I wasn’t sure about what I wanted to talk about this week. I didn’t have it perfectly planned. While trying to process my thoughts, I found it difficult without actually sitting down and typing. I thought back to the snowball effect that generally tends to happen when I do begin to type. So what do I need to do to get my mind ticking? Get the proverbial snowball gently nudging down the hill? I need to write. So, here I am and who knows, maybe in the next hour I’ll see an avalanche.
I think this week I want to talk about guilt. The guilt our clients feel for non-compliance to a treatment plan, and also the guilt associated with physiotherapists if we “fail to fix” someone.
We are currently riding the wave of a worldwide pandemic. We are trying to survive and grow simultaneously. Physiotherapists trying to grow and expand their knowledge or better themselves for the benefit of the individual in front of them, clients trying to reach goals and rehabilitate. But to grow, we need to survive. Survival always comes first. And when I think about it, it’s why we experience pain, run a fever or even vomit. Because survival has to come first and that will be our natural instinct. How can a sunflower reach 6ft if it doesn’t have sufficient food, sun and water merely to survive.
How often do we guilt ourselves into going for the run, or feel guilty for having the cake with our Tuesday morning Elevenses. How often are we blaming ourselves for not being able to fix a person? Maybe sometimes, we need to just cut ourselves some slack?
I think that it’s important to acknowledge that this “new normal” as we’re hearing so often currently, and the changes this awful virus have forced us to implement haven’t been all that easy. The element of uncertainty around jobs, health, family, the economy… the list goes on. There’s just a whole lot of uncertainty surrounding this pandemic and it’s not an easy time for many people. Right now, I think it’s only fair to say, that survival is the priority. Should we feel guilty for that?
As humans, I feel we don’t like uncertainty. It is a powerful place to be, but not a comfortable one- initially anyway. I say initially because, for me I initially hated uncertainty. Prior to doing The Peak Simplicity Masterclass, I feared uncertainty. I did not like stepping out of my comfort zone, although on reflection, I realise my comfort zone was never even that comfortable. I am beginning to relish that uncertainty. But previously, I know I used to see uncertainty as a failure, a weakness in myself. A lack of knowledge or understanding. And so, with uncertainty came guilt. The guilt of not being able to fix the person who sought me out for help. Guilt for not having all the answers despite me being the “expert”. And at times the guilt ate me up. I didn’t enjoy going to work. I didn’t enjoy seeing new clients for fear I wouldn’t have the answer they were looking for.
I look upon this uncertainty as a way to relate to clients. They generally come to me when they are uncertain. They’re not sure if there is something they could or should be doing to help their condition. Should they stop running? Can they play their match on Sunday? Are they going to make it worse?
People come to me with ideas; ideas of what they think might be the issue, questions; questions about what I think might be the issue and uncertainty; uncertainty about what they should or shouldn’t do. But they also often come to me with guilt. Guilt for not seeking help sooner, guilt for not being very compliant with the exercise program. It is not a feeling I ever want to have associated with my treatment plan.
I often reckon clients come to me for permission to move. YES! Please Move. Maybe we’ll alter it for now but continue to move. I am trying to think of a scenario that a physio would not encourage movement. I can’t think of one off hand. We are health and movement promoters aiming to maximise quality of life and movement potential. Not hinder it.
So if I want my client to move, how best do I facilitate that. I have heard clients tell me before that they find the physio exercises boring. I am not proud to say it but my attitude before probably would have been “Well that’s just what you have to do”. But what sort of message is that sending. Am I encouraging people to enjoy movement? Am I encouraging a healthy relationship with exercise? Or am I giving them a negative experience that will shape them for the future? By prescribing an exercise program that the person is not invested or interested in, am I starting them off on the back foot? Am I already opening them up to having that guilt for not being compliant?
How often do I have people tell me they have to “confess” to not doing their exercises? Or “I know it’s my fault because I haven’t done the exercises every day” or just the sheer expression of guilt across their faces. Who is really to blame if a client doesn’t do their exercises? If compliance is an issue, maybe we need to look at our treatment plan?
I think guilt is an emotion I do not want to have associated with my treatment of people. How is it fair, how is that promoting our profession in a positive way when people dread their appointment because “the physio will know if I did my exercises or not”? How does that foster an environment for growth and safety? Is guilt now a negative experience winding up the sensitivity of the system? Is it impacting their progress? So how can we allay that guilt and promote a more encouraging and collaborative approach.
