– Helpful tips whether you are new to, or already acquainted with the biopsychosocial model in clinical practice
The predicament
So, you’ve put down the hours and the days to develop your biopsychosocial (BPS) skills and you are pouring them out daily in your clinic, but somehow it doesn’t seem like the skies are turning so rosy and red as you imagined. It might even feel like the harder you try, the more you are distancing yourself from the patients.
More importantly, it feels like it’s getting harder to bring the patient over the finish line which subsequently creates poorer results and difficulties keeping a financially sound business. So, if both you and your patients are suffering from your new found knowledge, have you wasted your time learning about the BPS model of care? Of course not, I will explain.
Fine tuning
As with everything else, mastering a new skill is about fine tuning, finding that effortless easy path that creates a lot without taking a lot. Getting acquainted with the BPS model is one thing, putting it into effective practice is a completely different task. Fortunately there are many therapists putting their minds into making this work and many of them like to share their experiences, and my hope is that this article might be of help to you.
There is usually no way around trial and error and I believe the journey you are on right now will demand errors if you are ever to master it properly. Please remember, the theoretical framework around the BPS model, and more so the clinical framework, is not properly established. In addition, most active therapists have never been taught this at school so it is basically loads of therapists without pre-training trying to implement a package of scattered information and making it into clinically effective approach. If you were making a soup with those preconditions you probably wouldn’t expect much of the soup.
– The message is: just trust that you will get better. With trial and error, and seeking knowledge around you, you will get control over this seemingly untamable beast.
Problems with applying knowledge to practice
There are ideas out there about what “ideological treatment” should look like. It’s not up to me to give you the right or wrong answer here, I can only provide my experiences. You will soon learn that ideology and “success” (treatment or financial) doesn’t always go hand in hand. Here are some examples:
Overloading the patient
This is when you talk too much. Gaining knowledge might easily get your mouth watermill going endlessly, and I believe this is a necessary part of trial and error which is hard to learn without experience. However, knowing that overtalking might be the issue when a patient looks confounded or doesn’t come back might just save you some failures or some valuable pennies.
Having overconfidence in the patient
Current “guidelines” talks a lot about empowering the patient, and rightly so. Creating, unlocking or playing on an existing patient self efficacy has shown to be of outmost importance to have good results clinically. However there are ways to screw this up as well; when you believe there to be self efficacy when there isn’t, or the other way around.
Some of our patients need an advisor, some need a coach and some need a personal trainer. If you act advisor to someone who need a personal trainer, they might fall off quickly without anyone to guide and hold their hand. If you act a personal trainer with someone who just needed some advice you might create unnecessary treatment dependency, taking away a well functioning self efficacy from the patient. Subsequently you have either ruined rehab, or you have created a mess, none of which are good for the patient.
Dismissing your own importance
This was actually a huge problem for me and had some serious negative impact on my self confidence as a therapist. This is similar to having overconfidence in the patient, but revolves more around you as a therapist. If you constantly try to empower the patient you might find your own importance to wane or even disappear. You don’t necessarily recognize that you’ve lost self confidence, it’s more a creeping feeling of starting to doubt your own importance as a therapist. Research shows that how you talk, heck even how you look, plays an important role in creating successful outcomes. I can promise you, if you lose the sight of your own importance, others will too. So instead of saying to every patient on the first visit: “See, now you know everything to get by on your own”, it will often be smart, and even indicated to say: “See, now we have found your strengths, now we’ll work together to make the most out of them and work on your own independence”. It all depends on the individual in front of you.
Charity work
In the process of empowering the patient it can be tempting to have them contact you through phone or email instead of seeing them in the clinic. For the record, having several follow-ups like this might be a good solution for some patients, and one email follow-up might be a good solution with all patients. However, if you are putting hours every week into giving free mail advice with your patients you might be doing well ideologically, but you are also doing something everyone else around you are not doing: working for free. Do not be afraid to charge for your services, especially when the patient needs a coach or personal trainer. When it comes to giving advice, ask a lawyer about the cost of good advice.
Suggestions
A basic skill that is learnt from trial and error is prioritizing. Getting priorities straight will help you create treatments with less mishaps and more efficiency. Below is a list of things that has helped me prioritize better. It has brought me back to full confidence with much fewer mishaps, while simultaneously creating better treatments within an ideological perspective.
1: Make sure to always aim for therapeutic alliance.
Therapeutic alliance is not just a fancy word, it is the glue that makes everything stick together. It has the patient listening, fuels the important self efficacy and has the patient completing the set program. This will consequently decide the treatment outcome and satisfaction, plus it provides clinical balance. Here’s a few tips for bettering your therapeutic alliance:
- Sense the patients’ expectations through reading the situation and their words. It might be their impatient facial expression, or their eagerness to get on with the conversation.
- Be sure to have them talk, ask for their story. Act more on the information you get rather than the information you seek.
- They didn’t book the appointment to hear about pain science, they booked the appointment to get better. They must believe they can get better with YOU and more often than you think pain science is not where to start.
- Not giving a proper physical examination and/or treatment in the first visit (because of a very thorough psychosocial evaluation) may sit well with some people, but others will never come back, especially if the treatment cost is high.
- Put the patient in the drivers seat by learning Motivational Interviewing. It will improve patient-therapist communication and cooperation.
2: Expressing uncertainties.
Our profession is full of uncertainties and they become painfully obvious when you start reading up on science. This will in turn lead to cognitive dissonance, that sometimes unpleasant feeling of holding two conflicting “truths” in your head. You may have days where you feel it’s your duty to inform all patients about every myth and all we cannot know, but trust me, many will end up feeling you don’t know anything. You will learn the difference between timely education and unhelpful truth bombing.
3: Tailoring.
Make sure you recognize what is actually needed to get the individual in front of you from A-Z and follow that path. After all, the patient seeks your help and your responsibility is to provide it, regardless of ideology. Don’t confuse the patients’ wants and needs too much with your own. Also remember, manual therapy or pain neuroscience education are not flashy tools that you swing around to impress, they are components of individualized treatments (paraphrasing Jason Silvernail).
4: Make sure you recognize and avoid creating treatment dependence.
This is achieved by learning to recognize when you are the advisor, the coach or the personal trainer. You also need to be able to screen for certain patient traits that either show an ongoing dependency or warning signs in the psychosocial background that might suggest that the patient is in a risk zone of having one.
Final thoughts
There is no reason you should have to go out of business because of your treatment ideology. Of course, following these suggested steps you might have a thinner schedule than if you go with the old ways of subluxations and fearmongering, but this way you are adhering to best practice “guidelines”, giving individualized and effective care, and having the money to make the wheels go around. Maybe in a not so distant future, this is the kind of care that is also expected by our patients. If it also delivers better outcomes, maybe we won’t have to worry about personal economy at all.
Originally published in the Paincloud blog in 2017
