Lesson 1: Psychological Models - Minor

UNIT 8: Psychology

LESSON 1: PSYCHOLOGICAL MODELS - MINOR

There are innumerable ‘minor’ psychological models, including, but not limited to:

• There is no therapist
• The therapist says and does nothing
• Patient asked to strike out or scream
• Religion is stressed
• The patient is treated like a child
• The therapist treats patient with apparent lack of respect and makes fun of the patient

How will you treat your patients? Will you allow an aide to treat your patient? Will you encourage your patient status post total knee to scream when you stretch his knee? Will you encourage your patients to pray? Will you treat your geriatric patient like a child by addressing all of your questions to her adult daughter or son?Will you ridicule your patient when talking to another therapist?

LESSON 2: PSYCHOLOGICAL MODELS – MAJOR

There are several psychological models which are considered major models:

Freudian Therapy:

• Causality/unconscious affects actions.
• Reductionism
• People do anything to get pleasure/avoid pain
• People are inherently bad, compete

Freudian examples:

• An elderly female patient doesn’t want to participate in her therex program because she was badly hurt when she ‘rough housed’ as a child;
• A physical therapist refers to his patient that is status post a total knee replacement as the ‘knee patient’;
• A physical therapist assumes that his patient isn’t trying hard and just wants palliative care and modalities;
• A physical therapist faculty member undermines a colleague by subtlety disparaging her when talking to her students in a class.

Adlerian Therapy:

• Holistic view of the patient
• People are fellow human beings and are neither good nor bad;
• Freedom of choice
• Social interest
• The goal of therapy is competence.

Adlerian examples:

• Takes into account all aspects of a patient when developing her/his plan of care
• Encourages and motivates her patients
• Offers her patients treatment alternatives
• Provides pro bono services
• Appreciates her patient’s maximum optimal function when developing the long term goals

Analytical Therapy:

• Self-knowledge and self-healing potential;
• Symptoms hold the key to cure.

Analytical examples:

• During the initial session and each subsequent visit, the physical therapist does not neglect the self-report of the patient
• During the initial session, the physical therapist critically reflects upon the symptoms of the patients, and integrates the symptoms with the signs, to develop an appropriate physical therapy diagnosis.

Existential Therapy:

• The immediate person.
• Realistic approach that is optimistic and embraces human potential, but recognizes human limitations.

Existential examples:

• The physical therapist is careful to address the top complaint of the patient by the end of the initial session;
• The physical therapist is optimistic about his patient’s recovery, but appreciates that the limiting factors may necessitate a change in the plan of care and/or goals.

Person-Centered Therapy consists of the following components:

• Trust and unconditional positive regard;
• ‘he Actualizing Tendency’ – the patient is locus of evaluation and should experience her/his self and the world with flexibility and openness
• The goal of therapy is full potential

Person-centered examples:

• A physical therapist offers unconditional positive regard for her patient and takes time to bond with the patient so that patient can trust her
• A physical therapist encourages his patient to ‘take responsibility’ for his therapy and be open and flexible with his rehab
• A physical therapist appreciates that his patient’s maximum optional function when developing the long term goals.

Behavior Therapy consists of:

• Classical Conditioning
• Operant Conditioning
• Social Learning Theory

Classical conditioning is a type of associative learning which was first described by Ivan Pavlov- repeatedly pairing an unconditioned stimulus with a neutral stimulus. An unconditioned stimulus is a stimulus that naturally evokes a certain response. For instance, a light shone into a person's eyes makes them blink. In this example, the light is the unconditioned stimulus, and the blinking is the unconditioned response. A neutral stimulus, like sounding a bell, doesn't elicit this response. However, after repetitive pairings of the neutral stimulus with the unconditioned stimulus, the neutral stimulus comes to elicit the same response as the unconditioned stimulus. That is, if the bell is sounded every time a light is shone into a person's eyes, eventually they will blink when only the bell is sounded. Now the neutral stimulus (the bell) has become a conditioned stimulus. The response (blinking) to the conditioned stimulus is called a conditioned response.

