Finding Freud in Physiotherapy: Part 1

Visioning Practice Through a Psychotherapeutic Lens

M.A.S.H. is a 1970’s television show about people serving in\"\" a mobile army surgical hospital during the Korean War. The quality of writing and acting impeccably combine dramatic and comedic flare to address weighty social issues and complex interpersonal relationships. Some of these storylines relate to the scope of physiotherapy practice and how we as physiotherapists attend to the psychological component of our patients’ rehabilitation.
One example is the term “meatball surgery” and how it could be used to describe the way physiotherapists deal with their patients’ psychological needs. M.A.S.H. surgeons performed meatball surgery or surgery that is done as quickly as possible in order to address immediate life threatening issues.1 The primary focus was saving lives, which meant that important, although not essential, health issues might not be addressed. Typically, the surgeons did not have the time or resources to do more than patch the soldiers up in order to ship them to Tokyo or get them back to the front line.

Meatball Takes on New Meaning in Physiotherapy

I started to refer to us as “meatball psychotherapists” when I considered the following similarities:

  • we too have a primary focus, which is to address the physical aspect of rehabilitation to efficiently support our patients’ return to function;
  • we may not have (perceived or actual) time to target certain components of rehabilitation, such as psychological factors;
  • we likely do not have the personal resources (i.e. necessary training) to take a sophisticated approach to psychologically supporting our patients.

Many of us are on the frontline in the rehabilitation trenches, often managing stressful situations while trying to help as many patients as we can on any given day. In other words, I believe we psychologically “patch up” our patients the best that we can with the time and resources that we have.
Although these points might resonate, some could be uncomfortable with the word “psychotherapy”. Perhaps even one or two red flags have gone up in protest. This response is understandable, especially in light of the three points I just made. To address any unease, I will use the next few paragraphs to argue that meaningful physiotherapy is psychotherapeutic, and that whether deliberate or not, there is a psychotherapeutic aspect to what we do. As an interesting twist, I will use contextual theory from psychotherapy to back my argument. I will also suggest that current trends in physiotherapy support this view.

Meaningful physiotherapy is psychotherapeutic

Defining Psychotherapy & Clarifying Some Boundaries

Simply put, psychotherapy is form of treatment that addresses limiting attitudes, beliefs, and behaviours.2 It traditionally has had strong ties with the professional disciplines of psychology and psychiatry. In fact, many would equate psychotherapy with these disciplines, which is not a surprise considering that the main reasons people go to see psychologists and psychiatrists are to understand and change the thoughts, emotions and behaviours.3 These professionals, trained in psychological principles, deliver specific psychotherapeutic treatments (e.g. psychoanalysis) that are rooted in psychotherapeutic theory (e.g. psychodynamic theory).4 Furthermore, these treatments directly address conditions or complaints that have psychological origin or associated pathology (e.g. depression).5
In other words, a psychologist’s professional world centers on psychological concepts, diagnoses, and interventions. In contrast, physiotherapists are trained in musculoskeletal and neurophysiological principles and deliver specific treatments based on these principles to clients with conditions or complaints with a physical (versus psychological) origin.6
Despite this strong link between psychotherapy and the psychological disciplines, it is not an exclusive link. A pivotal point bears repeating: psychotherapy involves addressing psychological concepts such as attitudes, beliefs, and behaviours. It is this point that introduces the intersection between psychotherapy and physiotherapy. I will not dispute that the body and its function are central to treatment (hence, ‘physiotherapy’) and that referrals to diagnose or treat psychological conditions are not within our scope of practice. Although, I believe most physiotherapists would agree that the whole person is affected by physical impairment and disease, and the whole person comes equipped with beliefs, attitudes, and behaviours in addition to bodily complaints. Therefore, psychological factors like “adherence”, “pain beliefs”, “hope”, and “expectations” can show up in rehabilitation, and must be acknowledged if we want to help our patients achieve their rehabilitation goals. And although it is true that physiotherapists do not make or specifically treat psychological diagnoses, it could also be true that we indirectly influence diagnoses like depression through addressing physical limitations and their associated psychological elements.7
These insights are not new. Biopsychosocial8 and patient-centered9 models clearly describe addressing the whole person when supporting patients through their rehabilitation experience. What may be unique and somewhat edgy for physiotherapists is considering this approach as psychotherapeutic.
This wraps up Part 1 of Finding Freud in Physiotherapy. In Part 2, Maxi will share how contextual theory supports her discussion of physiotherapy being psychotherapeutic.
1. Wiktionary contributors. Meatball surgery. Wiktionary, The Free Dictionary, 2014 20 June 20, 2013, 12:27 UTC. Available from:;=21237860.
2. Frank JD, Frank JB. Persuasion and healing: A comparative study of psychotherapy. Baltimore: The Johns Hopkins University Press; 1991.
3. Psychologists\’ Association of Alberta. What is Psychotherapy. Available from:
4. Wampold BE. The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ: Lawrence Erlbaum Associates Inc.; 2001
5. Main CJ, George SZ. Psychologically informed practice for management of low back pain: future directions in practice and research. Phys Ther. 2011;91(5):820
6. Miciak M, Gross DP, Joyce A. A review of the psychotherapeutic \’common factors\’ model and its application in physical therapy: the need to consider general effects in physical therapy practice. Scand J Caring Sci. 2012;26(2):394-403.
7. Hall AM, Ferreira PH, Maher CG, Latimer J, Ferreira ML. The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: a systematic review. Phys Ther. 2010;90(8):1099-110.
8. Engel GL. The biopsychosocial model and the education of health professionals. Gen Hosp Psychiatry. 1979;1(2):156-65.
9. Mead N, Bower P. Patient-centredness: a conceptual framework and review of the empirical literature. Soc Sci Med. 2000;51(7):1087-110.

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