June, 1962 P H Y S I O T H E R A P Y Page 3 T h e Psychological A p p ro a ch t o P a tie n ts as seen b y a P h y s io th e ra p is t by INGEBORG SCHROEDL Senior Physiotherapist, T a ra H ospital, Johannesburg. State Licenced R ostock, G erm any Jn this era in which we live, now universally regarded as the "era o f anxiety” , there is a greater and growing aw are­ ness o f the role th at practical psychology or generally speaking, mental hygiene plays. W e have m any examples of this, such as the bringing up o f children which is so vastly different from the Victorian era. There are child-guidance clinics and countless num bers o f books on this subject. We have marriage guidance counsellors; social clubs have been formed to care for the psychological needs o f the aged. There are many m ore examples, fo r instance the expansion o f the field o f psychosomatic medicine, etc. We as a p ro ­ fessional group cannot isolate ourselves from this growing recognition and have to come to terms with it individually fcs well as in our role as therapists. ' The psychological approach to patients, o r any hum an being for that m atter, is a dynamic living situation which has so many facets th at one cannot hope to cover this vast subject beyond the scope o f this contribution. What do we m ean by “ psychological approach to patients” ? My own personal definition would be th at it is “an approach that has an awareness and an understanding of the human inter-relationship between therapist and patient” , thus not only recognizing the em otional and psychological needs o f the patient but also o f the therapist— and to use this therapeutically. We as physiotherapists all have one thing in com m on and that is, we are all treating patients in our professional capacity. O ur technical methods o f applying o u r various treatm ents may vary slightly, but n o t greatly. O ur approach to patients varies very much. It is im portant to realize th a t every patient is a unique hum an being and an individual who presents a new challenge to us and is striving for his adjustm ent. There may be a certain type o f patient such as the pre­ dominantly anxious patient, the predom inantly aggressive or demanding patient (though we should beware o f labelling), all o f them within norm al limits o r otherwise. B ut the degree of aggression or anxiety will never be identical nor the manner in which it is exhibited. In the sam e way we as therapists differ. We are also hum an beings and as such unique and have o u r em otional problems find shortcomings. T he sooner we realize our own needs, the patient’s needs, and the patterns o f satisfying those needs, the more profitable can we m ake this hum an relationship and o u r approach to the patient—even to the benefit o f physiotherapy. The first im portant step is therefore to have a greater understanding and acceptance o f ourselves as persons— o f the patient as a person and n o t ju st another case, and understanding o f the inter-reaction o f the two personalities. There are enough people also in our profession who do not even want to know about the psychological needs o f the patient. M ost o f us do readily accept these needs, but we have difficulty in understanding or accepting them , because e rT’1?ht frustrate o u r own needs completely. We are so otten blissfully unaw are o f the processes that go on within us or we ignore them , because this might be a painful experience. So we cover up under the cloak o f a superior being in our white uniform which gives us already a sense o f security and use the patient indiscriminately to satisfy our own ego. i would like to m ake one p oint quite clear, I am pleading r greater understanding o f the patient and ourselves and • ° by any means visualize a process by which we feel T to Psychoanalyze every move we or the patient maice and to m ake our own interpretations. We are no t psychologists nor psychiatrists but physiotherapists and a little knowledge can be very dangerous. We need a degree o f insight, an ability to observe the patient objectively and to come to terms with o u r own problem s so that we can accept the patient in a non-judgem ental way. H ow can we achieve th is? One learns by experience. We have all had a certain am ount o f experience in hum an relations—starting from the m other-child relationship, which is the basis o f the first group; o u r whole life is m ade up o f movem ents from one group to the oth er; school, home, university and in our work. We thus evolve our own pattern o f behaviour which we use w ith a varying degree of success. We have all experienced anxiety, aggression, guilt, frustration, resentment, etc. How we deal with it and w ork out our adjustm ent-techniques is up to us. We may have been guided by other people, but we still have to solve the problems ourselves. O ur so-called norm al patient goes through very much the sam e experience and we should therefore n o t find it too difficult to understand him. We must realize th a t one cannot lay down any hard and fast rules (such as: this is the way to deal with a dem anding, aggressive patient). I t will never be successful, because it is a living situation where one cannot anticipate every m ood and move o f our patient and the