Physiotherapists Support Mental Healthcare
2
‘significant others/the family’ creates a form of selective blindness that results in the overall decontextualisation of the individual who appears as a patient and avoids providing a real frame in which to place the narrative (as discussed by the psychiatrist R D Laing in 1967). The position that appears to be taken in the most recent article is antithetical to the ‘high/academic’ post-modernism referred to, in contrast to a ‘low/popular’ modernism, in the previous article by Harland, relating physiotherapy practice to post- modernism. Physiotherapists working in mental health have argued for a phenomenology that embraces discourse analysis regarding the wider social and political contexts in which distress is manufactured. Furthermore, they believe that this approach should also incorporate neuroscience and biomechanics (as exemplifying a ‘high/academic’ modernism) alongside an inherently post-modern perspective. We have done so for the best part of twenty years, consistently drawing these issues to the attention of the profession at the Annual Representative Conference and Congress. We have led in fighting for a partnership approach to working with people in distress based upon a shared educational process, rooted in social- constructionist concepts, rather than a simple application of psychological techniques as a replacement for, or addition to, physical techniques. Low back/chronic pain-related problems and depression/mental health-related problems are the iconic expressions of distress within 20th and 21st century Western societies. Physiotherapists working within chronic pain management and dealing with related disability may yet have things to learn from a ‘specialism’ that appears to be regarded as a poor relation (mental health is certainly disproportionately under-funded regarding the supportive evidence in comparison to out-patient physiotherapy). It might be better to explore common ground, to learn from one another. Michael Skelly MSc MCSP Clinical Specialist in Mental Health, Rosslynlee Hospital, Roslin, Midlothian References Greenfield, S (2000). The Private Life of the Brain, Penguin, Harmondsworth. Laing, R D (1967). ‘The obvious’ in: Cooper, D (ed)The Dialectics of Liberation, Pelican, London. Melzack, R (1999). ‘From the gate to the neuromatrix’, Pain, supplement 6, S121-S126. Wessely, S, Hotopf, M and Sharpe, M (1998). Chronic Fatigue and its Syndromes, Oxford University Press, 1st edn, pages 250-276. Physiotherapy July 2003/vol 89/no 7 452 SOME interesting points are made by Harland and Lavallee (2003) in their recent article, although it also raised a few concerns with the Chartered Physiotherapists in Mental Healthcare (CPMH) committee. First we believe they have misunderstood the role of physiotherapists in mental healthcare, which they seem to see as a completely separate area from psychology. We would argue that this is the area where the Physiotherapy Pain Association and CPMH overlap, and that far from requiring a separate Clinical Interest Group, the profession should benefit from the two working together, albeit from different parts of the psychology spectrum. Mental health physiotherapists have a working and extensive knowledge of many psychiatric conditions. Cognitive behaviour strategies are not limited to chronic pain but are commonly used in the treatment of chronic fatigue, depression, phobia, eating disorders, alcohol and drug addictions, psychoses and conversion disorders (Hawton et al, 1989; Behr, 1996; Donaghy and Durwood, 2000). Many physiotherapists specialising in mental health either have or are currently undertaking further postgraduate training in cognitive behaviour therapy. They also work holistically in addressing the body and mind, and use many of the techniques used in pain management on a daily basis with their clients. With the recognition of potential dependence, patients are normally encouraged to take an active role in their own care, and the therapists’ role is often in supporting or facilitating the treatment plan. Building up a positive self-image and the patients’ use of their own resources are fundamental to our role (Gyllensten et al, 2000). However, physical treatments are also often necessary to gain patients’ trust, particularly in an environment where they are always being ‘talked to’, and rarely, if ever touched. We would agree that cognitive behaviour therapy and psychological techniques such as those the authors outline are generally under-used by the wider profession, and often not seen as part of its core role. Motivation and communication skills seem essential for all physiotherapists (Lamba and Crossman, 1997; Hemmings and Povey, 2002). Unfortunately as soon as their use by physiotherapists is suggested, others often query whether they lie within our ‘boundaries of competence’, and suggest that we should not ‘overstep the mark’ (Booth, 2002). Indeed some physiotherapists have been recorded as saying that self- motivation is pre-requisite to receiving physiotherapy at all (Pope, 2003). The authors go on to discuss the number of psychological questionnaires available, and advance their use as screening tools. We agree that such tools should be used only by experienced practitioners, but would also warn physiotherapists against relying on the results of such screening tools without also clarifying with patients the answers given in them. For example, sleep problems may be interpreted as resulting from depression, but may also be due to back pain. It is therefore important that such screening tools are not used Physiotherapists Support Mental Healthcare
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Transcript of Physiotherapists Support Mental Healthcare
‘significant others/the family’ creates aform of selective blindness that resultsin the overall decontextualisation ofthe individual who appears as a patientand avoids providing a real frame in which to place the narrative (as discussed by the psychiatrist R D Laing in 1967).
The position that appears to betaken in the most recent article isantithetical to the ‘high/academic’post-modernism referred to, in contrastto a ‘low/popular’ modernism, in theprevious article by Harland, relatingphysiotherapy practice to post-modernism.
