Do You Have to Do Internal Work to Be a Pelvic Floor Therapist?

This is one of the most contested questions in our field, and it stops people from entering it: do you have to do internal work to call yourself a pelvic floor therapist?

To be clear about what this conversation is not: all three of us agree OTs should be able to add internal work to their skillset if they want to. That isn't in question. The question is whether you have to.

"Are you only a psychologist if you only offer CBT?"

— Lindsey Kaupp

Lindsey Vestal: Do you offer internal work in your practice? If so, when do you typically do an internal exam — and if not, why not?

Lindsey Kaupp: I do offer it. It's allowed in my geographical area under our scope of practice, and I believe internal work can add a lot. It can be part of your skillset if you want it there. It doesn't necessarily need to be.

The way I decide whether an internal component will help a client is through a lot of good screening and discussion. First, is this even something the client is open to? They need to be comfortable with it. Second, what's the benefit? Can the client achieve this outcome without internal work? Or will it be a useful tool that helps them carry forward what we're working on?

So I use it with quite a few clients, but much more sparingly than a lot of pelvic floor therapists.

Once we've established what we're using it for — especially if we're using it to help someone feel something differently, like feeling a muscle relax — then once we've achieved that, I want to step away, or create a way they can use internal work themselves.

I step away because it isn't something most people will do for themselves between sessions as readily as their other tools. And I want them doing as much for themselves as possible, rather than me doing to them.

If it's someone with the ability to continue internal work on their own, we might. If not, I use it to create small changes to start, or to give them evidence and feedback of what we're looking for. Then we achieve the goal through other means if we can.

Lara: I love that answer, and that its use is directed by the client's readiness.

Internal work isn't part of my practice, primarily because it isn't within my scope of practice in Ontario. That kept me stuck for a really long time — can I work in pelvic health? Should I? Because I was seeing a lot of strong opinions out there that to practice in pelvic health, it had to be all about internal work.

The more comfortable and confident I've become, the more I see the breadth of how we can address pelvic health in lots of different ways. That keeps me much less stuck.

I'll also say: I do think OTs can do this work, and I hope to see the legislation here change. But at this point in my practice, I don't think it would be my strength even if I could offer it. And I work collaboratively with a ton of awesome pelvic health therapists who do provide it, so I can easily refer when the client wants it as part of their plan.

Lindsey Vestal: And practitioners who do offer internal work often refer to you, don't they?

Lara: The bulk of my clients come to me from pelvic floor therapists where they've done internal work — or in some cases haven't. But there are other pieces of the puzzle that haven't been addressed, or they're not seeing gains from the manual therapy or the pelvic floor muscle training.

My strength is addressing the psychological pieces, and the relationships people have with their symptoms and their bodies. When those are what's keeping someone stuck, that's when I get great referrals.

Lara: If someone's referred to me because there's a psycho-emotional piece, I'll use psychotherapy — cognitive behavioral therapy, acceptance and commitment therapy — to look closely at their relationship with their body, their symptoms, with movement. Maybe there's a lot of fear of movement.

Lara: I think of a lot of these as different ways to help a client dip back into their body — breath work, manual work, touch. And people learn and make connections in different ways. That's actually one of the arguments for internal work: some people really value that tactile input to reconnect with their bodies. But there are so many ways to do it.

Lindsey Kaupp: That's exactly the most effective way I see internal work used. As feedback. Creating the connection for someone who's tactile, then backing away and seeing whether they can create that same connection themselves.

Lara: The most powerful pathway to learning, I think, is connecting the dots with someone's own experience. At a follow-up I ask a lot of questions — how did that strategy go, where did you get stuck, where did it work well — and help them put the pieces together.

I'm looking for evidence of self-efficacy. Maybe they created proof for themselves that they could work through a flare-up, or do something they believed they couldn't, even as a baby step. Those are the nuggets of gold from between sessions.

Lindsey Kaupp: And that's why I love Lara's answer. I was going to say experiential learning.

