The Four Agreements: Building Strong Therapeutic Relationships

by | Mar 10, 2021 | Small Animal Rehabilitation

Although we are always focused on the behavior of our patients and creating positive associations with us and our treatments, it is always valuable to gain more information on improving relationships, increasing compliance, and gaining the trust of our patients.
Last week’s webinar with Ashley Foster from the Complete K-9 had some valuable insights, and I would love to share my take-home points from the lecture with you!!

After discussing the different ways in which dogs communicate, Ashley asked us some key questions, and they really made me pause and think, and really question whether I am as fluent in dog as I thought I was:

  1. Do you know what is being communicated with a bark, whine, howl, or growl?
  2. Do you recognize a dog’s reflexive signals as quickly as they occur?
  3. Do you easily decipher deliberate signals and communication that allows you to meet a dog’s needs in that moment? 

As she spoke, she pointed out the ‘obvious’ signs we all recognize, and highlighted them with less obvious signals that I would have missed, signals that are easily missed if we aren’t looking closely enough.

The biggest thing I am taking away from this lecture, is the four agreements. As Ashley spoke, she highlighted that these agreements can be practiced until they become second nature.

Four Agreements

In every interaction with our patients, there are four areas or questions we need to be aware of, where we are stepping into an agreement with our patients. They may seem a little obvious, but bear with me:

  1. Who are you?
  2. How are you?
  3. Will you do this with me?
  4. May I do this to you?

When we are aware of and focused on these questions and their answers, we can build strong therapeutic relationships with our patients that are mutually beneficial.

Who are you?

This is essentially when you meet your patient. During this meeting, there are 3 key areas you need to be aware of:

  1. Getting to know the bigger picture – their breed and it’s characteristics, their age, and their previous clinical experiences. This is easily a part of and added to the subjective history taking. It is so important to be familiar with the functions of different breeds and how they communicate.
  2. An appropriate greeting sets you up for success or failure, and this is often where most of us go horribly wrong. Most dogs don’t enjoy being greeted loudly, enthusiastically and with in-your-face cuddles! An appropriate greeting means you need to greet the humans first, allow the dog time to familiarize and investigate the environment, and recognize the consent they give you to interact with them. They need to come to you first.
  3. Dig a little deeper with the owner, find out what the patient likes and dislikes, where they are reactive or sensitive to touch, and if there are any recent changes in their behavior. Again this is already a part of and is easily integrated into our subjective history taking.

There are a few ways you can violate this agreement with you’re patients, including by greeting them abruptly, loudly and enthusiastically, attempting to talk them out of concerns, and by rushing them into the next thing on your agenda.

How are you?

This agreement is constantly relevant every moment you are with your patient – their emotional state can change in an instant, just like yours can. Continuously assess the patient’s state of mind and response to you and their environment. Respond to their emotional state with compassion and understanding, and with appropriate adjustments to your plan. A quick break can work wonders for keeping a patient in a functional and calm mental state.
You can violate this agreement by ignoring or not picking up on the signals they send out, being unaware of and insensitive to how they are being impacted by pain and medication, assuming they will remain in the same emotional state throughout the session, and by forcing them into something they are uncertain about.

Will you do this with me? 

I love this question – it’s all about aiming for active participation and learning from the patient, giving the patient the opportunity to choose their preference, and about rewarding engagement and participation.
When we offer choice, give frequent breaks, engage in a learning process and reward our patients often for the behaviors we are aiming for, we get a patient that is excited about what we are doing, actively participates in our sessions and most importantly feels safe, engaged and stimulated!

When we are aiming to have the patient actively participate with us, we ideally need to use shaping to get the behaviors we are after. If we use luring, some learning will still occur, but it is much less engaged and valuable. Placing is the third option, but starts to infringe on the patients choice, and has very little learning value to them, and for that reason should be avoided. For more on the differences between shaping, luring and placing, please listen to Ashley Fosters lecture in your members portal!

You can violate this agreement in multiple ways, including forcing a behavior instead of asking, cornering the patient to control them, by not taking breaks, and by failing to reinforce and reward the behavior you are looking for.

May I do this to you? 

Again this question strongly resonates with me! We need to make sure that we use the least amount of restraint necessary while remaining safe, we need to ask for permission and let them know what to expect from our actions, we need to maintain contact with the patient and maintain consent – their consent can change at any point. And very importantly, we need to make sure that it is safe for them to communicate with us, and that we are listening when they do.

We have a few things to consider here:

  1. Use the least amount of restraint necessary to remain safe – if we maintain control of the head, we have control over the body. We can use co-operative restraint practices, and should spend some time studying and learning about these practices.
  2. Ask permission and give them information on what to expect from us – we can achieve this by touching them before we treat or assess an area, and letting them investigate the equipment we will be using.
  3. Maintain consent and contact – we need to ask for consent before we touch the patient, and once given we should maintain that contact. Once we have broken contact, we need to again ask for consent to touch them.
  4. Allow an open channel of communication with the patient, pay attention to and respond to any feedback they give. Allowing them to say no will empower them, and build trust in you.

You can violate this agreement by forceful restraint, surprising them with a treatment or modality, not asking them for consent before you make contact, and ignoring their communication and feedback.

For more information on where these four agreements really fit when it comes to our understanding of behavior and training, and most importantly establishing therapeutic relationships that are positive and mutually beneficial, I would really encourage you to watch Ashley Foster’s webinar in your members portal on The Advances in Training And Behavior. 


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