Shared Decision-Making: Putting the Patient Back in the Driver's Seat - With Walt Fritz

As our profession pushes toward patient-centered care, one thing is becoming clear — the old clinician-as-the-expert model isn't serving our patients the way we think it is.

In this episode, Jamie sits down with Walt Fritz — a physical therapist with nearly 40 years of experience and someone who famously walked away from a prominent role in the myofascial release world to publicly question the narratives he'd built his career on.

They talk about shared decision-making, informed consent, power sharing in the therapeutic relationship, and why the "soft skills" might actually be the most important skills we have.

In this episode:

• Why the clinician-as-the-expert model is failing our patients
• How the language we use (like "releasing fascia") affects informed consent
• What shared decision-making actually looks like in a treatment room
• The concept of *metatherapy* — and why how you apply a technique matters more than the technique itself
• How to give patients a range of treatment choices including home care, frequency, and movement
• Why the "micromanaging patient" is actually your greatest asset
• Carl Rogers' 1957 paper and what psychotherapy figured out 70 years ago that manual therapy is still catching up to
• Why Walt calls these "human skills," not soft skills

Whether you're deep into manual therapy or just starting to question some of the narratives you were taught — this conversation is going to make you think differently about the person on your table.

Safety video Walt Referenced can be found by clicking HERE

References: 

Helou, L. (2017). Crafting the dialogue: Meta-therapy in transgender voice and communication training. Perspectives of the ASHA Special Interest Groups, 2(10), 83-91.

Cerritelli, F., Chiacchiaretta, P., Gambi, F., & Ferretti, A. (2017). Effect of continuous touch on brain functional connectivity is modified by the operator’s tactile attention. Frontiers in Human Neuroscience, 11, 368.

Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of consulting psychology, 21(2), 95.

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Transcript

00:00 As we push more towards patient-centered care in our industry, there are certain things we need to start changing in our practices. For so often, the manual therapy professions have been using something more along the lines of the clinician-as-the-expert model. And this is where a patient comes in, and they have a certain expectation where we determine the cause of their problem, develop a treatment plan, and they have that certain confidence that we can remedy whatever issue it is they're dealing with.

00:32 But doing things this way isn't really including the patient in the process, nor does it give us much insight into their lived experience. So part of what we need to do in shifting to more patient-centered care is to start including the patient in what is called a shared decision-making process and encourage power sharing in our therapeutic relationship. Now, there's a lot to this process, and if you're committed to having a better patient-centered care in your practice, well, keep on listening.

01:05 Jamie Johnston: Hey there. I'm Jamie Johnston, and you're stepping into a new era of thriving as a massage therapist. We're embracing who you are, pursuing what you love, and confidently shaping your practice. We'll challenge industry norms, spark change, and discuss what truly matters—things like mental health, evidence-based practice, and some topics we've long avoided. Let's create better outcomes for our patients, and happier, more fulfilling practices together. Welcome to the New Generation Massage Therapist Podcast.

01:42 Jamie: Okay everybody, we're here today with an old friend, Walt Fritz, who I've known for I think 10 or 15 years or something like that now, Walt. Just meeting through online things and in person at some courses. So, why don't you give us a little bit of background about you?

01:57 Walt Fritz: Oh gosh, um, I've been around the business a long time. Jamie, I think I—did I first meet you in Vancouver at one of those, um, things, yeah, I can't remember the name of that place, but yeah, that was a fun one.

02:08 Jamie: The RMTBC Conference?

02:09 Walt: Yes, thank you. Um, and uh, but I've been a—I've been a physical therapist since 1985. Um, manual therapy is—I mean, it's what I do, it's what I teach, it's kind of what I specialize in, both as a clinician here in my office in Upstate New York, as well as uh, traveling and teaching. Uh, my background is uh, myofascial release—I mean, I was one of the guys. Um, the inside club guys of myofascial release. And then I had the audacity to uh, to leave that model, and uh, and start publicly questioning it. Which uh, it created a lot of like um, I-I guess a lot of um, um, friction in that MFR community, but I know a lot of people actually appreciated the dialogue. The narrative of why would you question something that's so effective? Why would you question something that's given to us by this guru um, type of educator? And to me, it was pretty simple. It's like, you know what, there's more to life than just fascia. So, um, and now I-I sort of um, well, over the last 6 years kind of veered off on a slightly different path. I, prior to 2—uh, co-the beginning of COVID, I was teaching pretty much um, half and half classes to massage and physical therapists, as well as classes to speech pathologists. But during uh, that early COVID period, I had a really good chance to sort of regroup and take a look at myself, and um, and I decided to make a shift, and now the only classes I teach live are my voice and swallowing disorders classes. I do get—I do get a-a wide range of therapists attending those, it's not just speech therapists, speech pathologists, but um, I don't know, I found a real freshness in that um, in that new community. And honestly, Jamie, they didn't have a lit-a lot of really bad habits that were sort of um, instilled from them by sort of those closed um, concept uh, multi-tiered trainings that, I mean, let's face it, you and I, that's-that's kind of our bread and butter on how we learn this work, right?