I've worked both in clinic and in people's homes, and I love homes because everything is right at your fingertips. The kitchen, the bathroom, the bedroom, the vehicle. I'll often take clients out to their car and work on positioning there.

In the clinic, I have people recreate what they're doing. A single mom wanted to be able to cut down a Christmas tree and pull it back to her vehicle on a sled. So we brought in a big sled, loaded it with weight, and pulled it around the clinic — so she could try different things in the moment, get feedback, and take it home.

Lindsey Vestal: Lindsey practices in a very rural area in Canada and does home visits, so going out to the car makes complete sense — her clients might spend an hour a day in there. At The Functional Pelvis in New York City, it was more like taking the session up to the third-floor walk-up in Brooklyn, where they've got a toddler, a car seat on the other hip, a stroller, and bags of groceries. Or down a flight of subway stairs.

But as OTs, we pivot. We bring it home.

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Lindsey Vestal: Some people think you can only call yourself a pelvic health therapist if you offer internal work. What would you say to a hiring manager, a fellow therapist, or a client who said that to you?

"Are you only a psychologist if you only offer CBT?"

That was Lindsey Kaupp's first answer. She admits it's a bit cheeky.

"Do you only use one school of practice?"

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Lindsey Kaupp: In reality, I ran my practice for six months before I did any internal work.

What I'd say to a hiring manager, a therapist or a client is that we're looking for a desired outcome. And in life there are many different ways to achieve that outcome. Not everyone is the same. We're all individuals.

So the same applies to a pelvic health therapist. If internal work is going to help, let's do that. If it's not — or if it's not available — there's absolutely another way to reach the outcome.

Lara: This is something I've wrestled with a lot. My biggest takeaway, for myself and for other OTs interested in practicing pelvic health from a different perspective — whether you can't provide internal work where you are, or you don't want to — is not to get caught up in the semantics of it all.

I don't label myself a pelvic health therapist, partly because our legislation requires us to call ourselves OTs first. I say I'm an occupational therapist who supports people struggling with their pelvic health.

For a long time I was really caught up in explaining why I don't offer internal work. I don't do that anymore. When people ask what I can offer, I communicate my strengths, the angles I come at it from, and the pain points people are struggling with. This is how I can help you better support your client. Or, this is how I can help you manage your pelvic health challenges and get back to living life.

That gives people an option they often don't know exists. So many clients are surprised and excited to find there's an alternative.

Lindsey Vestal: It's the same as kegels. People think that's the only thing we can do. Maybe some people think internal work is the only thing that's offered, or that can be effective.

I love the strengths-based answer you've evolved into, Lara, and I can share it too. I got very caught up in defining what OT was, always having to explain how we were different and what value we brought. A real pivot happened in my practice — and I saw a lot more referrals — when I started talking about what I offer, instead of comparing and contrasting with what my competitors do.

Lindsey Vestal: How do you think the comparison between therapists and practices might be hurting the people we're trying to help?

Lara: I see it a lot on social media — a territorialness. And I truly think it's fear driving it. Fear of losing our footing in what we can offer clients. Fear of getting our toes stepped on.

In ACT, one of the tools for making space for fear while still taking action is refocusing on your values. So when I find myself getting pulled into a defensive stance — and sometimes defending is necessary, for advocacy — I try to recenter on what my values are and how I want to show up. Some of my core values are being client-centered and giving clients choices.

And if I'm in a conversation where we strongly disagree, or where there's a lack of professionalism in acknowledging that other professionals with different perspectives can work in this space, I work hard to refocus my energy elsewhere. Toward building strong partnerships with people where it does mesh.

Lindsey Kaupp: The comparison piece is one of the hardest things for me.

The term "pelvic health therapist" was only coined to better communicate what we help clients with. It's a marketing piece. It tells people who to go to for their specific issue.

When we put ourselves out there to a wider audience — and a wider audience always has diverse opinions — it's scary. You can get trapped in fear, and in feeling like you have to one-up or disprove somebody. When if we come back to the marketing side of it, none of that matters. What matters is putting out the solutions you offer so someone can identify who'll be helpful to them.