therapist. You have all encountered this phenom enon. F o r example: You treat a very dem anding patient, a really trying patient— the type who is never com fortable n o r satisfied, the so-called “ pain in the neck” . You might have been able to contain your frustration fo r weeks on end and think th at you have managed to cope with him. Then one fine m orning, when you missed the bus because you overslept and did not have time for breakfast, your first patient arrives late and the physiotherapist in charge is telling you th at you cannot have your afternoon off this m onth. In effect you have been exposed to m ounting frustration. A long comes this very patient, he or she m ay n o t even be too trying th a t very m orning bu t here comes your opportunity to let off steam, and you virtually w ant to “ wring her neck” . H ere your own frustrating agent is triggering off your violent reaction and you turn him into a symbol fo r all the frustration. W hether you actually let off steam or n o t is not so im portant, bu t that is the way you feel. Y ou are even entitled to it but you m ust realize th a t you are projecting your own em otions on the patient—and th at if you allow your feelings to get the better o f you, you will feel very guilty afterw ards. A nxiety is precipitated and the next m orning you try to m ake up for it by giving him all the attention he wants. You are then truly responsible fo r creating a situation where the patient m anipulates you and n o t the other way round. H ow should one deal with a situation like th is? There are many avenues and we all react differently. Some o f us will be able to tolerate this magnificently and contain our own frustrations until we go hom e, but then it pours o ut and the poor husband or boy-friend suffers. O r we may even w ork it out on the tennis court by hitting the ball extra hard! T h at is even a socially acceptable way. I f we could try to look a t the whole situation objectively from the beginning we would never become so hopelessly entangled in it. I f we realize th at this demanding patient is merely testing our tolerance and in fact craving for love and recognition, that he is n o t necessarily directing his aggression against us personally but as a symbol, thereby repeating his lifelong pattern o f response. H is needs fo r love and recognition might have been frustrated at one or another time and his only means o f getting any attention or recognition, even on R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) the negative side and forcing it, is by demanding th at atten ­ tion. The Difficult Patient T he best illustration o f this negative approach is the child throw ing a tem per tantrum . We shall never succeed w ith this p atient if we reject him completely. T his is w hat has been happening to him all the time. We can only hope to re-educate him if we show and prove to him th a t there are m ore profitable and constructive ways o f getting our attention. T h a t is in fact if we give him attention when he really needs it and assure him and explain to him th at we shall give it to him if his dem ands are reasonable. Even more than that, if we show him th a t we accept him as a person, not necessarily accepting his behaviour. I f we give him o u r attention the way he dem ands it, we are merely feeding his neurotic needs and this is where we will m ake mistakes so easily in the beginning, because it is no longer a therapeutic relationship. The Group or Teamwork I t is difficult when one becomes em otionally involved to be able to solve the problem alone. T h at is where the group should w ork as a training mechanism in hum an relations. We are not w orking alone, we have our fellow workers, the doctors, nurses, etc. with w hom we w ork together and who experience very much the sam e thing. I feel personally th a t this training in hum an relations is a vital factor which is not being given enough credit in our training program m e. We do have lectures in psychology. B ut it does n o t help one very much in the handling o f a difficult patient to know the theories of Jung, Freud and A dler combined. T he young physiotherapist is most often completely unaw are and ignorant in th a t respect and I feel, th a t if no time can be spared to include this in the training program m e, the m ore experienced o f us should m ake it o u r task to help them. We d o n ’t seem to mind sharing our technical and practical knowledge w ith them but we forget the hum an psychological elem ent far too often. Perhaps we ourselves are n o t truly orientated. I t w ould be so much more profitable if we w ork it o u t together and discuss it. I f we feel inadequate to deal with a p articular problem we should get help from the d octor in charge or the whole team working w ith the patient. F o r a sound therapeutic relationship it is not only im portant th a t we alone strive for it but th a t we help to create a thera­ peutic climate in o u r departm ent. By th at I mean having a tru e team spirit in our departm ent and making the patient an active p a rt o f the team, the most im portant p a rt o f the team . I f we do not realize o u r interdependence and are only working for our own glory, the enhancem ent o f our ego, unable to