04:08 Jamie: Totally, which is—which is very interesting because um, uh, like looking over some of your articles and things like that, looking uh, one that I found um, you talk about that approach or that old narrative approach of being the—the clinician-as-the-expert model. Um, and it's—I find it really interesting to-to come up with that as sort of a label because that's what many of us were doing and many of the instructors were doing. Was that they were this huge expert that, you know, you had to do whatever they said um, and it's—it's awesome to see the transition that you've made. But what I find interesting is, like when we're taking that approach, we're not genuinely getting informed consent from our patients. When we're using the old narratives of the, you know, "I'm releasing your fascia" or whatever like that. Um, and I'm just wondering if you have any thoughts on that around like actually getting informed consent when we're using that older model?

05:07 Walt: Yeah, I-I think it's a really—I think it's a really valid point, Jamie, because I-I don't always think of it quite that way in terms of the informed consent piece, but I know that um, as soon as you said it, it resonated really well. Patients or clients, whatever you call your people, um, they have a tendency to sort of hand over power to us. "You're an expert." You know, nobody's helped them, and "You've been told to me you're the guy, right?" Um, "So I trust you, do what you think is best for me." And, well, you know, I understand that model, it's-it's basically part of medicine and healthcare in general um, in terms of how that-that-that division of power or separation of power happens. I think it also makes—puts the patient in a rather vulnerable position where, yeah, we-we haven't really gotten that clear informed consent from them. I believe strongly in boundaries and permission, you know, staying within our boundaries, which, again, I don't want to get too um, inflated—inflammatory here, but in a lot of models boundaries are easily crossed, you know, in terms of, especially when it comes to emotional, somatic type works where we're taught that, oh gosh, I was taught that, you know, "Until the patient comes to terms with their emotions, they're never going to truly deal with their pain." And it's like, boy, that's a fine line between um, you know, being a physical therapist, being a mental health counselor. And now with the-the onset of trauma-based therapy, I think there's some really good ideas and concepts that are being taught, but I also think we're missing some of the granular piece down low is, you know, what should we be doing and what should not we-we we not be doing? What are allowable techniques and what aren't? And you know, I, again, I don't want to ruffle too many feathers, but I was taught a lot of my myofascial release training that I look back and say, boy, that's a huge boundary inflection um, in terms of what we did, what we said, etc. How we lay out our website, Jamie. I mean, have you ever go to-to an expert's website and it's all leading you down the path of, well, stick with the fascial model, right? It's all about your fascia, because people don't know about fascia, right? Um, that's what they say because we've heard it, so we repeat it, we regurgitate it, it becomes to a-a shrine to the guru that we we learned from. And you know, there's value, that-that can certainly draw public in. But can you know with 100% certainty that this person's problem is their fascia, and can you know with 100% certainty that you're releasing it, whatever that means? And if not, I don't know whether really we're really clear on that informed consent piece.

07:44 Jamie: Yeah, and which makes it also difficult because when we're—when we're using descriptions like that, it's also giving the patient something to blame for their pain. Right, because they're going, "Oh, it—it must be my fascia. I got to go get that released," or whatever the technique is, you know, we're not just picking on fascia. You know, it could be that, "Oh, I need to go have somebody do this to my tissue in order to-to feel better." So, um, it's good to see that—that many of us are starting to make that transition and making the change.

