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Responsibility to Improve - Yours or Your Clients?

At the start of our Strive & Thrive in Private Practice course, participants write down the three biggest challenges they are experiencing as a new and recent graduate. "Time Management" perennially features highly, but so does "feeling guilty" – recently expressed by Chloe in these words;

"taking on the patients' problems personally and blaming myself for being the reason why they are not responding quickly enough"

Let's look at this in two parts.
Take the first part; "taking on the patients' problems personally and blaming myself"
Now I see this statement as coming from a clinician with a big heart, who, however, is heading towards a train wreck. Why? As clinicians, most of us got into this profession to help others. However, we are only one part of the relationship and just like in any relationship, there need to be relationship rules and both parties need to be heading in the same direction.... if the relationship is to grow and mature in a positive direction.

Let's unbox that a bit. Rules & Direction. As the clinician who is being sought for professional skills, we have a degree of authority (based upon our skillset) in the relationship, otherwise, why would they be coming to see you? Sure, having a dazzling personality helps, but at the end of the day, it is your caring attitude and skills that are more helpful for your clients.
So as the person with authority, you need to set common ground rules to provide a framework in which the relationship will work;
• Want and willing to get better (therapist + client)
• Be on time for appointments (therapist + client)
• Provide necessary information (therapist + client)
• Be actively involved in goal setting (therapist + client)
• Follow the advice, feedback that is provided (client + therapist)
• Complete the treatment, exercises as prescribed (therapist + client)

These can be developed subtly, or directly e.g. 24-hour cancellation policy (client), guarantee to be seen within 15 minutes of appointment time (therapist). I find these ground rules often involves 'educating' clients and I really notice that my expectations differ quite a lot from other health professions who clients have previously attended, and this often becomes apparent during the first appointment. Laying out your ground rules at the start means there is much less likelihood of misunderstanding later on.

How does this relate to Chloe's statement? An overarching ground rule is that we as clinicians are NOT responsible for our client's improvement. They are. Period. If they don't improve, it could be due to a multitude of reasons (including not complying with your other ground rules) that orbit outside of your understanding or awareness. Don't get me wrong here. I care deeply about most of my clients. I WANT them to get better and have invested big time in self-education, self-reflection and self-personal development to facilitate this happening. I LOVE playing detective and trying to work out to the best of my abilities, what is causing their problem, what is holding them back, what they can do to improve and then providing them with those necessary skills.

BUT

If they don't want to get better, don't attend their appointments, don't do what I ask, or don't practice their homework ...... them not improving is not my problem. Sometimes I can't help them because their requirement lies outside of my current skill set, so the best thing I can do is identify what I have checked/cleared and refer them onto the profession I think is most appropriate to assist them next. That is my responsibility.
I love this quote 'The gap between expectation and reality is ..... frustration.'

If you expect to get all people better, then (based upon the above information) you will not only be frustrated, potentially blame yourself, but you will also burn-out, and a burnt-out clinician is no good for anyone. We must protect ourselves and our colleagues from this draining experience. You can only do what you can do at that point in time, self-reflect and determine if there are areas in your skill set that need development and then seek out that information.

Now let's take a look at the second part of Chloe's statement "why they are not responding quickly enough"
Keeping in mind the above information there are a couple of extra considerations.
You have to ask yourself, what is the measure used to determine what is "quick enough"?

Firstly, we as clinicians, are facilitators of mother nature. The body can only heal at a certain maximal rate, influenced by genetics, attitude, appropriate load, nutrition, and sleep. We can't speed up mother nature (not that I am aware of), but by doing the wrong things we can inadvertently retard progression.

We can't change genetics, but say in a client with hypermobility, we can alter our management strategies appropriately. Attitude and load we can influence through our training and skills. For improving your nutrition education, check out this upcoming awesome course and with regards to sleep, stay tuned.

Secondly, when it comes to tissue, there are biological timeframes to be acknowledged;
• bones (3 to 12 weeks depending on location and age)
• muscles (4 to 12 weeks depending on location and degree of eliteness required)
• ligaments (6 weeks to 12 months @ 80% tensile strength)
• tendons (200 – 400 days for collagen remodelling)

Take a 45-year-old, who presents with no known trauma, or only a minor lifting or pulling trauma, involving their shoulder. I know they will already have prior minor tendon tears or maybe a full thickness tear, that will resolve with short stay rest, correct advice, correction of obvious muscle and postural problems and progression of exercise load over several months.

My job is to explain the reality of the tissue involved; collagen, its quality, its age and its circulation (nutrition source). I can explain that the remodelling period for collagen is approximately 200 – 400 days. The best thing they can do is to progressively load the structures, so they move from new and immature collagen cells, into strong mature collagen cells. It will probably take 3-4 weeks for the pain sensitivity to settle (helped by gentle loading), and then the collagen/tendon will continue to strengthen (if loaded) over the next 6-12 months. IMHO, clickif you really want an awesome course on shoulder rehabilitation.

Explaining these timeframes in the first couple of appointments, means you don't have the question of 'why isn't my shoulder better?' after a few days, a week, or two weeks or ..... "why they are not responding quickly enough"

In summary, you are not responsible for your clients getting better. It is shared. We provide our professional skills and education, but the application and ownership lie with the client. Keep in mind biological healing time frames, and work to identify factors that might slow down mother nature's normal healing capacity.

Keep on developing yourself - education and experience. 

 

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