There is a question that burns within all of us at one time or another: What do our patients need to succeed? What are the requirements?
In this article, I want to talk about something that I believe to be a key requirement for our patients to succeed, and for us to have a successful working relationship with them.
Let me start by setting the stage.
Much of what we’re dealing with when working with people is subjective in nature.
The experience of pain is a subjective experience. There are biological correlates that can be observed and measured, but it is well understood that these are merely parts and are not representative of the whole. And the effects on patients' quality of life from pain or functional loss are also subjective.
Yes, we deal with things that are objective and measurable, but these things mostly exist in relation to the person’s goals and their definition of success, which again is subjective.
Dealing with subjective things requires us to rely heavily on the individual to give us information about their experience so that we can work with them. But in order for them to give us information, they first need to know the information for themselves.
This requires awareness. Without awareness on the part of the patient, there is little we can do to help them.
This is where we begin.
In this article, we’ll discuss:
Why awareness is critical to the success of our patients
What kind of awareness is important
How we can help our patients build awareness so that they can succeed
I also created a printable tool that you can use to help your patients in the awareness-building process.
Why Is Awareness Important?
Let’s first talk about the importance of awareness.
Aside from the crucial role that awareness plays in our ability to work with people on subjective aspects of their lives, there are two other important aspects of awareness:
1. Awareness Leads to Influence
Think about anything that you want to change in your life. It could be a habit, a problem, a circumstance, a lightbulb.
Changing something requires intentional action. Action that is aimed at something specific.
In order to take intentional action, we need to know what we’re aiming at. We need awareness of what is, and what needs to change.
The more aware we become, the more potential we have to influence something.
Let’s say I want to exercise more. Well, I can leave it at that and hope that it happens. But if I become aware of what kind of exercise I want to do, why I want to exercise more, what I mean by more, what would help me to exercise more, and what could get in the way of me exercising more, it’s much more likely to happen.
This is due, in part, to the next aspect of awareness.
2. Awareness Leads to Care
It’s human nature for us to take care of ourselves and take care of others. This is wired into our DNA. It’s part of how we’ve survived as a species— by taking care of ourselves and by living in groups (which requires prosocial behavior).
But we can’t take care of that which we’re oblivious to.
The more awareness we build around something, the more likely we are to take care of it— naturally.
When we become aware of ways in which we’re sabotaging ourselves, ways in which our behaviors are discordant with our values, or ways in which our actions are contributing to our pain or suffering, we naturally course-correct. Perhaps not immediately, as it’s not always easy, but we have the drive to do so nonetheless. It’s in our nature.
These two aspects of awareness, combined with the role of awareness in forming a working relationship between us and our patients, make it a critical piece of our patients’ paths to success.
What Kind of Awareness is Important?
Now let’s talk about what—specifically—is important for our patients to be aware of.
There are 3 main foci for our patients’ awareness that I call The Big 3.
The Big 3
1. Awareness of the body
This has to do with what we’re feeling in our bodies and how we’re using our bodies (how we’re moving, positioning, holding our bodies)
2. Awareness of the mind
This has to do with what we’re experiencing in our minds (thoughts, emotions) and includes our beliefs.
3. Awareness of cause & effect
This includes :
The related factors (how certain factors cause/contribute to the problem)
Other contextual factors
How we respond to the problem (the effects of the problem)
Getting More Specific
Let’s walk through an episode of care and see where these 3 show up.
For us to understand the problem on the symptom level, the person must have some awareness of cause & effect to relay information such as:
Daily symptom pattern
Their behavioral response to the symptoms
For us to understand the problem on the quality of life level, the person must have some awareness of the mind to relay information such as:
How they hope we can help
In order for us to test appropriately, the person must have some awareness of the body & mind to relay information about:
What they’re experiencing (in their body, in their mind)
How things are changing during the testing process
The relative familiarity of sensations (so we know if we’re reproducing their familiar symptoms or not)
In order for us to navigate the person’s symptoms with them, the person must again have some awareness of the body & mind to relay information about:
What they’re experiencing (in their body, in their mind)
How things are changing before/during/after interventions
Conclusion of Care
If our goal is to help our patients get to a place where they don’t need us, they must have a certain level of awareness for this to happen.