Physiotherapists working in mentalhealth have argued for aphenomenology that embracesdiscourse analysis regarding the widersocial and political contexts in whichdistress is manufactured.
Furthermore, they believe that thisapproach should also incorporateneuroscience and biomechanics (as exemplifying a ‘high/academic’
modernism) alongside an inherentlypost-modern perspective. We havedone so for the best part of twentyyears, consistently drawing these issuesto the attention of the profession at theAnnual Representative Conference andCongress. We have led in fighting for apartnership approach to working withpeople in distress based upon a sharededucational process, rooted in social-constructionist concepts, rather than asimple application of psychologicaltechniques as a replacement for, oraddition to, physical techniques.
Low back/chronic pain-relatedproblems and depression/mentalhealth-related problems are the iconicexpressions of distress within 20th and21st century Western societies.
Physiotherapists working withinchronic pain management and dealingwith related disability may yet havethings to learn from a ‘specialism’ thatappears to be regarded as a poorrelation (mental health is certainlydisproportionately under-funded
regarding the supportive evidence incomparison to out-patientphysiotherapy).
It might be better to explorecommon ground, to learn from oneanother.
Michael SkellyMSc MCSPClinical Specialist in Mental Health,Rosslynlee Hospital, Roslin, Midlothian
References
Greenfield, S (2000). The Private Life ofthe Brain, Penguin, Harmondsworth.
Laing, R D (1967). ‘The obvious’ in:Cooper, D (ed)The Dialectics ofLiberation, Pelican, London.
Melzack, R (1999). ‘From the gate tothe neuromatrix’, Pain, supplement 6,S121-S126.
Wessely, S, Hotopf, M and Sharpe, M(1998). Chronic Fatigue and its Syndromes,Oxford University Press, 1st edn, pages250-276.
Physiotherapy July 2003/vol 89/no 7
452
SOME interesting points are made byHarland and Lavallee (2003) in theirrecent article, although it also raised afew concerns with the CharteredPhysiotherapists in Mental Healthcare(CPMH) committee.
First we believe they havemisunderstood the role ofphysiotherapists in mental healthcare,which they seem to see as a completelyseparate area from psychology. Wewould argue that this is the area wherethe Physiotherapy Pain Association andCPMH overlap, and that far fromrequiring a separate Clinical InterestGroup, the profession should benefitfrom the two working together, albeitfrom different parts of the psychologyspectrum.
Mental health physiotherapists havea working and extensive knowledge ofmany psychiatric conditions. Cognitivebehaviour strategies are not limited tochronic pain but are commonly used inthe treatment of chronic fatigue,depression, phobia, eating disorders,alcohol and drug addictions, psychosesand conversion disorders (Hawton et al,1989; Behr, 1996; Donaghy and
Durwood, 2000). Many physiotherapistsspecialising in mental health eitherhave or are currently undertakingfurther postgraduate training incognitive behaviour therapy.
They also work holistically inaddressing the body and mind, and usemany of the techniques used in painmanagement on a daily basis with theirclients. With the recognition ofpotential dependence, patients arenormally encouraged to take an activerole in their own care, and thetherapists’ role is often in supportingor facilitating the treatment plan.Building up a positive self-image andthe patients’ use of their own resourcesare fundamental to our role(Gyllensten et al, 2000).
However, physical treatments are alsooften necessary to gain patients’ trust,particularly in an environment wherethey are always being ‘talked to’, andrarely, if ever touched.
We would agree that cognitivebehaviour therapy and psychologicaltechniques such as those the authorsoutline are generally under-used by thewider profession, and often not seen as
part of its core role. Motivation andcommunication skills seem essential forall physiotherapists (Lamba andCrossman, 1997; Hemmings and Povey,2002). Unfortunately as soon as theiruse by physiotherapists is suggested,others often query whether they liewithin our ‘boundaries ofcompetence’, and suggest that weshould not ‘overstep the mark’ (Booth,2002). Indeed some physiotherapistshave been recorded as saying that self-motivation is pre-requisite to receivingphysiotherapy at all (Pope, 2003).
The authors go on to discuss thenumber of psychologicalquestionnaires available, and advancetheir use as screening tools. We agreethat such tools should be used only byexperienced practitioners, but wouldalso warn physiotherapists againstrelying on the results of such screeningtools without also clarifying withpatients the answers given in them. For example, sleep problems may beinterpreted as resulting fromdepression, but may also be due toback pain. It is therefore importantthat such screening tools are not used
Physiotherapists Support Mental Healthcare
451-454Letters 17/6/03 10:24 PM Page 452
Physiotherapy July 2003/vol 89/no 7
Letters 453
Nicholas Harland, co-author of the article, replies to Catherine Pope and Sharon Greensill:
INITIALLY in response to the letter itwas not the intention of the primaryauthor to suggest that physiotherapistsin mental health do not have expertise
in areas such as cognitive behaviouraltherapy, or to suggest that thesetechniques only have use in the field ofchronic pain. The purpose of the
comments made regarding expertise insuch techniques was simply todemonstrate that as a profession,physiotherapy requires groups
as a replacement for clinical interview.We would question the authors’
assertion that such screening toolsshould lead to a psychology referral. Ifpatients have expressed suicidal intent,or a psychiatric condition is suspected,it would be more relevant for them tobe referred to a community mentalhealth team. We suggest that anytherapists detecting any symptoms ofmental health problems have a duty ofcare to ensure that they areimmediately discussed with thepatients’ general practitioners, ratherthan taking it on themselves to makeother referrals, or to simply dischargeas not appropriate for physiotherapy.
