Health Behavior Change is an important concept for the practice of physical therapy. The nature of physical therapy typically requires that we explore what motivates our patients and clients in addition to determining what may be creating a barrier to performance or that is hampering compliance. As the profession focuses more on lifestyle change, nutrition and epigenetics and its relationship to health in the services we provide, long-term sustainable behavior change is critical. Dr. Bezner helps you customize the interventions recommend based on the changing attitude your patient or client may have toward a healthier lifestyle. Behavior change is essential in pain care.
Thank you for joining me this week on the Healing Pain Podcast. I am your host, Dr. Joe Tatta. It’s great to here with you once again.
On the podcast this week, I have Dr. Janet Bezner. She is a Doctor of Physical Therapy and a Certified Health Coach. Currently she is an Associate Professor at the Department of Physical Therapy at Texas State University and conducts research on physical activity. Prior to joining Texas State, she was the Vice President of Education, Governance and Administration at the American Physical Therapy Association. Prior to that, she was a Senior Vice President for PeakCare Incorporated, which is a health care technology firm, where she managed the development of a wellness and prevention software and video library aimed at employers to assist in decreasing health care costs associated with illness and injury at work. She’s worked in a variety of health care settings and is a recipient of the Lucy Blair service award. She’s also an experienced speaker on topics related to leadership, personal development, strategic planning and health promotion and wellness. Dr. Bezner, welcome to this week’s episode of the Healing Pain Podcast. It’s a pleasure to have you on.
Thank-you! Thanks for having me.
So, you have a very interesting bio in the physical therapy world. You’ve done everything from clinical practice, to obviously working as a professor on the university level. You’ve worked in the American Physical Therapy Association, or our larger governing body. Can you tell me how, as a physical therapist, you became so interested in behavioral change and how that kind of became present in your professional experience?
Sure, yeah. So early in my career, I got involved in cardiac rehab and I started a community program in Northwest Huston. I was working with a nurse and physicians and dieticians and I was obviously in charge of the exercise portion. And so, I felt like I knew how to create an exercise program. I just couldn’t get anyone to do it. So, it was very frustrating. I’d see these 45 year old men, mostly males come in, have their heart attack. We would put them through 12 weeks of cardiac rehab and then they’d be a lot better. They’d [inaudible 00:02:17] habits, but then they would get discharged and they would not do anything. So I really realized I was missing some huge body of knowledge that I felt was out there, but I didn’t know anything about.
So that led me to go back and get a PhD in Health Promotion, and really the focus of my PhD at the University of Texas was on behavior change. So, that’s when I really got sort of hooked on it and every since then, I graduated from UT with my PhD in ’95 and my sort of personal goal at that time was to bring this information into physical therapy. And so I’ve spent the last 20 years trying to do that in various ways. So yeah, that’s the story.
Which is very interesting, cause I think when I went back to school, let me age myself and say 1995, we were not talking about behavior change, but we were talking evidence based medicine. So we were trying to figure okay, what really works? Where’s the evidence on what we do? And I think now we have all professions have a really good base of evidence as far as what works as far as changing chronic disease. But I think the behavior part is so interesting because that’s something we didn’t talk about 20 years ago. And even to this day, when you mention behavior changes to a lot of patients, no matter who they are, they sometimes say, “Well, it sounds like something that’s more like what a psychologist should do.”
Why is behavior change important and why does it really fit into almost every profession?
Yeah, it’s a really good question Joe. So, the top diseases that we deal with today are lifestyle diseases, everybody knows that. Chronic diseases, lifestyle diseases. And they have to do with behaviors and choices. And so there’s no professional, no health professional, who doesn’t need to know this information because we now know that just giving patients the information about how their choices affect them, negatively or positively, doesn’t work. And so we have to have other knowledge, other skills, other strategies to actually help them change their behaviors.
If behavior change was easy, everyone would be doing it. And the statistics clearly point to the fact that they aren’t. So yeah, you’re right on. This is relevant for every type of professional but I think more important to our conversation today, it’s relevant for every physical therapist, no matter what setting. The information I’ll share today is going to help you help your patients do their home program better, for example. So, if there’s anything you’re trying to get your patients to do, this information’s relevant.
So where can a doctor of physical therapy start? I have other professionals who listen to my podcast so, where can they start as far as motivating their patients toward this behavioral change?
Yeah, so I think the first thing to recognize is that we don’t motivate other people. No one motivates anyone else. It’s finding the motivation within the person. And so that was a valuable lesson that I learned early on.