08:15 Walt: Yeah, in fairness though—in fairness, I mean, that's part of—that's part of the sell, right? It is part of the sell, and let's face it, we are selling our services. But I think there's more ethical ways that we can do that. I still get patients, even though I let go of those words myofascial release 6 years ago now, I still get patients who said, "You know what, my doctor or somebody else said that you're the guy for fascia in the Rochester area." And yeah, over time I sort of soft-pedal that that's changed a lot, but I do think it's important, Jamie, not to fracture elements of the therapeutic relationship. If they feel that we're that person, right, um, I want to be very clear on the boundaries, etc., but you know, I also don't want to just sort of step on a story that they really sort of become accustomed to and feel is the, you know, their missing link to pain relief, that sort of thing. It's a real fuzzy area that I don't know that a lot of us are taught that. I was teaching a class overseas earlier this year, and on the second day a therapist sort of interrupted me—not interrupted me, but she said during a break, um, "You know, you're teaching us the soft skills that we're supposed to know, but nobody really teaches us, right?" And I thought that was really insightful because I never really sort of looked at the way I approach this work from a shared decision-making perspective, that it's the soft skills. And you know, I-I-I've got a really interesting paper, if you're interested later, Jamie, about this on metatherapy, that really describes those soft skills and the need for those really well.

09:51 Jamie: Yeah, and—and I started to make a shift there, too, because they're—like I-I've gone away from calling them soft skills because they're really hard skills. And I'm actually starting to call them more human skills, rather than soft skills.

10:04 Walt: Yeah, yeah, and I think that's probably an-an even better way to put it, right?

10:08 Jamie: Yeah, yeah, because we're treating that—that human in front of us, right? So, how we connect with them and how we talk to them and all those different things that makes such a difference in a treatment.

10:17 Walt: Exactly. And if I could just—I'm just going to get rid of this one already, since I just wrote it down and I don't want to forget that, but uh—

10:22 Jamie: Sure.

10:23 Walt: —I was doing a um, I was doing a podcast—not a podcast, but a meeting. I was invited to do grand rounds at the University of Pittsburgh Medical Center um, uh, 2022, and it was a group of ENT surgeons and speech pathologists, and they wanted my whole take on-on treating, you know, using manual therapy for voice th-um, um, issues. And I was sort of going through the concept of, yeah, we use these techniques to help with that. But we're really trying to-to get the patient more involved via shared decision-making. I was kind of describing loosely my shared decision-making model, and one of the clinicians stopped me and said, "Hey, um, have you heard of metatherapy?" And I hadn't, and she said, "Then let's talk later." So we separated via another Zoom later on, and it was a researcher by the name of Lea Halou. Lea Halou's a PhD speech pathologist who has written extensively on a concept called metatherapy. And the way she describes it is, the therapy is what you and I do, right, whether it's a exercise or a, you know, a cognitive behavioral intervention or a manual therapy or a massage type, it's the technique we're using. But what she described was the meta that surrounds that therapy, and the meta in her view was possibly equally impactful, if not more impactful, than the technique itself. And what she did in her research was she took a look at two re-two clinicians. One was a brand new grad, and one was a more experienced clinician. And they were using specific voice techniques for a voice disorder, and I'm-I won't go into that for the sake of this, but anyway, what she did was she observed the new clinician using the technique, and they did everything properly. They-they did the technique exactly how it's taught. And then she compared that to how the technique was applied by a-a more experienced clinician. And what she saw was that skilled clinician did the exact same thing with the technique, but how she enveloped that technique was very different from the new grad. The the meta that surrounds it is our language, our understanding, our relatability, the context that we figure out to apply it in, and yeah, it comes from mentoring, from experience, from education. But what she was describing was to me, and the reason she interrupted me at that point, because she saw my shared decision-making model falling right into the metatherapy model. That we think it's the skill of isolating the pterygoid when we're trying to do a jaw technique, right? And it certainly is, it's—that's important. But it's the context that we ground that technique that really becomes more important, and to me, I accomplish that through shared decision-making, meaning, Jamie, what I'm doing right now, does it feel like I'm doing something that might be productive? Is there anything about this that feels like it could be threatening or harmful, or does it feel like a big waste of time? Is there a place you'd rather have me go? So, I'm using techniques as I learned them in MFR and all these other classes over the years, right, but we're sort of handing over, not handing over, but opening up the window to power sharing with the patient. And I know I'm going on a little bit here, I apologize, but I-I linger, I-I lurk on a lot of massage groups on Facebook especially, and one of the repeating themes that I often see brought up is people, therapists complaining, "How do you deal with the micromanaging patient? The patient who wants to control the session?" You know? And to me, it's like, I want my patient—

13:50 Jamie: Like them.

13:51 Walt: —to let—yeah, to have me tell them, "No, you're not quite on it. No, stay there longer. No, it's time to move on." But a lot of people feel that that's a real infringement on their expertise, and I think we've got that backwards. I think that's that patient telling you how to help them better.

