September 14, 2025 • 30 mins
In this mini episode of You Matter, Joanne and I discuss the power of setting agreements with your patient, not just at the beginning of an episode of treatment but at every session, and even within a session. Rather than wondering, "Is this right? Are they happy? Am I doing a good job? " You get an answer in real time. Your patient gets seen and heard, and you are relieved from the pain of wondering. There are surprising benefits for both of you.Coaching Unpeeled: https://www.tickettailor.com/events/mehab/1737501Future Dates: https://tinyurl.com/4f5nh8fm
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Episode Transcript
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(00:01):
Hello and welcome to this episode of You Matter where I am
once again with my great friend and colleague Joanne
Elphinstone. We are going to talk today about
an aspect of your experience in the clinical room or one we hear
about a lot, which is the the idea is my patient happy and
(00:23):
there are some concepts that we're going to dig into around
that, that relate to coaching. But I'm just going to let that
all unfold in the conversation. So welcome again to you matter,
Joanne. Thank you.
So much. It's delightful as always, to be
here with you, our little our little space where we get to
just jam on each other. Exactly.
And that's what it's going to be.
(00:44):
This is not me interviewing Joanne.
This is just us having a conversation, isn't it?
So we both agree that is my patient happy?
Am I doing a good enough job? Variations of that statement are
something we hear quite often. I'm thinking with coaching
(01:05):
clients definitely, but with clinicians I work with posts I
see online from clinicians. Are you finding the same?
Oh, absolutely, Joe, you know it.
I would say that almost 100% of coaching clients that are
clinicians and a lot of people when they come on to the GEMS
(01:29):
courses as well. The, the big thing that does
start to surface is I'm worried that my patient is happy or
satisfied and that's a a source of ongoing stress.
And then there's the the secondary aspect of am I good
enough? Because we've been on ourselves
(01:51):
and as you know, we have you andI have talked a lot about this
and this is so avoidable. And it's not that complicated to
be avoidable. Yeah, and here's me going down
possibly a rabbit hole straight away.
Bring me back if this isn't helpful.
But it's interesting, isn't it, how that is such an important
(02:14):
thing for our patient to be happy?
Almost like that is the goal. Where do we pick that up from?
Yeah, yeah. Because actually, it's not about
happiness. Oh, you're frozen, Joan.
Oh, you're back again. No, it's all right.
You're back. You're back.
Probably. Back.
Yeah, because if we take out thehappy part and work out well,
(02:40):
what is it that the patient, thepatient doesn't come in to say,
my goal is to be happy. And that's the first interesting
thing that we've already gone off track into our own little
world of agenda when actually ifwe just start with what is the
patient actually coming for? What are what are their hopes?
(03:01):
What's their vision for this? Yeah.
And that's the that's really important part of the framework
that we work with, that you and I work with, isn't it?
We, Joanne and I teach this ideaunder the heading of agreements.
And it is what it says in the tin.
(03:22):
It's it's from the start making sure there is agreement between
you and your client about what they came in for.
Absolutely. And you know, it's so
interesting Joe, because I, you know, since we obviously we've
both been working with this for a long time and it's a part of
both of our trainings from from way back.
And I would say that, you know, every single patient
(03:44):
interaction, it's so interestinghow agreements are what locate
both of us in the session and give us a calm place to move
from. Because if we've actually both
agreed on what's important today, that you've already
probably agreed on what's important for the overall goal,
(04:07):
but then at A, at a session level.
Yeah. What's important today, if you
both know that, then you don't have to keep wondering, well, is
the patient happy because you'veboth agreed on where you're
trying to go? The other thing about that,
though, is that people think that, right?
That's the commitment for the whole session.
(04:29):
But I think we've all been in a session where we're like, do you
know what? We were heading this way.
But it turns out, I don't think that's actually going to be the
route today. And somehow people feel like
they've got to just make that first thing happen rather than
going, do you know, I think there's going to be a better way
forward here. This is what I propose.
(04:52):
How does that sound to you? And then the patient can choose,
well, actually, no, I want to persist with this, which is fine
because they've decided that that's what they want to do.
Or they decide, actually, yeah, I'd I'd be willing to look at
another angle here, but you've made another agreement.
(05:15):
We make it and the other way as well.
Sometimes you find the decision is just taking a different
course and at that point, ratherthan just going, oh, well, we
seem to be going here and hopingthat's OK.
You check in and go, oh, we seemto be taking a different tack
here. Is that OK?
Is that what you want to do? And again, as you say, if they
(05:36):
say yes, great, you can do it with confidence that that is
what they wanted or you've just done a really good job of
highlighting that. Oh, no, actually, that isn't
where I want to go. Patient.
Let's let's get back to what I said.
So I don't know, there seems to be often a, a sort of thought
that you shouldn't ask. I hear lots, I have lots of
(05:59):
conversations with, you know, from doing 1 to ones with people
where they orbit a supervision or something and say, oh, you
know, I didn't, we had these three sessions.
I don't really know if it was going the right way or I did
this thing. And I don't really know if they
were happy with that. And almost to the point of being
irritating. I'll usually say, well, did you
ask them? And it seems to be just that
(06:21):
people don't feel that they can,like we do the telling we don't
do or we ask certain questions, but not those questions.
Absolutely, Yeah, we're very good at the telling and we think
that's our job and we we think that's informing the patient and
therefore that's part of what weshould be doing as the expert in
the room. However, first thing are we the
(06:42):
expert in the room? Well, we're the expert on the
stuff that we know and of coursethe patient is the expert on
their first person experience and have so much insight to
offer if we but ask them. But I really picking up on what
you're saying there, Joe, is forsome reason we think we have to
hold all of this inside and not actually share it.
