96 TO BE D IFFER EN T P. C O M P A A N * F I S I O T E R A P I E DESEMBER 1981 SU M M AR Y Society (including health professionals) ascribes inferiority to the disabled in interaction, be it con­ sciously or unconsciously, thus further com plicating a d iffic u lt new situation, physically and psychologically. E xam ples are cited. A plea is m ade fo r m ore em phasis on psychosocial rehabilitation early on. Society determ ines w hether som e individuals should b e regarded as d ifferen t by selecting certain facets of their being, and attaching to these facets degrading labels and interpretations. E xam ple. B ecause you are in a w heelchair, you look d ifferent, and because you look different, I am going to H A N D L E you differently. M any times this H A N D L IN G is by placing a p e r­ son in an in ferio r status position: degrading him! In m any cases, ascription of difference represents a slowly developing process beginning w ith a traum atic experience in a person’s life and resulting in hospi­ talisation fo r m any months. By repetition at every occasion of direct and indirect interaction, people w eave a p attern of inferiority, ostensibly covering the w hole of the individual. T his m ay happen consciously or unconsciously. P rofessional people in hospital thus participate in the difference input process and m ould the course of the disabled perso n ’s life. Becom ing disabled and finding oneself in a w heel­ chair, alters a person’s life situation n o t only w ith respect to w hat he can o r cannot do physically — which is often the m ajo r focus of the rehabilitation personnel — b u t also w ith respect to the social in ter­ action with others. T he newly disabled person K N O W S th a t he is the sam e person th a t he was before the injury to his body occurred. Y et, he is so frequently an d persistently placed in inferior status positions by his professional “ helpers” that, in time, he is coerced into w ondering if he has becom e a d ifferen t kind o f person., T h e w hole illness and disability experience places him in new psychological situations w here his custo­ m ary beh av io u r may stim ulate responses so radically d ifferen t from th a t he is accustom ed to, th a t he may often, consciously o r unconsciously, question w ho he is, w hat roles are a p p ro p riate fo r him , and w h at he can expect to be able to do. T he earliest and possibly the critical answ ers to such identity and role questions com e from th e hospital personnel in the everyday situations during treatm ent. T hese answers are m ore often subtle and nonverbal. I t makes explicit the probability th at th e p atien t may have to a d ju st to being a second class citizen faced n o t only w ith physical obstacles, b u t also w ith social devaluation. I t teaches him th a t as society views him , he is no longer a responsible, em ployable ad u lt . . . b u t psychologically and sociologically a child. t T alk given on 27 A pril 1981 in the A u ditorium at the Physiotherapy College, P retoria. * Q uadriplegic. Received 17 A ugust 1981. OPSOM M ING D ie gem eenskap (insluitende gesondheidspersoneel) s k r y f m inderw aardigheid aan die gestrem de toe tydens interaksie, bew ustelik o f onbew ustelik, w a t dan ’n m o eilike tuiwe situasie, fisies en psigologies, verder kom pliseer. V oorbeelde word gegee. ’n P leidooi word gelew er vir m eer kle m op vroee psigososiale rehabili­ tasie. S om e co m m o n exam ples • W heeling down the co rrid o r an a tte n d e n t/n u rse hustle alongside and challengingly o r even sar­ castically say: “ Hey, w here do you think y o u ’re going?” or “ Y o u ’re no t supposed to be here — go to your room .” ^ • G etting your w heelchair hijacked by som ebodjT w ithout com m ent, and being w heeled to the dining­ room . • S taff meetings, where the p atien t is supposed to participate in his rehabilitation, are held w ithout him. • W hen patients enquire ab o u t why som e therapeutic procedure is being em ployed, it is n o t uncom m on fo r them to be told: “It is good fo r yo u ” o r “ D oc­ to r’s o rders.” P erh ap s the m ost com m on way o f telling the p atient th at he is a m achine in the shop fo r rep air is the hab it of com m unicating with the person pushing the w heel­ chair, instead o f w ith the p atien t him self. T h e p atien t finds him self sandw iched betw een two w hite coats with the one asking the other: “N ow w here does she go?” It can be asserted th a t th e job o f p ro p e r reh ab ilita­ tion o f patients is im possible w ithout giving full cog­ nizance to the im pelling psychosocial problem s th a t they face. It is regrettable th at treatm en t o f persons w ith such conditions should have becom e fixed w ithin an essen­ tially m edical, ra th e r than a m ore general rehabilitative m ode because, except for the initial period and fo r the subsequent m aintenance o f good physical health, the p red o m in an t problem s are: • em otional • interpersonal • functional • vocational A N D in th a t order! N ow, lest physicians and o ther m edical persons directly involved, becom e offended at this point, let it be understood th a t when th e term ‘psychosocial’ is used, it does n o t refer to the activities and concern o f any p articu lar profession. It refers to th e percep­ tions of the patient, o f him self and o f his im m ediate and extended interpersonal environm ent, which should be understood and responded to by all personnel, p ro ­ fessional and non-professional alike. T h e focus o f rehabilitation should be to assist the person tow ard refo rm u latin g a self th a t approves o f continuing to be, th e prom otion of a new self-im age predicated on w orth, ego-integrity and self-esteem , rath er than on deficiency and self-contem pt. E arly reh ab ilitatio n should include facilitatio n of a restitutive orientation so th a t recrystallisation of the self is in term s o f acceptance, ra th e r than hate. T he direction of this recrystallisation will be a m ajo r d e­ term in an t of response to later specific rehabilitation procedures. R ejection