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Why aren’t clinicians taught self-regulation?

My musings after noticing the rising tension in my body as the week progresses…..

A MASSIVE part of supporting individuals with pain and other discomforts (#pain #pelvicpain #urgency #prolapsesymptoms #diastasisrecti #painfulsex #pelvicgirdlepain #backpain #incontinence) is understanding that these are primarily nervous system events. Outputs/alarm bells influenced by a multitude of inputs from the bottom (our bodies), from the top (our brain – emotions/thoughts/beliefs/expectations) and from all around us (our environments).  The opportunity to effect change in the experience of these discomforts in different ways, with different tools is, in a word, AMAZEBALLS! #nervoussystemoutputs #notjustpain

What if we wrap our heads around the fact that our nervous systems are also designed to interact with, influence, and be influenced by the people around us? We are social beings hared wired for connection! We are bound to be influenced at a nervous system level by our clients and them, by us.


Photo by Rod Long on Unsplash

When folks seek our clinical “expertise” for their symptoms, their nervous systems are primed to be influenced not only by what we have to say (shaping how they feel about their symptoms, their beliefs about their symptoms, their beliefs about their capacity to recover and be an active participant in the process) but also by HOW we say it (influencing their state of arousal and receptiveness to the chosen treatment at a more primal level). Our own arousal levels will influence our choice of language, our tone of voice, our quality of touch, our capacity to truly be present and take in the stories that our clients need to tell us. This stuff really matters!

The development of skills to foster our own self-awareness and examine how we ask questions and deliver information is not typically taught to the health providers in these “expert” roles. In fact, these skills are often referred to as “soft skills” and dismissed as not as important as “hard facts” or “evidence-based tools”.

But what if we are too caught up in the specific tools and explaining to our clients why they hurt, why our tools are superior and how we can “fix” what ails them?

The tools do matter but supporting our clients with engaging their tools optimally, that is, in a way that promotes connection to their bodies, connection to what is meaningful to them, confidence in recovery, and self-efficacy in recovery is where I believe the magic happens. A lot of this comes from HOW the tools are packaged and delievered….the “soft” (let’s change that to essential?) skills.

Also, WHY are we so caught up in our specific tools and explaining to our clients why they hurt, why our tools are superior and how we can “fix” what ails them?

I recently listened to an interview in which a leader (a clinician) in this field acknowledged that there remains a ton of uncertainty when it comes to pelvic health and core rehabilitation. She was asked by another leader (a researcher), why aren’t clinicians being honest with their clients about this uncertainty? Her response was that despite not having the answers, “we can’t tell them, we don’t know”. We have to give them a reason or they’ll go elsewhere. Hmmmm….

Will they? Or is this an assumption that we hold as clinicians who have been nested in an educational and health care system that is largely intolerant of uncertainty?

I have found that when people have been struggling for a long time with their symptoms and have experimented with clinicians who claim to have THE answer but that answer addresses one piece of the puzzle, symptoms may linger AND the individual may begin to internalize their lack of progress as something inherently wrong with them. “The expert told me this would resolve things, things aren’t resolved, therefore there must be something wrong with me.” I often find that after such a journey, when an individual connects with a clinician who is honest about the layers of uncertainty that remain in this domain and the multifaceted nature of health, there is a sense of relief. There is often liberation involved in taking on an attitude of curiosity vs. control. A process of guided self-discovery is often refreshing.

Also, when we, the clinicians, have biases towards creating rules around movement and behavior in order to limit or prevent uncertainty about the impact they may have, these biases can be expressed explicitly in explanations and prescriptions as well as in body language that conveys fear/discomfort. Our clients’ brains take on those rules and their bodies take on that learned fear, discomfort, and rigidity in movement and behavior. Perhaps, not the intention of the clinician but, given the social nature of our nervous systems, an inevitable outcome when these biases and their impact go unacknowledged.

This leaves me wondering…how would our health systems change if health providers were taught how to…

  1. notice our own biases/beliefs/rules along with learning how to tune into our clients’ and reflecting on how these factors may influence our clinical decision making and their recovery?
    Can we eliminate our biases? No. We all come with experiences that are going to shape our lens. But being more aware of and acknowledging our beliefs as such can help us to invite some curiosity into practice, thereby promoting more flexibility in our approach and intention in our language.
  2. notice and regulate what’s going on in on in our own nervous systems in the treatment room and beyond to help us stay present with our clients and be intentional in our care but also to disconnect afterwards, reset and address our own needs as our nervous systems are hard wired to inevitably take on some degree of the pain and distress that shows up with our clients?

Lara Desrosiers OT Reg. (Ont.)