(07:05):
And along with agreements, one of the huge parts of coaching
for me is this idea of transparency.
Yeah. Oh, you know, we could actually
put that thought that's going onwith us out into the room
because as you say, it's just like, you know, sometimes let's
(07:26):
say, you know, worst case scenario, you've taken that
three sessions and you kind of don't really feel like it's
going anywhere and then you're there worrying about it.
But it's so interesting when we say to the patient, right, let's
just take stock here. How do you feel we're going at
the moment? Like what do you, what's your
(07:47):
feeling about where we are at the moment?
And it's so interesting because sometimes they're like, well, I
just don't feel like we're really heading in this
direction, in the right direction.
Fine, then you get to task more questions about what that might
be. But I've been really intrigued
with how many times I've asked apatient in that situation,
(08:10):
expecting them to say, you know,I'm not really, not really
thinking we're going anywhere. And then they kind of turn
around and go, actually, I really want to follow this
because I think there's something here or they tell me
they're getting something out ofit that I'm completely not
expecting. And that's intriguing too.
(08:31):
And if I hadn't been transparentand asked, I would never have
known. Yeah, both ways.
It's all information and stuff you can move on from.
Carry on same direction with change tack.
It opens up the options and it settles that part of you that is
(08:52):
making up the answers to the questions that you're not
asking. Absolutely.
And I mean what better way to make somebody feel hood than you
actually ask them and something and actually give them the space
to express it. Yeah, I had a conversation just
today with a physio who said something really interesting and
(09:13):
insightful. She said, oh, should I tell you
what? I hate the biopsychosocial
approach. It was interesting because she's
very good and experienced and very empathic clinician.
And she was saying that's the problem.
She said, you know, by the time I acknowledge the bio, the
psycho, the social and all the other things that are going on,
you know, then you know, which one of those do I decide to
(09:36):
focus on? Invariably I can get really
stuck in the one that probably isn't the thing.
And then I'm spending, you know,2 sessions on the fact that the
patient's having a terrible timewith their mum or something like
that. And so we had a conversation
about agreements under the the question, which lots of people
(09:58):
listening well have heard of thewhat matters to you most today
in all of this? And she said, yeah, now I do
know that one, but it doesn't really work for me.
And we sort of battered around afew different variations.
And in the end, she liked to simply where should we focus
today? And she wanted some variation of
(10:20):
where is my expertise best placed today?
And that probably isn't something you would say in those
words to a patient. But just like, OK, I could help
you in a number of ways from thethings we've talked about, where
do you think my help is going tobe most valuable today?
Something like that. I knew exactly what she meant.
You know, we're taught to open up the smorgasbord.
(10:42):
And then what if you pick the wrong thing?
But it goes back to, you know, pick the the thing you have
another conversation about whichthing.
Absolutely. And.
Even in those discussions, just as you say, Jay, sometimes
someone will say something that you think, oh, and a little bell
rings and you, you kind of hear a bit more.
(11:03):
And, and it may be that you say,you know, that there's something
really interesting there that wecan perhaps look at in a little
bit more depth. Is that something you're you're
interested in? Or shall we keep moving forward,
you know, in the story or whatever it is?
And it could go either way because sometimes people are
(11:24):
like, well, nobody's actually paying any attention to that.
That would be great. And and so we do.
But we've had agreement and we haven't taken on because, as you
say, we've got this kind of paradox of opening up all these
things, but then deciding to take control somehow.
And of course, I know people will be listening, going, but
(11:46):
isn't that our job to know whichway to go?
Well, that's when we can wield our bit of knowledge and say,
this is what I propose for this session and this is what we can
realistically expect where we can get to.
How does that sound to you? And sometimes a patient comes in
(12:08):
and, and yesterday I, I had two female patients, two women, 2
exhausted women going through lots.
And one we would normally be moving her back work on in a
certain direction. And she's just white with
exhaustion. And, and I looked at a few
(12:30):
things and she's really locked up.
She's been crouching over a computer blasting out high
stress work, just like, shall wejust look a little bit and see
if we can help you to move a little bit more freely?
Can we take a bit of tension outof your system?
She said that would be great. And Lissa, dare I say it, I did
(12:50):
some hands on work with her. We looked at the movement wheel
that was really, really stuck beforehand.
We did some work, we talked while we were doing it.
We got some breathing happening.We got back up.
She had colour in her face and she said I feel so much better.
And she was standing in herself in a way that was no longer
(13:11):
stressing her back. So actually her back much less
painful. She also got the experience of
understanding the relationship between where she puts her body
under stress and why creates more pain.
She made that agreement. You know, it wasn't saying, ah,
(13:33):
we have to, you know, move on forward with your program.
She just like this is what I need.
And, and when she left, she leftvery satisfied and even next
time for us to pick up the reins.
Great programmes going. And I can see how that kind of
interaction, in a very natural way, it provides the opportunity
(13:54):
at the end for your patient to reflect on really how successful
you've been on your agreed aims in that treatment session.
As opposed to, I'm thinking backwith a wry smile of my Maitland
days where you were taught to doyour, however many Mobes, it was
stand them up, retest the movement which you decided was
(14:16):
the problem, and then somehow try and convince yourself and
then that that was different. And it was all predicated on
something you had decided from the start, something you then
decided to do and then reassess.And you know, lo and behold, the
if the patients are people, please, if they'll sort of smile
at you and agree. But as many times as many other
(14:37):
times, just look at, you're quite confused.
