Too Many Choices: Building Agency in Pelvic Health

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Pelvic OTPs United - Lindsey's off-line interactive community for $39 a month!
Inside Pelvic OTPs United you'll find:​

• Weekly group mentoring calls with Lindsey. She's doing this exclusively inside this community. These aren't your boring old Zoom calls where she is a talking head. We interact, we coach, we learn from each other.
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• Highly curated forums. The worst is when you post a question on FB just to have it drowned out with 10 other questions that follow it. So, she's got dedicated forums on different populations, different diagnosis, different topics (including business). Hop it, post your specific question, and get the expert advice you need.

More info here. Lindsey would love support you in this quiet corner off social media!

Transcript

Lindsey: New and seasoned OTs are finding their calling in pelvic health. After all, what's more ADL than sex, peeing, and poop? But here's the question. What does it take to become a successful, fulfilled, and thriving OT in pelvic health? How do you go from beginner to seasoned and everything in between? Those are the questions and this podcast will give you the answers. We are inspired OTs. We are out of the box OTs. We are pelvic health OTs. I'm your host, Lindsay Vestal, and welcome to the OTs in Pelvic Health Podcast. 

Welcome back to the OTs in Pelvic Health Podcast. Today, we are diving into something that's really close to my heart as somebody who co-runs the first and only trauma-informed pelvic health certification course, and that's the concept of choice and agency in our sessions.

Picture this, you're with your client in maybe your third or fourth session with them, and you say something like, which of the movement patterns that we went over in your last couple sessions do you want to review? And instead of an empowered response that you were hoping for, you kind of get this deer-in-the-headlights look, followed by a long pause, and then they say something like, whatever you think is best. If that sounds familiar, you're not alone. It literally just came up today in Pelvic OTPs United, which is my office social media community where we meet weekly and we have really active forums where people post questions like this all the time.

If you're interested in joining us, by the way, there is a link in the show notes. It's just $39 a month. So you're sitting there thinking, I thought offering choice was always good.

I thought agency was one of the ways I differentiated myself as a practitioner in healthcare. Well, stick with me because we're about to explore why sometimes this beautiful approach of client autonomy can actually start to feel overwhelming rather than empowering. So I want to acknowledge something that might feel a little bit uncomfortable.

As pelvic health practitioners, I think we pride ourselves on being different than the traditional medical model. We offer choices. We ask for preferences.

We consider the sensory system, the lights, how bright they are, the fabric, the texture of the fabrics, the, whether or not there's a sound machine, right? Whether or not we're playing music, right? We emphasize consent and agency, and these are amazing things to be proud of. But what I've learned throughout the years of not only treating pelvic health clients, but training close to 2000 practitioners to get their start in pelvic health is that sometimes our enthusiasm for offering choice can inadvertently overwhelm clients who aren't used to having any say in their healthcare. Think about for a brief second, the typical healthcare experience.

From the moment someone walks into a doctor's office, they're told what to do. They're told where to sit. They're told, put your feet up in stirrups.

They're told, scoot down to the edge of the table. It's directive. It's efficient, but it's directive.

And for many people, it's what they've come to expect from healthcare. And then they come to us. And especially if you're trained as a level one functional pelvic health practitioner, we're suddenly asking them to make decisions about their own care.

Where do you want to sit? Where do you want to start today? What position feels best? Is this amount of pressure comfortable to you? And so on, right? And while this shift towards client autonomy is absolutely in the right direction, it can feel disorienting for someone who's been conditioned to be a passive recipient of care. Now, there's actually some psychology behind this. When we're vulnerable or nervous or our nervous system is ramped up, which many of our clients are when they first come to see us, decision-making becomes more difficult.

And to the fact that they may have never been asked their preferences about intimate medical care before, it can definitely lead to a bit of choice paralysis. Some clients may even interpret our question as a sign that we don't actually know what we're doing, right? They might think, well, shouldn't the therapist know what's best? Others worry about making the wrong choice as if there was a test they might fail. So how do we recognize when choice is overwhelming? We talked about in Pelvic OTPs United today that there are several signs to watch out for.

And once you start noticing them, you may see them more often than you expect. The most obvious sign is a long pause. You ask a simple preference question, and instead of a somewhat quick response, you get silence while they're trying to figure out what they should say.

Another one might be when a client's repeatedly asked, what do you usually do? Or what do most people choose? I think that this our clients who are looking for a template or a normal response that they can default to because making the choice themselves can feel risky or overwhelming. You might also notice physical signs of anxiety when you present options. They may fidget.

