Contextual Theory --An Unexpected Ally

Although physiotherapy supports models that acknowledge psychological elements of rehabilitation, it may be surprising that support also comes from psychiatry.

American psychiatrists Jerome and Julia Frank broadened the definition of psychotherapy by arguing that it is the healing relationship between a healing agent (therapist) and a sufferer (patient).1 The sufferer, wanting to alleviate disability, engages in a therapeutic relationship with the healing agent in order to transform limiting beliefs, attitudes, and behaviours.26  As such, this definition conceivably includes physiotherapy, but the similarity does not end there.

Frank and Frank also argue that health professionals will inevitably encounter and address, albeit intuitively, the psychological overlay of their patients’ rehabilitation struggles, and therefore, become psychotherapeutic for their patients.2 While helping clients change attitudes and beliefs may be a mainstay of psychology encounters, physiotherapists, as helpers in confiding relationships, also address attitudes and beliefs because disability can be a result of individual perception in addition to physical impairment.10 

My argument is further strengthened by contextual theory.2,4 Frank and Frank outline four essential elements of psychotherapeutic encounters (see Figure 1).

These principles seem congruent with what physiotherapists would aspire to in their patient interactions. For instance, the idea of a confiding relationship is common to both psychology and physiotherapy although the client may confide markedly different things to each professional based on the intention of the clinical encounter.

Engaging Creates Therapeutic Relationship

These principles are not simply steps within a linear process. I argue that they describe a complex encounter that requires both the physiotherapist and patient to ‘engage’ in the rehabilitation. By engage I mean that both are:

(a) present or are completely focused on the task at hand;

(b) actively interested or deliberately working to understand the various factors that are influencing rehabilitation;

(c) genuine or are honest about their intentions and expectations and demonstrate an authentic respect and care for the other person.

Engaging opens the door to connect in ways that ultimately personalize the treatment process. This inevitably results in a bond, or sense of trust and respect, that is based in both therapist and patient as credible participants in the patient’s rehabilitation. In other words, a therapeutic relationship is formed. And this is important because research supports what physiotherapists know - good therapeutic relationships can lead to better outcomes.7,11 


This wraps up Part 2 of Finding Freud in Physiotherapy (Part 1 here). In Part 3, Maxi will wrap her article and challenges physiotherapists to widen the role we play in providing psychotherapeutic treatment to our patients.

Stay Tuned for Part 3!

Footnotes:

1. Frank JD, Frank JB. Persuasion and healing: A comparative study of psychotherapy. Baltimore: The Johns Hopkins University Press; 1991.

2. Frank JD, Frank JB. Persuasion and healing: A comparative study of psychotherapy. Baltimore: The Johns Hopkins University Press; 1991.

4. Wampold BE. The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ: Lawrence Erlbaum Associates Inc.; 2001

6. Miciak M, Gross DP, Joyce A. A review of the psychotherapeutic 'common factors' model and its application in physical therapy: the need to consider general effects in physical therapy practice. Scand J Caring Sci. 2012;26(2):394-403.

10. Hill JC, Fritz JM. Psychosocial influences on low back pain, disability, and response to treatment. Phys Ther 2011;91(5):712-21

11. Ferreira PH, Ferreira ML, Maher CG, Refshauge KM, Latimer J, Adams RD. The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain. Phys Ther. 2013;93(4):470-8