THE IMPLICATIONS OF THE BEHAVIOUR OF PATIENTS IN THE ILLNESS-ROLE ON THE PSYCHOSOCIAL RELATIONSHIP OF PHYSIOTHERAPISTS WITH THEIR PATIENTS A J van Rooijen INTRODUCTION The aim of p atien t treatm en t is to p ro ­ m o te a retu rn to h ealth. The W o rld H ealth O rg an isatio n 's defin ition.of health entails the co n ce p t of "w h o le n e ss ". H ealth is a con d itio n of c o m p le te p h y sical, m en tal and social w ell-bein g, and n o t m erely one w h ere d isease or infirm ity is ab sen t1. G ood health is a p h en o m en o n b oth of the m in d an d b o d y , a n d the th e ra p ist n eed s exp ertise an d skills in both these areas in o rd er to ach iev e h i s / h e r g o als2. The q uestion that then a rises is, how m u ch train ing d oes the p h y sio th erap ist receive in the d e v elo p m en t of m ech an ism s to treat the "w h o le " patient and is she tau gh t to d e a l w ith h er o w n e m o tio n s skillfully en o u g h to help a p atien t to co p e w ith his illness? Successful p h y sio th erap y d ep en d s not o n ly on p h y sio th e ra p y tech n iq u es, b ut a ls o o n th e p s y c h o s o c ia l re la tio n s h ip s w h ich the th erap ist d ev elo p s w ith h is /h e r p atient. This im plies an o p en ness to the p atien t's feelings and em o tion s, and a rec­ og n itio n th at the p atien t and p h y sio th era­ pist h ave sim ilar needs. R ap h ael stated th at the p hy sio th erapist m a y b e the only p erso n in the m ed ical care team w ith w h o m the p atien t sp en d s suffi­ cient tim e, o v e r a reason ab le p erio d , to enable h im to talk ab o u t his an xieties and fears, his sadn ess and d isap p o in tm en t, as w ell a s his an ger and gu ilt ab ou t w h at has h ap p en ed to h im 3. " M an is a com p lex being, w ith am o n g oth ers, p h y sio logical, cu ltu ral, religious and social requ irem en ts. T h e in teractio n of these qualities w ith the in d iv id u al's en vi­ ro n m en t, including p eople, will d eterm in e his b eh av io u r, his reactio n to his illness, to health ca re w o rk ers and to his exp erien ce of the illness-role. L ind esm ith and Strau ss feel that the p a ­ tient identifies h im self b y seeing him self from the p ersp ectiv es o f the co m m u n ity of social g ro u p s4. Th e p h y sio th erap ist m u st th erefore critically e v alu ate the b eh av iou r o f the patient and also the influence of h is / h e r o w n b e h av io u r on the patient. Th e p atien t's reaction s to w ard s his ill­ n e s s -ro le a n d the a d o p tio n o f w h a t is d eem ed to be accep tab leb eh av io u r, will be d eterm in ed b y so ciety 's p ersp ectives. P a ­ t i e n t s w i t h p r e v i o u s e x p e r i e n c e o f p h y sio th erap y trea tm en tw ill therefore be­ h ave differently from those p atien ts w h o h ave no p rev io u s exp o su re4. A p a rt from these co m p lex social influences, the illness- role will also be influenced b y the p atien t's in terp retation of the role.of the p h y sio th er­ ap ist in the total treatm en t plan. P arson s, w h o exam in ed society 's p e r­ sp ectives on the illness-role, reached the follow ing conclusions: • the p atien t is exem p ted from all his social responsibilities • the patient can n o t be cu red b y p erson al resolution • it is exp ected from the p atien t to h ave the desire to b e cured • it is exp ected from the p atien t to seek m ed ical help for his illness, as well as to c o -o p e ra te w ith the treatm en t plan • in the case of a p atien t w ith chron ic disease, it is exp ected th at the p atient will h a v e a d esire to function at his optim al level of "h e a lth " w ithin his ow n limits4. In o rd er to ad o p t a h olistic ap p roach , the p h y sio th erap ist m u st critically ev alu ­ ate the b eh av io u r of the p atien t and also the influence of his o w n b eh av io u r on the p atien t. P ain an d illness b eh av io u r are p resen t to so m e exten t in v irtu ally ev ery p atien t a th erap ist sees. It m u st n ev er be ov erlo ok ed th at patients, first an d fore­ m o st, are p eo p le w h o are en titled to feel an d exp ress em o tion s in d ifferent w ays. The th erap ist m a y find it easier to tolerate the w id e ran g e of b ehav iou rs that a specific p atien t m a y d em o n strate, if he con sid ers for a m o m en t w h at the p atient is go ing th rou gh. N eg ativ e feelings and b eh av iou r can b e exp ected if the p h y sio