THE HUMANISTIC APPROACH IN PHYSIOTHERAPY* The R ole of the Physiotherapist in Motivating and Counselling the Patient N . L E N N A R D , B.Sc. Physio. (Rand)* SEPTEMBER 1977 F I S I O T E R A P I E Die skryfster beklem toon die belong van m otivering raadgewing as deel van die rol wat die fisioterapeut f 1, in 'n no u e en dikw els intiem e verw antskap m et n ncient wat gerehabiliteer word. H ierdie verw antskap P f ei voort uit die fisieke ko n ta k gedurende behandeling. cv bepleit beter voorbereiding vir en insig in hierdie hters belangrike aspek van fisioterapie. D ie sukses, al l, n nje, van rehabilitasie hang grotendeels a f van ’n jmpatieke dog objectiew e uitvoering van hierdie belang- rike taak. The following definitions were published by the Chartered Society of P hysiotherapy in its Journal in April 1975, in an article w ritten by D oreen B auer. “Physiotherapy is th e a rt and science of therapeutic movement supplem ented by the selective application of certain physical agents w hich m ay relieve pain and enhance tissue response and program m ed upon the evalu­ ation of a detailed assessm ent based upon a physician’s diagnosis and relevant medical in fo rm atio n .” A physiotherapist is a skilled person who should on consultation w ith a physician be capable of applying his or her own judgem ent and know ledge and training for the appropriate assessm ent and tre a tm e n t of a patient. The role of a physiotherapist em braces nine equal functions: (1) Assessing. (2) E valuating. (3) P rogram m e planning. (4) T eaching, instructing and training. (5) Motivating o r counselling. (6) T reating. (7) Supervising. (8) Recomm ending. (9) D ocum enting. It is N u m b er 5 on the list, M otivating and C ounselling which I propose to discuss. A lthough m otivating and counselling the p atien t is an in h eren t p a rt of the practice of physiotherapy, the physiotherapist m ay recognise her role in motivating the patient but not be fully aw are of her power and influence as an indirect counsellor of the ^patient. She m ay feel th at she does not have sufficient * training o r she m ay lack confidence in h e r ability to counsel, yet her contact with the p atient is often so close th a t she is th e best person available to do so. In fact the p atient will solicit her opinion o r the circum ­ stances will be such th at adequate replies o r advice must be given before th e p atient will be satisfied. W here the p atient is concerned it is always the physical aspect which is the official reason for consulting the physiotherapist. T h e physical elem ent is often the least important, yet in th e eyes of th e patient or p aren t it is almost always by far the m ost im portant consideration. In young children or young adults it is often stressed out of all proportion while faulty m em ory o r em otional disturbance, which have such an im pact on rehabilitation go relatively unrem arked. jP aper presented at Post-registration C ourse preceding the 12th N ational Council M eeting of the South A frican Society of Physiotherapy, M ay 1977. *Physiotherapist, St. V incent’s School fo r the D eaf, Johannesburg; Professor Solom on, Professor o f O rthopaedics at the W itw atersrand U niversity, at his inaugural lecture sug­ gested th a t em otional stress or crisis is often the u n d er­ lying cause of accident o r injury; alternatively the p atien t who sustains injury may subconsciously be resist­ ing recovery because the injury is a convenient hook on which to hang em otional problems. T he im pact of severe physical trau m a transcends its physical limits and frequently gives rise to an em otional crisis. W e know th a t following serious in ju ry th ere is a period in w hich the p atien t as well as close relatives experience overw helm ing fear, grief and loss; a period of m ourning follows and finally there is adjustm ent and rehabilitation. T h ro u g h o u t this period it can be ot inestim able value if th e physiotherapist has some know ­ ledge and understanding of p s y c h o l o g y and counselling. This knowledge used wisely is th e basis o f a sensitive hum anistic approach which can im m easurably increase the effectiveness of m echanistic skills. . T h e p atien t’s relationship w ith the physiotherapist is often the first close relationship after the onset of physical disability and as such it is a relationship em otionally charged. It is w ith the physiotherapist th a t the p atient makes his initial discoveries of w hat he can o r cannot do. W ith the physiotherapist th e patient n o t only tests his physical,prow ess but also his self-esteem and this is perhaps the most im p o rtan t p a rt of his adjustm ent and rehabilitation. , Q uoting D r. Y vonne Blake, a well know n Jo h an n es­ burg psychologist: “ R ehabilitation will depend on: 1. W ho the p atient is and w hat he expects, hopes ana fears from the situation. 