Pelvic Organ Prolapse & Modification: An OT Perspective

In the rehab world, pelvic health practitioners are leading the charge by teaching tools for integrating biopsychosocial approaches into clinical practice. These conversations overwhelmingly occur in discussions about pain. There is a TON of great research about pain!

What are our next steps for encouraging rehabilitation professionals to generalize these strategies to other outputs from the nervous system/symptoms that are distressing and that can be influenced by distress? For example, symptoms of Pelvic Organ Prolapse (POP)?

Teaching specific psychosocial tools (i.e. CBT, mindfulness) for supporting our clients with distress related to pain, POP, urgency, incontinence, Diastasis Recti…AWESOME!

But perhaps we are putting the cart before the horse and need to first consider looking at this symptom-related distress through a preventative lens. To do this, we have to get a bit vulnerable (growth necessitates vulnerability), do some soul searching, and take responsibility for the role that our language and treatments can play in creating or perpetuating distress.

A response that is unfortunately not uncommon from practitioners upon hearing of my involvement in their patient’s care…

“I am happy to hear that an O.T. is working with my patient/client. She needs to MODIFY her day to day movement to AVOID bending, squatting, and lifting heavy objects”…

So life then? She needs to avoid her life? Hmmmmm…..I have questions.

Such began some serious reflection on how I use modification in pelvic health practice and how I can be clear with other team members about the importance of doing so JUDICIOUSLY!

Fear Based Modifications

A VERY conservative and sadly a very common approach to POP is blanket recommendations to avoid activities that GENERALLY increase intraabdominal pressure (IAP). These blanket recommendations simply don’t hold any weight. There is an individuality to the pressures created with various movements in various bodies and we can learn strategies for managing pressure in different ways, with different movements, to feel safe and supported.

So…these restrictions aren’t super productive. More importantly, they can be very harmful. They often breed fear, undermine hope, undermine self-efficacy, strip people of meaningful activity and movement, create a sense of loss and grief, and have a detrimental impact on how they engage in their recovery journey.

Empowering Modifications

Yes! OTs are skilled at helping our clients to get creative and modify their meaningful activities and their environment to support continued engagement in their life.  An ethical question that we all need to be asking when we are considering modification as part of our treatment plan….

Am I creating restriction due to my own discomfort with uncertainty or am I promoting flexibility, adaptability, and participation?

Some reflections on hallmarks of modifications that create empowerment vs. breed fear…

Empowering Modifications Fear Based Modifications
Driven by client goalsImposed
Focus is on life/value engagement     Focus is on controlling/
eliminating symptoms
Reduces the cognitive load
involved in day to day movement
Increases the cognitive load
involved in day to day
movement
Focuses on the HOW’s of
movement and learning new
strategies
Focuses on defining WHAT
movement is safe/unsafe
Reduces distress associated
with movement
Increases distress associated
with movement
Increased participation/movement
repertoire/flexibility
Creates fear-avoidance patterns
and a decrease in participation/
movement repertoire/flexibility
Necessitates tolerance of
uncertainty
Often fuelled by discomfort/
intolerance of uncertainty
Creating a toolbox of strategies to
manage flair ups (i.e. sensory,
cognitive, relaxation, movement,
dietary, etc.) is a part of the
treatment plan
Attribution of flair up is often
towards the restricted movement
FEAR GENERALIZES
Any restriction (if necessary)
is temporary and accompanied by a plan for scaling up to the activity if it is meaningful to the individual.
No time frame or plan suggested.

Have you noticed any others in your practice or in your recovery?

So how am I shaping my OT practice for addressing the impact of POP?

TASK ANALYSIS and EXPERIMENTATION (EMBRACING UNCERTAINTY)! We accept the unknown in service of creating an openness to challenge fear, beliefs, and expectation.

We search together for modifications or slight shifts in how, when and where we engage in these activities in order to promote feelings of strength, safety, and support AND promote the GENERALIZABILITY of these experiences to multiple contexts that are meaningful in the individual’s life.

Some necessary shifts that need to happen for clinicians to embrace a truly biopsychosocial approach to POP and really ALL pelvic health challenges…

  • Get vulnerable, and practice self-compassion…we are always learning!
  • Get comfy with (or at least tolerant of) the uncertainty
  • We need to place much more value on the client narrative as a strong source of evidence that should guide our treatment

OTs tend to have a hard time wearing the “expert” hat…I often joke that we are the Canadians of the health care world. A good friend recently proposed, “perhaps we, as OTs, are the experts at helping people to become their own experts?”

NOW THIS IS AN EXPERT ROLE THAT I CAN GET ON BOARD WITH! Thank you Sarah Thomas Rheinberger of Empowered Space!

