Using Social Psychology Principles to Gain Compliance in Rehabilitation

Maya Chandra, a 70-year-old female is recovering from a broken hip, Benita, her Physical Therapist is expressing frustration at the lack of progress she is making in therapy. “Ms Chandra is often refusing to go or participate. She often states that she is in pain or too tired to go. Her therapist explained to her that this is impacting her being able to walk well again and if she doesn’t participate her insurance company may stop payment.

Benita has noticed a lack of health literacy and has explained all the benefits of therapy to Mrs. Chandra. Her goal is to make Ms. Chandra a partner in her care but she remains non-compliant. The nurses on the unit are hesitant to be more aggressive in pushing Ms Chandra to go to rehabilitation as they believe this would be coercive. Coercion is seen as getting someone to do something through punishment or threats.

So, Benita consults with Dr. Choudry, a unit psychologist to see what can be done. Dr. Choudry is quick to point out the power of persuasion as a tool.  He points out that persuasion is not coercion. Persuasion is defined as a positive tool to influence or change one’s current process of thinking.

Social psychology is the scientific discipline that looks at how people behave, think and feel in social situations. He suggests several social psychology principles and tools Benita can employ to get better compliance. 

Principles of Social Psychology 

1. People prefer to be with people in circumstances similar to their own. While protecting her privacy, introduce Mr G to other patients with similar issues or rehabilitation exercises as hers. The need to affiliate is based on the desire for approval, support, friendship and information. These patients can provide support and are a good source of information about what they can expect in therapy. 
2. People’s desire for self-evaluation motivates them to associate with others. Group membership fills a need for social comparison (comparing your actions, feelings or abilities to others). Point out to Mrs C. that by attending the rehab group she will be able to assess his progress by seeing how others with the same condition are doing.  
3. People are more compliant with people with whom they have frequent contact. As her therapist, go into Mr. G’s room frequently to check on her or ask if she needs anything. Engage in conversation about her life, family and interests. Once she knows you, it will be harder to say no. In contrast, a Physical Therapist who only comes to her room when called or goes infrequently will have little rapport needed to gain compliance 
4.  People like people who are competent. Showing you are a caring, competent therapist will increase Ms. C’s desire to be obedient. However, studies suggest competence is not just knowledge or proficiency. Patients want a therapist who is “human,” too, not perfect. 
5.  Moderate self-disclosure leads to reciprocity. Self-disclosure can be tricky. We must retain our boundaries. However, hearing one of your own experiences or perhaps a story about a past patient in a similar position to MS..C who did well may help get her to discuss his feelings.  
6. There is an expectation of conformity and the influence of others can be helpful. Talk to Ms C about rehab along with other rehab patients. The larger the group, the more people are influenced. Three people are usually sufficient. By showing their conformity to therapy, it will be harder for her to refuse. And we also know having one person in your corner can greatly reduce pressure to conform, so keep negative influences separated. Place her in a room with a compliant patient. We know people are more likely to like and model those in close proximity. 
7. Use the “door in the face” technique, which is the tendency for a person who has refused a major request to subsequently be more likely to comply with a minor request. For example, if your neighbour asked you to feed and walk his dog daily, cut his grass and clean his garage while he went on vacation for a month, you would refuse. If he then said, “OK, but could you pick up my mail for me?” chances are you’d say yes (even though you might have refused otherwise). If you say to Ms C, “I want you to go to both rehab sessions today and all meals,” she will refuse. But if you follow it with “OK, but could you go to one group and one all today?” chances are good she may comply. And if she goes to one, then you have momentum. Behaviourists and social psychologists believe if you can get someone willing to do one thing you have started the ball rolling. 
8. Switch to the “foot in the door” technique (the tendency for a person who has first complied with a small request to be more likely to later fulfil a large request. Now that he has completed and attended one group, you can ask her to try two groups and more meals.
9. Cognitive dissonance can make people uncomfortable. The theory of cognitive dissonance states contradictions or clashing thoughts cause discomfort. Her not going to rehab clashes with her desire to be seen as a “good” patient. A way to reduce dissonance is to change our behaviour. Suggesting the rehab staff might have to come to her room to provide her therapy might increase her thought that she is not being a “good patient” and motivate her to go, thus reducing her dissonance. 
10. People will usually be obedient to authority Research suggests people will respond to those who have authority. If other initiatives aren’t working, it may be necessary to call in “the big guns.” If the patient perceives one as an authority figure, utilize this person to gain compliance. This could be done by saying, “I’ll have the Director speak to you.” Or, if necessary, have the physician address the patient. (1)
11. And never forget the power of family members. They may be your best ally in obtaining compliance.  

In summary, we cannot wait for patients to be compliant with rehab as this period can make the difference between a full recovery or permanent loss of some ability. Remember that persuasion is not coercion. It is motivation with the patient’s best interest in mind.