2. W ho the therapist is and w hat m otivates her w ork and relationship w ith the patient. . 3. H ow they in teract and how flexible the physio­ therapist can be so th a t the skills in which she is trained can be used to the best advantage with any given patient.” . . . t t From the beginning of physiotherapy it is im portant th a t p atient and physiotherapist understand each o th er s motives and establish m utually acceptable, realistic g ° a ,s- If the long-term goals a re not im m ediately acceptable, then at least the short-term goals can be settled It is also im portant th a t all those people associated w ith the patient com m unicate well with each o ther and have the opportunity to do so in o rder to form ulate shared aims for the p atient so th a t they can work as an effective team . T his consultation s h o u l d if possible include the family or influential friends. If this is not done, the relationship w ith the p atient is liable to be frustrating and reflect on the results of treatm ent. ■Ideallv a psychologist o r psychiatric social w orker should be available so th a t the mem bers o f the medical team can seek advice and thus prevent or solve fru stra ­ tions or seek a direction acceptable to the patient and the mem bers of the m edical team , but unfo rtu n ately the ideal situation frequently does not e x ist H °w evcr no m atter how close the com m unication is with experts in psychology, th ere will be m om ents during the close daily contact of the physiotherapist w ith ^ e patient when th e physiotherapist is forced to depend on w hat knowledge of psychology and counselling she can m uster. In this situation u n fortunately, w arm th and sym pathy and a desire to help are often not enough. 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. ) 12 T he physiotherapist is particularly close to the p atient because she experiences a physical closeness, a tactile co ntact with the p atient which w ould not be allowed outside a treatm en t situation. T his situation frequently initiates voluntary com m unications of a kind th a t no o th er m em ber of the medical team experiences. In this situation o r som etim es in a cheerful relaxed w orking situation when the patient does not feel threatened, he may com m unicate m ore easily th an during an official appointm ent with the psychologist. Likewise this may happen spontaneously in a m om ent of fru stratio n while attem pting som ething physically o r em otionally difficult. If the confidences are relevant to the p atien t’s treatm en t and recovery, a way should be found of sharing th e inform ation w ith o th er mem bers o f the medical team . D uring these valuable m om ents o f com m unication it is im portant to listen and draw out the patient ra th e r than tell him w hat to do. T he focus should be kept on the patient. H e should be encouraged to give vent to his feelings freely, though good practical suggestions or solutions from th e physiotherapist are always helpful and valuable. T h e arm y is a place w here the stiff upper lip is traditional, but a p atient needs a tim e when en­ couragem ent o r perm ission is given to express feelings. T alking things over w ith a sym pathetic listener can help a great deal and by thinking things through logically em otional grow th is often achieved. Crisis can be a time o f challenge and em otional grow th, impossible as it may seem at the tim e. W hen a crisis occurs it is very im p o rtan t fo r the physiotherapist to recognise th e crisis and to be available and to p u t aside o th er work. T alking in term s of em otional grow th as a consequence o f physical injury and disability, I can think of a re ­ m arkable exam ple — a m an injured while with the South A frican forces during W orld W ar II. My first job as a student was in the military wards at the Jo h an ­ nesburg H ospital. A fellow student w orked in the ward with me and for some time she had struggled unsuccess­ fully to m otivate a man with a spinal injury to do breathing exercises and tru n k strengthening exercises. He shouted at anyone who touched him , and it was clear th a t he could no t reconcile him self to living as a paraplegic. T he student was becom ing desperate, and I looked up one day to see these two confronting each other. She was really telling him w hat she felt about the im pact his behaviour was having on his wife