Clinical Reasoning and Goal Setting in Pelvic Health: Where to Start?

Why a Framework Matters once the Biopsychosocial Model gets Hard

Most pelvic health practitioners already accept the biopsychosocial model. That argument was won some time ago.

The harder question is what to do on a Tuesday afternoon with a patient whose story includes three years of urgency, a difficult birth, a demanding job, a belief that things will only get worse, and a pelvic floor that does not relax. You know the psychosocial factors matter. You have thirty minutes. Where do you start?

This is where most of us get stuck, and the research agrees. Hutting and colleagues report that clinicians consistently find it difficult to address the psychosocial aspects of a condition, and frequently focus instead on the biomechanical and biomedical. The obstacles they name are not attitudinal. They are limited consultation time, gaps in knowledge about this kind of care, gaps in the skills to deliver it, and, the one that matters most here, a lack of tools that let a clinician reason through different clinical scenarios.

That last point reframes the problem. The barrier is not belief. It is scaffolding.

This blog looks at two pieces of scaffolding that came up in Carolyn Vandyken's My Year of Mentorship program: a clinical reasoning model built specifically for pelvic health, and a three-level approach to goal setting. It then uses one 2026 session from Shan Morrison as an example of how practitioners are putting both into practice.

1. The gap between agreeing with the model and using it

The implementation gap is well documented across musculoskeletal and pain practice.

Linton and colleagues, writing on the competencies needed for psychologically informed care, argue that this kind of care is recommended almost everywhere and delivered rarely; and that part of the reason is a competency gap rather than a willingness gap. Their review focuses on chronic pain, mostly low back pain, so it is not a pelvic health paper. But the pattern it describes will be familiar to anyone working with persistent pelvic pain.

Goal setting shows the same pattern. Hutting and colleagues cite work by Stevens and colleagues reporting that physiotherapists find shared goal setting difficult because of time constraints, limited skills, and inexperience with involving patients in their own treatment. They also cite Moore and Kaplan on shared decision-making being underused in physiotherapy, with mismatches between what patients want from rehabilitation and what their therapists think they want.

 

None of this is a failure of commitment. It is what happens when a complex model meets a busy

caseload without a structure to hang it on.

 

2. A clinical reasoning model built for pelvic health

Until recently, pelvic health clinicians borrowed their reasoning models from elsewhere. Fraser and colleagues make the case that this was always an awkward fit: the existing frameworks: SCRIPT, the pain and movement reasoning model, and the Musculoskeletal Clinical Translation Framework, are built around the musculoskeletal system and around pain.

But many pelvic health presentations are not painful at all. Urinary incontinence and pelvic organ prolapse are the obvious examples, and both involve contributing factors well outside the musculoskeletal system.

The Pelvic Health Clinical Reasoning Model was developed to close that gap. Published in Continence in 2026 by Fraser, Morrison, Richards, and Brennen, it organises a presentation into six categories.

Three are mechanistic, describing where the problem is being generated:

1. Central mechanisms: the brain and spinal cord, and psycho-neuro-immune-endocrine activity. This includes prolonged afferent input, thoughts and beliefs, emotions, social and cultural factors, and past experiences or trauma. The authors note that pelvic health carries particular weight here, because beliefs about toileting, sexual practices, sexual self-identity, and childbirth are rarely neutral.
   
   
2. Regional mechanisms: organs and remote sites. Bladder and bowel storage and voiding, pelvic organ cross-talk, and the kinetic chain.
   
   
3. Local mechanisms: tissue issues at the site of symptoms. Pelvic floor muscle tone and function, genital tissues, sphincters, local joints, injury, and surgical history.

Three are influencing factors that shape the whole picture:

1. Medical co-morbidities
2. Behaviours
3. Physical function.

What makes it usable is the final step. After mapping a patient across all six categories, the clinician marks which mechanisms they think predominate,  and that judgement drives treatment priority. If central mechanisms dominate, the authors point toward psychologically informed education, working with thoughts and beliefs, stress management, and relaxation. If regional mechanisms dominate, toward bladder or bowel training, manual therapy, and regional or neural mobilisation. If local mechanisms dominate, toward pelvic floor muscle impairments, local joints, and reducing inflammation.

It is also explicitly dynamic. You repeat the process as new information emerges, and the balance is expected to shift as treatment changes the picture.

Two things worth being clear about. The authors state the model is still being validated in ongoing studies, so it should not be described as validated or proven. And Shan Morrison, whose 2026 session is below, is a co-author of the paper.

3. Goal setting: three levels, and the one most of us skip

Goal setting is where the biopsychosocial model either becomes real or collapses back into symptom management.

The three-level model most often cited in physiotherapy comes from Vermunt and colleagues, and is described in Hutting's person-centred care framework. It separates:

• Symptom or disease-specific goals: relief from leakage, heaviness, or pain
• Functional goals: what the person wants to be able to do
• Fundamental goals: values, hopes, and life priorities

Hutting and colleagues report that the authors recommend setting goals at all three levels and starting with the fundamental ones, because those drive the discussions about function and symptoms.

