Dignity in the rehabilitation and training context

My last post about shame in the rehabilitation and movement space seemed to strike a chord, and I am grateful to those who have expressed an interest in more discussion around the subject of how to avoid inadvertent shaming of a patient or client.

Unlike sadness, anger or despair which can be attributed to life events or circumstances outside ourselves, shame turns us in on ourselves and shreds our sense of intrinsic value. It is one of the most painful of emotional experiences, because it is the one that reaches into our shadows to whisper “I am not good enough” or “I don’t belong”.

Shaming is so deeply institutionalised in the training realm to the point that it is scarcely recognised, despite being widely experienced. Many healthcare and fitness professionals have endured shaming as a part of their own training experience, but few would acknowledge it, as it feels like personal inadequacy rather than the result of unexamined communication practices.

There are several measures that we can practice to reduce our chances of accidentally causing this kind of distress with our own clients and patients.

The first of these is defining our values, personally and professionally. When I speak of values, I am not talking about the general sense of being a good person, but the deep and specific bedrock that underpins our interactions and integrity, the essence of what we stand for. Explicitly articulating and committing to our values unconsciously shapes our language and approach. Dignity, respect and compassion may represent values that can be transmuted into intentions that you uphold in your professional interactions. Dignity is powerful – if you commit to honouring the dignity of others, and also to upholding your own dignity, shame struggles to get a foothold. Personally, along with the big three of dignity, respect and compassion, I like to add my special sauce of  joy, wonder and fun.

The next is our own self-regulation: To have sufficient empathy, perception and patience to uphold our intentions, we ourselves need to be aware of our own autonomic state. Empathy has been shown to be dependent upon our ability to process interoceptive information arising from our own bodies, yet these processing centres in our brains are affected when we are stressed. When our limbic system is highly activated, it can also have an inhibitory effect on our rational, reasoning pre-frontal cortex, affecting how we form and articulate our communication. We now ask our course participants to begin their day with a centering practice along with affirming their intentions, and to repeat this when they become aware of when they may be struggling in a client/patient interaction during the day. This simple practice helps them to remain aligned with their intentions.

Our mode of communication is then the focus. In the conventional instructor role, generally one person in the interaction takes the role of controller and active imparter of information and the other is assigned the role of receiver, in the more passive role. The subject of the interaction becomes the performance of the exercise, and the object becomes the person performing it. It is a conventionally patriarchal dynamic which is linear, outcome-directed and hierarchical.

In this model, the “receiver” becomes aware of the instructor’s expectations of a specific outcome to be met. Phrases like “you should feel” are common, or the more dominating “I would expect that…”. If they are not experiencing what they “should” be feeling, some patients/clients may experience feelings of frustration and others will feel that they are failing. The result can be disempowerment, hopelessness and shame.

How do we avoid this?

Well, uncomfortably, we have to ask who the outcome of this particular task is more important to. Yes, we’d like to help the person to get better, but there are few more gnarly self-reflective questions to answer.

Do I need to feel in control, rather than being comfortable creating a collaborative interaction which equally involves and values the client/patient’s own discoveries and contributions?

Do I have independent self-esteem, or am I dependent upon my patient’s outcomes to feel valid?

If the patient does not feel “what they are supposed to feel”, does that make me feel frustrated/uncertain/panicky/not sure what to do next/a sense of failure?

Full disclosure, I have been in all of those places over the thirty plus years I have been working professionally with people! In fact, I doubt that anyone escapes that process, so there is nothing to feel ashamed of if something in that list resonates.

It will not shame us if we realise this is not about who we are as people, but about how we are at present, and what models we have been offered to work from.

Learning to work with other human beings is a process. If you are stuck in one of those feelings above, own it. Acknowledge it as a stage in the evolution of yourself as a practitioner working with people. Then decide: do these feelings align with my values and identify? If not, then congratulations! It is now time to move to the next level.

Let me offer an alternative model. In this model, we start with what is meaningful to the patient. We understand that they come with an intriguing blend of interests, motivations and histories, which will inform our choices and communication. We value that the patient possesses real time information that we do not have first-hand access to, so we foster an interaction that invites them to contribute, to articulate what they are experiencing without judgement, opening an opportunity for increased understanding between both parties.

This is not possible unless they feel safe. In JEMS, we say that we set the patient up to succeed. So, we might start with something that we know they will achieve a quick ‘win” with, and use it as a stepping stone. Albert Bandura, who shaped the field of self-efficacy, called this a “mastery experience”, where someone gets to feel the “can do”. It is here when you establish their foundations: that they can learn to sense themselves and that they can change that sensory experience by altering something in the way they use themselves, perhaps a body position or movement trajectory, attitude or visualisation. That is a powerful sense of agency when perhaps there has been no sense of control before. Then we gradually expand their functional window with gently graded progression, so they can learn to embrace challenge with curiosity and confidence.

If the patient/client feedback isn’t what we “want” to hear, and they don’t feel what we expect them to, we could choose to realise that this is valuable information which will then inform our next treatment step. Perhaps what you are really learning is that the patient is struggling to perceive a sensation. So, you understand that this will shift your focus from achieving a certain movement or muscle response, to offering techniques which can help them to feel. Perhaps instead what you learn is that the patient’s nervous system needs an additional piece of information that might become available using a different technique. So, you take that sideways step that will allow the patient to move forward.

Ultimately, if the patient discovers what they can do, and that anything else is just information to inform the next choice, the interaction will preserve and support them. When you catch yourself falling into looking for “what’s wrong”, or things are not going as you had planned, here’s a little trick. Say to yourself, “How interesting! I wonder what would happen if….”… and that breathless moment which could tip either way suddenly rolls on and into the next exploration in the spirit of non judgemental curiosity….


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