th erap ist's ro le is n e g a tiv e ly o r in c o rre c tly in te r­ p reted . V ery often the p atient will h av e diffi­ cu lty in p ro tectin g his self-im age while cop ing w ith p rob lem s asso ciated w ith the stress of h and ling the illness. H e m a y then p resen t w ith a v ariety o f reaction s to re­ lieve the stress he is exp erien cing. A cc o rd ­ ing to Kolb, the m an n er and d eg ree to w h ich these b eh av iou rs a re exercised m ay v a r y am o n g individuals4. Som e p atients need few p sych ological m ech an ism s in d ealing w ith illness, while o th ers require a h ost of m ech anism s. There are so m e p atients w h o, even with the use of all their ad o p tiv e m ech anism s, n ever co m e to accep t the illness-com p onent of the w ellness-illness role4. Th e p hy sio th erapist should be fam iliar w ith the m o st im p o rtan t p attern s and re­ actio n s of p atients in o rd e r to be able to ap p ro ach the patient co rrectly and holisti- cally. T he com b in ation of assessm ent tech- f SUMMARY N In order for the physiotherapist to adopt a holis­ tic approach in the treatm ent of her patients, it is necessary for her to bear in mind the patient’s previous experience of the illness-role. This ex­ perience will influence the patient’s behaviour in any subsequent illness-role and thus his inter­ pretation of the role of the physiotherapist in the total treatm ent plan. It follows then that the physiotherapist should critically evaluate the be­ haviour of her patient in the illness-role while also evaluating the influence of her own beha­ viour on the patient in order to make treatment ^effective.________________________________ ^ f DPSOMMING ^ Die pasient se gedrag in die siekrol word deur vorige ervaring daarvan en die rol van die fi- sioterapeut daartydens bei'nvloed. Die fisiotera- peut moet die gedrag van die pasient in die siekrol en haar eie reaksie daarop krities onder- soek om pasiente in totaliteit te behandel. v ______ ;_______________________________ ^ niques of b eh av io u rs to g eth er w ith the traditional skills of the th erap ist can p ro ­ d u ce a v e ry excitin g an d p o w erfu l tool for rehabilitation an d o n -g o in g go od health. The m atter-o f-fact, crisp , objective a p p e a r­ an ce o f m a n y p h y sio th e ra p is ts is often called "p ro fe ssio n a lism " w h ich m a y p re ­ v e n t the therap ists from b ein g total p er­ sons and from treatin g the w h o le patient, as it m a y d istan ce them from their p atien t5. M an y p atients will fear the u n k now n a sp ects of their illness, thus exp erien cin g a fe e lin g o f e x p e c t a t i o n , d i s c o m f o r t o r a n x i e t y a s s o c ia te d w ith an u n k n o w n so u rce of p ossible d an g er. P atien ts of the s am e sex, ag e and s o cio -eco n o m ic b ack ­ g r o u n d s m a y r e a c t d iffe re n tly to fear. Their reaction s will b e influenced b y p re ­ vio u s e xp erien ces o f the illness-role, as w ell as b y the p a tie n t's em o tion al m a ­ tu rity . Th e p h y s io th e r a p is t w ill find a m o d era te d eg ree o f fear in a pa tien t benefi­ cial for his ad justm en t to his' treatm en t p lan, b ecau se the p atien t is w a ry an d a d ­ justs m o re easily. On the c o n tra ry , a v e ry frightened p atien t b eco m es d iso rien tated and tends to o v e r-re a ct. A fearful p atient can b e helped b y reco g n isin g his fear, by a n sw erin g his question s, and thus his u n­ spoken fears, in a sim p le m an n er and by resp ectin g his p riv acy . This will help the p atient to ad just to the ch an ged en viro n ­ m en t and to ch an g ed relationship s6. V ery often, a p atien t will h a v e conflict­ ing em o tion s ab o u t seekin g m edical help and follow ing the ad v ice giv en to him . This can cau se em o tion al lability b ecau se of the co -existen ce of o p p o sin g em otion s, atti­ tu des and desires to w ard s his illness. The p h y sio th erap ist can , afte r re co g n isin g this b e h a v io u r p a tte rn , re a s s u re the p atient th at conflicting em o tio n s are n o t u n co m ­ * M Sc Physiotherapy, Lecturer, Department o f Physiotherapy, University o f Pretoria Physiotherapy, August 1993 Vo! 49 No 3 Page 43 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. ) m on and m a y help the p atient to vo calise his feelin gs. R eflexive re a s s u ra n c e is a sp o n tan eo u s reactio n w h ich o c c u rs in the th erap ist