and two little sons. N ow 1 feel pale at the th o u g h t of the risk she was taking, b u t at th a t tim e th ere was no expert available to consult before taking such a risk. H owever it was a case of a m an of innate strength and a m atch of tem peram ent or chem istry and she Jbroke down the b arrier and got thro u g h to him. H e becam e his old courageous self and finally w ent back in a w heelchair to training horses. H is spiritual strength and stoicism increased steadily and others in the w ard were helped by this m a n ’s courage and understanding. N ow adays one would go and find expert help before taking this sort of action. E very physiotherapist experiences m atch and m ism atch of personality at some time, often due to transference o f feelings from the past encroaching on the relationship. T h e film “T h e Raging M oo n” was an excellent picture o f a p atien t suddenly struck down by serious disability, and his slow adjustm ent and relationships w ith the staff and o th er patients. I am told th a t the book is even better. M ism atch of tem peram ents is often a hopeless situation and best recognised for w hat it is. T h e patient can be quietly and tactfully changed to an o th er physio­ therapist. W here there is a very w arm relationship, be careful to keep it w ithin limits th a t will rem ain con­ structive fo r the patient. W ithdraw al from a relationship w hich has m ean t a g reat deal to th e patient, because it has becom e too taxing, is difficult to handle. R ew ards of praise and appreciation from the physio­ therapist fo r good co-operation should be im m ediate in the case of a young child, and even older patient appreciate this; poor w ork should receive far less obvi0lr attention. T he family should be ta u g h t this too. Clas w ork in arm y wards m ay help a m an appreciate that hS is n o t the only one w ho has suffered shock and l0Sse T here are m any practical ways o f showing sympathv as well as knowledge. y A happy flexible w orking atm osphere th a t gjVe cognisance to peoples’ em otional needs is well worth striving for, both for the patients and fo r the members o f the m edical team . In conclusion, in view of the fact th a t so m any illnesses are regarded as having a psychosom atic origin o r jn. fluence and th a t w here health is concerned so many factors in teract and overlap, physiotherapists should be fully aw are th a t they are frequently involved in a counselling situation and th a t w henever long-term re­ habilitation w ork is u ndertaken this is p articu larly true. O ther param edical professions have long acknowledged the im portance o f this counselling relationship by virtue of the fact th a t in their courses psychology is studied for three years. T h erefo re it would seem necessary f0r< the physiotherapy profession to press fo r better theoreti* cal education and practical involvem ent in th e field of psychology and counselling. SEPTEMBER, 1977 ACKNOW LEDGEM ENTS G oodm an, M., Snr. Physiotherapist, Transvaal M em orial Hospital. D iscussion and advice. H erb ert M artin , U niversity o f Leicester, Paediatric Assessment C entre, Royal Infirm ary. L ectures and notes on B ehaviour Modification and techniques of Counselling. Irwin, C., Snr. Psychiatrist, T ransvaal Memorial Hospital. O bserver status granted at counselling sessions at T ransvaal M em orial H ospital, D epartm ent of Psychology. M athias, A., C hief Physiotherapist, Johannesburg Hospital. D iscussion and advice. Poss, S., Snr. Social W orker, Johannesburg Hospital. D iscussion and advice and reading references. Solom on, L ., Prof. of O rthopaedics, U niversity o f the W itw atersrand. Inaugural lecture. T he H um anistic A pproach as opposed to the M echanistic A pproach to O rtho­ paedic Surgery. Z im m ler, A., Snr. Psychologist, Crisis Clinic Johan­ nesburg. L ecture to the S. Tvl. b ran ch of the SASP on “ Crisis In terv en tio n ” . BIBLIOGRAPHY 1. B lake, Y. (1975), P atien t T h erap ist Relationship. Paper read at the Jubilee C ongress, S.A. Society of Physiotherapy, Johannesburg. 2. B auer, D. (1975), C hartered Society of Physio­ therapy Journal. 3. D yer, L. (1975), Hospital Advisory Service. Paper read at the Jubilee Congress o f the S.A. Society of Physiotherapy. 4. M acK eith, R. (1973), T h e Feelings and B ehaviour of P arents of H andicapped C hildren. D evelopm ental M edieine and C hild N eurology, 15, 524-527. 5. M cL aren, S. H. (1975), Play fo r W ork. S.A.J. Physiotherapy. 6. M athias, A. (1976), Counselling in Physiotherapy. S.A. J. Physiotherapy. C ontinued on page 13 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. )