Dealing with patient resistance in physical therapy

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Physical therapy which is also known as therapeutic exercises includes all movements that are prescribed by the physical therapist or physician to help the patient restore their normal bodily functions and well as help them achieve a state of well being. This means that the application of therapeutic exercise has its basis on the restoration, improvement and maintenance of the strength, coordination and elasticity of muscles. Such exercise can only be deemed to have achieved their key objectives if they are in tandem with the individual needs of patients. To affirm whether the applied therapeutic exercises have been instrumental in achieving the health objectives, their medical evaluation are therefore based on the patients disability(Weiss 1998).          Ideally, physical therapy encompasses all those exercises that can be described as either active and passive. A sub classification of the active movements include assistive and resistive movements. The inability of physical therapy to achieve its treatment objectives is mainly attributable to the physicians insistence in carrying out therapeutic interventions that are not in agreement with the clients psychological needs. It is because of this resistance by the patient to physical therapy that other therapeutic interventions such as therapeutic dialogue help restore patients support on the prescribed treatment options as well as developing an aspect of treatment commitment on the part of the patient.

Psychotherapy has grown into a major component of therapy that is usually carried out in conjunction with physical therapy for effective therapeutic outcome. Respect for the power of patient physician relationship in improving therapeutic outcomes was considerably noted in antiquity. Modern medical practices has enshrined the therapeutic power of dialogue through the evolution of technological and methodological sophistication that not only allows observation but also makes it possible for an evaluation of the effectiveness of therapeutic dialogue to be determined(Roter 1988).

In psychotherapy, self disclosure; usually understood as a self subjective, is a process which enables the conveyance of a self that is in most cases dissimilar to the one that the therapist receives, registers and consequently reflects back. Such a discrepancy is attributable to the use of empathy which is an imperfect tool when the therapist tries to understand the self of the of the patient. Even though empathy has been instrumental in the effectiveness of psychotherapeutic models, it is nonetheless an instrument that can not achieve absolute approximation on the status of the self of the patient. For this reason, self disclosure is gaining popularity as a tool of knowing the  feelings, thoughts, and the experiences of the patient. Self disclosure can therefore be conclusively referred to as any exchange of information that is in reference to the self. This is inclusive of personal states, their dispositions, past and present events as well as the personal future plans(Leger 1998).

A critical analysis of this definition yields notable likeness with the definition of therapeutic dialogue which is described by Lynch as the communication between persons involving the sharing of physical sensations, thoughts, ideals, ideas, hopes and feelings. It is to be understood that this definition simply surmises the aspect of sharing all information that pertains to life experiences(Leger 1998). Since personal experiences have a direct effect on the success of physical therapy or any other form of therapy, resistances associated with physical therapy can only be solved when therapeutic dialogue is employed to help unravel some personal experiences that may occasion the patients refusal or resistance to effectively participate in physical therapeutic interventions.

When patients resist physical therapy for one reason or the other, therapeutic dialogue is called upon to  help identify and accurately understand the subjective experiences of the patient. Conducting a therapeutic dialogue therefore requires that the practitioner not only enlist preformed diagnostic notions such as physical therapy that primarily try to correct what is diagnostically proven to be the cause of the patient’s health status or assume that their understanding of the patients problem and well as the patient’s experiences is accurate but that a conversation built on trust is used to verify both the patients’ experiences and the therapeutic interventions.

Therapeutic dialogue is only different from commonplace everyday conversation when the the relationship occurs in the therapeutic environment. Moreover such conversations can only achieve their prominence and objectives in improving health outcome when specific rules are used to model the therapist-patient relationship. Even though therapeutic dialogue is akin to everyday dialogue in so many instances the difference lies in the specific patterns of framing the different worlds. In other words therapy is lonely achieved when the conversation between the therapist and the client converse in agreement with defined rules in a frame, for instance therapeutic environment(Bertrando 2008). In many cases inner dialogue tends to be monodic as opposed to polyphonic. Therapeutic dialogue leads to the fusion of the inner voices into a single voice. During conversation between the patient and the therapist, a discussion of the therapy regimen enables a close interaction where different experiences are exchanged at a more personal level so long as the language of the conversation is largely unified and uniform with respect to the therapeutic environment(Bertrando 2008).