accept constructive critisicm we shall find this reflected in the atm osphere o f the departm ent. Very often this responsibility rests heavily on the leader o f the team but every single m em ber o f a unit m ust be aware o f her share and contribution in this responsibility. The H uman Being One might still argue ab o u t the validity o f the points m entioned so far and still ask how does it affect you person­ ally if you have to treat a fibrositis or a fractured femur. O ur whole way o f thinking is w rong as long as we consider our patients not as hum an beings but as cases such as frozen shoulders, sprained ankles, etc. We leave out the most vital element. N aturally the depth or intensity o f relation­ ship varies. A so-called straightforw ard, short-term ed case, otherwise well adjusted, does n o t need our attention and consideration as much as a paraplegic patient for instance. Still even this p atient needs our acceptance and under­ standing. W ith any long-term ed case—such as a polio­ myelitis patient, a paraplegic patient, a rheum atoid arthritis, etc. our whole treatm ent and the success o f our treatm ent is based on the soundness o f our relationship w ith the patient. There we are hopelessly failing if we accept our responsi­ bility only as far as his physical rehabilitation is concerned. I t is equally im portant to help the p atient emotionally, help him to learn to accept his disabilities and learn to make the Page 4 m ost o f his abilities o r helping him to keep his fighting spirit going—as the case m ay be. The Long-term Patient and Rehabilitation These patients, however norm al and adjusted—are under terrific em otional stress and in their striving fo r adjustm ent they need all the encouragem ent and recognition o f their efforts th a t we can possibly give them . This aspect should n o t be ignored and every effort m ade to talk with the patient. As one o f the leading members in the team in rehabilitating handicapped patients it is not only our duty to assist the patient him self w ith his em otional problem s but to re­ educate his family as well. T o illustrate this point one sees this so clearly in the example o f the over-protective m other w ith a handicapped child, who means so well in her own mind but who obstructs the child’s striving for independence and equilibrium com­ pletely and thereby also obstructs w hat we are aiming at. T o quote another example: the situation th a t arises when one tries to teach a little polio child to walk outside the the departm ent w ith an audience o f other people around and all they can say is: “ shame, poor little thing” ! We have an obligation for re-education o f the public in , general— indeed a huge task! There is another problem , a l problem th a t we all come across a t one stage or another and th at is having to accept failure. The Acceptance of Failure I do no t like the w ord “ failure” very much. I t is difficult to define and m ay have different meanings for the individual. G enerally speaking, failure implies to us th a t we have not reached a goal th a t was set and the afterthought that follows right away is who or what is to be blam ed. W hom can one blame, if one cannot get a deteriorating patient, such as an am yotrophic lateral sclerosis patient to walk again. Very often we ourselves are to blam e because we are not sure in o u r own mind ab o u t w hat we are trying to achieve. It is indeed not easy, particularly for a physio­ therapist w ho has had little experience w ith this type of patient to decide how m uch one is likely to achieve, and it requires careful consideration in order to save disappoint­ ment. I t m ay be wiser to p u t one’s goal forw ard step by step—until one can be really sure ab o u t the final goal. I have always found th a t not being able to achieve the physical im provement th a t one w ould like to achieve is a very traum atic experience for everyone o f us. It provokes doubts ab o u t one’s own abilities and can result in a withdrawal, followed by a very real depression o r can result in an aggres­ sive, rejecting reaction. One thinks “ju s t too bad” and that again is followed by very uncom fortable guilt feelings and resentm ent tow ards the patient o r fate in general. W h at/ conflicts! I Before one knows w hat is happening one becomes s o ' deeply em otionally involved that one cannot possibly help the patient any more. On the other hand once one feels immensely sorry for a patient the relationship with the patient cannot possibly be therapeutic any m ore either because then one starts identifying one’s self or somebody close to one with the patient, consciously or unconsciously: “There by the G race o f G od, go I .” M ost o f the time it is an unconscious process. We m ust all learn to accept th at there are patients for w hom o u r treat­ m ent o r medicine as such—has limited value. T he danger o f accepting failure too readily is ju st as em inent and results too easily in this attitude o f “ there is nothing we can d o ” . T here is always som ething that we can do. I f it is n o t for the physical benefit o f the patient we can a t least give him em pathy and help him psychologically. I personally struggled very much w ith the problem o f facing incurable