Additionally we feel it is important tostress that these tools will indicate notonly if clients have clinical depressionor anxiety, but also that they willidentify patients who may have normaldepressive or anxiety responses to theirphysical illness. Although we agree thatdepression and anxiety are commonlyassociated with chronic low back pain,studies have also shown that themajority of patients attendingphysiotherapy with musculoskeletalproblems will score highly on scalessuch as the Hospital Anxiety andDepresssion scale and SF36 (Mossbergand McFarland, 1995; Rose et al, 1999;Jorgensen et al, 2000). We would arguethat the use of such scales to filterpatients as inappropriate forphysiotherapy can only increase thedistress caused to them.
While we accept that physiotherapistsworking in areas other than mentalhealth may be unable to recognisethese symptoms, they should realisethat they may contribute to patientsbeing unable to cope with theirtreatment programme. A homeexercise programme is not veryeffective for patients with poormotivation, concentration and short-term memory problems. Their copingmechanisms for the pain may alreadybe affected by their depression and anincrease in their pain may simply be
too much for them, leading to non-attendance or poor progress.Consideration of these factors wouldgo a long way towards providing this‘elusive’ bio-psychosocial approach.
While patients with chronic pain, orcoexisting mental health problems,may take longer to respond totreatment, and have less favourableoutcomes – what alternative are weoffering? It is ironic that many of theskills commonly used byphysiotherapists can positively affectpatients’ mental as well as physicalhealth. Improvements to posture, forexample, can benefit self-image andraise mood, in addition to decreasingback or neck pain.
Although much of this letter mayappear negative, we completely supportthe authors in their desire to raise theawareness and use of psychological andcognitive behavioural techniques in theprofession.
Catherine Pope MA MCSPPhysiotherapy ManagerNottinghamshire Healthcare NHS Trust
Sharon Greensill MCSPPhysiotherapy Clinical Specialist –Mental Health Rotherham Primary Care Trust
References
Behr, J (1996). ‘The role ofphysiotherapy in the recovery ofpatients with conversion disorder’,Physiotherapy Canada, 48, 3, 197-202.
Booth, L (2002). ‘Views of charteredphysiotherapists on the psychologicalcontent of their practice: A preliminarystudy in the UK: Commentary’, BritishJournal of Sports Medicine, 36, 64.
Donaghy, M and Durwood, B (2000). A Report on the Clinical Effectiveness ofPhysiotherapy in Mental Health,Chartered Society of Physiotherapy,London.
Gyllensten, A L, Gard, G, Hansson, Land Ekdahl, C (2000). ‘Interactionbetween patient and physiotherapist inpsychiatric care: The physiotherapist’sperspective’, Advances in Physiotherapy,2, 157-167.
Harland, N and Lavallee, D (2003).‘Biopsychosocial management ofchronic low back pain patients withpsychological assessment andmanagement tools: Overview’,Physiotherapy, 89, 5, 305-312.
Hawton, K, Salkovskis, P M, Kirk, J andClark, D (1989). Cognitive BehaviouralTherapy for Psychiatric Problems: Apractical guide, Oxford Medical Press.
Hemmings, B and Povey, L (2002).‘Views of chartered physiotherapists onthe psychological content of theirpractice: A preliminary study in theUK’, British Journal of Sports Medicine,36, 61-64.
Jorgensen, C, Fink, P and Olesen, F(2000). ‘Psychological distress andsomatisation as prognostic factors inpatients with musculoskeletal illness ingeneral practice’, British Journal ofGeneral Practice, 50, 537-541.
Lamba, H and Crossman, J (1997).‘The knowledge of, attitude toward anduse of psychological strategies byphysiotherapists in injuryrehabilitation’, Physiotherapy in Sport,XX, 1, 14-17.
Mossberg, K and McFarland, C (1995).‘Initial health status of patients atoutpatient physical therapy clinics’,Physical Therapy, 75, 12, 1043-53.
Pope, C (2001). ‘The attitudes ofphysiotherapists to patients withcoexisting physical and mental healthproblems’ (unpublished MAdissertation) Chartered Society ofPhysiotherapy, London.
Rose, M, Stanley, I, Peters, S, Salmon, P, Stott, R and Crook, P(1999). ‘Wrong problem, wrongtreatment: Unrecognisedinappropriate referral tophysiotherapy’, Physiotherapy, 85, 6, 322-328.
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