biomechanics and tissue load, imaging being the miracle diagnosis and surgery being the miracle treatment for everything etc). That is something big to keep in mind when working on belief change with clients.

A big part of effective therapeutic alliance, communication, and overall psychologically informed therapy is making sure the client feels listened to and validated.

Some examples of validating that I use are:

“That’s a common concern/belief I see in a lot of my clients”
“Yes, that was the common belief around that in ”
“That’s interesting – tell me more about that.”
“I can certainly understand why you feel that way”

I also like to ask where clients got those beliefs from – it may have been friends, family, the internet, other health professionals, or even their own perception.

Nugget #6: Ask permission

Going in head first and challenging your patients’ beliefs is the Urban Dictionary definition of how to lose therapeutic alliance in a hurry. I’ve made this mistake – and probably everyone reading this article has made that mistake at some point.

Once you’ve read the person and determined that challenging certain beliefs is appropriate, and for some it may be not even worth initiating at that stage, asking permission is the next big step before challenging beliefs.

Examples of this include:

“I’d like to challenge that if that’s OK?”
“Is it OK if I share some new research and a different perspective on the topic?”
“Is it OK if I help you understand where those came from along with an alternate view on the topic?”

Often, with any kind of tougher conversation, asking permission first can make it a whole lot easier.

Nugget #7: Make it relevant to them

An example of this is disc herniation research. A lot of research done in the 90s and 2000s, along with some problematic knowledge translation at the time, gave the impression that discs were like jelly donuts and inert car parts that wore down over time with flexion. Now with more recent research we know that the vast majority of disc herniations heal (3) and that discs can adapt to some degree (4) although this is an area that needs FAR more research.

Some qualitative research on pain education (5) has shown that it needs to be made relevant to the patient to be effective.

Nugget #8: Have multiple approaches

Having multiple ways to change beliefs through different analogies and different modes of communication can also make things more effective.

Nugget #9: Combine it with movement

There is some research (6) that combining pain education with movement is better than just education alone. It’s one thing to teach someone a concept but another for them to actually learn it.

Some examples I use are:

For people who are guarded with lumbar movement and find bracing painful, teaching people to move while focusing on breathing can help make these movements more comfortable plus help teach the client to be in control of his/her pain.
For clients who tend to rush through things using a timer and going through the task with them to slow them down and take appropriate breaks can help them realize that those strategies can be helpful.

Nugget #10: Be patient

Again belief and behaviour change are hard and take time. You don’t see your fear-avoidant client with chronic low back pain who reads Explain Pain and then is automatically jumping for joy and living happily ever after. Belief and behaviour change are a long and painful process.

Nugget #11: Know when to break off

This is where Eric being a history buff comes in – Great generals in history knew when to break off an attack and come at it from a different angle.

I use the same idea with belief change in rehab. There will be some clients who may not be ready to change beliefs and may be very rigidly holding onto things. You may be getting a visible reaction that they’re just not interested, you may be heading towards a big disagreement or they just may not be getting it.

This is where knowing when to break off these discussions and come at the problem from other angles is effective. You don’t need to change every maladaptive belief of every client – I’ve made that mistake before and have seen others do the same. We know that things help such as:

Graded return to activity
Well tolerated exercise and movement
Positive general physical and psychosocial health

So don’t get stuck in a situation where you feel you may be losing therapeutic alliance with your client – switch and go in a different direction. You can always come back later.

Nugget #12: Know when to refer out to other colleagues

In the Fall of 2020, when things were getting under some degree of lockdown again here in Canada, I did the online version of Phillip Snell’s course on the Clinical Companion to Fix Your Own Back. In the course he talked about, if needed, referring clients out to therapists who are better at certain areas that your client may need (i.e. belief change, motivational interviewing, ACT, reassurance, pain science education).

Over the last few years that message has sat with me more and more.

I think part of the reason that people get into physiotherapy and rehab is, aside from just simply wanting to help people, physios tend to be more into manual therapy and exercise. It can feel like a big 180 to change from doing those things to emphasizing more communication and therapeutic alliance and psychology. Now it doesn’t have to be an either or. Again I’ve spent time doing manual therapy on someone while doing education, reassurance, motivational interviewing etc.

But for some clinicians it just may not be their cup of tea and in that situation working in conjunction with another clinician who can do those things is good.

Also – if there’s significant mental illness or other psychosocial factors driving the beliefs (i.e. phobias, PTSD) and/or a lot of emotional dysregulation then you may need to look at working in conjunction with mental health professionals to address those.

Wrapping up

Whew! That is a lot to read – but I hope this provides a few useful tips for the challenging yet rewarding topic of belief change.

Please check out Dr. Tim Mitchell’s Masterclass on A framework for optimising the patient interview & clinical outcomes here, if you want to learn more on this topic.

Thanks for reading!

12 Nuggets for Changing Beliefs