The practical problem the model solves is familiar:

When symptom goals are the only goals on the chart, care defaults to biomedical by design. Nothing in

the plan points at what the person actually wants their life to look like, so nothing in the plan can be

measured against it.

 

 

4. Inside a 2026 session: frameworks, principles, and goal setting

In September 2026, Shan Morrison delivered a two-hour session to the My Year of Mentorship cohort titled Applying Frameworks, Principles and Goal Setting in Clinical Practice. It is a useful example because it moved from theory to the specific mechanics used in practice.

She organized the session around three components of evidence-based practice: the practitioner, the patient, and the practice, and gave each its own implementation problem.

The practitioner. Clinical reasoning, frameworks for phenotyping and treatment selection, and the honest obstacles: confirmation bias, working as a facilitator rather than a fixer, and the practitioner's own regulated nervous system. She framed professional development as a move from acquiring explicit knowledge toward participating in a community of practice, which is a reasonable description of what mentorship is for.

The patient. Goal setting, person-focused communication, trauma-sensitive and neuro-affirming care, therapeutic alliance, and shared decision-making.

The practice. The infrastructure that determines whether any of it survives contact with a real schedule: questionnaire workflows, patient-facing resources, access to outcome measures, and goal setting for your team as well as your patients.

The most transferable material was the detail underneath the goal-setting model, the part the published papers do not supply. Her criteria for a good pelvic health goal: patient-driven rather than therapist-driven, written in the patient's own words, action-oriented, a mix of short and long term, a mix of symptom, functional, and fundamental levels, and specific enough to be realistic. She offered opening question stems for introducing goal setting, follow-up questions for moving a conversation from symptoms toward values, and a way of negotiating realistic stepping stones with someone whose pain has lasted ten years.

She also shared a simple review mechanism: a five-point scale for rating goal achievement, with a rating of four or five counted as achieved. That is the sort of thing that sounds trivial and turns out to be the difference between goals that get set and goals that get used.

 

5. What a year adds that a weekend course cannot

There is a reason this material keeps surfacing in a year-long program rather than a single course.

The problem isn't knowledge.

Pelvic health clinicians are not short on information. The frameworks are published, the courses exist, and most practitioners can define a fundamental goal, describe a biopsychosocial approach, and name the evidence behind it. The 2027 program has an entire session devoted to this gap: Carolyn's Why is a Biopsychosocial Framework so Difficult to Put into Practice? The question is worth asking because knowing the framework and working inside it on a Tuesday afternoon are two different skills.

What makes it hard is specific. It's asking for a fundamental goal the eleventh time with a patient who keeps steering back to symptoms. It's catching your own reasoning default to local mechanisms again, mid-session, when you meant to be somewhere else. It's the volume of systems to hold at once, trauma, gastrointestinal, urogenital, hormonal, and pain system hypersensitivity, and the quiet discomfort of working in the lifestyle and psychosocial realm where the evidence is strongest and the training is thinnest.

And it's the isolation. Pelvic health assessment and treatment happen in a private room with the door closed. Nobody watches you reason. There's no one in the room to say you drifted, come back, and no one afterward to bring the case to.

 

My Year of Mentorship 2027

A weekend course gives you material. It doesn't give you the repetitions, and it doesn't give you anywhere to take what happens in between.

The 2027 cohort is built around that gap. Twenty live sessions across the year, twice monthly, break the knowledge into systems and processes rather than dropping it all at once, so you're applying one piece while the next is still coming. You get practical tools rather than principles alone: the 3PSQ for distress screening, the FrePAQ and sensory-motor dysregulation, RAMS for exercise prescription, and the Fit-for-Purpose model carried over from low back pain into pelvic health.

Then there's the part that addresses the isolation directly. You're paired with a partner in your time zone for the year. Monthly office hours run twice, once timed for North America and once for Europe and South Africa, so you have a standing place to bring the case that didn't go the way you planned. The forum includes past cohorts, not just this one, and stays open after the year ends. Every session comes with a written summary, key insights, slides, and patient education handouts, and the recordings stay available all year, so missing a live session doesn't mean missing the content.

The difficulty was never understanding the framework. It's building the habit, out loud, with people who'll tell you when your reasoning slipped. That takes a year, and it takes company.

Registration for the 2027 cohort opens soon. If you would like to hear first when dates and details are announced, join the notification list:

Join the 2027 notification list →

 

References

Hutting N, Caneiro JP, Ong'wen OM, Miciak M, Roberts L.. Person-centered care for musculoskeletal pain: putting principles into practice. Musculoskeletal Science and Practice. 2022

Vermunt NP, Harmsen M, Elwyn G, et al. Health Expectations. 2018;21:528–538

Fraser E, Morrison S, Richards J, Brennen R. Continence. 2026;19:102818

Linton SJ, O'Sullivan PB, Zetterberg HE, Vlaeyen JWS. Scandinavian Journal of Pain. 2024;24(1):20240017