What I mean by that is that people aren’t really motivated to improve their health unless unless health is a value. Young folks especially, teenagers and young adults, they don’t really value health because it’s just a given, right? It’s taken for granted, and so the older you get, the more you tend to value health, and the more it can be a motivator. But the thing for PTs to understand is that we need to find out what are the most important things to our patients. So maybe the patient wants to return to golf. Maybe the patient wants to be able to cook and take care of their family, pick up their little one. Maybe the patient wants to go back to work. Whatever that connection is, that’s what’s gonna motivate the person.
So our task is to help them see how these health behaviors, whatever it is – home program, physical activity, better nutrition – how that will give them a better ability to return to what’s really important to them.
Which is interesting, cause I think of all the functional outcomes that we have nowadays, and some of them are quite long and they ask a number of different questions, but some of those questions on those functional outcome measures may not be what the patient’s goal is. Even though we’re kind of measuring it.
Yeah. Totally agree. I think we haven’t really identified an outcome tool that really hits the mark yet in this regard, related to motivation. However, those tools are really valuable and obviously support are using them. I think the PT can then use that tool and then also have that conversation. When you’re setting goals, you’re interacting with the patient and making sure that that’s a collaborative process. And so, knowing what the patient desires to return to do can really be the linchpin to get them to do it.
Yeah, and I think as you practice more, as a clinician, you really realize that behavior change is a really intricate part of what we do. And some of us are doing it without even thinking about it. We’re not really realizing we’re actually working on behavior change. But what skills does a physical therapist need to work on effective behavior change?
Yeah, so I think you’re right about the fact that there are PTs who do this really well and they won’t ever have heard of these theories I’m about to talk about and mention. I think that’s why it’s so, it makes so much sense for us to have this knowledge and these skills, because we’re natural at it. We’re very natural at it.
So to answer your question, we need to know how to have a conversation that keeps the patient in charge and doesn’t allow us to get into our expert mode. Because as it concerns behavior change, everybody is unique. What works for me might not work for you, vise versa. We’ve gotta keep the patient steering that conversation. So, knowing how to have these kinds of conversations is key, and the main skill there is a technique called Motivational Interviewing, which I’m sure you, and many of our listeners have heard of. I’ve been trained in Motivational Interviewing and I use it constantly. I use it with my family. I use it with my students. I use it with my clients. I am a health coach. That’s my primary area of practice. So, we’ve got to know how to have those conversations.
And really there’s a couple of key skills in Motivational Interviewing. One is empathy, and being a good reflective listener. And the other is how to increase self-efficacy, which is a term that means confidence. Our confidence to do a behavior in. Albert Bandura is a scientist from Stanford. He’s like 90 years old, still on Stanford faculty. If you Google Albert Bandura and self-efficacy, you can read all about him. But he basically has shown, as have numerous researchers since then, that self-efficacy is the most influential factor in terms of whether or not some will be successful changing their behavior. So the more confidence someone has that they can do the behavior, the more likely they are to do it. And the way we talk to patients is a way that increases their self-efficacy.
So can you define what self-efficacy is? Because I think it’s a term that there are both clinicians and people who have pain who listen to my podcast, and what does that really mean?
Yeah so, basically, one word answer is confidence. It means confidence. And it’s behavior specific. So I might have a ton of confidence that I’m gonna be physically active every day. But I might have really low confidence that I can get seven hours of sleep every night. So it’s very behavior specific and so, it’s not a global thing. It’s a specific thing. And so the confidence that a person has to do the behavior is really indicative.
So let me give you an example of how I might use this. So Joe, if you were my client and I have given you some stretching exercises to help you manage your pain, or your mobility or whatever, and I said to you, “Okay Joe, do you understand the exercises?”, and you said, “Yes.”, and you demonstrated them, then my follow-up question should be, “So on a 1 out of 10 scale, 1 being not confident at all, 10 being totally confident you know you’re gonna do it, how confident are you that you’re gonna go home and do these stretches every day?”. So give me an answer, just role play.
I’ll say 5. I’m right in the middle.
Okay, so that tells me that you’re not very confident. So my follow-up question is gonna be, So Joe, why didn’t you say 1 or a 2?
Well, cause I’d like my pain to go away so I’m gonna give it a shot.
Great, so you know it’s important and you think it would be connected. However, you didn’t tell me it was a 7 or 8, so that tells me that there’s something in the way, at home or in your life. So what would have to happen to get you to say that you were a 7 or 8 in confidence?