The quality of therapeutic involvement is a product of  the capacity of interpersonal relating(Binder 2004). Therapists can only be said to be successful if they foster active dialogue between themselves and their clients. It is for this reason that the main characteristic of a therapeutic relationship is dialogue rather than therapist or patient monologue. Competency in therapeutic dialogue therefor encompasses the ability to deftly balance the strategies used in the discourse(Binder 2004).

Drawing from empathy which is inadequate but nonetheless the basis of psychotherapeutic patient care, the therapist not only uses empathy to understand the patient in the course of therapy and also engages in conversations aimed at revealing the patients understanding of the situations(Tasman & Goldfinger 1990). Fruitful therapeutic dialogue is instrumental in changing or introducing corrections on the patients perceptions. Should the patient trust the therapist and engage him or her in shifting through personal experiences in relation to their resistance to  physical therapy, then their understanding on the role of such therapeutic interventions on their health outcomes can be challenged and hopefully the new understanding can necessitate the continuation of the therapeutic exercises as they were initially constructed. On the other hand, the physical therapy regimens can be reconstituted to be in line with patients preference so long as there is evidence that the health outcomes would not be adversely affected.

Therapeutic dialogue which is an active and effect laden engagement effectively replaces the early therapeutic alliance concept where the [patients ego was understood to be split into two parts. While one part become emotionally involved in the treatment process, the latter was akin to an observing entity on the experience off treatment itself and the subsequent effect of treatment. It can be conclusively surmised that it is the observing entity that ensured the rational commitment to the treatment process. Moreover, commitment as an action promulgated by the observing entity was embodied in curative fantasy(Tasman & Goldfinger 1990). One disadvantage on therapeutic alliance was the dependency on the practitioner on the health outcomes of the patient. While the paradigm shift to therapeutic dialogue was eventful, new questions on the capacity of therapeutic dialogue to understand the disavowed or repressed psyche arose since it mainly dealt with the conscious revelations of the patients while not taking into account the resistances and or defenses that were repressed to the therapist but which had an influence on the treatment process and outcomes.

In line with Gestalt therapy, therapeutic dialogue involves the therapist interacting with the client without any preconceived aim of pushing their own treatment criteria on the client. Such control of the  expected outcome of the therapy is given up when the therapist and client both become themselves and interact in an arena where the outcome of the dialogue is not predetermined but dependent on the agreements after the interaction. Phenomenological bracketing ensure contact, openness and dialogue that neither predictable or planned(Woldt & Toman 2005). The conversation and the sharing of the phenomenological experiences between the therapist and the patient not only preserves the unpredictability of the outcome of the interaction session as a whole but creates a situation where both parties are changed at the end of the interaction. This can only be possible when the therapist desist from maintaining a position of standing that is way above that achieved from the therapist-patient interaction. The success is only real when the therapists’ self is also changed as a result of learning from interaction. It is then that a commitment to therapeutic dialogue is attained.

Therapeutic dialogue is deified because it promotes introspection. Moreover, it is only through therapeutic dialogue that a cautious entry of important painful effects or any other subconscious inhibitions into the conscious arena can be afforded. This not only improves our understanding and awareness of such painful effects but also access such effects without increasing resistances and defenses. In cases where the therapist through efficient use of relevant language succeeds in drawing the patient to dislodge such obstacles to therapeutic interventions, the reasons behind resistances to physical therapy treatments can be identified, analyzed, understood and interpreted with the view or remodeling the physical therapy regimens or constituting a novel regimen of therapeutic exercises that are not only in tandem with the psychological benefit of the patient but also the treatment outcomes.

