The 6th and final free online Critical Physiotherapy Course for 2020 will be next week

How Are We Doing? Placing Human Relationships at the Centre of Physiotherapy

with Jean Braithwaite, Tone Dahl-Michelsen and Karen Synne Groven

As always, the session is free, all you need to do is click on the link below at the time of the meeting to listen in.

Zoom link: https://aut.zoom.us/j/4850164660

This session will develop Jean, Tone and Karen's chapter for the upcoming book Mobilizing knowledge, due out in a few week's time.

Here is the introduction to their chapter.

Introduction
As this anthology itself attests, an urgent spirit of reform and self-critical reflection is now widespread at the cutting edge of physiotherapy research. Three recent approaches are the ‘tinkering’ recommended by Gibson and colleagues (2019) in pursuit of person-centred care, Buetow (2019)’s proposal to rebrand the aims of therapeutic intervention as ‘ultrabilitation’ rather than ‘rehabilitation’, and Groven, Braithwaite, and Dahl-Michelsen (2019)’s exposure of unintended harms of treatment in the form of ‘iatrogenic dys-appearance’. This latter term refers to a variety of ways in which therapeutic interventions may make patients unpleasantly aware of their own bodies, ranging from physical pain and discomfort to embarrassment, alienation, feelings of social inferiority, stigmatization, conspicuousness, and so on, in any combination or degrees. We’ll return to this concept subsequently. (See Groven et al., 2019 and references within for a fuller discussion.)

It is scarcely in dispute that it is desirable for healthcare providers involved in rehabilitation practice, including physiotherapists, always to treat their patients foremost as fellow human beings rather than as raw materials to be sculpted by us into more desirable configurations. However, in a profession dominated by biomedical metrics (of illness and health), it is very easy, even with the best of compassionate intentions, to slip into a normalizing frame of mind, to follow the script of ‘best practices’, sometimes to the detriment of the individual person. Gibson and colleagues (2019) examine in microscopic detail nine ‘care events’. In one of these, a home healthcare provider, ‘Ginny’, unwittingly pressures ‘Irene’, an elderly patient recovering from a stroke, to work toward walking without an aid, at least indoors. The transcript, though, makes it quite clear that Irene strongly prefers to keep her ‘stick’ nearby at all times for the physical and emotional support it gives her. Ginny is attempting to follow the rules of her institutional treatment program, in which, according to Gibson, ‘care is focused on the person’s stated preferences to counter any paternalistic imposition of the practitioner’s goals’ (Gibson et al., 2019, p. 4). Yet because of the pressures Ginny’s job places on her (to solicit and record individualized patient goals related to recovering prior function), Ginny ends up pushing Irene in a direction she clearly does not want to go. ‘Paradoxically’, Gibson notes, ‘the patient and practitioner as persons became lost in the process’ (Gibson et al., 2019, p. 4).

Part of what went wrong in the Ginny–Irene interaction is the surrounding theoretical framework which takes for granted that recovery of prior function should guide Irene’s aspirations for her future. This sort of assumption is arguably etymologically inherent in the word rehabilitation, which is why Buetow and colleagues (2017) suggest replacing it with a different term. After all, what is the ultimate goal of treatment, if one thinks about it carefully? Surely it is not recovery per se but a flourishing life. Recovery is not a realistic goal in every case, and, in particular, when a condition is present from birth, there is no ‘prior’ unimpaired state. However, increased life satisfaction in accordance with patients’ own values and priorities is almost always available, no matter how dire the prognosis. Indeed, it is not uncommon that persons with a health challenge or disability even manage to use their atypical physical condition as a springboard to personal growth and sometimes extraordinary achievement (Solvang, 2019; Hatterud, 2018). Sometimes such individuals even end up considering themselves better off than they would have been without the disability (or health challenge) (Hatterud, 2018). Thus, Buetow and colleagues (2017) propose the cover term ‘ultrabilitation’ to describe the pursuit of flourishing ‘around, toward, and beyond recovery’. In a similar vein, Gibson describes the ‘micro-politics of caring’ in which both patients and care-givers commit to a fine-grained process of mutual ‘tinkering’ to find the optimal interventions to maximize patient outcomes from the patient’s perspective (rather than exclusively biomedical metrics) (Gibson et al., 2019). 

For several years now, Groven and Braithwaite and their colleagues (Groven et al., 2013; Groven & Braithwaite, 2016; Groven et al., 2019) have focused on studying patient accounts of physiotherapeutic treatment in order to discover insights useful to healthcare practitioners. In Groven et al. (2019), we introduced the concept of iatrogenic dys-appearance into the literature, comparing the cases of two prominent Norwegian authors, both suffering from chronic muscular degenerative diseases, Jan Grue and Geir Hellemo. Grue finally decided to reject physiotherapy on the basis of his lifetime of negative experiences with dozens of physical therapists, while Hellemo, though also critical of many of his caregivers’ attitudes, embraced a radically intensive program of physiotherapy going far beyond what his initial treatment team recommended. Similarly, we here present the contrasting cases of two young Scandinavians born with cerebral palsy, each of whom, in their own way, represents a success story. The two have quite different relationships to rehabilitation processes and physiotherapists, however. Maria Bjurstrøm is just 19, a competitive boccia player on the Swedish team, and has recently published a memoir Mitt liv som CP [My Life with CP]. Jacob Nossell is 31 and currently works as head of communications and disability consultant at Enactlab S/I, in addition to frequent public lecturing on disability, diversity, and related subjects.

In combination with our prior research, these two new cases persuade us that a key strategy in maximizing the patient’s subjective benefit from treatment is that the caregiver never lose sight of two relationships important to the therapeutic context: (1) the relationship existing between the patient and the caregiver and (2) the perhaps even more crucial ‘relationship’ existing between the patient and their own body. As Gibson and colleagues point out, ‘there is no guarantee of getting it right, no general “principle of tinkering” that can be universally applied to all situations’ (Gibson et al., 2019, p. 7). But we are convinced that a therapeutic mindset which keeps specifically these relationships at the centre of attention will generally lead to better results than practices which neglect them in favour of other priorities. What counts as success, what counts as progress, cannot even be determined without taking into account the patient’s own subjective experience, which requires a healthy two-way communication and shared goal-setting.