Well, you know, for me right now, I’m really busy. I have a podcast going and I’ve finished writing a book so I don’t have a whole lot of time right now. So if I had a little bit more time, if I could figure out a way to create more time in my life, then I think I’d be more confident in actually taking your advice and doing the exercises.
Okay, that’s really helpful for me to know. So then what I would say is, “So Joe, what could you go home and do that would help your pain right now, that you would feel like you were an 8 in confidence for? Can you think of something?”
Yeah, I think I need to get my cleaning lady to come in one more time a week so I could free up some time to have some extra time to do some exercise.
Awesome. So that’s your home program for this week. And so your home program for this week is to contact your lady, get ’em in there so that you can have some more time. So, that’s kind of- Great answers by the way, Joe. So that’s really real, that’s what everybody says, is time. But that’s the kind of conversation that we need to have with our patients. If they’re not a 7 or 8 on that 10 point scale, chances are they’re not gonna do it. And their self-efficacy will be less afterwards rather than higher.
And so, sometimes the first step is not the actual activity you want them to do, right? Sometimes it’s some kind of preparation, so, doing some research, thinking like- I worked with somebody this week who wants to eat less wheat in her diet and so she told me her goal was to substitute, to have one serving of wheat a day, and I asked her about her confidence and she said, “5”. And I said, “Okay, well, then this isn’t the right goal. So what could you do?” And she said, “Well, I need to go do some research. I need to figure out what is it that I can substitute for the wheat.”. And that’s what I sent her away to do. She’s gonna go away and bring back a list of foods that she likes that she can substitute that are realistic, and then next week we’ll go with the goal of eating less wheat.
I think it’s really powerful cause especially when we’re talking about patients who have pain, the trend is toward a more interdisciplinary approach. We’re looking at movement. We’re looking at nutrition. We’re looking at the psychology. And a lot of times were asking patients to do a lot of different changes, sometimes all at once. So as I listen to you, my question really is, is behavioral change a process and not a single event?
Wow, that’s a great question. I think it is a process and the one thing I say to my clients frequently is that these health habits, they’re not about perfection. Everyone thinks that if you don’t do something three times a week, which is what the guidelines say, that you shouldn’t do it all, they just give up. It is a process.
There are times in all of our lives where we just can’t do whatever the behavior is because there’s something more important. That’s humanity, right? That’s being a human. And so it’s not about perfection, it’s about being mindful in the moment and asking yourself, what’s the best thing for me right now? If it’s eating the chocolate cake, then for Pete’s sake, eat the chocolate cake! And don’t beat yourself up! Right? Because that causes more harm than the chocolate, I think. So I think it’s teaching people, especially people with pain, I think this is hugely important and I would love to hear your thoughts on this as a pain expert, if they can be mindful in the moment and ask themselves, what is really best for me right now, and do that, they’re going to build confidence. They’re going to build empowerment. They’re going to really take more control of their lives and their situation. So it’s definitely a process.
Yeah, and I think your example before about someone wanting to eliminate wheat from their diet, you know, gluten which is found in wheat, has been shown in a lot of evidence based studies to help people with pain. So a lot of times, when I talk about nutrition to patients, that can be one of the things I start off with. But for some people, it may not be gluten, it may be sugar. So really trying to work with a patient to see where they are today, where they’re willing to start with. If someone is saying, “You know what, I really am not going to stop eating a bagel in the morning” then I may not go to wheat right away. I’m just like, “Okay, well let’s focus on just taking the four teaspoons of sugar out of your coffee”. So it’s really finding where they are today and starting from there and then trying to get them to progress to a place where- Eventually, it’s a phase as you said, it’s a process.
Yeah, and one of the foundational principles around building self-efficacy is what I like to say, baby steps. And so, if you can build small successes over time, then you can build self-efficacy and you can eventually get to the ultimate goal. And that’s the best way. That is the sustainable way to change behavior. You can quit cold turkey, so to speak. People do that all the time. And with addictive behaviors like smoking that works pretty well for some. But for the rest of us, these behaviors are best when they’re sustainable and the way to make them sustainable is to build self-efficacy. And the way to build self-efficacy is to take small steps and get some success.