diseases and the feeling o f utter helplessness th at one experiences. One o f o u r doctors helped me trem endously by telling me ab o u t a patient w ho died o f an incurable disease and left the following note for his doctor, in which he said: “ I knew you could not help me, b u t you could at least have said ‘good m orning’ to m e” . Sometimes the process of identifying w ith our patients June, 1962P H Y S I O T H E R A P Y R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) June, 1962 P H Y S I O T H E R A P Y Page 5 can be very helpful and at times it would be good if we did it a bit more often. It is surprising how m uch one sees if one happens to become a patient oneself. q o we always consider, w hat the patient experiences, how he must feel if we are brisk and abrupt because he m i g h t upset our plans? If we were really good observers we should be able to see w ithout many words, th at it is more im portant for us to put this patient at ease and help him to overcome the anxiety that he experiences in this possibly new situation than to impress him. The demands on us are manifold, but so are the rewards in our work. O ur approach, bearing in mind o u r definition o f understanding and accepting th e patients’ psychological needs as well as our own and their inter-reaction should never become a rigid one. Adaptability and the Physiotherapist We are dealing w ith people o f all ages. This alone demands a great versatility from us and m oreover here in South Africa we are dealing with people w ith a very varied cultural background. We should accept this as a challenge which makes our w ork all the m ore stimulating. | One finds for example that some physiotherapists are very 'capable in the way th at they deal w ith norm al adult patients, but are at a complete loss when they have to treat children or old people or vice versa. Surely this has a significance. Treating a child can be very demanding on us, particularly, if we are unable to appreciate the child’s m ental level. We need a lot of tolerance and understanding. We are dependent on their co-operation and goodwill, particularly, if it is going to be a long-term treatm ent. If we expect the child to conform to treatm ent in the way th a t we expect an adult to conform, we have only ourselves to blam e if we fail. We have to be adaptable o r we should at least be honest enough to acknowledge ou r shortcom ings and leave this type o f w ork to others. We can fo r instance no t expect a child o f pre-school age to be wildly enthusiastic about P.N .F. patterns right from the start, even if one is convinced that P.N .F. is the best form o f treatm ent for this polio child. One has to modify. W hether one does it w ith marbles or brick houses or stories does n o t m atter as long as one can get the child to take an interested, anim ated p a rt in the treatment that does a t least ensure an 80 per cent co-opera­ tion whereas if one w ould insist on an autocratic approach one could only hope for 50 per cent co-operation and at the same time create a fantastic am ount o f frustration in the therapist and child. If the relation between therapist and child is a sound one the child will allow one to build up one’s demands gradu­ a ll y . But one should go carefully about it so as no t to ■jestroy a trusting relationship th a t took a long time to ^develop. The Psychoneurotic Patient So far these thoughts w ith one exception only dealt w ith the so-called norm al, more o r less adjusted patient. W hat about the psychoneurotic p atien t? I t is an established fact that even in general physiotherapy the percentage o f con­ ditions with a psychogenic cause or overlay— is very high. How many really well adjusted patients do we meet in general practice ? It is all very well to say: “ it is ju s t psychogenic” thereby putting the blame on to som ething th at we do not w ant to know about. We only show that we cannot accept or under­ stand it. To illustrate this p oint we might only consider a patient with a simple fibrositis. H ow m any o f those we are treating are caused by tension alone? We can continue giving them frictions or any other physical treatm ent until eternity. We shall never cure them. The subject o f the psychoneurotic patient and our approach to him is a vast and complicated one. F o r our practical working knowledge I would like to distinguish three groups: 1. The purely psychoneurotic patient, e.g., the hypo­ chondriac and the hysterical patient. 2. T he psychoneurotic patient w ho also happens to have an organic condition such as osteo-arthritis or a traum atic condition. These we encounter very fre­ quently. 