14:09 Jamie: Yeah, and it's—and it's interesting like when you look at both ends of that, because the—like you look at, you know, some notes that you and I shared is that, you know, success breeds confidence. And you've got a—a therapist who's been successful for—for a while and breeds confidence, and then they've got that person in front of them who wants to take more control of the—of the therapeutic dynamic. But their success is maybe telling them, "No, I sh-No, no, this is like I'm the expert, so we need to listen to me." So, how do we—how do we take that and make that shift in the power dynamic to-to to take it from that person who maybe doesn't want to make that change, but-but should make that change and understand how to—how to hand that power over to the patient?

15:02 Walt: Yeah, I think the "should" is difficult, right? Because if you're—if you have a successful clinical practice being the expert clinician, why would you want to change? And you know, I'm-I'm not in the model of sort of beating people up to say you can't—you can't keep doing that um, if it's a successful model and your patients are happy with what you're doing, fine. I think, uh, no, not think, I know that one of the reasons I like teaching the class for speech pathologists is because I'm not getting experts in the room. I'm getting experts in speech pathology, but they're beginners when it comes to manual therapy. So, I can sort of sort of bend them in the direction that I want, right, which is shared decision-making. But the cool thing is it from their perspective and from your perspective is shared decision-making applies no matter what you're doing, whether it's manual therapy or massage or myofascial release or exercise. Exer-I use an exercise-based approach for my—for teaching patients exercise. You know, if the standard exercise that's supposed to be good for your biceps isn't quite resonating from peripheral to central, let's modify it to some until something feels like, oh, whatever we just changed, that feels more useful. You're sort of having a conversation with my pain, my weakness, whatever that is, right? So, um, I just offer it up as an option, one that really, I believe, at least from my profession, I'm expected to work from an evidence-based model. Those three basic components of the evidence-based model are the research, right, the evidence, clinician's expertise and experience applying that good research, but that third circle—patient preferences and values. I love asking people, like when they're doing manual therapy, myofascial release, "How do you account for that third, 1/3 of evidence-based practice? How do you account for patient preferences and values?" And there's a lot of a lot of sort of hesitation and stammering, and I'll hear things like, "Well, you know, I ask them how the pressure is." And certainly that's fine, that's a fine starting point, but in the original model that was 1/3 of the weighting. How do—how do you elevate that to essentially a level where you and I, if you're my patient, so you and I are having a relative equality in power in this therapeutic relationship? And there's a lot of different ways that people have talked about how sort of elevating pa-patient preferences and values, and I think shared decision-making is a really good one, all right? Um, so, if you're expected to—and in Canada, I know you have a lot different education program than the United States for massage therapists, is the evidence-based model supposed to be a basic tenet of what your work from?

17:42 Jamie: Um, I mean, it's been quite a while since I was in school. I don't know how much they've updated it, but I know our college, uh, like our um, regulatory body is pushing that more, that—that they want that. So, um—

17:55 Walt: Yeah.

17:55 Jamie: —to me it's a good thing to hang my hat on, it's like, okay, I'm giving you one way, it's not the only way, I'm giving you one way to at least see that, okay, I am honoring the basic components of the evidence-based model through shared decision-making.

18:10 Jamie: Yeah, which is—which is great because then how do you introduce a range of treatment choices to a patient? Because it—like a range of treatment choices isn't necessarily that I'm going to use a different technique with you, it can also be we're going to use some movement or we're also going to maybe adjust the time of the treatment and the frequency of the treatment and all that sort of thing. So, how do you present a range of treatment models to a person to—so that that shared decision-making is taking place in your treatment planning?