And of course, that's that's such a confusing process, isn't
it, that your patient probably feels no understanding of or
involvement in and no ability toreflect.
Well, is that better? Whereas if you actually agreed
what it was you were trying to change at the start, then it's
much easier for the patient to assess at the end whether it has
(14:59):
changed or not. Absolutely.
And look at the difference in patient agency.
So the first example is absolutepassive, isn't it?
The patient is utterly passive in the entire interaction versus
the second situation where the patient has been active in the
choice and engaged in what's actually happening and why, and
(15:22):
then able to actually give that feedback at the end.
So arguably in both scenarios, there has been some form of of
manual therapy. 1 is very passive and the other one is
actually actively a way for themback into their bodies again, a
way for them back into understanding what's happening
(15:44):
and actually leaving with. She left with a far greater
understanding of the relationship between stress and
why her back pain gets worse and.
What might help next time? Absolutely.
And you know, I, I look at it and see the, the struggle people
have with this is, but I'm the expert.
(16:06):
I'm supposed to be the person who drives this forward, has the
plan, you know, and, and all of that.
And I think sometimes people getinto a little bit of an identity
crisis. You see, if I'm not actually
driving at all, am I? Am I fixing them?
(16:28):
And so that kind of relates to that thing as my job is to fix
them. So then again, we have the
patient as the receiver and you can have that dynamic, but that
is going to lead you to an entire lifetime of.
But is the patient happy? And therefore have I been good
enough AD? Infinitum.
(16:51):
Yeah. And I think, John, the biggest
distinction in this approach is as you said at the start, the
the number of times you repeat and revisit the agreement.
Because lots of people do talk about the great phrase, what's
most important to you today or what have you come here for
(17:11):
today? What can I do for you?
People will often say, Oh yeah, I do that at the start, but
that's the only time. And it's almost like that's a
new box to tick. But then you're back in the
world of, OK, so I've done that bit right now I'm back to
default fixing. And it's that willingness to go
(17:34):
back again and again and again and keep keep agreeing, keep
checking in, keep being vulnerable enough to put stuff
back on the table rather than just gloss over any
misunderstandings or discomfort on your part or their part.
It's it, I think it really is that that continuity, which is
where you see the value of agreements.
(17:55):
It's not just a one off. I'm I'm listening to you in the
first instance, it's I'm listening to you and I'm every
time things change, I will listen to you again.
Absolutely, absolutely. And it's it is really
interesting because this I mean,agreements, it sounds easy,
doesn't it? I mean, there are skills to
(18:16):
learn. It does sound like, oh, it's
fine, I'll just keep asking. But as you say that that
vulnerable space is sometimes difficult to sit with if you're
thinking drive this forward. But I mean, we've all been in a
situation with a new patient andit quickly becomes evident that
(18:36):
this subjective is complex and long.
And you're starting to worry about the time I've got to get
an objective and some treatment.And, and what's super
interesting at that, there is a moment there where, you know,
I've often had to say to the patient, OK, the what we can
realistically do today is I can hear, I'd like to hear all of it
(19:00):
because all of it actually is really important.
We will have enough time to do that and have a look at some
evaluation and get a clear picture of, of what our next
step is going to be. Is that OK with you?
Now the patient gets a choice and gets to say then, well,
(19:21):
actually I'd really like to havea couple of things to go away
with. Fine, you know, I can say that's
fine. We will have to then not be able
to hear all of the story this time.
We can come back and you can reflect and then we can look at
that a bit more next time in order to make the space for us
(19:42):
to do a couple of things for youto take home with.
Is that does that sound OK with you?
So in both instances, no matter what they come back with, it
doesn't matter as long as then you frame it so everybody knows
what's going to happen and we don't have expectations that
(20:02):
have been missed because they were never brought into the ring
in the first place. And the power of that last bit
you said, is that OK with you? I was sort of in my head playing
the part of people listening to this suggestion that you might
have to, you know, the patients talking and they're really
getting to their story. And they're probably, you know,
looking very thoughtful and introspective.
(20:23):
And then you come in and go effectively, I need to cut this
short. And I could feel my stomach
going, Oh, and then the is that OK with you?
That's that's what eases the wayfor both of you.
You're not dictating, you're calling something out into the
open and then checking in at theend.
And you know, for people who do find it difficult to, well, just
(20:47):
in that instance, if you think you would find it difficult to
stop a very verbose patient and suggest that we might need to
stop that story today and come back to it.
Just that last bit, is that OK with you?
It's kind of a, it isn't there for a softener, it's there for
the agreement. But in terms of our own comfort
with a slightly uncomfortable situation, it's really helpful.
(21:08):
You know, haven't we all be in that place where you don't like,
you know, that if you cut them off, that's going to create an
issue and stuck with that? We've all had that patient.
And to be honest, often that patient can have some really
valuable information that you'rekind of like storing.
But yeah, I mean, sometimes, youknow, as I said, I gave a, a
(21:29):
couple of choices and maybe they'll ask, well, what, what
would you prefer we do with thistime that we have, we have this
much time. What is your preference for
that? And now let's see if that, you
know, we can make that work for what the overall objectives are.
So they have to, you know, there's a choice, they're making
(21:49):
a choice. And again, you know, that gives
us that opportunity to go, OK, when we get to the end of our
session, have we done what we set out to do?
Absolutely. So hopefully people are hearing
that this process has obvious benefits for your patient in
(22:11):
terms of being heard properly and being given choice and also
being challenged to make choice.But for you as a clinician,
there are so many benefits in terms of settling that part of
you that wonders and worries about it at home and takes that
(22:34):
thought into the next patient and cumulatively starts to build
up this concern of is this patient happy enough?
