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Stop and think: how is philosophy relevant to physiotherapy practice?

 

Historically philosophy has been largely absent from physiotherapy pre-registration training and literature. However there has been a move towards considering philosophy in relation to physiotherapy, so is this about pretentious academics, ruminating in corduroy jackets with elbow patches, or is this relevant to clinical practice and if so how?

Philosophy seeks to provide conceptual clarity to a complex world and an understanding of philosophy allows us to think differently, to accept multiple realities and challenge our beliefs and understanding. Having trained many years ago and having spent most of my clinical and academic life to date having little understanding of philosophy, one might question how important this knowledge is. I believe that my changing understanding has resulted in a sensitivity to everyday language which is plagued with positivist terminology; towards a single truth, to mathmatisation as a measure of this truth and to establishing causal explanations. An everyday language which may reflect our underlying beliefs and perspectives and our interaction with others including those seeking therapeutic care. Academically I am more critical of what quantitative studies such as RCTs, can tell us about management of individual people and question the traditional view of hierarchy of evidence (which doesn’t feature qualitative research).

Traditional hierarchy of evidence.

Clinically philosophical understanding can open one’s mind to viewing each clinical encounter from different perspectives and consider the nature of reality as experienced by each individual person. Engaging with philosophical discussion has made me stop and think and this has resulted in a change in my ‘way of being’ with persons receiving my care.  The way in which I open the clinical encounter has become more flexible; now, it might start with asking ‘can you explain to me your experience of living with your complaint; what it is like for you’ or inviting a person to ‘tell their story’. I might then continue with probing questions to explore how the experience is meaningful to that individual person. Previously mapping of the body chart or asking about aggravating and easing factors would have been the priority. So what might this changing priority reveal and how might it influence our practice? Here I could reflect on my anecdotal experience or we might turn to qualitative studies for example phenomenological studies, which will help us understand the phenomena of the lived experience of pain. It is acknowledged that these studies are context limited and do not seek to generalise the findings, but to explore how experiences are meaningful to a few. As consumers of qualitative research it is for us to consider how the findings resonate and transfer with our own experiences of caring for persons suffering pain and whether, when receiving our care, persons have been provided with sufficient space and opportunity to express how the experience of their complaint is meaningful to them.

Evidence from qualitative studies highlight the ‘loss of self’ experienced by persons experiencing chronic pain, for example, in a phenomenological study, persons with chronic LBP described that their battle to retain ‘the self‘ were worse than the experience of pain (Smith and Osborn 2007). Persons with LBP described pain as an intrusive threatening object distinct from the pain free-self and on periods of decreased pain described reconnecting with their former personalities / former selves (Snelgrove et al., 2013). Other studies and syntheses of qualitative research have reported similar findings as reflected in the quotes below:

‘I’m not my bubbly self like I used to be ‘…’I am not the human being I used to be. I was born to be’ (Crowe et al., 2010).

‘…This is not human life at all’ (Ojala et al., 2015).

‘chronic pain..led me to question if I am whole anymore’ (Ojala et al., 2015).

Persons with LBP also described the emotional aspects of their experience such as anxiety, anger, depression and shame (Osborn and Smith 2007). Stories of the distress caused by living with chronic pain leads many sufferers to consider taking their own lives (in a survey of persons suffering from chronic pain attending a self-help group 50% had considered suicide (Hitchcock et al., 1994). One participant in a phenomenological study of the experience of chronic pain expressed this by explaining ‘I really don’t fear death because one day I won’t hurt’ (Thomas 2000).

How many persons you have seen in a therapeutic context have expressed their pain experience in similar ways? Do you in your clinical practice give each person the space to express the distress and their changing perceptions of themselves? How good are we at really listening to and understanding the experience of those receiving care? In relation to the therapeutic encounter, in a hermeneutic phenomenological study exploring physiotherapists’ experience of managing persons with non-specific low back pain, physiotherapists acknowledged the importance of the therapeutic alliance, but found communicating with persons with different beliefs and attitude to themselves challenging (Jeffrey and Foster 2012). Physiotherapists didn’t feel that persons were listening to them. This suggests a lack of philosophically informed practice where physiotherapists appear to believe that there is one reality and may not understand that reality for an individual is not the same as their reality. One quote from a person disappointed from a therapeutic encounter highlights how this may be perceived by those seeking care ‘But I was most of all disappointed with not being taken seriously’ (Lillrank 2003). In a narrative study of persons with LBP, Walker et al (1999) claimed that participants’ stories revealed a catalogue of poor communication and understanding from health professionals reflected in quotes such as:

‘they treat you like you don’t understand what you are talking about’

‘you don’t feel like you have been treated as a person at all’

Persons receiving care want to be listened to and believed (Verbeek at al., 2014) and when we get this right it can make a difference to the therapeutic experience:

‘To have a diagnosis was a relief, but being taken seriously as a person was the greatest relief ‘(Lillrank 2003).