Self psychologists attest to the fact that patients are usually not adequately prepared to consider events such as treatment regiments from other perspectives different from their own perspective. The presence of the therapist may be instrumental in introducing the other perspective to the patients. However, such a perspective can only be introduced if the principles of therapeutic dialogue are taken into consideration. The therapist self verbal exposure through conversational interaction constitutes a fresh perspective point different but related to the patients own perspective(Stricker & Fisher 1990). Therapeutic dialogue therefore allows the therapist to present his views in a manner that is not oracular as to suggest omniscience as this will effectively stifle therapeutic dialogue but to verbally self disclose himself or herself in a way that denotes that despite the fact they are medical professionals, they are but fallible. Such an introspection achieves wonderful results in creating multiple perspectives for the patient to analyze, their own perspectives, create new understanding hence leading to the process of dissemination as defined by Bollas(1995)(Scalia 2002).Thus therapeutic dialogue acts as an activator of the dissemination process. The patient elicits a response usually as a result of the intersubjectivity (Scalia 2002).

The creation of the therapist-patient role relationship is vital in that it both parties acknowledge the uniqueness of the other. The aspect of the roles of each party in the relationship comes into play in that the therapist acting on a specific therapeutic frame in self disclosing themselves do not specifically transgress into personal contents but that these personal contents must have a direct relationship with the subject matter at hand. Since the therapist do not present themselves to the patient in a predetermined therapist monologue, the connection and the relationship modeled thereof will not only be unique but follow its own unique trajectory even though at the start of the therapeutic dialogue salient patterns of therapist engagement will aid in the reconstruction of the therapeutic dialogue(Gurman & Messer 2003). As the dialogue develops the therapist recedes into the role of supporting the enactment of the patients novel narratives occasioned by change in perspectives while maintaining their availability for future consultations.

Developing the Skills Crucial in Advancing Therapeutic Relationships

It is an attested understanding that the therapeutic relationship between the practitioner and the patient is a crucial and an integral part of a patient oriented approach provision of health care. For this reason the degree of efficiency of therapeutic dialogue in patients who have resisted physical therapy possesses a direct correlation with the extent of skills acquired by the practitioner to enhance the healing experience(Duxburry 2000). Such skills therefore have to be developed if better health outcomes have to be achieved. In this analysis some of the therapeutic skills that will be looked into include;

1. Empathy
2. Attending and Listening
3. Silence
4. Unconditional acceptance
5. Open Questioning
6. Reflection
7. Physical and behavioral techniques
8. Professionalism
9. Concreteness
10. Warmth and being genuine

Cases of disease afflictions that progress into physical disability require a multifaceted treatment approach that not only recognizes physical therapy as a major component of such a multifaceted treatment program but also takes into account other therapeutic interventions that have the potential to improve the health outcome of the patient. Therapeutic dialogue is such an intervention that is commonly applied in conjunction with the therapeutic exercises or as a way of advancing the psychological advantage in cases where patients possess some resistance to physical therapy. Since the causes of such resistances are diverse and that they are perpetuated by the psychological environment only therapeutic dialogue have the capacity to dislodge inhibitions or fears that cause the resistances. For this reason treatment models aim at not only understanding the disease alone but also the patient as a whole. Patient oriented approach not only recognizes that the necessity of the practitioners expert knowledge but also relies on fruitful practitioner-patient conversations  as a way of empowering the patient with the desirable knowledge and the ability to improve recovery(Owen 2004).

If a practitioner has the skills that are invaluable in the nurturing of practitioner-patient relationships then the patients will be more willing to lend their trust and additionally open up. Opening up enables the practitioner to understand the real causes of patient resistance to physical therapy. An a more effective treatment model can thus be modeled and implemented with the acceptance of both the practitioner and the patient. On the other hand, the extra trust that develops between the patient and the practitioner has the capacity to improve health outcomes. Since patients genuinely value such therapeutic relationships which offer trust, care and respect, the relationships improve health outcomes in the broadest sense(Mitchel & Cormack 1998, p50). In practice therapeutic dialogue promotes the exchange of knowledge hence giving the patient control over their treatment outcomes.