And because nobody lives their life pain-free (unless they have a genetic abnormality) they must be able to problem-solve when things arise in the future. This requires awareness of body, mind, and cause & effect so that they can take themselves through a similar process that we’ve taken them through when future problems arise.
How Can We Help Our Patients Build Awareness?
So now let’s get into the ‘how.’
How can we help our patients build awareness so that they can succeed?
Much of what we do throughout the process of care, I believe, is teaching our patients to become more aware. Through our questions, our conversations, and our process, we’re constantly cueing our patients to pay attention whether we know it or not.
But the more intentional we can be about this, the more impact we can have and the more likely it is to stick.
Again, we’ll break this down by phase of the episode of care, and by the kind of awareness we’re targeting.
Through The History
Awareness of Cause & Effect
If someone doesn’t know the related factors (aggravating factors/easing factors, etc.), we can’t just gloss over this. It’s really important that we discover these factors.
We can hope to find some of the answers during the physical exam, but if they are to succeed we need them to put in some effort to discover this in the context of their own life.
Two options for helping people explore the related factors are:
Simply asking them to pay attention and let you know at the next visit
I often strongly encourage them to look broadly and to write things down as they discover them.
Fill out a symptom journal
This is the process of examining the entire context during episodes of pain or other symptoms. The person can be guided to look broadly through the use of a template that prompts them to reflect on:
What they’re doing
What they’re thinking about
How they’re feeling
Who they’re with
How much sleep they got last night
What their diet/fluid intake has been lately
How they’re responding to the symptom
The effect of their response
Click here to scroll down to a free printable symptom tracker you can use with your patients.
It’s very important to let the patient know why this information is important. If we’re asking someone to put forth some effort, they must feel that it’s important, or else they probably won’t do it.
I often say something simple like, “The more we understand how the pain behaves, the more potential we have to influence it. Without this awareness, we’re shooting in the dark when it comes to treatment.”
Awareness of Mind
The second kind of awareness we can target in the history is awareness of mind.
Simply asking questions that speak to this type of awareness can be an insightful process, not to mention rapport-building. This can include such questions as:
At this point, what’s your main concern?
How do you hope that I can help you?
What are you hoping to get out of today’s session?
What doesn’t make sense to you about all of this?
What questions do you have?
Asking open-ended questions such as this leads the person to reflect. And reflection leads to awareness.
When asking open questions, it’s very important to keep them open. “What’s your primary concern?” is a very different question from, “What’s your primary concern— is it more this, or that?” Adding that little closed-ended tail shuts down the range of possible answers to two unless the person is willing to speak up and say neither of those options.
It’s also important to allow for silence. Open questions call people to think, which can mean a pause. Pauses are OK. Embrace the awkward pause.
Through The Physical Exam
We’ve talked about cultivating awareness of cause & effect and awareness of the mind through the history-taking process, now let’s talk about how the physical exam can be used to build awareness.
Awareness of the Body
The physical exam is a huge opportunity for building awareness of the body. Much of this involves simply cueing the person to pay attention and keeping them engaged throughout the examination process.
Let’s follow the exam process and see where our opportunities lie:
1. Explaining what’s about to happen & the purpose
This can look something like, “I want to try to reproduce/change your symptoms. If we can do this, it will help tremendously to guide treatment. So pay close attention to your body and let me know what you’re feeling. And don’t worry, you’re not complaining, you’re giving me information.”
2. Establishing the baseline
We want to find out where they are at baseline by asking, “What are you feeling right now?” Or, “Any symptoms right now?”
We also want to cue them to remember how they’re feeling so that we can compare later: “We’re going to do some testing then come back to this, so remember how you’re feeling so that we know if it changes, OK?”
3. Performing the testing itself
During this process, it’s important to keep the person engaged in the process.
If they don’t have symptoms at baseline and we’re trying to reproduce their symptoms, we’ll constantly be asking them things like:
“Anything with this?”
“How do you feel with this?”
If they do have symptoms at baseline, we’ll likely be asking them things such as:
“How are you now?”
“How is it now?”
*If at any point it seems like they’re not getting it, we might need to pause and explain again the purpose: “Remember the goal here is to try to reproduce/change your symptoms so we can figure out what will help. So remember to pay close attention to your symptoms and let me know what you’re feeling. Does that make sense?”
It’s not uncommon to need to remind people of this. They may have never been part of a collaborative investigative process like this.