Not that we always do it perfectly, but connecting with our clients in this way and working towards engagement and self-determination is a MASSIVE part of our education.

I am trying to call upon my confidence as an “EXPERT in self-efficacy” for the sake of my clients, when I must harness the confidence to challenge pelvic health practitioners (who have been doing this pelvic health stuff a heck of a lot longer than I have!) to reflect on their chosen approach and whether it bolsters or undermines self-efficacy…This is pretty freaking scary but also pretty freaking critical.

But First – Just Breathe!

Common Breath Cues in Pelvic Rehab

Alignment first
Expand on inhale/contract on exhale
Relax on inhale/ engage on exhale
“Blow before you Go” – start your exhale before exerting effort (i.e. lifting, standing)
Umbrella breathing – open rib cage around the spine on inhale and allow it to close on exhale your rib cage
Pelvic Floor Cues – Drop/open on inhale, close and life on exhale

Wowza that’s a lot of instruction!!! Since when was is it so freaking hard to breathe?!?! Unfortunately, a common experience for folks in pelvic rehab is the perception that they are breathing “wrong” and therefore they have to relearn how to breathe “properly”. The amount of effort that is often asked of people to learn how to breathe “correctly” can be incredibly overwhelming, making the breath seem far too complicated.

Don’t get me wrong! I use these cues and they can be very helpful. BUT… I think that we, your guides on this journey (OTs/PTS/Yoga instructors/fitness Pros/ETC), need to be much more intentional about the language that we use during this process to help you connect with your breath in ways that promote healing vs. contribute to rigidity, fear and stress.

What the heck does my breath have to do with my pelvic floor?

One of the functions of the pelvic floor muscles is to work in collaboration with our other deep core muscle groups (the diaphragm/breathing muscle, the transverse abdominus/the deepest abdominal layer, and the multifidus/muscles running along our spinal column) to regulate the changes in pressure in our chest, abdominal, and pelvic cavities as we breathe and move throughout the day. TYPICALLY as we inhale, the rib cage expands, the diaphragm descends, and the abdominal and pelvic floor muscles relax to accommodate the breath. As we exhale, the pelvic floor muscles recoil, the abdominals are gently drawn back in towards the spine, the diaphragm ascends, and the rib cage closes around the spine. This generally happens without much effort.

But…is it a problem if these actions are not happening with every breath? NO!!!!!!!!!! In fact, the capacity to VARY our breath and the action of these muscles groups in response to different types of movement and demands can be incredibly adaptive!

So WHY do we use “the typical breath” and these cues to facilitate pelvic health recovery?

Pelvic floor dysfuntion is OFTEN a sign that we could benefit from more variety in our breathing or movement patterns as opposed to the philosophy or perspective that we are breathing or moving “wrong”

We can use a couple of cues to guide you to connect to these TYPICAL breathing patterns in order to help you to build a map/connection to these deep core muscles so that you can more readily access them as you play with variation in your breathing and movement. Accessing & integrating this TYPICAL (NOT ‘CORRECT’!) breathing pattern into movements or activities that are triggering for your symptoms (i.e. pain, pressure, leaking, bulging) can be particularly helpful. We are playing with new strategies to find what feels good for YOU!

A pathway into the nervous system

With most (if not all) pelvic health challenges (i.e. persistent pelvic pain, urgency, pelvic organ prolapse), the nervous system plays a central role in the experience of symptoms. When we are in pain, feeling very anxious, or otherwise feeling threatened, the sympathetic nervous system (SNS; our fight/flight) system is leaping into action. The SNS is a branch of the autonomic nervous system (ANS) which operates largely outside of our conscious control. However, we can tap into the ANS by intentionally manipulating the breath in ways that inform the nervous system that you are safe and that bring about a sense of calm. This can have a huge impact on pelvic health symptoms. Connect on Social Media as I provide some tips/tricks for tapping into the nervous system using the breath in our Wellness Wednesdays over the next several weeks!

But First…OBSERVE

Before we try to manipulate or cue the breath for connection, variability, and self-regulation, it can be useful to practice simply observing the breath! The breath can be an informative window into the body , nervous system and believe it or not, even our beliefs about our body and how it “should” look and function. How our muscles tend do move (or don’t) with the breath can tell us where there may be tension. The rate, depth, and balance of our inhale/exhale can tell us about the balance within our autonomic nervous system in a given moment. These observations are not good or bad but USEFUL. This process often prompts a conversation about how you may have been told you “should” be breathing and even some thoughts you might have related to body image (i.e. is it difficult to let your tummy relax?). These observations and conversations can help with identifying the type of work that will best support you with reconnecting to your body AND finding variations that feel good to you and reduce your experience of symptoms.