Are my patients plural, happy enough?
Am I good enough? This this process amongst other
things that we teach alongside agreements, but I think you and
I both agree agreements is absolutely fundamental to
(22:55):
starting the process of creatingthis framework which actually
keeps you safe and grounded as well as benefiting your patient.
Absolutely, absolutely, Joe. I mean, yeah, it is.
It's kind of really creates thatwonderful start point.
But there is a container then. And as you say, you know, when
we look at what the the pillars are that we have for coaching
(23:15):
unhealed, we're actually like taking, taking that journey.
But all of those pressure pointsthat come up as clinicians,
there are there are principles that can help you to ground the
interaction again. Yeah.
So that things can then start tomove forward, because I think we
get to that point sometimes in asession where everything kind of
(23:38):
grinds to a halt. I'm not really sure where to go
next, but we just know we don't feel good about that.
Yeah. And actually, there are simple
techniques which do take a little practice and we do
obviously, you know, coach everybody on this, but they're
not complicated, well known in some ways, communication
(24:01):
techniques, but knowing how to place them in a clinical setting
so that you're really upholding,you know, your own ethics.
You're also upholding the evidence base because hey, this
is the absolute key to being patient centered, which is a a
(24:22):
term we see bandied around a lot, but not a lot about how do
we actually do that? Yeah.
Just being nice to people is notthe same thing as being patient
centered. But in this way, as you say,
interestingly, if we can locate the patient with these
techniques, we also locate ourselves in a place where we
(24:45):
can retain our own equanimity. Yeah.
And not end up at the end of thesession going, oh, not really
sure how that went. Ishan will come back.
All of those kinds of things, which I know so many people, you
know, all of you out there listening, who hasn't had that
feeling? Yeah.
(25:06):
And I think that's maybe just asa final point, that's the proof
in the pudding, how you feel when you walk away from these
interactions. It's in some ways it's similar
to the coaching principle of boundary setting.
And I always say to people, don't judge how you feel about
the conversation you had, judge how you feel when you walk away
from it. Because anyone can learn a
(25:28):
script of words and learn to deliver them.
But that isn't the problem. You know, you're all intelligent
people. You can find words.
It's whether you can deal with the feelings you get after an
interaction that's the issue. And you know, if you, if you
fancy it, play with some of these techniques and then just
where do you walk away? Think, OK, how do I feel about
(25:51):
that? How do I feel in my body?
How do I feel about the content of the session?
What's going on in my mind? And I really hope it won't be.
Is my patient happy? Am I good enough?
Absolutely. Because I mean, we're not saying
that we, you know, we don't carehow people feel, but whether
there's a big difference betweensomeone walking out feeling
(26:12):
like, you know, there's some satisfaction of that they've
listened to and that they're, what they've come with has been
respected and taken into account.
And that they have been involvedin the shaping of that session
from beginning to end. There's a there's something that
someone leaves with there which is not quite the same thing as,
(26:34):
are they? Happy.
Because sometimes someone leavesfeeling quite thoughtful and not
sure how they feel because they've been introduced to to a
thought that maybe they haven't had.
And. Sometimes they're not that easy
either. You know, we have sometimes
tough conversations and maybe the patient doesn't leave happy,
(26:55):
but they don't necessarily leaveunhappy or dissatisfied.
They leave thoughtful but not, you know, so there's, there's
that huge difference, you know, that distinction between whether
they're happy or whether they dofeel that they've had some value
(27:15):
from the session. Yeah.
That's. Do what we agreed.
Yeah, exactly. Then that's just to, well, you
know, we have so much to to share, don't we?
We yes, and we believe in it andwe want to help people.
Yes, Joanne mentioned coaching appealed a couple of
conversations ago and then agreements is part of the five
(27:39):
pillars that Joanne mentioned. We've we've taken this array of
coaching, these coaching skills and what we realise because we
are both coaches ourselves trained I guess in regular
coaching, we realise that there's huge benefit in
distilling these skills down so that they're directly applicable
(28:02):
in the clinic room because it isn't the same as a coaching
session. You are to an extent an expert
in the room and therefore the way you use coaching skills
needs to respect that and be interwoven in a very particular
way That wouldn't be the same asa regular coaching session.
So that's what Joanne and I did over a period of two years and
(28:24):
lots of coffee and cake in Monmouthshire.
We thrashed out how to distil these coaching skills for
specifically for clinicians. Absolutely, because I mean, the
bottom line with coaching is it's it's basically sound
communication skills. Yeah.
And sound communication, some self connection, you know, to
(28:45):
understand the feelings we're having that maybe framing how
we're perceiving the stories we're telling ourselves about
what's actually going on. All of these things are are, you
know, embedded in these, these, these pillars, these principles
that we're talking about. And hence that's why it's called
coaching and peeled because there's so much out there now
(29:06):
people are talking about coaching and there's courses,
huge amounts of information, buta lot of it is really not
specific to the clinical setting.
And So what we've done is we have literally unpeeled the
concepts, which we both know very well.
We've had to do great big multi hour exams and all sorts of
things on that. We know that stuff, but we're
(29:27):
also clinicians ourselves and wework with those clinicians.
So yes, we've peeled away all the stuff that you don't really
need to know and then clarify the things that are going to be
the most powerful for you to be able to apply directly
immediately into your clinic setting.