18:43 Walt: Yeah, so um, uh, I so I-I work from a myofascial release traditional perspective, at least the way I learned myofascial release, there's a lot of different schools of MFR, right? Some are more a Rolfing fascia, um, but mine's a slow lingering fascia. And I use a lingering fascia, number one, because I'm used to it, but not because of what I was taught originally that if you don't stay in that—in that hold for 90 to 120 seconds or 5 minutes, whatever it is now, that you're never going to release the fascia. I hold it for a period of time, so it gives the patient time to reflect, to feel reflect, first of all, "Do I feel safe?" And I think that's the basic um, component we have to get over first: does this feel safe? And if they don't feel safe, they're not going to go to the next level of reflection, right? So I want to make sure whatever we're doing feels safe, and not just my pressure, but me, the situation, all the context that I've created here, do they feel safe in my presence on my table right now? And until they get past that, um, we can't move into reflection. But reflection to me is where it really comes in, it's like, okay, I feel what you're doing, Walt, but it's not quite connecting with my problem. I use words like that: connect with the issue, whether that's making it more aware, right, or calming it, quieting it, soothing it, right? I want to—I call it a continuum of relevance. I want to do something with you, Jamie, that I'm I jump on that continuum. Now, where we go, one end of the other, that's for you and I to figure out. So, that shared decision-making model of let the patient help you help them, right, I in terms of my lingering touch perspective, it gives them time to relate and reflect. I don't—I'm not going to sort of weigh this conversation down, but I have a lot of research that takes a look at, for instance, the effects of continuous touch, not just on the tissue, but on central nervous system in terms of brain centers, right? There's a lovely study in 2017 by Ceratelli that took a look at the effects of continuous touch on the receiver, all right? And to me, I'm—my work is all about trying to get that patient's central nervous system to say, hey, whatever you're doing, this feels useful. Now, MFR to me, the way it was taught to me, it's not like I would say to them, "No, you can't say anything to me, I'm the boss, I'm the expert," right? But it was often done in silence, right, so we could let them go deep and reflect and relate and find their emotions and is it relatable, not that those don't have value, but my interactions tend to be more verbal, more verbal in the way that, "Does this feel safe? Does it feel useful? Are we on the right spot? Would you like me to move on now, or would you like me to linger?" Right? So, that's kind of how I arrange my sessions, and you know, there's times when the patient says, "No, whatever you're doing, stay there. I want you to stay there right now." And people will look at me and say, "How," you know, especially speech pathologists, "Well, how can you hold a technique for 20 minutes?" And I'll say to them, "Because my patient asked me to." They were finding value in it. And to me, that is good ethics right there, actually listening to what the patient is requesting without me feeling like, "Oh no, we have to do these other things in this session, too."

22:15 Jamie: Yeah, and which makes it a contributing factor back to informed consent as well, right? That's the—the consent that they're giving to-to you, that that's what's feeling good at the moment and what is feeling effective for them. So, to go with that, quite often our biases will play a role in the technique we pick or different things like that. And I know um, you've had uh, gone over quite the bridge of dealing with your bias from—from your old narrative. So, uh, me—like how does biases bias influence our treatment choices when we're connecting with maybe a new person or somebody that we've seen for quite some time?

22:58 Walt: Yeah, now, you know, I don't know, again, I don't know the exact scope of a massage therapist and RMT in Canada, but um, you know, in I I'm a physical therapist. I'm legally allowed to use manual therapy, I'm legally allowed to prescribe exercise, right? Um, my website is sort of a weeding out tool in a way, because if a patient comes to me off the street um, never having seen my website or heard about what I've done, and they look around my office and it's like, well, where's all your stuff? Where's all your machines? Where's all your ex—where's all your TheraBand and all those things, right? So, inherently there's a bias because I lean toward um, a manual therapy type of approach. Over the last 5 years though, I've found myself sort of going back to some of my roots, using more of an exercise-based model, not I'm going to watch you do three sets of ten, but realizing that that movement, that exercise has incredible value, and I'm—I'm combining manual therapy with that sometimes simultaneously, right? But, I mean, I have strong biases the way I treat. I've got patients ask me, for instance, Jamie, "Why are just holding a stretch? Why aren't you rubbing it? Why aren't you massaging it?" And I say, "Well, because that's a lot of my training, and if you'd like, I can do that. Um, I tend to lean into more of a-a static hold because that's what I've done, and that's what I've had good success with. But I want to see if I can sort of modify what I do to meet your needs and values and expectations, right?" So, um, I mean, we can't get rid of our biases, we have them, right? I think I think shared decision-making in is an integral aspect of what we should be doing, there's a bias right there, right? Other people other people are working as the expert, and they see no need for that. Um, am I right and they're wrong? Not necessarily.

24:49 Jamie: Yeah, and the thing is, the patients will have biases as well, right, because they—they could have gone to some uh, some treatment providers in the past that, you know, they had some low back pain and a certain technique worked for them, and they might be coming in going, "Well, I know that worked for me before, so I want the same thing." And then maybe we have to have the conversation with them, sort of like you were just having, that, "Well, this has been my experience and what I've done for a long time, and this is why I use this hold, but we can change and do some more of the things that—that you feel you like," and incorporate that in.