Can you think of an example of classical conditioning in the realm of physical therapy?

Operant conditioning is a method of learning that occurs through rewards and punishments for behavior.Operant conditioning is distinguished from Pavlovian conditioning in that operant conditioning deals with the modification of voluntary behavior through the use of consequences, while Pavlovian conditioning deals with the conditioning of behavior so that it occurs under new antecedent conditions Reinforcement and punishment, the core tools of operant conditioning, are either positive (delivered following a response), or negative (withdrawn following a response). This creates a total of four basic consequences, with the addition of a fifth procedure known as extinction (i.e. no change in consequences following a response).

It's important to note that organisms are not spoken of as being reinforced, punished, or extinguished; it is the response that is reinforced, punished, or extinguished. Additionally, reinforcement, punishment, and extinction are not terms whose uses are restricted to the laboratory. Naturally occurring consequences can also be said to reinforce, punish, or extinguish behavior and are not always delivered by people. Reinforcement is a consequence that causes a behavior to occur with greater frequency. Punishment is a consequence that causes a behavior to occur with less frequency. Extinction is the lack of any consequence following a response. When a response is inconsequential, producing neither favorable nor unfavorable consequences, it will occur with less frequency.

Can you think of an example of operant conditioning in the realm of physical therapy?

The Social Learning Theory, developed by Bandura, involves external stimuli, external reinforcement, and the cognitive ‘meditational’ process.

A scenario which illustrates the social learning theory follows: My daughter and I were on a cruise and there was a rock climbing wall. My daughter wanted to climb the rock wall to the top and ring the bell. The external stimuli included the rock wall, the height of the ship, etc. The external reinforcement included me cheering her on. She engaged in a cognitive meditational process to get her to the top of the rock wall and ring the bell! Can you think of an example of the application of the social learning theory to physical therapy?

Cognitive Therapy is rooted in the notion that how one thinks largely determines how one feels. Cognitive therapy uses Guided Discovery, which involves:

• Determine how the function developed.
• Apply the Inductive Model.
• Determine a hypothesis.
• Initiate a cognitive shift.
• Conduct verbal discussions and behavioral experiments;
• Examine the alternatives;
• Perform re-adjustments as indicated.

Can you think of an example of the use of the Guided Discovery method in physical therapy?

The inductive method which is also referred to as the scientific method involves a process using observations to develop general principles about a specific subject. Similar subjects or events are observed and studied. Findings from the observations are then used to make broad statements about the subjects that were examined.

Rational Emotive Therapy (RET), also known as Brief Therapy, developed by Albert Ellis, involves the following components:

• Acceptance that the client is fallible
• Homework and discipline
• ‘Bag of Tricks’

Reality Therapy involves the following components:

• The basic psychological needs of a person are belonging, freedom, power, and fun
• Therapy should be simple in terminology

Reality therapy examples:

• A physical therapist is careful that her patient feels that he is an integral part of the rehab team, does not force him to engage in a treatment or therapy, seeks his input regarding treatment alternatives, and incorporates activities that she thinks will be fun for the patient
• A physical therapist refrains from using technical and medical jargon when discussing issues with his patients

Critical concepts of Multimodal Therapy (MMT) are:

• Modalities- Physical, Interpersonal, Behavior, Affect, Sensation, Imagery, Cognition.
• Bridging - addressing a patient in her/his current preferred (or current) modality
• Multiple interventions - utilize multiple interventions, rather than just one

LESSON 3: MENTAL CONDITIONS AND ILLNESSES

The mental conditions and illnesses that a physical therapist may encounter include, but are not limited to: Stress, Anxiety, Depression, Malingering, Factitious Disorder, and Somatoform Disorder.

Stress

Stress is an individual reaction to real or perceived positive or negative factors & change in homeostasis. Conflict can be considered in one of three ways: An approach / approach conflict; an avoidance / avoidance conflict; and an approach / avoidance conflict.