(29:48):
Yeah. And agreements is just one of
five of those. So I think we're going to come
back and maybe have a similar conversation about other
pillars. But for now, I hope you enjoyed
this conversation and I will putin the coaching notes details of
the next time we're going to runthe coaching unpeeled course if
anybody's interested. Thank you so much, Joe.
(30:09):
Thank you everybody for listening.
Hopefully that has been cool. Thank you, Joe.
Hello and welcome to this episode of You Matter where I am
once again with my great friend and colleague Joanne
Elphinstone. We are going to talk today about
an aspect of your experience in the clinical room or one we hear
about a lot, which is the the idea is my patient happy and
(00:23):
there are some concepts that we're going to dig into around
that, that relate to coaching. But I'm just going to let that
all unfold in the conversation. So welcome again to you matter,
Joanne. Thank you.
So much. It's delightful as always, to be
here with you, our little our little space where we get to
just jam on each other. Exactly.
And that's what it's going to be.
(00:44):
This is not me interviewing Joanne.
This is just us having a conversation, isn't it?
So we both agree that is my patient happy?
Am I doing a good enough job? Variations of that statement are
something we hear quite often. I'm thinking with coaching
(01:05):
clients definitely, but with clinicians I work with posts I
see online from clinicians. Are you finding the same?
Oh, absolutely, Joe, you know it.
I would say that almost 100% of coaching clients that are
clinicians and a lot of people when they come on to the GEMS
(01:29):
courses as well. The, the big thing that does
start to surface is I'm worried that my patient is happy or
satisfied and that's a a source of ongoing stress.
And then there's the the secondary aspect of am I good
enough? Because we've been on ourselves
(01:51):
and as you know, we have you andI have talked a lot about this
and this is so avoidable. And it's not that complicated to
be avoidable. Yeah, and here's me going down
possibly a rabbit hole straight away.
Bring me back if this isn't helpful.
But it's interesting, isn't it, how that is such an important
(02:14):
thing for our patient to be happy?
Almost like that is the goal. Where do we pick that up from?
Yeah, yeah. Because actually, it's not about
happiness. Oh, you're frozen, Joan.
Oh, you're back again. No, it's all right.
You're back. You're back.
Probably. Back.
Yeah, because if we take out thehappy part and work out well,
(02:40):
what is it that the patient, thepatient doesn't come in to say,
my goal is to be happy. And that's the first interesting
thing that we've already gone off track into our own little
world of agenda when actually ifwe just start with what is the
patient actually coming for? What are what are their hopes?
(03:01):
What's their vision for this? Yeah.
And that's the that's really important part of the framework
that we work with, that you and I work with, isn't it?
We, Joanne and I teach this ideaunder the heading of agreements.
And it is what it says in the tin.
(03:22):
It's it's from the start making sure there is agreement between
you and your client about what they came in for.
Absolutely. And you know, it's so
interesting Joe, because I, you know, since we obviously we've
both been working with this for a long time and it's a part of
both of our trainings from from way back.
And I would say that, you know, every single patient
(03:44):
interaction, it's so interestinghow agreements are what locate
both of us in the session and give us a calm place to move
from. Because if we've actually both
agreed on what's important today, that you've already
probably agreed on what's important for the overall goal,
(04:07):
but then at A, at a session level.
Yeah. What's important today, if you
both know that, then you don't have to keep wondering, well, is
the patient happy because you'veboth agreed on where you're
trying to go? The other thing about that,
though, is that people think that, right?
That's the commitment for the whole session.
(04:29):
But I think we've all been in a session where we're like, do you
know what? We were heading this way.
But it turns out, I don't think that's actually going to be the
route today. And somehow people feel like
they've got to just make that first thing happen rather than
going, do you know, I think there's going to be a better way
forward here. This is what I propose.
(04:52):
How does that sound to you? And then the patient can choose,
well, actually, no, I want to persist with this, which is fine
because they've decided that that's what they want to do.
Or they decide, actually, yeah, I'd I'd be willing to look at
another angle here, but you've made another agreement.
(05:15):
We make it and the other way as well.
Sometimes you find the decision is just taking a different
course and at that point, ratherthan just going, oh, well, we
seem to be going here and hopingthat's OK.
You check in and go, oh, we seemto be taking a different tack
here. Is that OK?
Is that what you want to do? And again, as you say, if they
(05:36):
say yes, great, you can do it with confidence that that is
what they wanted or you've just done a really good job of
highlighting that. Oh, no, actually, that isn't
where I want to go. Patient.
Let's let's get back to what I said.
So I don't know, there seems to be often a, a sort of thought
that you shouldn't ask. I hear lots, I have lots of
(05:59):
conversations with, you know, from doing 1 to ones with people
where they orbit a supervision or something and say, oh, you
know, I didn't, we had these three sessions.
I don't really know if it was going the right way or I did
this thing. And I don't really know if they
were happy with that. And almost to the point of being
irritating. I'll usually say, well, did you
ask them? And it seems to be just that
(06:21):
people don't feel that they can,like we do the telling we don't
do or we ask certain questions, but not those questions.
Absolutely, Yeah, we're very good at the telling and we think
that's our job and we we think that's informing the patient and
therefore that's part of what weshould be doing as the expert in
the room. However, first thing are we the
(06:42):
expert in the room? Well, we're the expert on the
stuff that we know and of coursethe patient is the expert on
their first person experience and have so much insight to
offer if we but ask them. But I really picking up on what
you're saying there, Joe, is forsome reason we think we have to
hold all of this inside and not actually share it.
(07:05):
And along with agreements, one of the huge parts of coaching
for me is this idea of transparency.