to c o u n te ra ct feelings o f an xiety, u n certain ty o r w o r ry ab o u t the c ircu m ­ stan ces in w h ich the p atien t finds himself. This re s p o n s e re fle cts the p h y s io th e ra ­ p ist's a tte m p t to b alan ce the p a tie n t's feel­ ings an d to calm the p atien t b y u sin g v e r­ bal assu ran ces in a ton e o f v o ice w h ich is n o t unlike th at o f a p a re n t7. W illiam s h o w e v e r, cau tio n s u s to be carefu l o f "th e p a re n t tra p ". This o ccu rs w h en p atien ts, feeling m iserab le, tu rn to us, as if to p aren ts, fo r sy m p a th y , u n d e r­ stand in g , c o m fo rt an d w isd o m , in the h op e th at w e c a n re s o lv e their p ro b lem s for them 2. A d e lib e ra te m o v e b y th e th e ra p ist a w a y from the tra d itio n a l p ro fessio n al "ca rin g -e x p e rt-in -ch a rg e "-ro le , to a rela­ tionship w h ere the p atien t is seen as an equal a d u lt w h o h as a p ro b lem h e is teach ­ ing him self to tackle an d co p e w ith , m u st be m ad e. It m u st b e e xp ected o f a p atien t to take resp onsib ility for his o w n sh are of the effort an d to m ak e his o w n d ecision s; o n ly then can a p atien t re tu rn to norm al b ehav iou r. S uspiciou s an d h ostile p atien ts are dif­ ficult to h andle. Th e p h y sio th erap ist m a y p erceiv e su ch a p a tie n t as irritable, s a rc a s ­ tic, d e m an d in g , critical, u n com plian t or q u arrelsom e. It is im p o rta n t to rem em b er that w h en a p atien t d irects an g e r at the therap ist, he is u su ally a n g ry at w h a t the th erap ist rep resen ts, n am ely health and the health c are sy stem , b oth of w h ich he m a y fe e l h a v e b e t r a y e d h im 5. T h e p h y sio th erap ist m a y feel th reaten ed b y the hostile b eh av io u r of the p atien t, since this b eh av iou r en d an g ers the th erap ist's p o si­ tion o f a u th o rity o v e r the p atient. This can lead to transferral o f n eg ativ e feelings to­ w a rd s the p atien t, esp ecially th ro u g h the b o d y -lan g u ag e o f the therapist. Th e p a­ tient m u st b e e n co u ra g e d to verbalise his hostile feelings in o r d e r to p reserv e his s e lf-e s te e m . T h e p h y s io th e r a p is t m u s t learn to co p e w ith this typ e of hostility and n ot to o v e r-re a ct. A rg u in g is of n o benefit; w h a t is n eeded is u n d erstan d in g and a w illingness to sh are6. A patient m a y re a ct to the illn ess-roleb y taking on a role suitab le to earlier stag es of d ev elo p m en t. T h ese cou ld in clu d e w ith ­ d raw al from all resp onsib ility, an inability to feed him self, w ilfu lness and ch an ged in te rp e rs o n a l relationships. H e w ill d e m ­ o n strate this b eh av io u r b ecau se it is easier for him to reg ress to an earlier stage of d e v elo p m en t than to a d a p t to the stressful situ ation in the illness-role. This reaction c an be a n atural on e, b ecau se it can p ro ­ m o te the h ealin g p ro cess, for e xam p le, w h en a p o s t-o p e ra tiv e p atient allow s the h ealth c are w o rk ers to turn him on the first p o st-o p erativ e d ay. In the early d ay s fol­ low ing trau m a, the p atient receives intens­ ive m e d ic a l, s u rg ic a l an d p h y s io th e ra ­ p eutic intervention aim ed at p rev en tin g fu rth er com p licatio n s and if possible, re ­ storin g function. The fo cu s o f rehabilita­ tion is on the p atien t's p hy sical needs. It w ill be difficult for the p atien t to u n d e r­ stan d w h at is h ap p en in g to him , even if he h as h ad the n atu re an d exten t o f his injuries e x p la in e d to h im . H e m a y e x p e rie n c e shock , d enial, num bn ess and d espair. H ere the p hy sio th erapist h as a vital role to p lay in facilitating h is / h e r p atien t's transition from the w ell- to the illness-role b y p ro v id ­ ing h ope, cou nselling and su p p o rt . T her­ ap ists m u st e n co u ra g e their p atients to ta k e p a r tin the treatm ent. E v e ry successful atte m p t m u st b e e n co u rag ed and praised, b ut c are should be taken n ot to e xp ect too m u ch from the patients. D ep ression is a m ajo r p ro b lem w ith m o st p atients in that they feel trap p ed in the illness-role. Feelings of so rro w , infe­ rio rity and loss of the joy of life a re n orm al h u m an reaction s to being ill. D epression m a y also set in after a p eriod o f an xiety and d istress. Th e p atien t m a