Three years ago I stepped away from my teaching job in the physiotherapy programme here at AUT University, in Auckland, New Zealand, to manage a team of psychology and psychotherapy lecturers and researchers. The secondment comes to an end in a few weeks time and it’s given me an opportunity to reflect on what it’s like working with people who think and work completely differently to physios.
The first thing that struck me about my time with the ‘psy’ disciplines is how little time physios actually spend thinking about what they do. Personal therapy and supervision are absolutely intrinsic to the profession, and no-one here believes that you can be a mindful practitioner without also taking time to think deeply about your work.
Psychotherapy students, for instance, might spend 50 minutes with a client, and then the next hour with a supervisor talking about what they thought. Each will also then have their own personal therapy, in which their thoughts and feelings are explored. And all of this is designed to help them be better therapists.
Imagine, for instance, that a student is working with someone who is anxious and depressed because of childhood experiences of a bullying, violent parent. The therapist might, themselves, have their own experiences of this, as might their supervisor. So both spend time working through their reactions and responses, so they don’t pollute the session with their own anxieties and can focus on offering good therapy to the client.
Of course, this all takes time, and one hour with a client might have 3 or 4 hours of support work behind it. But I find it interesting that physios aren’t encouraged to relate to their clients in this way at all, and that at no time in the history of the profession have we, as educators and professional leaders, really thought this mattered.
Psychotherapy students spend a huge amount of time thinking about, analysing and utilizing transference and counter-transference in their therapy, and these concepts are so relevant to the work of physiotherapists but, again, we do nothing with them.
Transference happens when a client projects feelings about someone (classically a parent, but it could also be a significant other person, like a coach or teacher) onto their therapist. The therapist has to recognize this and manage it. Sometimes the therapist makes the client aware of it and opens the space for them to explore why this might be happening. Sometimes the therapist uses it to model how parents/significant others might behave differently. At other times they might try to block it.
At the same time, the therapist has to recognize that they might also be projecting feelings of their own onto the client – particularly if they remind them of someone else important to them.
The point is, this is complex stuff and takes time and training.
Think about the times you’ve been frustrated by a client who won’t do what you want, or the person with chronic pain who seems to be demanding or needy. And what about the practitioner who has an inappropriate relationship with a client, or the supervisor who seems to enjoy bullying their staff or students. Are these not instances where transference is being played out in the physio clinic? Are these not things that we could, should, pay attention to?
Of course, the objection will be that the physiotherapy curriculum is far too full already, and there’s no space for any new material. Some might also reasonably argue that things like transference and counter-transference are the province of the ‘psy’ disciplines, and don’t belong in the ‘phys’.
But if leaving physiotherapy for a while has taught me one thing, it’s that no-one holds a monopoly on these ideas and that if we are truly patient-centred, we’ll do whatever we can to help people manage and recover.
Having said that, all of this might just be me transferring my frustrations onto you like a disappointed parent.
I should probably talk to someone about that.
Thank you for an important perspective from the psychoanalytic field. I agree that the relational psychoanalytic perspective is very important in physiotherapy. I’m a Norwegian psychomotor physiotherapist. I`m also the only physiotherapist in Norway that has a specialized education in relational psychoanalytic body-based psychotherapy (Character analysis). In Norway Character analysis and Psychoanalysis are specialized educations in psychotherapy for doctors and psychologists supported by the health government. In Norwegian psychomotor physiotherapy we need 20 hours with personal therapy and 72 hours with supervision during the master degree education. In Character analysis we need more: 200 hours with personal therapy and 180 hours supervision during 4 years with seminars. I recognize very well the huge wall ande the limits between physiotherapy and psychotherapy and for me with both educations I think its time to try to integrate some of the knowledge from both sides of the wall. In 2016 I finished my master thesis in mental health. My research was within the relational concept. I compared the theoretical and phenomenological relational concept between Psychoanalysis, relational psychoanalytic body-based Character analysis and Norwegian psychomotor physiotherapy. I also asked if it was possible to integrate the different relational concepts within the different therapies. Some of the results was that (psychomotor) physiotherapy must consider more knowledge about the psychotherapeutic relational concept, such as transference and counter-transference. Psychoanalysis needs to consider the embodiment. In 2018 my master thesis was published as the book Relasjon og kropp (Relation and body). I plan and hope to publish my master thesis as an English article in the next future.
Hi Dave
Thanks for the post. I just wanted to comment on one very small aspect of your piece, related to this excerpt, “Of course, the objection will be that the physiotherapy curriculum is far too full already, and there’s no space for any new material.”
I’d say that, conservatively, we could simply delete 20% of the current undergraduate curriculum and see zero impact on the quality of service provided by new graduates. With some effort, I think we could wipe out 30% and again, see very little difference. With some clever design and a shift into a different educational paradigm, I’d put money on being able to remove 40% of the curriculum and *see an improvement* in clinical practice by new graduates.
The numbers don’t really matter though. What matters is that the curriculum may be full but it’s full of stuff that we could easily get rid of in order to make space for the kind of deep relationship-building you’re suggesting.
Thanks again.
It is an interesting idea to identify and understand emotional and social reactions for the PT, and the client, in the PT/client encounter. Some questions may include:
1) What does viewing a person with a disability bring up in each therapist?
2) What does it mean to have a normative body—that is normative just by being, help a non-normative body— that needs to work hard— become more normative?
3) Does the physical therapy profession demand “fixing” what an individual therapist sees as part of the person— or the individual part of themselves?
4) Would collaboration in healing be similar in the mental health and physical professions such that demands understanding of emotional responses from all parties?
5) How would the teaching professions and any educational and health profession require and apply the same kinds of introspection?
I have found that therapists become therapists because they have experienced injury and healing or struggled with physical learning and are trying to master it themselves. Some PTs love dance and athletics but have no experience with personal disability….these are all important factors for what PTs bring to client interactions, expectations, and treatments and how clients read PTs.
Many thanks for raising the topic!
Devorah