Yeah. Oh, you know, we could actually
put that thought that's going onwith us out into the room
because as you say, it's just like, you know, sometimes let's
(07:26):
say, you know, worst case scenario, you've taken that
three sessions and you kind of don't really feel like it's
going anywhere and then you're there worrying about it.
But it's so interesting when we say to the patient, right, let's
just take stock here. How do you feel we're going at
the moment? Like what do you, what's your
(07:47):
feeling about where we are at the moment?
And it's so interesting because sometimes they're like, well, I
just don't feel like we're really heading in this
direction, in the right direction.
Fine, then you get to task more questions about what that might
be. But I've been really intrigued
with how many times I've asked apatient in that situation,
(08:10):
expecting them to say, you know,I'm not really, not really
thinking we're going anywhere. And then they kind of turn
around and go, actually, I really want to follow this
because I think there's something here or they tell me
they're getting something out ofit that I'm completely not
expecting. And that's intriguing too.
(08:31):
And if I hadn't been transparentand asked, I would never have
known. Yeah, both ways.
It's all information and stuff you can move on from.
Carry on same direction with change tack.
It opens up the options and it settles that part of you that is
(08:52):
making up the answers to the questions that you're not
asking. Absolutely.
And I mean what better way to make somebody feel hood than you
actually ask them and something and actually give them the space
to express it. Yeah, I had a conversation just
today with a physio who said something really interesting and
(09:13):
insightful. She said, oh, should I tell you
what? I hate the biopsychosocial
approach. It was interesting because she's
very good and experienced and very empathic clinician.
And she was saying that's the problem.
She said, you know, by the time I acknowledge the bio, the
psycho, the social and all the other things that are going on,
you know, then you know, which one of those do I decide to
(09:36):
focus on? Invariably I can get really
stuck in the one that probably isn't the thing.
And then I'm spending, you know,2 sessions on the fact that the
patient's having a terrible timewith their mum or something like
that. And so we had a conversation
about agreements under the the question, which lots of people
(09:58):
listening well have heard of thewhat matters to you most today
in all of this? And she said, yeah, now I do
know that one, but it doesn't really work for me.
And we sort of battered around afew different variations.
And in the end, she liked to simply where should we focus
today? And she wanted some variation of
(10:20):
where is my expertise best placed today?
And that probably isn't something you would say in those
words to a patient. But just like, OK, I could help
you in a number of ways from thethings we've talked about, where
do you think my help is going tobe most valuable today?
Something like that. I knew exactly what she meant.
You know, we're taught to open up the smorgasbord.
(10:42):
And then what if you pick the wrong thing?
But it goes back to, you know, pick the the thing you have
another conversation about whichthing.
Absolutely. And.
Even in those discussions, just as you say, Jay, sometimes
someone will say something that you think, oh, and a little bell
rings and you, you kind of hear a bit more.
(11:03):
And, and it may be that you say,you know, that there's something
really interesting there that wecan perhaps look at in a little
bit more depth. Is that something you're you're
interested in? Or shall we keep moving forward,
you know, in the story or whatever it is?
And it could go either way because sometimes people are
(11:24):
like, well, nobody's actually paying any attention to that.
That would be great. And and so we do.
But we've had agreement and we haven't taken on because, as you
say, we've got this kind of paradox of opening up all these
things, but then deciding to take control somehow.
And of course, I know people will be listening, going, but
(11:46):
isn't that our job to know whichway to go?
Well, that's when we can wield our bit of knowledge and say,
this is what I propose for this session and this is what we can
realistically expect where we can get to.
How does that sound to you? And sometimes a patient comes in
(12:08):
and, and yesterday I, I had two female patients, two women, 2
exhausted women going through lots.
And one we would normally be moving her back work on in a
certain direction. And she's just white with
exhaustion. And, and I looked at a few
(12:30):
things and she's really locked up.
She's been crouching over a computer blasting out high
stress work, just like, shall wejust look a little bit and see
if we can help you to move a little bit more freely?
Can we take a bit of tension outof your system?
She said that would be great. And Lissa, dare I say it, I did
(12:50):
some hands on work with her. We looked at the movement wheel
that was really, really stuck beforehand.
We did some work, we talked while we were doing it.
We got some breathing happening.We got back up.
She had colour in her face and she said I feel so much better.
And she was standing in herself in a way that was no longer
(13:11):
stressing her back. So actually her back much less
painful. She also got the experience of
understanding the relationship between where she puts her body
under stress and why creates more pain.
She made that agreement. You know, it wasn't saying, ah,
(13:33):
we have to, you know, move on forward with your program.
She just like this is what I need.
And, and when she left, she leftvery satisfied and even next
time for us to pick up the reins.
Great programmes going. And I can see how that kind of
interaction, in a very natural way, it provides the opportunity
(13:54):
at the end for your patient to reflect on really how successful
you've been on your agreed aims in that treatment session.
As opposed to, I'm thinking backwith a wry smile of my Maitland
days where you were taught to doyour, however many Mobes, it was
stand them up, retest the movement which you decided was
(14:16):
the problem, and then somehow try and convince yourself and
then that that was different. And it was all predicated on
something you had decided from the start, something you then
decided to do and then reassess.And you know, lo and behold, the
if the patients are people, please, if they'll sort of smile
at you and agree. But as many times as many other
(14:37):
times, just look at, you're quite confused.
And of course, that's that's such a confusing process, isn't
it, that your patient probably feels no understanding of or
involvement in and no ability toreflect.
Well, is that better? Whereas if you actually agreed
what it was you were trying to change at the start, then it's
much easier for the patient to assess at the end whether it has
(14:59):
changed or not. Absolutely.