3. T he patient w ith an organic physical condition with a strong psychogenic element or overlay. I would say th at this is the case in at least 50 per cent of our general patients. We might be able to get away w ith not paying too much attention to a more psychological approach w ith general patients, but when dealing w ith any o f tnese three groups, we shall fail miserably if we do not understand the underlying dynamics. W hy do we find psycho-neurosis as such so difficult to accept and why is the stigma that we attach to it still so strong even with professional people? If one goes really deeper into this one finds we deny it because of lack o f understanding. These particular patients m ight present a feature o f behaviour that we dislike intensely in ourselves and have therefore repressed and cannot accept. T o see it openly and w ithout disguise in others is therefore a painful experience for us. O r it m ay be, th at we associate th at particular feature o r a particular situation w ith an u n ­ pleasant m em ory o f our childhood experience; to give you an example o f the mechanisms th at may be involved. Is it no t significant, th at some o f us are able to tolerate a hysterical patient or an aggressive patient and others cannot stand the sight o f them ? O r that we take an u n ­ realistic dislike to some people? A ny o f these three groups of patients cannot be cured w ith physiotherapy alone, even w ith a correct psychological approach by the physiotherapist. We can only m ake our contribution w ithin the fram ew ork o f the team which m ust include related professions: medical, nursing, etc. If we think, that we can do this alone by telling the patient to pull him self together or the classical: “ do n ’t w orry” or rationalizing, we only prove our inadequacy to tackle the real problem. Even in general practice we might help the d o cto r already by pointing out o u r objective observations as we see the patient for so much longer periods. Even if we said th at we are unable to cope w ith it and that o u r treatm ent is o f no benefit. It w ould be more honest than to accept being the dum ping ground fo r a large num ber o f patients the doctors w ant to get rid of, a t least temporarily. H ysterical Paralysis I t might be worthw hile to discuss one type o f patient who is a particular problem , th at is the p atient w ith a hysterical paralysis. We need to understand that this patient is ju st as sick or even m ore so than the patient with an organic lesion. T he sym ptom s that he presents are nothing b u t a defence m echanism th at he has built up as a disguise for the real problem . It is n o t ju st as simple as th at he does n ot w ant to walk any more. H e is in fact crying out for help by dem onstrating his sym ptom s and using an escape mechanism. I f we are only concerned w ith bullying his defence mechanism away by means o f high faradic current or other forceful treatm ent, we are only breaking dow n his last reserve and leaving him completely at sea. We may, th a t way even contribute to his complete breakdow n. There we can only be successful if we build up a strong non- judgm ental relationship and w ork in close co-operation with the psychiatrist. T h at means, th at we accept a support­ ing role and proceed w ith o u r attem pts in tune w ith the progress th a t the patient m akes in his psychotherapy. As he gains insight and can accept and tackle his real problem and does not need his defence mechanism any m ore we are ready to take over and prepare him for it, also physically. In the beginning our m ain task lies in building up a strong supporting relationship and observing as well as looking after his physical symptoms. Conclusion M y final plea is th a t everyone o f us should aim at not (iContinued on Page 9) R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) GENERAL W ORLD C O N FE D E R A T IO N FO R PH YSIC A L TH ERAPY The Training o f Physical Therapists is published in English, French and now in Spanish. T his docum ent has been found very u sefu l by many physical therapists, doctors and inter­ national bodies setting up physical therapy services. Any members who w ould like to have a copy may obtain ne from the W .C.P.T., Tavistock H ouse (South), Tavistock Square, London, W .C .l, England. Summary o f Annual Report for 1961 1961 savv change and progress in the affairs o f the W orld C on fed eration for Physical Therapy. By 1961 the W .C.P.T. had reached a stage in its developm ent which necessitated the appointm ent o f its own secretariat with Miss M. J. Neilson, M.B.E., who fo r seventeen years had been secretary of the Chartered Society o f Physiotherapy, as the first Secretary General. New offices have been acquired in Eastbury House, A lbert E m bankm ent, L ondon, S .E .l, and all physical therapists visiting Londonw ill be welcomed there. The scope and volume o f the C onfederation’s work I increased rapidly in the year. Advice was given on the formation and activities o f professional associations of physical therapists and on the planning and equipping o f physical therapy departm ents and training schools in various parts of the world. The Federation Suisse des Physiotherapeutes was adm itted for membership subject to confirm ation at the G eneral Meeting 1963. In the early m onths o f 1961 physical therapists were recruited by the W orld C onfederation, on behalf o f the League o f Red Cross Societies, to treat M oroccan patients paralysed as a result o f using adulterated cooking oil. In conjunction with the Save the C hildren Fund o f G reat Britain, the W .C.P.T. found a physical therapist to w ork in the C hildren’s Pavilion o f the H ospital in Fez. Several physical therapists were recruited to the A guash Rehabilitation C entre in Cairo to join the team there, con­ sisting of fourteen physical therapists from D enm ark, France, G