3 1/2. Getting specifics
Another way that the physical exam boosts body awareness is when we ask for more specific information during testing.
For example, If they have pain with a forward bend and we ask things such as,
“At what point in the movement does the pain start?”
“Does it stay the whole time or does it come then go?”
“Is it your familiar pain?”
“What does it feel like?”
All of this requires them to pay close attention to their body, and of course, it’s valuable information for us as well!
4. Assessing for changes
This is where we return to baseline and provocation testing to make sure they aren’t significantly worse. This is the first opportunity for the person to compare how they’re feeling now to how they were feeling before, which requires—you guessed it—awareness!
You can see how the person’s body awareness can be boosted simply through the process of the examination, so long as they’re engaged in the process.
Awareness of the Mind
The physical exam is also an opportunity to build awareness of the mind.
This happens when we ask about other aspects of their experience during testing. If you’ve ever paid close attention, you know that when we experience pain it’s always accompanied by thoughts and emotions.
Asking about these other aspects of experience can help the person become more aware of the mind as it relates to their problem and can open a conversational door for us.
When we notice distress on their face, in their breathing, or through other signs, we can simply ask:
“What’s coming up for you?”
“What comes to mind as you do this?”
“You look concerned, what are you feeling right now?”
Now let’s talk about how treatment can be used to build awareness.
Awareness of the Body
Similar to the physical exam, treatment is an excellent opportunity to build awareness of the body
1. Treating in a test/retest model
Treating in a test-retest model is a key way to build body awarenesss.
This process requires the person to be aware of their body and symptoms during the test phase, feel their body during the intervention, then check back in with their body to compare during the retest phase.
This is a nice positive reinforcement cycle that teaches them how to use the information from their body to make decisions. This is a huge step toward teaching them how to self-manage.
The more explicit we can be about how we’re using the information we’re gathering from testing and retesting to make decisions, the more the person will learn.
2. Cueing the person to check in with their body
Another way of building body awareness through the treatment process is to cue the person to check in with their body.
We can do this by asking them things such as:
“What are you feeling?”
“Where do you feel it?”
“How is it changing as you keep going?”
Awareness of the Mind
Similar to the physical exam, we can ask them about their experiences during interventions to boost their awareness of the mind.
This is especially salient when they are experiencing their familiar symptoms during interventions. We can ask things like:
“What’s coming up for you?”
“What does that make you think?”
“Do you feel safe right now?”
Now let’s talk about how our discussions or education can be used to boost awareness.
Awareness of Cause & Effect
Sometimes people come to us with very little awareness of cause & effect.
1. Connecting the Dots
They have little insight into the aggravating and easing factors or the relationship between these factors and their activity limitations. If through the process of the exam, we uncover some of these factors, it can be quite useful to connect the dots for them.
Let’s say the person has right-sided low back pain when they walk, pain with lumbar extension, and limited right hip extension. Laying out how this all relates can expand their awareness of cause & effect.
This could sound like, “When we walk, our back leg needs to be able to trail behind us. If it doesn’t, the areas above or below can get annoyed by that. If we can improve your hip flexibility when you walk to allow your back leg to trail behind you, it will help your back feel better.”
2. Summarizing Behavioral Patterns
Another way of improving someone’s awareness of cause & effect through discussion is by summarizing their behavioral pattern(s)
For example, If they seem to fall into an avoidant behavioral pattern, we can say something like, “It sounds like you’re in a bit of a cycle where every time you encounter the pain you stop, but we just found that when you keep going, the pain actually improves.”
If, on the other hand, they seem to fall into a persistent behavioral pattern, we can say something like, “It sounds like you’re in a bit of a cycle where you push through the pain, and it tends to get progressively worse. What do you say we try backing off a bit so as to not make it worse, and progressively building from there?”
Giving them this zoomed-out view of how they’re responding to the problem and what another option is can help them to see their problem from a different perspective, thereby expanding their awareness.
Specific Awareness Exercises
Finally, I want to offer you some very simple and specific awareness exercises.
These aren’t necessary for everyone, but they can be tremendously helpful for some. I’ve personally benefitted greatly from practicing these techniques.
Positional Body Awareness
If someone has pain in a specific position, such as sitting or standing, it can be useful to guide them to bring their awareness to their body and see what they discover. They can notice how they’re holding their body and can play with different positioning options.
This is an extraordinarily simple thing but can be tremendously useful.
