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. ) In many cases tim e is the great healer. O th er de­ fence m echanism s include: w ithdraw al, projection, identification, rationalisation. In conclusion, the im portance of a personalised re­ lationship betw een th erap ist and p atien t m u st be stressed. T he physiotherapist m ust un d erstan d th e p e r­ sonality and em otional type o f the p atien t she is treating, thus enabling h er to treat the whole person. 98 A relationship based upon openness, give and take m utual trust and em pathy will help th e paraplegic appreciate his own self worth as a un iq u e h u m an being. In tu itio n and experience are n o t sufficient in un­ derstanding o u r patients fully. A know ledge of psy. chology m ust be an integral p a rt o f th e physiothera­ p ist’s skills. It is therefore essential th a t psychology be included in the education of all physiotherapists. DESEMBER 1981F I S I O T E R A P I E MANAGEMENT OF THE SEVERELY DISABLED R E P O R T O F A S Y M P O S IU M H E L D I N A P R IL 1 9 8 1 A one-day sim posium on the M anagem ent o f the D isabled was arranged by the D ep artm en t of Physio­ therapy, U niversity of C ape Tow n (U.C.T.) in c o n ju n c­ tion with the P ost G raduate M edical C entre, as p a rt of the activities o f the In tern atio n al Y ear fo r the D isabled. D uring the m orning session several professionals gave an outline of th eir respective roles in handling the dis­ abled and a p atien t also put his point o f view. In the afternoon session specific problem s o f a selected n u m ­ ber of disabilities/diseases were discussed. A bstracts or full papers w ere m ade available to all participants (over 80 of all disciplines), and adequate tim e was allowed for discussion. P rofessor G eorge W aterm eyer of th e D epartm ent of C om m unity H ealth, U .C .T ., set the scene by dis­ cussing the Philosophy o f Rehabilitation in 1981 and stated that reh ab ilitatio n is a concept whose m eaning varies from the precise to the vague, according to individual taste, practice and experience. Q uoting A. M air, traditionally reh ab ilitatio n was restricted to phy­ sical m ethods applied to local parts of the organism , designed to im prove function and alleviate sym ptom s. T his had to be re-defined since the definition of the healthy state has becom e much wider and now en­ com passes a state of positive physical, psychological and social well-being. M any attem pts, however, have become bound by the discipline they represent and end up with M air’s definition. M ore note should be taken of m ental and social factors which m ay be m ore crippling than the obvious physical com ponent, w hilst cultural and environm ental factors, totally am enable to correction, may com pound a disability and enhance dependence. H e cited the 'exam ple of the am putee, “ fully reh ab ilitated ” , th a t is discharged hom e and then becom es hom ebound, isolated and depressed because a sandy sidewalk prevents him from getting his w heel-chair out o f the house; sim i­ larly, disrupted fam ily relationships, cross-cultural con­ straints and o th e r social issues m ay m odify the o u t­ come of an otherw ise w ell-intentioned and carefully designed rehabilitation program m e. T he process of re­ habilitation does no t have a certain starting p oint and an end point in the course of disease/disability; how­ ever, periods o f optim al intervention and tim es of m axim um effect m ust be identified and utilised m axi­ mally for each individual circum stance. R ehabilitation goals should be realistic both for the p atien t and the therapist and sufficient time devoted to the assess­ m ent of progress. E voking false hopes an d expectations often result in a loss of confidence an d com pliance, thus it is im p o rtan t to state an acceptable goal and adhere to it. A ssessm ent of the residual ability should not only be o f physical and m ental capability, but include the fam ily, social, cultural and com m unity resource potentials. A ctive rehabilitation, be it com plex and m ulti­ faceted, occupies a relatively short period and then the real problem s start. Long-term support of the disabled in the com m unity is essential. T he concept of “ alleviate c are” put forw ard by A bel-Sm ith, namely th at a com m unity health care facility can care for the chronically iil within the com m unity and that^ facilities can be m obilised in the com m unity to heljjf ease the burden of the care required by disabled at hom e, seem s ideal. It w ould thus seem th at the responsibility fo r rehabilitation and after-care of the chronically ill/d isab led should be accepted by both health professionals and the com m unity alike and we w ould be nearer to the ideal or broad definitation as stated by M air. In South A frica the acceptance of the concept o f rehabilitation by professional bodies has been slow, fragm ented and unco-ordinated but the H ealth A ct of 1977 has laid the ground rules for a total strategy which aims at a com prehensive, m ulti­ disciplinary approach to long-term care of persons w ith chronic disability. Miss Ida Bromely, Superintendent Physiotherapist of the Royal Free H ospital and D istrict P hysiotherapist of C am den, as well as C hairm an of the Council of the C.S.P., addressed herself to the role o f the phy­ siotherapist and titled her paper “Observation + A ction = Prevention”. A trial docum ent, the International Classification o f Im p a irm en t D isabili­ ties and H andicaps, published by the W orld H ealth O rganization in 1980 w ith the sub-title A M anual of C lassification R elating to the C onsequences of Disease, attem pts to give guidelines to assess and classify dis­ ab lem ent so th a t inform ation can be gathered on a sound basis and a b etter understanding of the pro­ blem s can be obtained. In developed countries c h r o n ic illness and m edical responses to it occupy a d o m in a n t position and m ore atten tio n needs to be focussed on the disabling and handicapping consequences of disease rath er than the pathology. She w ent on to define com­ m on term s; im pairm ent is any loss or abnorm ality of psychological, physiological or anatom ical structure or function; disability is any restriction o r lack (resulting from an im pairm ent) of ability to perform an activity in the m anner or w ithin the range considered norm al for hum an beings; handicap is a disadvantage fo r a given individual, resulting from an im pairm ent o r disability, th a t limits or prevents the fulfilm ent of a role that is norm al (depending on age, sex, social and cultural factors) for th at individual. H andicap thus occurs when there is interference with the ability to sustain what m ight be described as “ survival roles” . D escribing the consequences of disease m ore accurately and cate­ gorically will clarify the issues and give less offence through inadvertent stigm atising of people who have disabilities o r handicaps. She cited the exam ple from the N orw egian poet Bekke: “ 1 used to be M rs. Lind with a stiff hip. Now 1 am a stiff hip called Mrs. L in d .” H an d icap o r disadvantage if >ulting from a p a tie n t’s im pairm ent may be increased through in- 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. )