Autonomy: How to give it away…to get the most back in rehabilitation!

Active listening, motivational interviewing and a comprehensive consideration of the individual that you are working with. Are you leveraging all three of these in your rehabilitation efforts through a meaningful patient interview? Do you continue to use these, in each patient session? Great, as Crosby, Stills and Nash sang in 1988, “glad that you’ve got it made”. You may be missing one VERY important element – autonomy. As we learn in the OPTIMAL theory of motor learning, autonomy includes the principle of shared decision making, but takes it a step farther, as therapists ask for permission to offer advice. Autonomy can be challenging to provide, more specifically, difficult to apply, in rehabilitation. 

Autonomy has a “dosage”. Some people rebuff advances of autonomy. Partially, this can be the case due to the paradox of choice or “choice burden”, in behavioral economics terms. 

So, if you are looking for a few quick-read applications on how to apply autonomy, here’s three:

1) Full patient control: Patient decides when they are ready for more and what amount to raise the difficulty-by (treadmill speed, eyes closed, resistance, time, complexity, dual task, proximity of assistance, assistive device). “Okay…let’s start here. I know that you will let me when you are ready for more, so I will wait to hear when and how to raise the difficulty.”

2) Patient provides permission, not direction. Patient identifies that their performance has met or exceeded their personal preference for success. Therapist determines how (mode) and how much (volume) to raise the difficulty. “Well, I think that we can both agree that you have mastered that. May I increase the difficulty?”

3) Partnership with autonomy. Patient is offered control over the direction or the volume. Therapist decides when the difficulty must be either temporarily or permanently raised. “I see that you are doing well with this, consistently. In an effort for this practice to be challenging enough for us to realize improvement, we should look for a way to make this harder. In what direction would you like me to make this harder?” Therapists may offer a short list of options (modes) at this point, considering both the paradox of choice and the order of the options (choice architecture). 

 If this all makes sense to you, what are you waiting for? Close the web browser and go apply it! If not, email me: mike@northwestrehab.com