I want to say this as someone who shut down her pelvic health practice: that was a huge piece of it. I got so far into my head that it affected my own mental health. I wasn't keeping up, or moving in the same direction as other therapists in my area.

It can absolutely be the downfall of your business if you let it sit and ruminate.

"Our area was down a whole pelvic health therapist for a year. We saw way bigger waiting lists. We saw people who just weren't going to therapists, because there wasn't anyone available."

— Lindsey Kaupp

Lindsey Kaupp: So allowing that into my head directly impacted my clients' ability to seek help.

If you find yourself in the comparison game — and I think everyone does at some point — that's when we need to be most vulnerable and open ourselves up. To a coach, a mentor, a therapist, a colleague. Get that external support to quell some of the fear, then move into the internal work of why am I feeling this way, what's happening for me.

I feel strongly that we need to be kinder. When we draw a hard line — you may not be a pelvic health therapist if you don't do internal work — that is not a helpful statement. Everyone's bringing value. The question is only where on the spectrum that value sits.

Lindsey Vestal: I used to call it imposter syndrome. I've started calling it self-doubt Sally instead — because it isn't that something's the matter with us. It's a human condition. These struggles about whether we have a seat at the table, whether we're enough, are universal experiences.

Lindsey Kaupp: We say therapists weren't trained in business. But dang, were we trained in communication.

I've been investing in real estate recently, and I went to a two-day course where the homework beforehand was to call twelve for-sale-by-owner listings and just talk to them. Why are they selling? Do they still have a mortgage? What would the best win-win look like for them?

I found it pretty easy. Less than 10% of the people there had done the homework, and they'd struggled hard with it. The presenters asked me why it was easy for me, and I said: this is therapy. You connect with someone, build rapport, find out what the desired outcome is, what's going on in their life, who's important to them.

Therapy, marketing and sales are enormously transferable. The core values are the same at the bottom. It's only how we go about it that differs.

So coming back to pelvic health and the underdog feeling — we placed ourselves there. As a profession, that's the narrative we tell ourselves. We place ourselves in the underdog position with our language and our posturing.

Lindsey Vestal: One thing that's helped me with marketing — because even that word can feel icky — is remembering that all marketing is, is building relationships. And as OTs, that's one of our superpowers. Building rapport, helping the client feel at ease. When I think of marketing as an extension of that skillset, I can roll up my sleeves and do it.

Lindsey Vestal: Lara, I'd love to ask you about trauma-informed practice, because I suspect you have a lot to say.

Lara: Because I often get clients referred to me after they've done internal work with a pelvic floor therapist, one of the challenges I see is that — not always, but sometimes, especially when pain is part of the picture — it hasn't been a good experience.

Lindsey Kaupp: I 100% agree.

Lindsey Kaupp: We ask our clients to be open to a myriad of perspectives and approaches. I'd encourage therapists to do the same.

When you hear a bold statement — do you need to do internal work to be called a pelvic health therapist — take a step back. Seek out four or five people with different perspectives. Then decide for yourself.

Some people will only feel comfortable calling themselves a pelvic health therapist if they do internal work, and that is 100% okay for them. Others feel very confident working in pelvic health without it. If we're asking it of our clients, we have to ask it of ourselves. That gives us freedom, and the autonomy to pay attention to our core values, how we work best, and what our superpowers are.

Lara: Mine goes along with that — checking our own beliefs and biases.

Because I don't offer internal assessment, something I'm careful about: after I hear a client's story at our first session, I present what I call a menu of options. These are some different ways we could approach what you're describing. It puts them back in the driver's seat of their own care.

It was important to me to understand the interventions I don't offer, so I could present them without bias. I have therapists I can refer you to for these pieces, if this is important to you — and here's the value of that approach. That was a crucial part of staying true to my values and providing genuine informed consent.

So if you're not offering internal work, whether by choice or not: know when it can be of value, and know what it looks like, so you can describe it and have a real conversation with your client about it.