I can still remember sitting under the fluorescent lights of my semi-private treatment room, in a bay with four other therapists, next to four other bays just like mine, sharing my PT-related beliefs with one of my fellowship mentors as she laughed at my nerdiness.
It was during my time in fellowship that I got into the practice of writing down my beliefs as they related to patient care as they became known to me.
We often aren’t fully aware of what our beliefs are, yet they have much to do with our thoughts and behaviors. Becoming aware of them gives us the opportunity to assess the truth of them and to rewrite them if we want to.
My experience has shown me that the moment I say them out loud or write them down, I realize how silly and narrow many of my beliefs are. After writing many of these down, I immediately had ways of modifying them to make them more true.
In this episode, I’m going to share with you:
Some of my former beliefs
How they lead me astray
My updates that better reflect the truth as I see it
My hope & expectation is that some of these will resonate with you, and might even spark some investigation into your own beliefs and how they inform your practice.
This should be fun.
Belief #1: If my rapport is too good, my patients will never want to leave
This is a great one to start with because it has a nice tinge of arrogance.
Basically, I feared that if I became too chummy with my patients, they would want to keep coming to therapy forever.
As a result, I’d subconsciously detach if I sensed that my rapport was becoming too strong, often leaving me hastily trying to discharge people.
I think a lot of this resulted from a deeper belief, that I’m a bad PT if my patients come for a long period of time. Much of my training and efforts after graduation had a lot to do with getting people better, faster. I really took this concept on board, and it led me at times to try and discharge people as quickly as I could as some sort of badge of honor.
The reality is, everyone’s different. Some people require more time than others for a massive variety of reasons. That’s OK. That’s normal. & helping people who need it, who are making progress, for a longer period of time, is not me being complacent or a shitty PT.
The irony of my original belief is that having solid rapport will help people get better faster. This has been shown in research (1,2), but also makes intuitive sense. The more trust that is built, the more both parties can work together to achieve the goal. And if the goal changes, seems out of reach, or other parties are required to assist in reaching the goal, all of that can be better worked out in the context of an honest, trusting relationship.
I had it exactly backward.
UPDATE: My rapport can’t be too good.
Belief #2: Treatment is the most important thing that I can offer my patients
I’ve found this one to be quite common when discussing cases with colleagues or mentees.
Many of us have an action bias. We want to help by doing.
We’re physical people, that’s why we became physical therapists. That’s great; there’s nothing wrong with helping by doing.
But what I began to notice is that while I was focusing on the action-oriented things: what interventions to perform, how to change the patient’s symptoms, or even how to change their beliefs; the patient was focusing on more basic questions:
What’s going on?
Why am I feeling what I’m feeling?
Can PT help me?
Do I need surgery?
Is it safe for me to do my usual activities?
Will I be able to do the things that I want to be able to do?
& I only realized this once I started asking people about their concerns.
“At this point, what’s your primary concern?”
It’s a simple, yet profound question. What I found when I started asking about people’s concerns was what they shared with me was often discordant with what I assumed they were concerned about.
Because as we discussed in Law II of the Four Laws of Quality Care, it’s not their symptoms that bring them in, it’s their concerns about their symptoms that bring them in.
Understanding the person’s concerns has allowed me to more fully understand how I can help them.
Instead of assuming I know what they want, I now simply ask.
Because it’s not up to me to decide what’s best for them. I’m here merely to help them in the way that I can, based on what help they’re looking for.
Sometimes what they’re looking for is treatment: exercises, symptom modification, relief. Other times it’s advice. Other times it’s reassurance. Other times it’s someone to listen to them. I don’t know until I ask and listen.
UPDATE: (Aside from ensuring safety), addressing the person’s concerns is the most important thing I can offer my patients
Belief #3: The most important aspect of treatment is improving confidence & reducing fear
This one’s a bit tricky because fear is a big thing. It’s a driving force that brings people to see us, as concerns are merely fears.
And fear has been shown to be an important mediator between pain and disability, meaning that it (among other factors) explains the relationship between pain and disability (3).
This point can be illustrated by the fact that someone can live with pain but not be disabled by it. Add in fear, psychological distress, or low self-efficacy, and suddenly disability emerges (3).
So it’s reasonable to want to help people reduce their fears and help them rebuild confidence in their bodies.
But trying too hard to allay people’s fears can lead to unintended consequences.
For example, in an effort to try to reduce people’s fears or concerns, there were times when I was too cavalier with people. I thought that if I wasn’t concerned, they wouldn’t be concerned. But this attitude can come off as dismissive of their concerns and lacking thoroughness, which can lead to a lack of trust by the patient, resulting in the opposite effect—more fear; more distress.
The problem was, I was looking at safety through a narrow lens. I realized that ‘safety’ doesn’t only include physical safety. ‘Safety’ also includes psychological and social safety.
Ensuring that the patient feels safe from a biopsychosocial standpoint can lead to more trust and more willingness to challenge themselves and face their fears.
Trust & willingness are the bedrock of an effective therapeutic relationship. When either one is lacking in the relationship, little progress can be made.