reat B ritain, Norway, W estern G erm any and Yugoslavia. A physical therapist from G reat B ritain (Miss Lois Dyer, one-time o f the G eneral H ospital, Johannesburg and form er editor o f Physiotherapy Journal o f S.A.S.P.) who had lately returned from M orocco, was appointed jointly by the Egyptian Veterans and W ar Victims’ A sso­ ciation and the W orld Veterans’ Federation as leader o f the team. In July 1962 at the E uropean International Conference on R ehabilitation to be held in K ing’s College, Cambridge, the W.C.P.T. will be responsible for a session on Physical Therapy. A Swedish physical therapist will read a paper on “The Rehabilitation o f Forestry W orkers w ith Back Injuries in Sweden” and a B ritish physical therapist will speak on “The Physical T herapist’s R ole in the R ehabilitation o f Patients o f all Ages” . The Executive C omm ittee, in subm itting this report, records its gratitude both to the M em ber O rganizations and to their individual members who have supported the organi­ zation in many ways, such as w orking on docum ents and pamphlets prepared by the comm ittee, by representing the Confederation at international meetings in their own countries and reporting thereon, and last b ut not least, by providing the financial resources which make possible the work o f the W orld C onfederation for Physical Therapy. This report, in full, was subm itted by R udie Agersnap, President on behalf o f the Executive C omm ittee, W .C.P.T. F O U R T H C O N G R E SS Copenhagen, 17th to 22nd June, 1963 The S.A.S.P. C entral Executive C omm ittee is investigating the possibilities o f arranging reduced A ir Fares to C open­ hagen for the Congress. Interested persons are asked to contact the G eneral secretary, P.O. Box 11151, Johannesburg. June, 1962 JO H A N N E SB U R G C O U N C IL F O R TH E CARE O F T H E AGED Mr. A. R othberg has been elected to represent the S.A.S.P. on the above Council. C O M PU L S O R Y R EG ISTR A TIO N The Society’s publicity campaign has swung into top gear with the C entral and B ranch A ction’s C omm ittee w orking at high pressure. Two News Letters have been sent to members o f the public and encouraging replies have been received from influential people including Members o f Parliam ent and doctors. Page 9 Letter to the Editor RE— FIB R O SITIS D ear M adam , While there is at the m om ent great interest in the attain ­ ment o f com pulsory registration o f physiotherapists fo r the protection o f the public, I would like to express an opinion on a subject closely connected with this. Recently I read in the parliam entary report o f a S.A. newspaper that one honourable mem ber felt that many M .P.’s would not have been cured o f their fibrositis had it not been for C hiropractors. I do not doubt the truth o f this statem ent, as in m y opinion this is a condition fo r which the medical and physiotherapy professions in South Africa have yet failed to find a cure. In fact, physiotherapists are often required to treat cases with referred pain in the cervical o r lum bar region (“ fibrositis” or “ lum bago” ) w ithout a diagnosis, i.e. w ithout an indication o f the cause o f this pain. T he result is th at the sym ptom atic treatm ent so often administered (heat, massage, etc.), does little but keep the patient under the illusion th at he or she is receiving treat­ ment, while nature is effecting the cure. In m y experience, m any of these patients can be success­ fully treated by spinal m anipulation and traction, properly applied according to the pathology indicated by an accurate diagnosis, and the signs presented by each case. If physiotherapists in South A frica were trained to carry o ut these techniques under the guidance of doctors, the honourable M .P .’s could be cured o f their “ fibrositis” under proper medical care. It is time the S.A.S.P. seriously considered asking an expert in these techniques to visit this country in order to initiate the training. Y ours sincerely, Brun. W inter, M.C.S.P. (iContinued from page 5) ju st being a “ physio” , b u t also a “ therapist” , in fact try to make it a happy com bination o f “ physiotherapist” . I think in our profession the danger of becoming and training mere technicians is even greater than in m any other related professions, I w ould personally even go further and say th at a really good therapist will also aim at giving the patient the treatm ent th at has a high professional s ta n d a rd ; but that may be debatable. F o r the end results it might not m atter w hether we arrive at a happy solution from one end or the other as long as we give consideration to both. Any one who has seriously and sincerely tried to apply a more psychological approach to patients will bear m e out th at this can m ake our w ork so much m ore rewarding and richer. I wish to place on record my appreciation to D r. H. M oross, Medical Superintendent, T ara H ospital for his help and permission in the writing o f this contribution. B i b l i o g r a p h y G i l l i s , L. S., M .D ., D .P .M ., 1962. Title: Human Behaviour in Illness, Psychology and Interpersonal Relationship. Publisher: F aber and F aber, London. P H Y S I O T H E R A P Y R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )