On Accountability and Anxious Patients

I have a client who is very anxious and very sensitive. She often emails me to check in after an appointment with questions about every bodily sensation she has after the session, or to ask me about unrelated things going on with her. She isn’t exactly high maintenance in the traditional sense - she is undemanding, overly apologetic, aware that her anxiety makes people think she is difficult, and concerned that she is bothering me - but high maintenance in the way a person who is anxious all the time, is. She needs a fair bit of hand holding.

In one of our last sessions she presented to the clinic with more anxiety than normal - a big trip involving plane travel was coming up - and was quite a lot more sensitized than usual. At the end of her treatment I failed to keep this sensitivity in the front of my mind and, when finishing the treatment with a good old head/scalp pull, used more force than I normally would for her. As I was stepping out she said “wow I feel like my head was about to pop off.” Damn. I didn’t make a fuss about it; I knew that, while I had used more force than usual, it was not a force that could be dangerous, I don’t work like that anyway. She got up, said thanks, felt relaxed and left. Usually a day or two after every appointment she contacts me worried that she’s experiencing something bad as she has a lot of health-related anxiety and I take a few minutes to discuss what she is experiencing. As usual, she texted me the next day with pain at the back of her head and neck. Bingo. I had done something her body did not like and it was telling her so and she was - courageously - telling me. Not blaming. Not pointing fingers. She wasn’t angry with me, she was worried something bad was happening. While I knew that I had not done anything that would cause injury - minor or serious - I had done something unexpected with a higher degree of intensity than she was prepared for. It wasn’t that the massage had been bad or harmful, it’s that it had pushed her window of tolerance a bit too much and it had further tightened on her. Her own anxiety was beginning to spiral and she was trying to stabilize the anxious feelings with education and reassurance. She was reaching out a hand asking me for help with a problem she couldn’t manage on her own. In all honesty, based on her comments and my self reflection, I was expecting to hear from her.

The first thing I did was acknowledge the feeling was real. Her body was expressing to her that something happened it wasn’t sure about and was producing painful sensations to get her attention. The second thing I did was point out that she had indicated I had pulled too hard, validating her feelings from the day before. I repeated her comment to her which had alerted me to how my work had made her feel, demonstrating that I had been listening and heard her voice and understood what she had communicated. The third thing I did was apologize for not checking in with her throughout the treatment, and state that in all future appointments I would be more conscious of checking in and making sure she knew she can ALWAYS say “that is too much, please be more gentle with me.” This demonstrated that while she has a responsibility to speak up for herself it is my obligation to ensure she always knows this, is always allowed, and that I am always listening for those requests. Always. Always. Always. Then I explained the concept of “DIMs and SIMs” to her, discussing how a sensitive nervous system can be easily put on the defensive, even when there is no biological danger present. That defensiveness can look like pain messages. I apologized again for this lack of communication during treatment and gave her some suggestions for SIMs she could give to herself on a cold, blustery snow day. This helped her. Acknowledging and validating her feelings reminded her she is important and her feelings are real. This taking of responsibility demonstrated that I value being accountable and will hold myself to that accountability. It sets a high standard for professionalism (and maybe even basic humanity but now I’m just tooting my own horn 😉 ). Taking the time to explain to her in a way she can understand how our bodies sometimes work helped soothe her worry; it’s not something bad, Jen just used a bit more force than my sensitive nervous system can manage and now it is grumpy and whimpering and I need to love myself today. The moral of this is two fold; one, check in, especially with your anxious clients. Always make it clear they are the boss of their body and can ALWAYS say “please touch me like this and not like that.” Two, it does not demote your professionalism to be accountable for your actions but instead elevates it and builds an even deeper level of trust. By showing our clients we are willing to acknowledge when we made an error with them, collaborate on how we want to correct that error, and then follow through, we are demonstrating not just human decency, but what healthy relationships look, sound, and feel like between two people who respect each other and themselves.