The Breath As An Anchor

There is an individuality as to whether or not the breath is a helpful tool for managing high levels of anxiety or distress. Without manipulation, some find it helpful to observe the breath in order to get anchored back into their body and the present moment. However, for others, observing or trying to manipulate the breath (as discussed above) can contribute to further anxiety. In these instances using the senses OR movement to get anchored back to the body and the moment can be a a useful approach! The breath will follow without conscious effort! Check out this strategy called, Dropping Anchor, which uses the senses as opposed to the breath.

***As always, connect with a pelvic health therapist for individualised support!***

Written by: Lara Desrosiers O.T. Reg. (Ont.), Occupational Therapist

To move or not to move…Is that the question?

How about, “Why Move?”

Let’s talk extrinsic vs. intrinsic motivation.⠀


I was really sick leading up to and through the holidays this year.🤒⠀

I’m back to life and moving my body in ways that give me pleasure and help me to feel strong (my intrinsic motivators to exercise!)🏋️‍♀️🏃‍♀️🚶‍♀️🧘‍♀️⠀

Disappointingly, during a family gathering over the holidays, as I sat gaunt and clearly unwell, I received an interesting “compliment” about the weight I had lost during my illness. 🤬 This is a HUGE problem, no???🤔⠀

I am a recovering people pleaser, so in the past, PRAISE and COMPLIMENTS such as this were HUGE motivators for me to exercise and try to make my body look a certain way. The problem…these are extrinsic motivators.⠀

Research suggests that those who are intrinsically motivated to engage in an activity are more likely to stick with the activity, invest time in it, and experience greater success with it. ⠀

However, as I have shifted my focus away from movement driven by ego to movement driven by a desire to experience pleasure, strength, and connection with my body AND the moment, I must be honest in saying that I definitely exercise LESS than I used to…BUT maybe that’s ok? Maybe my body and mind have been begging for a break from the relentless ego-driven exercise that served to punish vs nourish me?⠀

Despite exercising less, I definitely feel more SATISFIED.⠀

Now when I exercise:⠀
❤It doesn’t feel like a chore.⠀
❤I am connecting with vs. fighting my body⠀
❤I don’t have a plan/routine laid out…I listen to what my body needs and I go with the flow. In the past, I got very cranky when my exercise was interrupted and I couldn’t finish what I started. Now, whatever I squeeze in is enough…I am enough!⠀
❤I embrace the days when exercise just isn’t the priority, offer myself compassion, and am present with the other important activities and people in my life.⠀

When it comes to exercise, we often rely on what we are told we “should” be doing.⠀

This can leave us floundering for a life time without a sense of our individual core movement VALUES (our intrinsic motivators).⠀ ⠀
What intrinsically motivates you to move More? Less? Differently?

Looking for guidance to mend your relationship with movement?

Postpartum Rage: We Need to Talk About It!

As a society we have a long way to go in terms of effectively screening for and addressing perinatal Depression, even further to go with Anxiety which is actually even more common…and buried way down the list (a topic layered with shame for a lot of mamas) is Anger and Rage. This was the emotion that I certainly struggled with the most during my transition to motherhood. Doing some reflection on the stories that I tell myself about anger and why has been crucial to my survival in this jungle we call parenthood.

Here is my Anger Story…

Once upon a time, anger was not allowed…but I felt it anyways.

I was a “difficult baby”

I was a child who could throw some epic tantrums

I was a “hormonal teenager” who terrorized my mother.

My mother, who just NEVER seemed to get angry, did not seem to understand why I couldn’t just sweep my BIG feelings under the rug which made me even angrier.

I excelled in school and in my extracurriculars.

But I felt that I never quite measured up at home because of my temper…infamous to this day when our family gathers and takes walks down memory lane.

My parents did their best with the tools they had (this is not a story of blame) but the mystery of my female rage really did seem to elude them throughout my time under their roof. The more I tried to bury this evil anger, the more powerful and toxic it seemed to become.

Fast forward to my transition to motherhood…I was ANGRY!

Of course I was angry!

In the early days, what was apparent was how much I had lost (sleep, freedom, control, my own physical space) and ALL that was gained was not yet fully realized.

Yet I was ashamed for feeling angry…it was modelled for me that mothers aren’t supposed to be angry.

My anger turned to my first born bub…who else could I blame? She just wouldn’t cooperate with my plans!

At its worst, I snapped at her, put her in her crib, and left the room to bawl in the fetal position, allowing her screams to fill the house. I was overcome with shame.