25:22 Walt: Yeah, I mean, bias extends to what the patients come in feeling is wrong with them, I mean, that's part of their bias, right? And I I remember um, back in the MFR days when patients came in to say, "You know, I'm having back pain because my my core is weak." And I would say, "No, it's got nothing to do with your weak core, it's your fascia that's restricted, right?" And you know, they'd say, "Okay, that's an interesting approach, I've never ho-I've never heard of that." But I have also learned that it's really important from a therapeutic relationship and everything that that conveys, that it's really important not to fracture, to provide fractures in the therapeutic relationship, because if we do, we lose credibility in the eyes of the patient. So, what I've learned to do is not to be a slippery chameleon in-and change colors for every patient's belief system, right, but to to provide a sense of validation to the beliefs that the patient come in with, even if all I don't believe it's correct, right? No matter where they got it from, a past therapist, from their physician, from their, you know, spouse, from Dr. Google, they all come in with an idea of what's wrong with them. And what I try to do is at least validate that, yeah, it could be that trigger point that your doc said that you're loaded with, or it could be, you know, just your nervous system is just loaded with remnants of his—of injury from the past that it hasn't figured out a way to let go of. I tend to give them two relatively disparate narratives, one that they came in with, and something set up on purpose to be pretty wide apart from what they said. And I'll tell them, you know, "The evidence, there's evidence to support both of those," and I love saying this, that at first confuses people: Jamie, I may help you, but I may never know what was wrong with you. And that's a real—that's a tough one sometimes because we're supposed to know, right? Um, the more I learn, the more I realize I don't know a lot, you know? I don't know everything, which sounds odd from an expert with this many years of experience.

27:26 Jamie: Yeah, yeah, well, the—I tell you, the more research that I read and the—the longer the tooth I get in this profession, the more I realize I don't know that much.

27:34 Walt: Yeah, yeah, but it's fun because we don't have to abandon what we're doing, you know? I didn't abandon my myofascial release hand holds and everything. I just sort of evolved the—the narrative that I use to explain what I'm doing, and why I'm doing it. To me, mechanism of action is hugely important. And all of those rabbit hole therapies that we learn from, right, those, you know, where you're sort of clustered as a group and we're all learning about trigger points or, you know, fill in the blank, right, there's so much evidence out there that there's—there's a lot more to it than just that single tissue story. And I-I, you know, I have a cluster of those sorts of studies that, when people start to challenge me on that, it's like, have you read these papers? There's a lovely paper that was written, it's like essentially by a researcher by the last name of Kolb, K-O-L-B. And he's essentially saying, we know so much, why do we continue to teach manual therapy from that pure mechanistic, biomechanical perspective when we know we're treating a human being and not a dysfunctional tissue?

28:39 Jamie: Yeah.

28:40 Walt: But, you know as well as I do, a lot of that often falls on deaf ears.

28:44 Jamie: Yeah, yeah, and—and again, it's every technique, right? It's—

28:47 Walt: Yeah, absolutely, yep.

28:48 Jamie: —we're working with the person in front of us, not just the tissue in front of us. Um, I wonder do you have any steps that we can take to ensure that we're getting more participation from the patient as—as far as shared decision-making goes?

29:05 Walt: Yeah, and I find it—it helpful to sort of um, warn them. I do things differently. Um, I'm—I I use humor a lot, sometimes maybe a little too much, but I tell my patients I'm very needy. I'm a needy therapist because I need their help. Even though previous therapists may not have found that of value, um, the more I know about you, the more I can I stand a chance of helping you. So, I do that on my website, I give sort of a-a synopsis of, you know, um, here's my history, here's my present, I may be different um, but the whole point of this is to see if we can do something that maybe somebody else hasn't done in the past. Um, I if I can share with you a real quick story here. I had a patient come in to see me a couple years ago with some jaw pain, and she had seen a lot of different therapists, but she really bonded with a craniosacral therapist who she found the work very insightful, very helpful. Um, she loved to be able to sort of drift deep into that—that emotion piece of what she was feeling, how it related to the past and present. And, you know, if most of us have been there in various trainings, and I certainly can recognize that approach because I trained in craniosacral therapy as well. But for some reason she left that person and came to see me, was like, "Great, okay, so let's—let's do this, right?" So, you know, I—I started my approach, I explained to her what we were trying to do, what the possible, you know, in terms of informed consent, here's the possible positive outcomes, here's the possible negative outcomes, which I don't know whether a lot of people include those sorts of conversations, right? Um, but then I went to work, you know, we did the standard pterygoid technique that I'm sure most of your viewers are familiar with, right? We put the finger between the—the mandible and the maxilla. Um, and instead of me saying, "Oh, there's the—the pterygoid and I feel it's restricted and hot and ropy and a little bit vibration," and all those things I used to be able to intuit in the past, I said, "What are you feeling? Is this relatable? Is this familiar? Are we doing something that feels helpful?" And, you know, it's not that I kept her fully conversant during the whole session, but I kept checking in with her, kept checking in with her. So, we finished the session, and I said, "How do you feel?" and she said, "That feels really good right now. Can I come back again next week?" And I said, "Absolutely." So, next week came and she came back, and I said, "So, fill me in. Tell me what happened between last session and today." She said, "You know, my jaw is still feeling really well, it still feels like it's looser with less pain." She said, "But I really didn't like your therapy style. I didn't like how you never let me go deep. I didn't like how you kept sort of interrupting my process." And I'm saying, "Okay, fair enough, right? You're entitled to that opinion." I said, so I asked her, "Would you like me to stay quiet during this session?" She said, "Yes, please." So I did. I did it a little bit like a pouty child, right, because—