of aids by quadriplegics well 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. ) DECEMBER 1981 P H Y S I O T H E R A P Y 97 illustrates the consequences o f resolution o f th e self in the direction o f hate. T he nebulous phrase ‘acceptance of loss’ m ig ht be defined as being the extent to which the reconstituted self is oriented tow ards self approval and responsive to reality. Some persons are restitutively oriented follow ing dis­ ablem ent, attem pting to com pensate fo r th eir condition. O thers a re n o t directed tow ards positive gratifications, seeking instead avoidance of th e im plications o f their condition, and th e ir prim ary m otivation is to w ard off anxiety, sham e and o th e r noxious effects. This latter resolution is th e basis fo r residual self-hate. Professional people should extend every aid possible to help the p a tie n t feel th at he, as a personality, still continues. T he obligation to give functional aid should be seen in the larger context o f enhancing self-respect. M y fear is th at th e em phasis on function serves as a readv way o f avoiding th e affective im plications of disable ment. T his year is the IN T E R N A T IO N A L Y E A R O F D IS ­ A BLED P E R S O N S (and I put the em phasis on persons) and now is the tim e to put things right in your own mind and also in the so-called reh a b ilita tio n centres. I did not choose the topic o f the a ttitu d e o f the public tow ards disabled persons because I firm ly b e ­ lieve th a t once a disabled person has learned th a t his disability is irrelevant fo r the a ttain m en t o f som e of his m ore basic goals, he will find the attitu d e o f the public not '^uch a great obstacle. Bibliography Social and Psychological A spects of D isability (1978). Second E dition. E dited by Joseph S tubbins P h. D. U niversity P ark Press. THE PSYCHOLOGICAL ASPECTS OF P A R A P LEG IA : A GUIDE TO PHYSIOTHERAPISTS R O S E M A R Y W O OD , BSc (Physio) U .C .T ., J E N N I F E R B A R R E T T , BSc (Physio) U .C.T. T he authors set o u t to investigate the psychological problem s involved in adjusting to paraplegia. T he purpose of the study was to serve as a guide fo r physio­ therapists. Personal interview s based upon a q uestionnaire were conducted w ith 14 paraplegics. T h e sam ple group ranged from 14 - 61 years o f age. T h ere w ere 9 males and 5 fem ales. A t the tim e o f interview th e d uration of disability ranged from 5 m onths - 20 years. Results show ed th a t 85% o f patients interview ed re ­ garded physiotherapy as essential. H owever, certain areas o f need were highlighted. These include well- defined goals an d ongoing explanation of th e im plica­ tions of paraplegia. Interview s revealed w hat p a ra ­ plegics considered th e ir w orst experiences. T hese in­ clude: • T he first realization of th e prognosis (43% ). • The inability to control blad d er and bow el (29% ). • Feelings o f clum siness, aw kw ardness and ugliness associated w ith th e ir first tim e in a w heelchair. Physical strengthening through therapy an d a close relationship w ith the physiotherapist were very en­ couraging aspects o f physiotherapy. D iscouraging aspects included boredom at th e repetition o f treatm en t and J h e slow progress in rehabilitation. Patients w ere asked w h at advice they w ould like to give to physiotherapists. A nswers were m ostly related to the relationship betw een p atien t and physiotherapist. It was felt th a t th e physiotherapist should take tim e to understand h e r patients, give them confidence and should not m erely concentrate on th e physical tre a t­ ment. The issue of professional closeness arose. T his may be defined as the deep caring of one hum an being fo r another, such a caring being based on m utual tru st and em pathy. E m p ath y involves a ‘fellow -feeling’ w ith * A bstract of a dissertation com pleted as p a rt o f the final year of study fo r B.Sc (Physio). Received 14 Septem ber 1981. the p atien t and differs from sym pathy w hich was viewed by the paraplegics as very destructive. A genuine caring relationship betw een p a tie n t and th e ra ­ pist can do w onders to im prove the p a tie n t’s self­ esteem and help him over com m on psychological problem s. Some psychological problem s encountered in p a ra ­ plegia are: • A ccep ta n ce o f one’s handicap. R esults show th at those individuals w hose fo rm er attitu d e to the disabled was one of acceptance adjusted to being paraplegic m ore easily. • N on-acceptance by others. T h e fear o f being sexually un attractiv e is a m ajo r psychological problem . M any m ale paraplegics are unable to attain an erection or ejaculate; this enorm ously affects th e ir sexual role and leads to the questions: “ A m I a m an?” o r “ I w onder if anyone could ever accept m e and w ant • to m arry m e?” • D epression. T his is a natu ral p a rt o f th e m ourning process. A p atien t who does no t show depression m ay in fact b e suppressing his tru e feelings and later m ay en co u n ter m ore severe psychological p ro b ­ lems. I t is im p o rtan t fo r the p hysiotherapist to give the depressed p atien t hope by, e.g., attain in g a goal in physical reh ab ilitatio n to help relieve som e despon­ dency due to increasing independence. • D efen ce m echanism s used b y paraplegics. D enial, which was com m only noticed, m ay be reinforced by sensory changes and m uscle spasm in th e p a ra ­ lysed p arts o f th e body. T h e a ttitu d es o f others njay also reinforce denial as portrayed in the fol- lo\ying typical com m ent: “ W e’re praying fo r you and know you’ll walk again.” W hen treatin g the patien t experiencing denial, it is im p o rtan t th a t the physiotherapist does not try to convince the p atien t o f reality b u t w orks w ith denial an d helps the p atien t to m ake the m ost of the present situation by encouraging particip atio n in rehabilitation. A defence m echanism cannot be discarded until the individual is strong enough to cope w ith reality. 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. )