And look at the difference in patient agency.
So the first example is absolutepassive, isn't it?
The patient is utterly passive in the entire interaction versus
the second situation where the patient has been active in the
choice and engaged in what's actually happening and why, and
(15:22):
then able to actually give that feedback at the end.
So arguably in both scenarios, there has been some form of of
manual therapy. 1 is very passive and the other one is
actually actively a way for themback into their bodies again, a
way for them back into understanding what's happening
(15:44):
and actually leaving with. She left with a far greater
understanding of the relationship between stress and
why her back pain gets worse and.
What might help next time? Absolutely.
And you know, I, I look at it and see the, the struggle people
have with this is, but I'm the expert.
(16:06):
I'm supposed to be the person who drives this forward, has the
plan, you know, and, and all of that.
And I think sometimes people getinto a little bit of an identity
crisis. You see, if I'm not actually
driving at all, am I? Am I fixing them?
(16:28):
And so that kind of relates to that thing as my job is to fix
them. So then again, we have the
patient as the receiver and you can have that dynamic, but that
is going to lead you to an entire lifetime of.
But is the patient happy? And therefore have I been good
enough AD? Infinitum.
(16:51):
Yeah. And I think, John, the biggest
distinction in this approach is as you said at the start, the
the number of times you repeat and revisit the agreement.
Because lots of people do talk about the great phrase, what's
most important to you today or what have you come here for
(17:11):
today? What can I do for you?
People will often say, Oh yeah, I do that at the start, but
that's the only time. And it's almost like that's a
new box to tick. But then you're back in the
world of, OK, so I've done that bit right now I'm back to
default fixing. And it's that willingness to go
(17:34):
back again and again and again and keep keep agreeing, keep
checking in, keep being vulnerable enough to put stuff
back on the table rather than just gloss over any
misunderstandings or discomfort on your part or their part.
It's it, I think it really is that that continuity, which is
where you see the value of agreements.
(17:55):
It's not just a one off. I'm I'm listening to you in the
first instance, it's I'm listening to you and I'm every
time things change, I will listen to you again.
Absolutely, absolutely. And it's it is really
interesting because this I mean,agreements, it sounds easy,
doesn't it? I mean, there are skills to
(18:16):
learn. It does sound like, oh, it's
fine, I'll just keep asking. But as you say that that
vulnerable space is sometimes difficult to sit with if you're
thinking drive this forward. But I mean, we've all been in a
situation with a new patient andit quickly becomes evident that
(18:36):
this subjective is complex and long.
And you're starting to worry about the time I've got to get
an objective and some treatment.And, and what's super
interesting at that, there is a moment there where, you know,
I've often had to say to the patient, OK, the what we can
realistically do today is I can hear, I'd like to hear all of it
(19:00):
because all of it actually is really important.
We will have enough time to do that and have a look at some
evaluation and get a clear picture of, of what our next
step is going to be. Is that OK with you?
Now the patient gets a choice and gets to say then, well,
(19:21):
actually I'd really like to havea couple of things to go away
with. Fine, you know, I can say that's
fine. We will have to then not be able
to hear all of the story this time.
We can come back and you can reflect and then we can look at
that a bit more next time in order to make the space for us
(19:42):
to do a couple of things for youto take home with.
Is that does that sound OK with you?
So in both instances, no matter what they come back with, it
doesn't matter as long as then you frame it so everybody knows
what's going to happen and we don't have expectations that
(20:02):
have been missed because they were never brought into the ring
in the first place. And the power of that last bit
you said, is that OK with you? I was sort of in my head playing
the part of people listening to this suggestion that you might
have to, you know, the patients talking and they're really
getting to their story. And they're probably, you know,
looking very thoughtful and introspective.
(20:23):
And then you come in and go effectively, I need to cut this
short. And I could feel my stomach
going, Oh, and then the is that OK with you?
That's that's what eases the wayfor both of you.
You're not dictating, you're calling something out into the
open and then checking in at theend.
And you know, for people who do find it difficult to, well, just
(20:47):
in that instance, if you think you would find it difficult to
stop a very verbose patient and suggest that we might need to
stop that story today and come back to it.
Just that last bit, is that OK with you?
It's kind of a, it isn't there for a softener, it's there for
the agreement. But in terms of our own comfort
with a slightly uncomfortable situation, it's really helpful.
(21:08):
You know, haven't we all be in that place where you don't like,
you know, that if you cut them off, that's going to create an
issue and stuck with that? We've all had that patient.
And to be honest, often that patient can have some really
valuable information that you'rekind of like storing.
But yeah, I mean, sometimes, youknow, as I said, I gave a, a
(21:29):
couple of choices and maybe they'll ask, well, what, what
would you prefer we do with thistime that we have, we have this
much time. What is your preference for
that? And now let's see if that, you
know, we can make that work for what the overall objectives are.
So they have to, you know, there's a choice, they're making
(21:49):
a choice. And again, you know, that gives
us that opportunity to go, OK, when we get to the end of our
session, have we done what we set out to do?
Absolutely. So hopefully people are hearing
that this process has obvious benefits for your patient in
(22:11):
terms of being heard properly and being given choice and also
being challenged to make choice.But for you as a clinician,
there are so many benefits in terms of settling that part of
you that wonders and worries about it at home and takes that
(22:34):
thought into the next patient and cumulatively starts to build
up this concern of is this patient happy enough?
Are my patients plural, happy enough?