31:51 Jamie: Yeah.

31:51 Walt: —it's like, you know, "Okay, I'm now the expert who has to make decisions." So, I remembered what we did, I remembered where we did, and I did it again, right, both sides, we did some other things, etc. We finished the session, and I say, "You know, okay, so how was that?" And she said to me, "You never found the spot. You never found the spot that I needed work done." And I tried to sort of hold in my sarcasm, which is really difficult for me. So, um, at the third session, and she came back again, I said, "Can we sort of find a place to meet in the middle, right?" She saw the value of the questions. She just hope-hoped that somewhere within those questions, that shared decision-making aspect, that she could find her time to reflect and relate. So, it was a really nice—it was a nice sharing of decisions, and that's what it is right there, we're making these together. And it's not always equal, it never will be equal. Sometimes the patient takes the—the huge role of power. Sometimes they hand it to me or I—I take it because they're not communicating, or maybe they're incapable of it, right? But she saw the value in shared decision-making and allowed her—her beliefs to bend a little bit. And yeah, I bent toward hers too.

33:14 Jamie: Yeah, what I really like about that is like when we look at, um, like how much you use shared decision-making when it comes to things like recommending home care?

33:28 Walt: Oh, it's huge. Like, what—okay, so, um, let me go to exercise for a second. There are really good studies out there that if I can align my recommendations with what the patient likes to do, I stand a better chance of them doing it. I could feel that, okay, core stability, Pilates is what this person need, and they're thinking, "Oh, I tried that, I hated it." So, that's where the intake comes important. I'll ask my patient, "What sort of things do you like to do for exercise, for activity, for enjoyment?" Not to shame them into, "Well, I don't exercise that much." That's not what I'm talking about. "What do you like to do?" Right? And then I'm going to make my recommendations based somewhat on—not somewhat, but based on what they said to me. And that becomes the same for home treatment, for self-stretching, etc. You know, "What's your day like? Do you have 14 little kids at home that you can't lay on the floor and do what I'm asking you to do, or a dog that's all over you, right?" So, what I don't want to do is make it such a chore that I'm dooming it to failure before they even started. And I think that's one of, at least from a physical therapist's perspective, is we have a tendency to overload patients with homework. And some of us, "Yeah, give me all you got, I want to get better." But here they go home with—with four pages of exercise that we tell them they need to do this three times a day, um, and it's almost like a recipe for failure. So be realistic, and to me realistic is, do one or two things that you, my patient, find most impactful, right? And then if you want more, we can also do it. So, to me, that's how we incorporate both shared decision-making, as well as a real brutal understanding of the human condition that the more I give you, the less chance you're actually going to do it.

35:16 Jamie: Yeah, awesome. Um, so I wonder if there's been any shift that you've made as far as like just understanding contextual factors of treatment? So, with looking at the shared decision-making model, has it changed like how you set up your treatment room or any of those kind of things that we know those contextual factors can be a contributing uh, towards better outcomes with treatment?

35:44 Walt: That's a really good question, and it's one I've never really pondered because um, I mean, I've been in—I think this is my fifth or sixth office space, and um, you know, it's—it's full of tchotchkes as a patient of mine calls it, all sorts of stuff and knickknacks and souvenirs. Um, but no, you know what, to be honest, I've never really given that any thought in terms of making sure that, you know, it's arranged accordingly for contextual factors, and that's an interesting thing that I need to ponder.

36:13 Jamie: Yeah, and—and I don't know how shared decision-making would—would alter the—the setup of your room or anything like that, but—but I'd be interested to see if there's some research out there on that.