y then feel that- n o-on e u n d erstan d s h im o r c a re s ab ou t w h a t is h app en in g to him. By recog n isin g t h e s e f e e l i n g s in th e p a t i e n t , th e p h y sio th erap ist can help the p atien t to feel th a t h e is a c c e p t e d . P h y s ic a l c o n t a c t th ro u g h the lig h t to u c h o f an a rm , a sh o u ld er o r a h and can show the p atient th at the p h y sio therap ist c ares ab ou t him an d accep ts him as he is. E xercise p ro ­ g ra m m e s h ave a th erap eu tic effect on the d epressed patient as they a llo ^ h im to u nload his p en t-u p stress o r tension in a s o c i a ll y - a c c e p t a b l e m a n n e r . W illia m s states that the p atien t's con fidence and s e lf-p rid e m u s t b e reb u ilt b y c o n sta n t p raise and e v e r y ach iev em en ts should be rew ard ed 2. This p ro cess should be stru c­ tured in v e ry sm all steps, p referab ly c o m ­ bined w ith lots o f fun and laughter. The benefits of h u m o u r h ave been a c ­ c e p te d th ro u g h o u t h u m an h isto ry , for ex am p le in P rov erb s 17:22, "A cheerful h eart is a good m ed icin e, but a d o w n cast sp irit d ries up the b on es". R obert Burton, P lato and Freu d also w ro te ab ou t laughter. S u ccess w ith h u m o u r is based on the p er­ son ality of and the relationship betw een the th erap ist and the patient involved. H u ­ m o u r and lau gh ter can be useful in helping a p atient to b alance a stressful situation by focusing on a less seriou s asp ect of it. T im ­ ing of hum ou r, recep tiv en ess of the patient and the con text of the h um ou r are all fac­ tors that m u st be evalu ated to d eterm in e if h u m ou r and lau gh ter are a p p ro p riate in a given situation. In ap prop riate h u m o u r can result in hurt feelings, anxiety, hostility and e m b arrassm en t8 CONCLUSIONS A l e x a n d e r s a i d t h a t t h e m o s t d i s t u r b i n g e m o t i o n w h i c h t h e p h y s i o t h e r a p i s t w i i l h a v e to co p e w ith is an g er, w h ich is often p rov ok ed b y the failu re o f a patient to resp on d to treatm en t, d esp ite d e v o te d and p ro lo n g ed care9. N o t o n ly m a y the an ger g i v e r i s e to f r a g i l e a n d i n a d e q u a t e d efen ces, p ro v o k in g gu ilt o n the p a rt o f the p h y sio th erap ist, b u t w h a t m a y be w o rse, is that this an g er m a y b e co m m u n ic a te d to the p atient. It is im p o rta n t to re m e m b e r th at the p h y sio th erap ist is h u m a n , an d is allow ed to feel an g e r at the h ealth c a re sy stem , the p atien t an d at him self. A b alan ce m u s t be k ep t b y recog n isin g h i s / h e r o w n stress an d b y fin ding w a y s to d eal w ith stress as it o ccu rs. O n ly then c a n the p h y sio th era­ p ist ha v e a posi ti ve im p ac t o n the p a tien t's ability to c o p e w ith his stre ss in the illness- role. P erh ap s the g r e a te stc o n trib u tio n that o u r p rofession will h a v e to m ak e in this in creasin gly tech n olo gical ag e, will b e the h an d s-o n carin g for the in dividu al. A s W ein b erg says: "S u ccessfu l physical th erap y d ep en d s n o t on ly o n p h y sio th er­ ap y techniques, b u t u p o n the p sy ch o -s o ­ cial relatio n sh ip s w h ich the th erap ist d e­ velo p s w ith the p a tie n t" 10. References 1. Glauber KA. Expanding physiotherapy. South African Journal o f Physiotherapy 1976;32(4):2-6. 2. Williams J. Illness behavior to wellness beha­ viour. Physiotherapy. 3. Raphael B. Crisis and the physiotherapist. A u s tr a lia n jo u r n a l o f P h y sio th e ra p y 1975 ;21 (2):5 1-56 . 4. Lambert VL, Lambert CE. Psychosocial care o f the physically ill. New Jersey: Prentice-Hall 1985;3-7,13. 5. Snyder R. Coping: You and your patient with cancer. Clinical Management 1992;12(4):64-69. 6. Ateer M. Some aspects of grief in physiother­ apy. Physiotherapy 1989;75(l):55-58. 7. Morse J et al. Beyond empathy: expanding expressions of caring. Journal o f Advanced Nursing. 8. Davidhizar R, Bowen M. The dynamics of laughter. Archives o f Psychiatric Nursing. 9. Alexander DA. Yes, but what about the pa­ tient? Physiotherapy 1973;59(12):391-393. 10. Weinberg L. Psychosocial relationships, training and the attitudes with reference to physiotherapists. South African Journal o f Physiotherapy 1977;33(4):14-15. Page 44 Physiotherapy, August 1993 Vol49 No 3 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. )