When this happened, it snuck up on me and I was NOT ok with it!

I began to get curious about when and why this happened and GRADUALLY realized…

  • When I have lots of difficult days, I begin to feel resentful.
  • I try to bury this feeling until I become completely overwhelmed by it.
  • When I let go of the expectations I hold for myself (not only what I should be doing but also what I should be feeling) it is easier to be present with my kids and be the mom I want to be.
  • When I allow myself moments of anger and as I slowly begin to unravel the judgements that I attach to it, I seem to have more patience with my kids and compassion for myself.

The greatest gift of motherhood for me (other than the muchkins of course!) has been the wake-up call that my core belief of anger being bad, wrong, and unladylike is utter bullshit and has been pretty destructive to my health and happiness in a lot of ways over the years.

My hope is that we begin to talk more openly & judgement-free about the myriad of postpartum emotional experiences that exist for women. That we begin to have a better understanding of the true experiences involved in the enormity of this transition rather than the simple airbrushed versions.

I would be honored to hear the story of your journey with anger! How was anger treated in your family or origin? How does anger sit with you now? What changes would you like to make in your relationship with anger?

lara@pelvicresilience.ca

Rage & Pelvic Health: Barrier or Bolster?

Why is it so hard to find a picture of a HUMAN woman enraged??

Anger is “the emotion that best protects us against danger, unfairness, and injustice” (Soraya Chemaly, 2018).

 

Men who express their anger are often seen as important and competent. Women expressing anger in similar ways are more likely to be perceived as emotional, unpredictable and incompetent.
Girls are socialized to be accommodating and likeable. Expression of anger just doesn’t seem to fit that mold. As a result, we tend to avoid, bury, and mask these inevitable emotional experiences.⠀

But at what cost?
-getting taken advantage of?⠀
-being dismissed and unheard?⠀
-building resentment in life roles and relationships?⠀
-shame and guilt when these emotions bubble to the surface?⠀
-out of the blue explosions that fail to serve us?⠀
-deteriorating physical and emotional health?⠀
-Missed opportunity?⠀⠀

Why does anger show up when struggling with pelvic pain, leaking, prolapse, diastasis or any other forms of pelvic health challenges?

The reality…There are TONS of reasonable reasons to feel angry!
😡It f***ing shucks (UNFAIR)
😡Maybe you felt ill-informed about your pelvic health (INJUSTICE)
😡The pain and discomfort is invisible so  maybe you feel alone and isolated (we are social beings that require connection for health and survival so this can feel a lot like DANGER)
😡It often shows up in seasons of life when there is already a TON on your plate (UNFAIR)
😡You may be inundated with messages about what your symptoms mean or things you should and shouldn’t be doing (FEAR and PERCEIVED DANGER).

It’s OK to be angry! Maybe the visceral and ACTIVATING sensations that come with anger are critical to our resilience while we navigate this shit?

So…What do you do with it?  How do you move towards awareness, engagement and change in the face of the unfairness, injustice and sense of danger?

Anger is often a catch all word to describe a myriad of emotions. Take, for example, these pictures…

Did you know that on average, folks can recognize and acknowledge just 3 different emotions? However, research from the brilliant Dr. Brene Brown indicates that emotional literacy requires the ability to acknowledge 30 core emotions!

So what’s the value of getting curious about what we are feeling and how it shows up in our faces, bodies, brains, and behaviour?

Recognizing the ‘granularities’ in our emotions can help us to tune in to what we truly need!

What does this mean in pelvic health recovery?

It can mean a bit more clarity in determining YOUR next best step.
Getting curious about WHAT you are feeling and WHY could help with the HOWS of moving from that place of fear, passivity, and withdrawal to awareness, engagement and change.

This could be…

-ADVOCACY
-GETTING INFORMED
-GETTING CLEAR ON YOUR VALUES AND WHAT’S IMPORTANT TO YOU
-MOVING YOUR BODY WHILE RE-ENFORCING A SENSE OF SAFETY
-SUBTLE SHIFTS IN HABITS/ROUTINES/HOW YOU DO THINGS
-PRIORITIZING YOUR REHAB EXERCISES
-TAKING A BREAK FROM YOUR REHAB EXERCISES
-PRIORITIZING YOUR MENTAL HEALTH
-SELF COMPASSION AND SELF CARE
-COMMUNICATING YOUR NEEDS TO HEALTH PROVIDERS, FAMILY, OR FRIENDS
-CONNECTING WITH A TRUSTED HEALTH CARE PROVIDER
-JUST DOING SOMETHING DIFFERENT

If you need support with determining your next best step in recovery, BE IN TOUCH!