An emphasis on exploring the person’s experience requires physiotherapist to have a humanist view. Exploring their lifeworld help them to create new understanding. Persons may need help to make sense of their experience and by revisiting their understanding and promoting positive images of ‘the self’ we may be able to help people to reconnect to their pain free self. This may help persons to change from living around the pain, to living with the pain. However qualitative interviews suggest that physiotherapist use reassurance to help those with negative beliefs about their pain, opposed to exploring their understanding (Sanders et al., 2013). Even more worryingly in a study exploring assessment of psychosocial factors physiotherapists felt that addressing psychosocial issues was outside of their scope of practice (Singla et al., 2015), physiotherapists in this study questioned their ability to assess and address psychosocial, with one physiotherapist describing that, due to a lack of training, physiotherapist using a counselling type approach were ‘on thin ice’. But how can we provide care without considering multiple dimensions of a person’s lifeworld?

A person is an ‘embodied, purposeful, emotional, thinking, feeling, relational human individual always in action, responsive to meaning (Cassell 2010). A holistic perspective accepts that it is through our embodied experience that we are in the world. Merleau Ponty (1945) stated that the perceiving mind is an embodied mind. Our body is our perspective on the world, the centre of experience. Persons are not necessarily aware of the body until it emerges to their perception, for example, when we feel thirst or hunger, and in the presence of pain persons become acutely aware of their body (Thomas 2000). Persons with LBP refer to their embodied pain experiences, describing physical and sensory descriptions of their pain (Snelgrove et al., 2013).

There are different philosophical concepts of human beings which influence the way we view people receiving care. Dualism views a distinction between the mind and body (referred to as Cartesian mind-body dualism, Decartes 1596-1650). In physiotherapy terms this philosophical view point fits with a biomedical approach to practice. Although in physiotherapy there has been a shift from a biomedical to biopsychosocial model of practice, this terminology remains reductionist, reducing people to their individual component parts rather than taking a holistic perspective.

The sum of the parts equals the whole but the parts can’t be reduced and retain the meaning of the whole. Aristotle

The term biopsychosocial is one of scientific disciplines and implies compartmentalised thinking and a lack of consideration of the person as a whole. The evidence suggests that physiotherapists may continue to view persons receiving their care in a reductionist manner, as although they have been found to recognise the importance of addressing psychosocial elements in persons with back pain they described a struggle to find ways to understand and address the psychosocial elements of a their experience (Saunders et al., 2013), this is highlighted in the following quote from a study exploring physiotherapists assessment of psychosocial factors ‘’….I would prefer to refer them to those specialists rather than me trying to solve psychosocial issues’. This may be in part due to a lack of clarity of what psychosocial means revealed in a qualitative study, with most physiotherapists categorising a person as either having psychosocial factors or not (Singla et al., 2015), again implying dualistic views. When discussing this with physiotherapy students many express difficulty in seeing the conceptual distinction between a holistic and a biopsychosocial approach and in order to explain this I have found myself drawing on a life experience where this distinction resonated with me.

Since completing my PhD, I have been asked on numerous occasions ‘how was it doing a PhD? Would I recommend it’ I have found myself unable to provide a coherent response. My PhD was undertaken whilst working full time, being a wife, a mum to three very young children (one of whom had multiple hospital admissions) and a daughter. My mother became terminally ill during the course of my studies and passed away following two and a half years of treatment. The guilt I felt when spending time away from my family to study was painful and it felt incredibly selfish (and this was topped with an unhealthy dose of sleep deprivation). My lifeworld was not one of solely consisting of a PhD, but was intertwined with everything else in my life. The thread of a PhD is inseparable and thus I am unable to express the experience of ‘doing a PhD’. The complexity of my story is ubiquitous and for me, it resonates with the complexity of the experience of many people I see in clinical practice.

I question how the biopsychosocial model is conceptualised by those delivering care and wonder whether it may result in therapists trying to untwine (reduce) the bio-psycho and social from one another rather than understand a person from a more holistic perspective as ‘being in the world’ (Heidegger 1978). If physiotherapists are able to consider holistic way of understanding health and disease with more focus on the existential dimensions of the experience, this may help physiotherapist to empower each person in the therapeutic encounter. In order to achieve this patients need to be able to speak about their lifeworld, and their personal perspectives (Barry et al., 2001). As physiotherapists we might engage with philosophical discussions which open opportunities for alternative perspectives and ways of being and make us stop and think.

 

Dr Clair Hebron

Course Leader MSc Musculoskeletal Physiotherapy