Am I good enough? This this process amongst other
things that we teach alongside agreements, but I think you and
I both agree agreements is absolutely fundamental to
(22:55):
starting the process of creatingthis framework which actually
keeps you safe and grounded as well as benefiting your patient.
Absolutely, absolutely, Joe. I mean, yeah, it is.
It's kind of really creates thatwonderful start point.
But there is a container then. And as you say, you know, when
we look at what the the pillars are that we have for coaching
(23:15):
unhealed, we're actually like taking, taking that journey.
But all of those pressure pointsthat come up as clinicians,
there are there are principles that can help you to ground the
interaction again. Yeah.
So that things can then start tomove forward, because I think we
get to that point sometimes in asession where everything kind of
(23:38):
grinds to a halt. I'm not really sure where to go
next, but we just know we don't feel good about that.
Yeah. And actually, there are simple
techniques which do take a little practice and we do
obviously, you know, coach everybody on this, but they're
not complicated, well known in some ways, communication
(24:01):
techniques, but knowing how to place them in a clinical setting
so that you're really upholding,you know, your own ethics.
You're also upholding the evidence base because hey, this
is the absolute key to being patient centered, which is a a
(24:22):
term we see bandied around a lot, but not a lot about how do
we actually do that? Yeah.
Just being nice to people is notthe same thing as being patient
centered. But in this way, as you say,
interestingly, if we can locate the patient with these
techniques, we also locate ourselves in a place where we
(24:45):
can retain our own equanimity. Yeah.
And not end up at the end of thesession going, oh, not really
sure how that went. Ishan will come back.
All of those kinds of things, which I know so many people, you
know, all of you out there listening, who hasn't had that
feeling? Yeah.
(25:06):
And I think that's maybe just asa final point, that's the proof
in the pudding, how you feel when you walk away from these
interactions. It's in some ways it's similar
to the coaching principle of boundary setting.
And I always say to people, don't judge how you feel about
the conversation you had, judge how you feel when you walk away
from it. Because anyone can learn a
(25:28):
script of words and learn to deliver them.
But that isn't the problem. You know, you're all intelligent
people. You can find words.
It's whether you can deal with the feelings you get after an
interaction that's the issue. And you know, if you, if you
fancy it, play with some of these techniques and then just
where do you walk away? Think, OK, how do I feel about
(25:51):
that? How do I feel in my body?
How do I feel about the content of the session?
What's going on in my mind? And I really hope it won't be.
Is my patient happy? Am I good enough?
Absolutely. Because I mean, we're not saying
that we, you know, we don't carehow people feel, but whether
there's a big difference betweensomeone walking out feeling
(26:12):
like, you know, there's some satisfaction of that they've
listened to and that they're, what they've come with has been
respected and taken into account.
And that they have been involvedin the shaping of that session
from beginning to end. There's a there's something that
someone leaves with there which is not quite the same thing as,
(26:34):
are they? Happy.
Because sometimes someone leavesfeeling quite thoughtful and not
sure how they feel because they've been introduced to to a
thought that maybe they haven't had.
And. Sometimes they're not that easy
either. You know, we have sometimes
tough conversations and maybe the patient doesn't leave happy,
(26:55):
but they don't necessarily leaveunhappy or dissatisfied.
They leave thoughtful but not, you know, so there's, there's
that huge difference, you know, that distinction between whether
they're happy or whether they dofeel that they've had some value
(27:15):
from the session. Yeah.
That's. Do what we agreed.
Yeah, exactly. Then that's just to, well, you
know, we have so much to to share, don't we?
We yes, and we believe in it andwe want to help people.
Yes, Joanne mentioned coaching appealed a couple of
conversations ago and then agreements is part of the five
(27:39):
pillars that Joanne mentioned. We've we've taken this array of
coaching, these coaching skills and what we realise because we
are both coaches ourselves trained I guess in regular
coaching, we realise that there's huge benefit in
distilling these skills down so that they're directly applicable
(28:02):
in the clinic room because it isn't the same as a coaching
session. You are to an extent an expert
in the room and therefore the way you use coaching skills
needs to respect that and be interwoven in a very particular
way That wouldn't be the same asa regular coaching session.
So that's what Joanne and I did over a period of two years and
(28:24):
lots of coffee and cake in Monmouthshire.
We thrashed out how to distil these coaching skills for
specifically for clinicians. Absolutely, because I mean, the
bottom line with coaching is it's it's basically sound
communication skills. Yeah.
And sound communication, some self connection, you know, to
(28:45):
understand the feelings we're having that maybe framing how
we're perceiving the stories we're telling ourselves about
what's actually going on. All of these things are are, you
know, embedded in these, these, these pillars, these principles
that we're talking about. And hence that's why it's called
coaching and peeled because there's so much out there now
(29:06):
people are talking about coaching and there's courses,
huge amounts of information, buta lot of it is really not
specific to the clinical setting.
And So what we've done is we have literally unpeeled the
concepts, which we both know very well.
We've had to do great big multi hour exams and all sorts of
things on that. We know that stuff, but we're
(29:27):
also clinicians ourselves and wework with those clinicians.
So yes, we've peeled away all the stuff that you don't really
need to know and then clarify the things that are going to be
the most powerful for you to be able to apply directly
immediately into your clinic setting.
(29:48):
Yeah. And agreements is just one of
five of those. So I think we're going to come
back and maybe have a similar conversation about other
pillars. But for now, I hope you enjoyed
this conversation and I will putin the coaching notes details of
the next time we're going to runthe coaching unpeeled course if
anybody's interested. Thank you so much, Joe.
(30:09):
Thank you everybody for listening.
Hopefully that has been cool. Thank you, Joe.
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