36:22 Walt: Yeah, well, I know, you know, certainly there's—there's aspects of agreement, right, in terms of the music I play, for instance, right? Um, you know, I—I was taught, well, you never want to play music with words in it, because then patients are singing along in their head versus going deep into the emotions. But it's like, screw that, I'm in this room for 8 hours a day, I like to play music that I like, right, um, to a certain extent. But I also, you know, I've modified that based on patient complaints, if you will, um, or preferences, and it's always on shuffle, so it's not like a continuous drone to somebody. I mean, that's just a real small case that I'm guessing a lot of your your um, listeners here do as well. But you know, even that sense of, no, never play music that has words, aren't I inserting my biases? Aren't I trying to manipulate the patient by—by sort of using that as one of the contextual factors that I set up? Um, I don't know, this is—it's almost like a-a never-ending questioning process for ourselves and our patients that I think is a useful one, but you know, eventually we we got to get them on the table and work with them, but you're right, the environment that we set up is—is really important.

37:41 Jamie: Yeah, I know I used to have, in one of the clinics I used to have, um, I had SiriusXM satellite radio in the—in the treatment room, and, you know, I'd there was one person that came in every time, I'd walk out of the room, they'd be on the table, as soon as I walked back in, they'd be like, "80s on 8! Put 80s music on!" And then another person that was like, "No, I want to listen to heavy metal," and I was just like, "Okay, whatever you want to listen to. I—it doesn't matter to me."

38:03 Walt: Exactly, yep, yep, yep, yep.

38:05 Jamie: Um, and one of the probably like the final big thing I'd love to touch on is how much of a difference, and I know it's going to be a big difference, but, um, I love the topic of therapeutic relationship, and I'm just curious, um, since you have started to implement the shared decision-making model, um, how much do you think therapeutic relationship has improved compared to when you weren't using it?

38:33 Walt: I-I think, well, again, we can't be objective with ourselves, right? We we have a bias. Um, I think I understand therapeutic relationship much better. I think I've learned ways to um, leverage it, to maximize it, to optimize it, to not provide a fracture in the therapeutic relationship, right? Um, you know, how much, that's a real hard one because a lot of my evolution has moved into more understanding those psychosocial elements to begin with, that even without knowing the therapeutic relationship in all the the qualities of it, you know, it's probably improved to a certain extent. Um, there's a, again, I hate to be overly heavy with some of these papers, but there's a lovely, very old paper that I think a lot of massage therapists, physical therapists, etc., should really take to heart. It's older than me, it was published in 1957, and it—it was published by a psychotherapist. Carl Rogers, famous psychotherapist, he was asked to present a paper at a psychological conference that, based on historical re-reports of the time, got him ostracized from his profession, which, which really resonated with me, because when I started speaking out, I got ostracized from the myofascial release perspective. So there was a bit of a-a kinship there, but what-what Rogers wrote about in this paper was the prevailing belief in the time in 1957 was that the choice of the correct modality was key to psychological change. That if a person presented with a certain psychological problem, the choice of the right tool or modality was key to change. And, you know, does that sound a little familiar today? Yeah. And what Rogers said is, the choice of the right modality is nowhere near as important as the relationship that we establish with each individual person. And to me, in a nutshell, that's exactly what we're trying to accomplish here. It doesn't matter whether you're using MFR, trigger point, or Rolfing or whatever, right? It's trying to build that bond. And by the way, that paper has been updated so many times by across the spectrum of profession, including um, a paper I just found by Eric Purves, another Canadian therapist who you're familiar with, who he and um, um, Robert Libard um, wrote a paper on knowing and those aspects of the therapeutic relationship that are really important, and I think I think we should learn more about that. That maybe it's our tool that's less important than than how we apply that tool, not to the tissue, but to the human being.

41:20 Jamie: Absolutely, work on those human skills.

41:23 Walt: Yeah, exactly.

41:25 Jamie: Yeah, yeah. Well, I think that's a—I think that's a good amount of content that we covered there. I really appreciate you coming on and uh, sharing your knowledge around this, and-and I know that uh, there's things that I'll be able to take away from this, and I'm sure lots of other people that are listening will have uh, some takeaways as well. And I'll link your—I'll go to your site and link that video you were talking about into the show notes.

41:51 Walt: Got it, great. And Jamie, it's been—it's been a lot of years since we had a conversation, so it's good to catch up with you as well.

41:56 Jamie: You as well, really appreciate it.

41:58 Walt: Yeah, no problem.

41:59 Jamie: All right, take care.

42:01 Walt: Bye.