Finding Freud in Physiotherapy-Part 3

Reconsidering Boundaries Moves Us Forward

(Read Part 1 & Part 2 here)

Are physiotherapists doing psychotherapy?

Applying Frank and Frank’s descriptions, I say yes, physiotherapy treatment can be psychotherapeutic. In my view, psychotherapy is not solely contingent upon the treatment of psychological diagnoses; rather, it is a form of therapy that addresses the psychological factors of a person’s experience.
Of course there are limits to what physiotherapists should be addressing given our training and the reason for referral. Referring to a psychologist when certain issues outside our scope of practice (e.g. marital issues, depression) or comfort is good practice. But this is not much different than the boundaries regarding physical treatments, such as spinal manipulation and acupuncture; not everyone is permitted to do them and must refer to an appropriate practitioner.
Yet it would be naïve to think that we do not or should not address expectations, beliefs, and behaviours as well as acknowledge emotions like anger and frustration when it comes to our patients’ experiences with rehabilitating physical issues. Addressing some of the psychological factors associated with a patient’s disability and developing a strong therapeutic relationship is good practice. In fact, just developing a strong therapeutic relationship can be therapeutic,12, 13, 14  and is a professional obligation.15, 16

Moving from Meatballs To…

The issue for me is whether it is “meatball”. Put simply, I do not believe it needs to be.
In addition to the criteria I described earlier, “meatball” can give the impression that actions are not deliberate, or as Frank and Frank describe, are intuitive.2  On the contrary, I believe we are becoming more sophisticated and deliberate in psychotherapeutically supporting our patients. For instance, interventions based on motivational interviewing17 and cognitive-behavioural18  principles are supported by rehabilitation research and are being used in clinical settings.
Implementing a specific psychotherapeutic intervention implies that psychological factors have been acknowledged: it also implies that there is associated knowledge and skill involved (i.e. not meatball). Understanding the theory behind the interventions is important. Psychologists do no not just ‘do’ cognitive-behavioural therapy; they have an understanding of the principles that underpin cognitive-behavioural interventions. Theories function to help explain, predict and plan; therefore understanding the theory behind the psychotherapeutic intervention is important in designing, administering, and evaluating the intervention.
I also believe that some physiotherapists have become experts in developing therapeutic relationships. In my research on the therapeutic relationship in physiotherapy, I have interviewed physiotherapists who have richly described the process of developing the therapeutic relationship. To these physiotherapists, initiating, deepening, and maintaining strong therapeutic relationships requires a deliberate attempt to understand their patients as people in addition to being diligent with the physical issues. Although each of these physiotherapists has been in practice over ten years, developing their skills through experience, physiotherapy programs are more actively teaching and assessing relational skills. This means novice physiotherapists have been introduced to some basic skills and can build upon them.


Our discipline is constantly evolving. I believe that certain clinical circumstances, such as the time and frequency of treatment sessions, uniquely position physiotherapists to develop meaningful relationships and address issues that other professionals may not. Bringing the psychotherapeutic aspect of our practice to the foreground from the background makes it less ”meatball” because we then can own and develop it from within physiotherapy to suit our scope.
Psychologically-informed practice5  is a new buzz-word circulating in the physiotherapy research world for addressing back pain, and for good reason – research for common conditions such as back pain continues to indicate that psychological and social factors play a prominent role in recovery10  and that addressing these factors could improve outcomes.7, 11, 14, 19
The bottom line is that we need to seek ways to better support our patients. If we do this everyone benefits – patients achieve their goals, physiotherapists get to share in that success, and management gets the outcome.

This wraps up the final section of Finding Freud in Physiotherapy. We hope you enjoyed the article!

2. Frank JD, Frank JB. Persuasion and healing: A comparative study of psychotherapy. Baltimore: The Johns Hopkins University Press; 1991.
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):820-4
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
10. Hill JC, Fritz JM. Psychosocial influences on low back pain, disability, and response to treatment. Phys Ther. 2011;91(5):712-2
11. Ferreira PH, Ferreira ML, Maher CG, Refshauge KM, Latimer J, Adams RD. The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain. Phys Ther. 2013;93(4):470-8
12. Rogers CR. The necessary and sufficient conditions of therapeutic personality change. J Consult Psychol. 1957;21(2):95-103.
13. Norcross JCW, Bruce E. Evidence-based therapy relationships: research conclusions and clinical practices. Psychother. 2011;48(1):98-102]
14. Fuentes J, Armijo-Olivo S, Funabashi M, Miciak MA, Dick B, Warren S, et al. Enhanced therapeutic alliance modulates pain intensity and muscle pain sensitivity in patients with chronic low back pain: an experimental controlled study. Phys Ther. 2013
15. Physiotherapy Alberta College + Association, Therapeutic relationships establishing and maintaining professional boundaries: A resource guide for physical therapists. c2007.
16. Physiotherapy Alberta College + Association. Standards of practice for Alberta physiotherapists]
17. Vong SK, Cheing GL, Chan F, So EM, Chan CC. Motivational enhancement therapy in addition to physical therapy improves motivational factors and treatment outcomes in people with low back pain: a randomized controlled trial. Arch Phys Med Rehabil. 2011;92(2):176-83
18. Asenlof P, Denison E, Lindberg P. Long-term follow-up of tailored behavioural treatment and exercise based physical therapy in persistent musculoskeletal pain: a randomized controlled trial in primary care. Eur J Pain. 2009;13(10):1080-8
19. Nicholas MK, George SZ. Psychologically informed interventions for low back pain: an update for physical therapists. Phys Ther. 2011;91(5):765-76.

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