The Core Skills
These are the skills of mental health physio, the other areas are best described as the knowledge of mental health physio.
This is the skill of delivering physiotherapy to patients who may need more skill consideration and adaptation.
This is the skill which allows a physio to work with more complex presentations. Not all mental health patients need their physio to have advanced skills in this area but many do. Because of this, physios in mental health need to quickly get good at this area of practice. The skills of patient interaction are obviously used in all areas of physio but to be successful in mental health physio these skills need to be more dedicated to the needs of mental health patients. What always interested me was what are these skills and how can they be explained. How is it that one physio may be able to work well with a patient but another may not. Some of the factors which are relevant are integral to an individual, like gender or size, but there are many factors which can be changed to improve interaction and therefore influence. Becuase influence really is all we have. We seek to influence people to do the exercises we have shown, change their posture, sit differently, if we cannot influence we can't help.
2 Core Principles
The are can be broken down into 2 core principles which when applied become increasing complex.
These 2 principles must be raised in importance within the decision making of the physiotherapist
1. Increased prioritisation of the patients mental state
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2. Adaptation
Increased prioritisation of the patient's mental state
As someone works within mental health they develop a very important skill which is to accurately read a patient’s mental state through their verbal and non-verbal cues. From reading these cues they can then make adaptations to their own behaviour to manage the appointment and to keep it on track.
As a general rule the person is reading the stimulation level of the patient’s sympathetic system (flight, fight or freeze) but there are other interplays present to read. These become increasingly complex and this article will stick to managing the level of stimulation of the patient’s sympathetic system as it is the most common factor to deal with.
If one works with the general population we will meet occasional patients whose fight or flight system hijacks the appointment. And when it happens it is easy to assume that this situation was an anomaly, an outlier, and that we don’t need to change. Our approach worked for every other patient we saw that month, there is no need to change. When one works exclusively with mental health patients, appointments will be hijacked by a patient’s flight or fight system on a daily basis unless the physio becomes adept at managing it.
Over time the physio will start to notice the verbal and non-verbal cues which suggest that the patient’s sympathetic system is becoming more stimulated and they will build up a bank of memories of what this leads to, i.e. the hijacking of the appointment. The physio may not know exactly what they are seeing, but they will know where it leads to and over time will start to make adaptations to stop the session being hijacked. These adaptations are often personal to the physio based on their own specific attributes but they will have the goal of decreasing the stimulation of the patient’s sympathetic system and keeping the session on track.
When a physio is assessing someone, they are thinking about what question to ask next, what condition do the person’s symptoms suggest they have, what tests should I do and what do I need to do to rule something in or out. These are the thoughts in the physio’s mind until the session gets hijacked by the patient’s sympathetic system and they realise that there is a problem and the appointment is not going the way they expected. At this point the patient’s sympathetic system is likely too stimulated and the session can not be turned around. The key is to maintain a constant thought about how the patient is feeling and a highly sensitive trigger for acting upon signs that the patient’s sympathetic system is becoming stimulated. The earlier the intervention the more likely it is to be successful. The physio must develop an ability to read the signs of a person’s sympathetic system becoming more stimulated and a low threshold for acting upon this information. The physio must be aware early and make the assumption that they need to do something about the situation. Intervening as early as possible will increase the chance of success. The physio must then have a bank of strategies to call upon to change the dynamic of the situation and to decrease the stimulation of the person’s sympathetic system keeping it as low as possible to or at least below the patient’s threshold for the appointment to effectively continue.
Adaptation
Instinctually the physio needs to prioritise adaptation around the patient. I have found this to be a core instinct of mental health physio's. It is the instinct to adapt anything and everything as much as necessary so that the patient can receive the service. If a patient I am working with cannot receive the service I am providing then it is my responsibility to adapt what I am offering until they can. Everyone will adapt from patient to patient, but the question is how far will you go and how far do the service constraints allow you to go?
There are many aspects to consider with adaptation. The skill is to be able to provide the service differently from patient to patient depending on what their needs are. Then there is the skill to be able to adapt and change in the moment depending upon what is happening in the appointment or how the person is presenting on any given day.
The more aspects of service delivery that the person can adapt and deftly move move between different approaches then the more varied patients and situations someone can work with.
Adaptation of self is a key aspect to consider. Who do you present yourself as to the patient. Who do people view you as? Do you have different personas to move between? We all have different personas in our every day lives. We are a different person with our friends, to who we are with our partners, to who we are with our parents to who we are at work. But, physios will tend to develop a 'professional persona' for being at work. They then present this person to everyone. There is huge utility to this professional persona. When we are in this mode we will make good clinical decisions about professional boundaries and maintain good governance. For example, someone in their personal life may swear quite freely, but when they are in their professional persona they would never do so. We are able to adopt a persona who would instinctually work in the way that we should. The problem comes when this persona feels to the patient like this is not a real person that they are talking to. Most of the time that does not matter, but to some patients they will take great offence at being presented with someone for whom they do not feel like they are seeing the real person and distrust will brew. That physio needs the ability to shift to a persona which is closer to their real personality. Get too close however and they will run the risk of making bad instinctual decisions but they will also offer themselves the ability to work with someone who needs their clinician to present themselves as authentic.
What is needed is the ability to present ones self as a different person from one person to the next. These people or personas that we take on are not fraudulent, they are not a lie, they are us, but, a part of us that get maximised and placed to the front of whom we are working with. The different personas that someone will use are still them, they will take an aspect of their personality and maximise it, minimising other aspects of their personality and through this be able to present different personas.
In addition to adaption of self and adaptation of who we are it can be adaptation of the clinical space. Where do sit, where do they sit, how do you sit. It can be adaptation of the appointment, how long is it, what frequency is the appointment, how do you teach an exercise, how many options do you have? It could be an adaption of the way the person is invited to the appointment or the way the appointment is promoted or the expectations given. As we develop more knowledge of the implications of mental health conditions we can improve our accuracy of these adaptations.
Critically we cannot expect the patient to adapt to us, our instinct must be to adapt to them. Until we make the decision that the best approach for a certain patient is not to adapt but to be very boundaried and to ask the patient to adapt. Even the choice to adapt or not needs adaptation.
A good mental health physio also needs the scope to be able to adapt by their service design. If you have no control over your diary and patients get booked in for you and the time and length of slots are fixed then there is a limit to how a service can be adapted. It may be that frequent short appointments are needed or it may be that longer ones are needed. It may be that a certain room is needed or a certain one needs to be avoided. If the service is set up in a way where the physio cannot make changes to factors like this then it is removing scope for adaptation. It's not just that the physio could make these adaptation if they pushed for it, the service must be set up in a way where the physio feels comfortable and instinctual changing things like this for the patient. The physio must feel that adaptation is easy and is a path which presents little resistance for them.