In University we learn about barriers and facilitators to exercise. I have done really detailed essays and projects on them. But for me, what does it mainly come down to? Enjoyment. What does the individual, the person ENJOY doing? I am going to take an example in women’s health, but it also applies to Musculoskeletal clients as well.
The amount of women I get telling me that pelvic floor exercises are boring or monotonous and I have to say I am very much inclined to agree. Yet they’re being told to do them 3 times a day, every day of the week. I read a recent systematic review stating “that PFMT using short sessions (10–45 min) and with a frequency of 3 to 7 days per week might evoke the greatest changes in women with Urinary Incontinence”. Interesting.
So NICE guidelines- 3 times a day? That’s a big difference when you add it up over an 8 or 12 week program. In the past I have been following the NICE guidelines. But was I looking at the person, what other exercise have they done today? Are they fatigued? What else is going on in their lives? Maybe you have a person who has previously become addicted to exercise, are they more likely to completely overdo it? We’ve all heard it before, but there really is no one size fits all. But what exactly do we mean by that?
If 3-7times per week seems to be sufficient, and to be a lot more manageable, then my question comes, does it have to be isolated? Maybe the reason the women have come to me “bored” of their pelvic floor exercises is because I haven’t progressed them sufficiently towards their function. Or maybe I haven’t incorporated meaningful activities. I never want to bore someone with exercise. So maybe I am guilty of that. Maybe I need to look a little harder at how I can incorporate these pelvic floor exercises into their regular exercise routine. It’s quite often incorporated into Yoga and Pilates for example- not always but it can be. If someone is walking daily, can we incorporate it into that? Do we add it into their gym program? Or does it have to be done in a stationary position? Does it need to be totally isolated? Can we have them incorporate a little bit of their rehab into something they actually enjoy doing?
Doesn’t it all come back to our exercise prescription principles? What is the end goal, is it endurance? Is it power? Is it strength? Is it hypertrophy? Is it motor control and coordination? When is the person experiencing symptoms? And why? What are they aiming to do? I would argue that all goals have different routes and require different ways of getting there. Different routes, to one destination. How quick we get there depends on the car we’re driving, or maybe we’re walking, or even taking the train. Maybe it’s raining and we don’t like the rain, maybe we don’t enjoy walking either. Or maybe walking in the rain is our favourite hobby. So maybe two people start off on the journey together, but one pulls away and one doesn’t.
Is It because of enjoyment, the environment, the type of exercise,? And so, what do we do? Do we take the train, even though we know we don’t enjoy taking the train and so might miss a few stops? Or do we walk, because even though it might take longer to get there, we prefer walking? Do we use a different route and aim for an intersection eventually? Do we forge a completely new path through fields and mountains, using movements I myself might not even be familiar with myself? Do we need to lean out of our comfort zone and play with uncertainty, for the benefit of the client?
I do think it’s important to read the research, I think it can turn us in the right direction. I think it can act as a road map, but maybe there are walkways as well, and train tracks. Listening to the story, the journey the individual has been on thus far, and the destination they’re heading for, I’d argue, is just as important. Do I decide on the route? Or do they? Do we decide together?
I think the research provided in the systematic review is a very positive one. It allows people to have freedom. Freedom from their condition. Freedom from the guilt of not having time, of life getting in the way. I think the study findings allow for the participants to be human with lives, and interests, and families. Because who wants to sit down and do pelvic floor exercises 3 times a day?
Does the study change my practice entirely? Maybe? Maybe not? But it gives me a little freedom to look at my client, decide how much is needed, how much is best, and tailor it specifically not just to the physical needs of the pelvic floor, but also to their needs as a person.
People often experience guilt for one reason or another. I often experience it when I think I haven’t helped in the way I should have. But people are complex. And I am not a fixer. I am here to facilitate, to guide and help other people in the best way that I possibly can. I say “other people”, because I am exactly that. A person. And so are you. So if you don’t have all the answers, that’s okay. If your treatment program isn’t helping, look outside the box, look outside the comfort zone and try to do something different.
Sometimes I will succeed, but not always. And that’s okay. I will no longer feel guilt for not fixing, because I am not a fixer. Trying my best to support and guide is all I can promise to do.Leave a reply