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Crucial Conversations in Rehab

Perhaps it isn’t the best assessment, most appropriate exercise or modality that is the key to someone’s success in rehab.

Uncomfortable conversations can be the key ingredient that allows the rest of rehab to fall into place. Unfortunately, they are often avoided in lieu of more appealing topics.

Being in pain or recovering from an injury or surgery can be an emotional experience. To further stir the pot, it is necessary for practitioners and patients to engage in discussions highlighting different beliefs, knowledge, and perceptions about aspects of the rehab process.

This is a blog post about some of those important and sometimes difficult conversations between PTs and patients.

First off, what is a crucial conversation?

In their book, Crucial Conversations: Tools for Talking When the Stakes are High -Grenny and co-authors provide the following definition of a ‘crucial conversation’:

“A discussion between two or more people
where the stakes are high, opinions vary,
and emotions run strong.”

Therapeutic relationships between providers and patients sometimes involve topics critical to a successful outcome. Their nuance requires work. Some might describe the experience as painful, or at a minimum uncomfortable. The distinction is highlighted in one crucial conversation.

There are circumstances when zero pain is not a realistic goal. Relating this to someone in pain can be difficult and might be met with resistance.

Pain, as a measure of improvement in rehab, is not always reliable. HOWEVER, it is highly significant for the majority of people seeking help.

We need to appreciate pain as a measure of one’s perceived day to day, or moment to moment, experience. We also have to acknowledge the limitations of a myopic view in its utility as a measure of progress. Reduced suffering and lack of pain are not one and the same.

I wrote a guest blog post a couple years ago titled “Is it Discomfort or is it Pain?” that dives deeper into why this can be a critical distinction.

Another important aspect of symptomology for patients to understand is that:

While it seems obvious that symptoms like pain or dizziness can be influenced by many reasons, a conversation about the multiple systems influencing the experience can lead to a crucial, possibly sticky, conversation.

Why? This conversation highlights the fact that symptom improvement depends on several contributing factors. Some of these elements may be disconnected from the realm of rehab. Several are dependent on the patient and still others can be perceived as outside of anyone’s control.

This discussion may lead into another. For example, the benefits of managing stress are emphasized as more important than the world’s greatest stretch.

Invariably, discourse about expectations from both sides of the table may arise.

  • What does the patient want out of the process? Is it realistic? Are you (the practitioner) the best fit to make this happen? At this particular time?

  • What are your expectations as a practioner? Are they clearly understood by the patient?

Common topics that should be explored when setting expectations:

  • Short term relief vs. long term gains

  • Progress is rarely linear. Flareups do not mean that PT is not working or getting better is impossible.

  • Patient expectations are strongly influenced by their past and current experiences with other health care providers. Plan to address this if you have a different approach.

Prognosis can be one of the more difficult questions to answer. Forecasting goes beyond protocols and knowledge of tissue healing times.

Conversations about prognosis benefit from specific questions. “How long until I feel better?” is not sufficient. “How long until I can resume playing golf with less back pain” is more direct and therefore better.

Specific questions are easier to formulate when there is shared knowledge of the client’s specific goals.

However, it’s important to remember that specific questions don’t always translate into exact answers. Prognosis estimates are most accurately with a time range.

Ending a (therapeutic) relationship is sometimes necessary for your health.

I wear many hats and relationship expert is NOT one of them. But years ago, I got the following advice from a friend when I struggled to cut ties with a provider who wasn’t a good match for me. My friend said: “All you have to do is say….

“It’s not you, it’s me”

If the person (physical therapist, doctor, or coach) you are cutting ties with is not serving your needs, you are doing this to take care of yourself.

This conversation can be short and sweet or longer with detailed explanation. Depending on the situation, feedback addressing reasons for the break up can be a great learning experience, especially if requested.

On the practitioners end, this conversation might occur because you are unable to meet their needs or you, like them, don’t feel the fit is right.

When it comes to good communication there is one important truth we often tend to ignore or forget. What you intended to say is not the message that was received.

Asking the patient what their takeaway was helps highlight any discrepancy between what was said vs. what was heard. This technique works very well in parenting (wink, wink).

If a discrepancy is acknowledged, this affords the opportunity to clarify and further communicate. Perhaps it is as simple as word choice that resonates more soundly with that individual or perhaps it is clarification of differing beliefs or assumptions.

And last, but certainly not least -

Consent might simply be a question-answer interaction but it can be a gateway for a significant conversation.

I have experienced a couple interactions in the past year where patients expressed gratitude when I asked for consent (to put my hand under their shirt or touch the front of their neck). This caused me to reflect how comfortable I am touching people and that comfort might not be reciprocated.

A therapeutic relationship built on trust in a safe environment cannot be emphasized enough. It’s a mistake to brush off consent as a given.

There is no universal playbook on how to best have these conversations. There are however, some core principles - Listening, Establishing Trust, Validation

Crucial conversations require that you take the risk in potentially feeling uncomfortable.

If we operate from the heuristic that less is more initially and that more can be given upon request, a graded approach to building trust occurs.

Crucial conversations can extend over time, over several sessions. Pivotal discussions beg repetition, revisiting of ideas and often reconciliation.

Starting from a place of curiosity, embracing discomfort and seeking to strengthen the therapeutic alliance are part of the recipe for success.


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