Anxiety and Anxiety Disorders

Anxiety can be either normal or neurotic. To determine if anxiety is normal or neurotic, the following questions need to be asked and answered: Is the anxiety proportionate to situation? Is there is a constructive use of anxiety? If the anxiety is too high in response to the situation and the anxiety is not constructive, the anxiety is neurotic.

There are two major types of anxiety conditions:

• State anxiety
• Trait anxiety

State anxiety is the perception of tension in response to a specific circumstance.- White coat syndrome.

Depression

Symptoms of depression: Agitation; sad mood; loss of energy; loss of interest; difficulty thinking; feelings of worthlessness; change in weight and/or appetite; trouble sleeping or oversleeping; recurrent thoughts of suicide/death.

Malingering and Factitious Disorder and Somatoform Disorder

Malingering- intentional production of false or grossly exaggerated physical or psychological, motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs.

To screen for malingering, a factitious disorder, and a somatoform disorder, the physical therapist determines if the patient believes the condition is organic and then evaluates the patient to ascertain whether her/his symptoms have an organic presentation. If a patient wants or guides her/his symptoms, realizes that her/his condition is not organic, and the patient is seeking a monetary or like reward, the patient is malingering. In the realm of physical therapy, the ‘stereotypical’ malinger is an individual that is status post a motor vehicle accident or a work related injury and waiting for compensation.

Factitious disorder - intentional production of psychological or physical symptoms or signs and a motivation to assume the sick role without other external incentives. In the realm of physical therapy, the ‘stereotypical’ patient with a factitious disorder is a home health care patient that ‘fakes it’ in hopes that physical therapist will not discharge her because the physical therapist is the patient’s only companion.

Somatoform disorders - symptoms suggest a medical condition but where no medical condition can be found by a physician. In other words, a person with a somatoform disorder might experience significant pain without a medical or biological cause, or they may constantly experience minor aches and pains without any reason for these pains to exist.

UNIT 9: Integration of Psychology in PT

LESSON 1: THE RELATIONSHIP BETWEEN PT AND MENTAL HEALTHEALTTE

The Relationship between PT and Mental Health

The ways in which a patient’s poor mental status can affect physical therapy are:

• The patient may lack adherence and/or not progress
• The patient may require a referral to a mental health practitioner
• The patient may refuse physical therapy – which may lead to the therapist discontinuing physical therapy
• The patient may be inappropriate for physical therapy and the therapist either does not move from a screen to an initial examination/evaluation or discontinues the patient.

Professional behaviors will also impact rehab. Professional behaviors consist of professionalism, professional development, critical thinking, communication management, interpersonal skills, personal balance, and working relationships. These are in are in the Professional Communication /Development course and are fully described by Jette and Portney.

A physical therapist must be adequately versed in mental health so that she/he can appropriately address the psychological issues that she/he will encounter in her/his career.

PTs must:

• Role model appropriate psychological health / wellness
• Assess the psychological status of our patients
• Integrate psychology into our provision of physical therapy
• As indicated, refer to appropriate psychological practitioners

The assessment of the psychological status of our patients is accomplished during our systems review which consists of:

• Communication, Affect, Cognition, Language, Learning Style
• Ability to make needs known…
• Expected emotional / behavioral responses
• Learning preferences
• Education needs
• Learning barriers

To integrate psychology into physical therapy, we need to consider our ‘bedside manner’ and integrate psychological treatment into our provision of physical therapy services, including the provision of physical therapy to those with a psychological diagnosis and those without a psychological diagnosis.

Referral to:

Psychiatrist - medical doctor that has additional credentials related to psychiatry

Psychiatrist - licensed to prescribe medications

Psychologist - not a medical doctor, and cannot prescribe medications; doctorate or a master’s degree in psychology

Licensed clinical social worker- master’s degree and a license in social work

Licensed mental health counselor - Master’s degree and a license in mental health

Poor mental health is positively correlated to physical ailments which can negatively impact physical therapy.