UPDATE: The most important aspect of treatment is ensuring biopsychosocial safety.
Belief #4: The body is strong & resilient, therefore movement & posture don’t matter
These last two are some of my favorites. They reflect many of the Twitter battles that I’ve witnessed (and taken part in). They also reflect the difficulty in achieving a balanced understanding of modern pain science and human biology.
Let’s start with the first part of this statement: the body is strong & resilient. This is true, but in no way does this mean that the way we move and position our bodies doesn’t matter.
True, there may be a very tenuous relationship between movement, posture, and pain. But this merely reflects the way that pain works.
In fact, there’s a tenuous relationship between everything and pain, because pain is exceedingly complex, and is never caused by one specific factor. But this doesn’t mean that movement and posture don’t matter.
This is because of another basic truth about the human body: it changes based upon the stresses & stimuli that it interacts with—it’s bioplastic.
This is why the body gets more flexible when we do yoga, stronger when we lift weights, and weaker when we lay around and do nothing.
This is also why physical therapy works at all. The bulk of what we do is carefully introduce stresses & stimuli to the person and let their body (& mind) do the rest.
So to say that it doesn’t matter how someone moves or positions their body certainly isn’t correct.
All that to say, I still don’t believe that there’s such a thing as a right or wrong way to move. Saying that there’s a right and wrong way to move is like saying there’s a right and wrong way to think, look, act.
At the crux of this confusion is the paradox that we’re all so different, yet at the same time so similar. We can think, look, act, and be in a staggering variety of ways, yet all be made of the same stuff and have the same basic humanistic needs.
What emerges from this paradox, for me, are less picky and more basic movement precepts that allow for the wide variability of humans, while still bowing to our remarkable similarities.
This includes such principles as:
Frequent and varied movement is important
Movement & posture matter relative to the person’s life & goals
Movement & posture are but one piece of the puzzle when it comes to pain
UPDATE: The body is bioplastic, therefore everything matters relative to our lives and our goals.
Belief #5: The body is self-healing, therefore what we do doesn’t matter
To some of you, this might sound crazy. Others might be thinking, yeah, I kinda dig that.
This belief arose during the peak of my pain-science-&-philosophy-rabbit-hole-nihilism phase. I was utterly awestruck by the amazing capacity of the body for self-regulation and self-healing. So awestruck, that I was finding it difficult to determine what the fuck I could possibly do about any of it.
Let’s take a closer look.
Similar to the last belief, the first part is true, the body is self-healing. We need only cut our finger, slap a band-aid on it, and take it off a few days later to witness the awesome healing capacity of the body.
But again, this doesn’t mean that the second part is right, that nothing else matters.
All this really means is that we’re not the ones doing the healing. We’re merely setting the conditions for the mind & the body to heal themselves.
And, importantly, the conditions that I speak of… are infinite.
We know that pain has everything to do with the relative amount of safety or danger that the body perceives in a particular moment (and when I say body I include the brain in that as the brain is part of the body) (4).
What this means is that anything that reduces the body’s perception of danger will reduce pain and anything that increases the body’s perception of danger will increase pain. This includes interoceptive data from the body, as well as exteroceptive data from the external environmental context. As Lorimer Moseley puts it, “When it comes to pain, everything matters (5).”
This means that there’s a lot that we can do to facilitate pain reduction by helping the body feel safe through reducing threat or danger data. This includes movement, exercise, listening, eye contact, therapeutic touch, compassion, positioning, movement modification, manual therapy, providing advice or information, and much, much more.
The same concept emerges from a tissue healing standpoint. When we treat someone with an acute ankle sprain or acute radiculitis, we merely set the conditions for their body to do its thing. We essentially help the person not get in the way of their body healing. This is an important job.
So while I was busy wondering how I could change anything, I was missing the fact that I couldn’t avoid changing things by working with someone.
It can be paralyzing or invigorating to know that there are infinite ways that we can help people.
These days, I prefer to keep it simple by saying: the body is self-healing. Our job is to set the conditions under which it can heal.
...& that’s the final UPDATE.
If you found this helpful (or at least amusing) and want to explore this for yourself, I put together a reflection form that you can fill out.
Click the image to download the form.
Thanks so much for reading! Good luck out there.
Hall, A. M., Ferreira, P. H., Maher, C. G., Latimer, J., and Ferreira, M. L. (2010). The influence of the therapist—patient relationship on treatment outcome in physical rehabilitation: a systematic review. Physical therapy, 90(8), 1099—1110.
Ferreira, P. H., Ferreira, M. L., Maher, C. G., Refshauge, K. M., Latimer, J., and Adams, R. D. (2013). The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain. Physical therapy, 93(4), 470—478.
Bunzli, S., Smith, A., Schütze, R., Lin, I., & O'Sullivan, P. (2017). Making sense of low back pain and pain-related fear. journal of orthopaedic & sports physical therapy, 47(9), 628-636.
Moseley, G. L. (2007). Reconceptualising pain according to modern pain science. Physical therapy reviews, 12(3), 169-178.
Mosley, G. L., & Butler, D. S. (2017). Explain pain supercharged. NOI.