Yeah. One of my platforms with this podcast is to be an advocate not only for the physical therapy profession, but also for people in pain. Now you know some statements, some broad statements from the NIH, coming through that we should use less opioids for pain and I think as professionals, we know that’s the direction to go. It has created some fear for patients cause they feel like were taking, that were taking something away from them. I also look at it as far as being advocates, we have to look at our current, probably our insurance system, both Medicare as well as private insurance. And when I think of physical therapy reimbursements where you’re getting let’s say maybe eight visits total, and we have to use those eight visits within let’s say a month, so we’re really given a tight time frame, does that system lend itself well to behavioral change when it sounds like that process may be a little bit longer and we may have to check in with someone periodically verses see them twice a week in the traditional sense of physical therapy?
Yeah, that’s a really good question. I would say that it doesn’t really fit the process. A typical engagement period for me with a client is three months. So, it takes about three months for me to help somebody help themself and really change, no matter what the behavior is. And so, I would say that, and that’s based on evidence as well, and so yeah, the insurance companies are being a bit shortsighted in my opinion. And they don’t really think that we, physical therapists, can do that effectively anyway. I think everyone sort of has us in the rehab box. And so when we start talking to insurers about our skills in behavior change, that’s when I think that might change.
So if I was that PT who got eight visits over a month, I would call the insurance and say, “Eight visits are fine, I’d like to spread them out over three months.” The worst that can happen is they say no. And that’s shortsighted. But I think in many cases that would be allowed, and so you can do a lot more if you have a longer period of time because then the person can go home and try what you’re discovering together and build some success. You can’t build self-efficacy in a month, for anything really, very effectively. It takes a little longer than that.
So if there’s a physical therapist or another practitioner listening to this podcast and they wanna learn more about behavior change, where can they learn about it?
Yeah, so if they’re a APTA member, APTA has a nice area of their website under the practice area that has some information on behavior change. I’ve written several chapters and books so you can Google me. If you’re a PT and you probably have a- I have a chapter in Bill Boissonnault’s Primary Care book, and Lori Thein Brody’s There Ex book. 2 of the neuro books and then the big red physical medicine book that’s about that thick. And I’ve got an article on PTJ that’s available that I just got published last year which is a really good resource. And then motivational interviewing, there’s a great motivational interviewing website called motivationalinterviewing.com. I think it’s .com, I was gonna look that up and I forgot. Either .com or .org. And it has a ton of free information. I do think that they ask you to register but it’s free.
And go to the conferences. I teach this stuff at our conferences. I’ll be at CSM. I’ve got a couple of sessions at CSM. One in the neuro track and one in- No, both in neuro, but one’s on sleep and one’s on working with neuro patients with stroke and how to apply this with them. So, I think there’s some resources out there.
Yeah, excellent. And thank you for the interview today, but if people want to learn more about you, they want to get in contact with you, how can they find you?
Yeah, so I’m on linkedin. You can just find me, Janet Bezner. Or my email firstname.lastname@example.org.
Great. So I want to thank Dr. Bezner for being on the Healing Pain Podcast. I will include both her- I’ll include her linkedin on this page so you can contact her through there. I want to thank her for the interview. It’s been really interesting to talk about behavioral change. It’s a really important topic for both clinicians and for even the lay person to kinda learn a little bit about it, so I want to thank her.
Stay tuned to the Healing Pain Podcast each week at drjoetatta.com and have a good week. We’ll see you next week!
About Dr. Janet R Bezner, PT, DPT, PhD
Dr. Bezner is an Associate Professor in the Department of Physical Therapy at Texas State University. Bezner teaches, conducts research on physical activity and provides service to the university community. She received her bachelor’s degree in physical therapy at the University of Texas Medical Branch, her master’s degree from Texas Woman’s University, degree PhD in health education from the University of Texas and a DPT degree from Rocky Mountain University of Health Professions. Prior to joining Texas State in August 2014, she was Vice President of Education, Governance and Administration at the American Physical Therapy Association and prior to that, senior vice president for PeakCare, Inc, a health care technology firm, where she managed the development of a wellness and prevention software and video library aimed at employers to assist in decreasing health care costs associated with illness and injury at work.
Bezner spent 7 years teaching physical therapy at Southwest Texas State University (now Texas State University) in San Marcos, Texas, and has practiced in a variety of health care settings, including hospitals, home health, long-term care and corporate wellness. Bezner served on APTA’s Board of Directors prior to joining its staff and is a recipient of the Lucy Blair Service Award. Bezner is a graduate of the 2009 Leadership Alexandria program and has completed a national training summit on physical activity. She is an experienced speaker and facilitator on topics related to leadership, personal development, strategic planning, and health promotion and wellness.
To learn more about Dr. Bezner visit www.linkedin.com/in/janet-bezner-19b9347
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