Honestly, how often do people come to us with pain with static positioning? And how often do we guide them to practice exactly that?
I’ve had low back pain that’s aggravated by standing for over 12 years and it was only fairly recently that I took a few minutes to stand up, close my eyes, and practice standing. And I learned so much from doing it just one time! Now it’s something that I more or less incorporate anytime I’m standing (when I remember, of course).
As we’ve discussed already, explaining the purpose of these exercises is important, because if people don’t understand why they’re likely not going to be engaged.
The way I explain it is something like, “So you mentioned that you have pain when you stand for long periods of time at work. Are you open to trying a simple exercise to see if we can’t find a more comfortable way for you to stand at work?”
The beauty of this lies in its simplicity. In my eyes, there are only 2 steps to this awareness exercise:
Finding the center or balance point
Finding the balance between effort and relaxation
I’ll guide you through it right now:
Close your eyes
First, notice where in your feet (or your bum and your feet if you’re sitting) you feel the most pressure
Can you find the center/balance point? Slowly move your body until you find what feels to be the center point, the point where you feel balanced
Once you feel somewhat centered, bring your awareness to the body breathing. Each time the body breathes out, let it relax a bit, staying in your center point
Keep relaxing until you find the minimum effort required to stay in your center point. This is the balance between effort & relaxation
Feel free to hang out here for a while. Take notice of how it feels. Breathe. And If you move out of your center point or out of your effort/relaxation balance, simply begin again.
Notice how dramatically different this is from me telling someone how their posture is wrong or telling them how they should be sitting or standing.
The fact is, every *body* is different, which means that everyone has a different center point, which means that I can’t possibly know the right way for them to position themselves. They have to figure it out for themselves. And through the process of figuring it out, they develop their awareness of their body. This ties into the next awareness exercise, movement awareness.
Movement is immeasurably complex, so just as with positioning, I take the humble approach.
This looks like guiding the person to discover the right movement option(s) for them, rather than thinking I know the best way for them to move.
If someone has a specific movement that bothers them (could be walking, bending, deadlifting, pressing), I start broad and get narrower as required
I’ll start by asking them what they notice during the movement, symptom-wise and movement-wise
“What do you notice?”
“Do you feel balanced/centered?”
Then (if necessary) I’ll bring their awareness to a body region
“What do you notice about your arm swing?”
“How does your left foot compare to your right foot?”
“What do you notice about your knees?”
Then (if necessary) I’ll point out what I notice & ask them if they notice it
“Do you notice that your left arm swings more than your right?”
“Do you notice that your weight is a bit forward on your toes?”
Finally, if all of the above isn’t happening, ask them to change a specific thing
“What happens if you swing your arms more?”
“What happens if you take smaller steps?”
“What happens if you sit back over your heels more?”
*The less that I have to cue, the more the person is relying on their own awareness to guide their movement and the more they will learn.
Finally, the best tool that I’m aware of for building awareness of mind is mindfulness meditation.
This is the simple process of sitting down and observing our minds. This can be useful in situations where you and the patient identify that thoughts or emotions are a salient factor related to their symptoms, from the standpoint of cause, effect, or both.
When I pull this out in the clinic, I simply bust out my phone and turn on a 3-5 minute guided meditation on the 10% happier app. I also like headspace. They both have free trials so it can be an easy thing for them to do at home.
Meditation is an exceptional way to cultivate awareness of mind (and body), and I’ve personally found it to be one of the most important tools in my life.
If you want to hear more about meditation, I discuss it in-depth as it relates to our own awareness in my article about clinical reasoning.
putting it all together:
Without awareness on the part of the patient, there’s little we can do to help them.
This is because much of what we’re dealing with when working with people is subjective in nature, which requires us to rely on them to give us information about their experience
Awareness is important because:
It leads to influence. The more aware we become, the more potential we have to influence something
It leads to care. The more awareness we build around something, the more likely we are to take care of it— naturally
The 3 main foci for our & our patients’ awareness are:
Awareness of the body
Awareness of the mind
Awareness of cause & effect
We can help our patients build awareness through the process of the history, exam, treatment, and with specific awareness exercises.
& remember, we’re doing this stuff already, but by being more intentional about it, we can make it more impactful and more likely to stick so that our patients experience long-term success through their heightened awareness.
Thanks so much for reading! Drop any questions or comments below!