Empathy

Empathy lies at the core of the therapist-client relationship and therefore it is a crucial skill for any fruitful therapeutic relationship. Empathy implies that one acquires the ability to accurately perceive the patients feelings and consequently communicate these feelings to the patient in a manner that is congruent to the professional ethics(Burnard 1992). This simply means that in the development of a therapeutic relationship the therapist relates to the ill patient not from an exulted position of stance but from their position as fallible beings(Oxen 2004). Ideally empathy lies at the center of patient centered treatment. By being empathic themselves, the therapist acquire the stance that is necessary in understanding the needs of their clients and hence formulating appropriate interventions through interaction with the patients.

Empathy do not always require that the patient enters into the perpetual world of their but rather personal experiences of life and disease or illness as drawn so as to support the patient. Alternatively it is only through empathy that the physician is able to share knowledge hence stimulating the process of personal healing since a knowledgeable patient is more likely to be inspired to take action that is beneficial to their health outcomes.

Attending and Listening

Apart from ensuring that the therapist attends the scheduled therapeutic sessions and focusing complete attention to a single unique patient without focusing any attention to other patients, listening is probably one of the most important skill. Without effectively honing the listening techniques, there is a possibility that the therapist might not understand whatever the patient has to say(Burnard 1995). Its only through attending and listening that the practitioner will be able to discern and fully comprehend what is being communicated to them. Any form of distraction either by individual thoughts or external interferences is a threat to the nurturing of the therapeutic relationship.

Notably the physician should develop skills that enable them to discern and accurately evaluate non verbal, linguistic or paralinguistic aspects of communication. While the linguistic aspects denote what is being said by the patient and the pattern or mode of expression of the subject matter, paralinguistic denotes aspects of speech like volume, fluency and timing. Likewise, none verbal aspects signify the facial expressions as well as the body language of the patient as can be observed during dialogue. All the three aspects are beneficial in directing the questioning and discussion process.

Silence

Silence is an integral component of the communication process particularly when discussing very pertinent patient- therapist issues. A situation should not always arise where people are always talking. Silence helps the patient to mull about issues and draw an appropriate well structured response that is not only honest but represents their patterns of expression. During these intervals, the practitioner is also given the time for thought recollection and assimilation of what the patient has communicated. However, as much as silence is important in the conversation process it should not be too long as to create an uncomfortable feeling or alternatively cause the questioning of practitioner ability.

Unconditional Acceptance

It is professionally ethical that practitioners cease from any form of conduct or behavior that implies any form of discrimination on the basis of patient background, ethnicity, social standing or presenting illnesses. Acceptance of patients must be unconditional since treatment can not be deemed to be successful of patients do not feel that they are worthy of the therapeutic interventions being rendered to them. On the other hand, practitioners should not always feel that their gestures of unconditional acceptance will be reciprocated. This skill aids in resisting the urge to operate on the basis of preconceptions in therapeutic dialogue.

Open-Ended Questioning

This skill ensures that the practitioner refrains from over talking as well as stifling the patients self disclosure through excessive questioning. It has been established that asking too many questions which is akin to an interrogation does nothing to improve the dialogue process instead it discourages openness an restrictiveness in the disclosure of information that may not only be beneficial in evaluating the reasons behind the resistance in physical therapy but also ensure improved therapeutic outcomes.

An important aspect of open ended questioning is reflection which promotes a deeper understanding of the client personality. The last words spoken by the patients can be included in the next therapist monologue to stimulate the patient to expand on a point. Closed questions are only necessary when recoding specific disease manifestations.