Following on from my post last week about defining good rehab – I want to start a conversation this week about how good rehab can look and feel different.
Good rehab requires many things, but at the core we learned that good rehab requires:
· Doing the right thing at the right time
· Collaboration with all key parties throughout the process
· Building of trust
When these core elements are present we have the foundation for creating a process of transformation with our clients. Taking them from a place of sickness and incapacity to wellness and capacity.
I don’t know about you, but when I have been really unwell I haven’t been able to simply “will” myself into wellness. The needs of my son and family haven’t motivated me as much as they have made me feel guilty because I can’t care for them the way I want to. When I have been unwell, my work output is slow, I feel concerned that I am making mistakes and I fear that people will think I am not good enough. My pain or fatigue increases as my stress increases. I know I am not alone. Most medical and allied health professionals will tell you there is a direct connection between feelings of stress and pressure and an increase in pain, fatigue, anxiety, depression and gastrointestinal symptoms.
The process of change or rehabilitation recovery and RTW can be stressful, we know this. We see this and watch our clients experience this. Therefore we have a responsibility to know how to help them through this. This does mean we need more credentials or more therapeutic modalities. It does however mean we need to think about where we are staring and what we expect of clients.
Have you ever wondered why one client with say CFS can participate in exercise, take a plethora of supplements, participate in psychological treatment and have the willingness to engage in retraining and learn how to manage their symptoms in preparation for work, while your other client with the same diagnosis, almost the same demographic and psychographic profile, even with best practice medicine, just can’t or won’t engage in activity planning and development?
The problem is we can’t apply a one size fits all approach to RTW and rehabilitation. In the common vernacular this is known as cookie cutter rehab. It just won’t work.
Sure, we can have best practice guidelines and best practice treatment. We can share with Client B how doing XYZ helped Client A, but when push comes to shove, every client is a person, every person is different and every person will bring a unique set of experiences, issues, beliefs, attitudes and behaviours to their experience of recovery, RTW and rehabilitation.
I’ve never had this more accurately expressed when speaking with an insurance company representative (who funnily enough was in an internal rehabilitation role) who expressed that my 24 year-old client with a brain injury who had been out of work for 4 years should really be back at work now, because the internal rehab consultant had worked with a client with a brain injury before and it didn’t take their client that long to develop work capacity. Now I know those of you reading this will all be going; Oh for goodness sake how short sighted, what a demonstrated lack of understanding of brain injury. Just like I did. I was stunned.
But it has me thinking. How often do we do this every single day?
How often do we read or hear things like
· It’s just a musculoskeletal strain – they will be fine in a couple of weeks
· It’s an adjustment disorder – which means they will make a complete recovery
· It’s like a heart attack – in three months they should be fine and back at work.
We hear and read this all the time, and if we are honest we are forming these judgements all the time. It’s OK. There is nothing wrong with this. In fact it helps us become forward thinking and to come to the process of recovery, RTW and rehabilitation with a mindset of, “dear client you will improve and things will get better and I am here to help you.”
BUT The problem is, our clients haven’t been here before. They don’t know what we know. They don’t have the 5, 10, 20 years of experience working in this industry that we have. Right now at this moment they are:
· In pain
They want everything to go back to the way it was the day before their injury, their accident, their diagnosis, and their trauma.
· They want to feel safe
· They want to feel secure
· They want to know that it’s all going to be OK
Have you also noticed that you can ask your client to attend a case conference with their treating medical practitioner to get a clear understanding of their diagnosis and their functional expectations of this diagnosis; can have your client participate in a FCE to help determine what their functional capacity is, and can explore their skills transferable to alternative employment, all the while the client is not moving, remains stuck and is resistant to change???
Do you ever notice that sometimes, despite all of the words from the medical professionals, the encouragement, the research and literature, the referrals to psychological treatment and exercise physiology…. the client participates just enough, yet you are left with the feeling that they are not 100% committed?