LESSON 2: PHYSICAL THERAPISTS’ USE OF PSYCHOLOGICA

To integrate psychological health into their practice as well as personal life, physical therapists need to be able to:

• Clarify their Values
• Differentiate at a High Level
• ‘Center’
• Be Empathetic
• Be Assertive
• Handle Criticism

Clarification of Values

(1) Assess what you are for and against and why

(2) Consider the pros and cons of the alternatives

(3) Choose and act freely but with thoughtfulness

(4) Evaluate the outcome.

Differentiation of Self

Differentiation of self - ability to separate negative emotions from the Intellect.

Low level of differentiation - fusion of the emotional & intellectual centers. Increased risk of inappropriately involving a third party in a conflict.

High level of differentiation- ability to screen, separate, and ‘control’ emotions.

Centering

Centering is self-talk and/or relaxation to feel objective and stable.

Empathy

This is the intellectual identification with or vicarious experiencing of the feelings, thoughts, or attitudes of another. If an individual lacks empathy, s/he ignores the situation or responds inappropriately.

Basic empathy - an individual appropriately responds to overt symptoms.

Trained empathy- an individual appropriately responds to covert symptoms and thereby prevents a progression to overt symptoms

Assertiveness - honest self-expression regarding:

• Positive and negative feelings
• Self-initiation (e.g., making a request and/or speaking up)
• Setting limits (e.g., saying no)

The opposite of assertive behavior is not passive behavior, but passive-aggressive behavior

To enhance your assertiveness, you should:

• Utilize appropriate body language
• Demonstrate good posture and use direct eye contact
• Use ‘I’ and avoid ‘you’

Handling Criticism

Criticism can be either constructive, which can be utilized for self improvement, or non constructive, from which you should extract any ‘grain of truth’ to improve yourself and ignore the rest. There are numerous strategies to handle criticism, including: Agree, Flow, Probe, Parley, Broken Record, Content to Process Shift, Momentary Shift, Time Out, Deflection, Humor, Stand Up For Your Rights.

If you agree with criticism, you acknowledge the error, but you do not try to give an excuse.

If you utilize flow to handle criticism, you are “like water, rather than a rock”.

If you probe to handle criticism, you ask questions to clarify comments and/or determine if criticism is constructive.

If the discussion has turned into a contest, you can parley. - Compromise

If you cloud to handle criticism, you agree in part with the criticism, or you can also agree in probability or principle.

If another is repetitive in their negative critique, it may be appropriate to use the broken record technique to handle criticism.

When the focus of a conversation drifts, you can shift back to the original topic with content to process shift.

To handle criticism, you can use a momentary delay, which will allow you to center and then respond.

To handle criticism, you can use a time out, which will reschedule the discussion when an impasse is reached.

To divert or “lighten” the mood, you can use deflection or humor to handle criticism

If you are being verbally used, for example, by a patient or another health care practitioner, you can stand up for your rights.

Affirmation - a positive thought one consciously chooses to achieve a goal.

Guided Imagery - self-use tool to move towards positive psychological Attitude. The goal of guided imagery is to stop/lessen worry or distress.

Neurolinguistic Programming (NLP)– goal is to enhance rapport. Must observe non-verbal cues and respond appropriately.

LESSON 3: “DIFFICULT” PATIENTS

An important ‘rule’ for interacting with ‘difficult patients’ - if not all patients - is to be pro-active by avoiding emotional subjects.

Remember, interpersonal skills and an affective demeanor is just as important as clinical skills

Guidelines

• Invite the patient to sit down;
• Show respect;
• Maintain eye contact;
• Listen attentively;
• Use a calming tone of voice;
• Do NOT use derogatory labels;
• Clarify you’ll work with the patient to identify and address problem(s);
• Engage the patient to work with you to identify solutions/goals.

If there are multiple issues, begin with the most immediate concern and progress. If the problem can’t immediately be resolved, develop a time-line