They may look away. They may look like a deer in headlights. They might even just incessantly chat to kind of use up the time or to prevent from answering the question.

And then there's the client who always defaults to I don't care or whatever you think is best, even when the choice does matter to them. This is not a sign that they truly don't have a preference. It just might mean that expressing preference feels too unfamiliar or maybe even a little bit vulnerable.

So what do we do about it, right? What do we do in these situations? How do we maintain our commitment to client choice and agency while acknowledging that sometimes we need to scaffold that process? 

OK, first up, start small. Instead of jumping into big decisions about a treatment approach or even, you know, what movement they want to practice, begin with tiny choices that feel safe. Something like, would you like to keep your socks on or take them off? These sort of micro decisions or micro choices help people practice having preferences about their care without the pressure of making what they may consider to be a significant decision.

The second idea is offer structured choices rather than open-ended questions. So instead of what exercise would you like to practice today, you could say something like last week we did a little bit of cat and cow to really help start to get your diaphragm back on line to help you breathe with your diaphragm. Some people like to do that on their side because it feels really comfortable and they get some feedback from the side of their body.

Other people really enjoy doing it on all fours with a block on their back so they can feel it rise and fall. Both work well. What sounds better to you? Right.

So in this scenario, you're still offering choice, but you're providing context and normalizing both options. The third idea, give explicit permission for them to change their mind. So you could say something like we can start here and adjust as we go.

Or if this doesn't feel right, once we begin, let me know and we'll definitely try something else. This removes that pressure of making quote unquote a perfect choice up front. Here's another strategy I love model decision making process out loud.

So something like I'm thinking we could start with the diaphragmatic breathing exercise because you mentioned you're feeling a little bit unsure that you're doing it the right way. How does that sound to you? So you're showing them your clinical reasoning that you were listening to them, but still involving them in the decision making process. Another key strategy is to normalize the learning process.

You could say something like some people know right away what feels best. Others, we need to try a few things first. Both are totally normal.

This removes that pressure to have that instant clarity that sometimes I think people need to have about their preferences. Now I want to address something really important here. Recognizing and responding to choice overwhelm doesn't mean we abandon our commitment to client autonomy.

It means we meet people where they are and we help them build capacity for self-advocacy over time. Think of it like occupational therapy for decision-making muscles that haven't been used much in healthcare settings. We start with assisted range of motion.

We start with scaffolding before we expect someone to lift heavy weights on their own. And remember this isn't about making assumptions based on someone's age, background, or any other factor. I've seen young assertive professionals when I had my practice in New York City who were completely overwhelmed by choices about their pelvic care.

And I've seen people who seem really quiet who actually have very clear preferences once they feel safe to express them. So I think the key is really about staying attuned to each individual client and be willing to adjust our approach based on what we observe. Sometimes that can mean offering more structure, sometimes it means slowing down the choice-making process, and sometimes it means explicitly teaching people that they're allowed to have preferences about their own care.

One thing I've actually found really helpful throughout the years is explaining why choice matters in pelvic health specifically. So I may say something like, in this work, your comfort and sense of control are really important for both the physical and the emotional aspects of healing. That's why I'm going to be checking in with you a lot about what feels best for you.

So as we wrap up today's episode, I want to leave you with this thought. Our goal isn't just to treat pelvic floors or to resolve physical symptoms. We're helping people reclaim agency over their bodies, often after experiences that left them feeling powerless or unheard.

That's profound work and it doesn't always happen instantly. Sometimes the most therapeutic thing we can do is notice when someone is overwhelmed by choice and respond with patience and scaffolding rather than more options. Building comfort with choice and self-advocacy is definitely a process.

While some clients are going to embrace it immediately and think, oh my goodness, why does not every healthcare professional do this? Others will need time and gentle encouragement. So as you head into your sessions with your clients this week, I encourage you to pay attention not just to how you're offering choices, but to how those choices are being received. Notice the pauses, the defaults to whatever you think.

And when you see signs of overwhelm, remember that slowing down and providing more structure isn't a step backwards. It's meeting your client exactly where they are and helping them build the skills they need to advocate for themselves. 

Thanks for listening to another episode of OTs and Pelvic Health. If you haven't already, hop onto Facebook and join my group, OTs for Pelvic Health, where we have thousands of OTs at all stages of their pelvic health career journey. This is such an incredibly supportive community where I go live each and every week. If you love this episode, please take a screenshot of this episode on your phone and post it to IG, Facebook, wherever you post your stuff, and be sure to tag me and let me know why you like this episode. This will help me to create in the future what you want to hear more of. Thanks again for listening to the OTs and Pelvic Health podcast.