Do you, like me, beat yourself up thinking that you aren’t good enough, that you have somehow missed what the secret sauce is that you needed to implement for your client? Do you fear the next case review of monthly statistical reporting spreadsheets where you have to say, yet again, there has been no change?
Dear rehabilitation professional: there is nothing wrong with you.
We have just overlooked the two features of Good rehab that actually promote change and transformation:
Preparing for Change.
I wonder how much time and effort in the early days of getting to know your client is spent on identifying their motivators for wanting to get well? Is it something you actually explore with your client? This isn’t just for the physiotherapist or psychologist. Understanding what motivates your client is going to allow you to:
· Do the right thing at the right time
· Collaborate meaningfully and with intention
· Build trust
Motivators cannot be prescribed. We can’t tell a client how they will be motivated. That is something they bring to their process of recovery, RTW and rehabilitation. And it is THEIR motivators that we need to be concerned about here, not what motivates us. Watch out, because sometimes we can actually confused the two.
Understanding what motivates and drives your client will help you plan effectively and develop the right actions, strategies and steps along the way that will fulfil all of the agendas of all of the people in this process. I know my rehabilitation planning and outcomes have been more successful since I have added to my initial assessment process discussion around motivators and rapport building BEFORE we launch into tell me what happened and what’s going on for you.
And please understand that people who are experiencing depression are also motivated. It just doesn’t look like the kind of energy we are used to working with.
Once we know what is motivating our clients then we can begin to prepare them for change. This is a stage in my rehabilitation assessment process where my client and I kinda “hang out” for a while. Not for weeks or months, but maybe for two sessions. Learning what change might look like and exploring what good change, painful change, graduated change might look like and exploring how my client’s motivators will be enhanced by preparing for change.
In adding Preparing for Change to motivators we now have a solid platform for which to determine what the right thing at the right time is, and we can then collaborate with other key stakeholders to understand why we recommend what we recommend. This is the key to building – and preserving – trust and respect.
Now I can imagine many people reading this thinking – “Jo, this all sounds lovely and wonderful and in an ideal world where we didn’t have so many time pressures… then yes of course this would be the best way to work with clients…. But…..” Can I share with you that in a time pressured, resource-limited environment this IS the only way we can move forward.
We can’t afford to ‘trial and error” any more. We can’t afford the let’s wait and see approach; we can’t afford the “I won’t ask about their family in case I open a can of worms approach” to find out that the client’s mother is dying and their youngest child has been kicked out of school. Because those things DO matter.
Not addressing motivators and preparing for change leads to expensive rehabilitation; poor off claim outcomes; lack of independence from clients and recidivism.
When we haven’t taught our clients how to tap into their motivators for themselves and prepare for change they simply won’t or they will want someone else to do it for them all the time. They will do what they have to do, or do what they want to do –and nothing more. We as a profession are better than that.
So how might GOOD rehab look different?
Good rehab looks different in that we have clients wanting to know what MORE they can be doing to help themselves.
It’s when we have employers, insurers, treating professionals, rehabilitation professionals asking – what else can we do to help?
It’s when we have all key parties taking responsibility for their roles and their outcomes because they know what is expected of them.
It’s when we have rehabilitation plans written and agreed to, and the milestones are being ticked off because the assessment was comprehensive
It’s when we know how to serve our clients’ motivators and how to help them prepare for change
To be honest, I don’t think we as rehabilitation professionals have to wear all the pressure that we do, whenever we try to make good rehab happen. The burden is shared and it’s not up to us to make it all work all of the time. Most of all, it’s important that we’re able to come back to our clients and have real and raw conversations about why they aren’t participating, why they aren’t making progress without blame to shame and get to the bottom of what’s really going on.
We can’t systemise a person out of their injury or illness experience. People are people first, they are injuries, disabilities and incapacities second.
Once we allow clients to be people first, and invite them to show up to this process with us, alongside us, as responsible, open adults, we can collaboratively address the injuries, the disabilities and the incapacitates. We can prepare for change. And then – make that change happen.