Physiotherapy: A process based approach Part 2

In my last post I shared my thoughts on the comparisons between dispositional reasoning and process based therapy, with the focus being on workable processes of change rather than trying to find the “magic bullet” of pain elimination.

To try and explain this, I would like to reference parts of a chapter from Rethinking Causality, Complexity and Evidence for the Unique Patient (Anjum, 2020) and from process based therapy research (Hayes et al, 2019).

Process Based Therapy vs Dispositionalism

In my previous blog, I shared the similarities in both reasoning models, in particular how both are philosophical theories and how both are context sensitive. I have one issue and that is the word causation. The term causation Thus both models flip reasoning on its head.

Instead of asking,

“what is the cause of the disease and how does it affect the person?”

The models asks,

“What is happening in the person’s life and how does this contribute to disease?”

Whilst this approach would appear to be fairly obvious it is rather novel. A paradigm of reasoning that shifts away from prioritising tissue state as the cause of suffering.

Christine Price’s chapter provides the reader with an emotional personal narrative of the challenges she faced during her 4 year arduous journey of living with pain.  Christine tells her story of how she ‘received an episode of care undertaken by Advanced Scope Physiotherapist Matthew Low.’ With Matt’s guidance, support and advanced knowledge of dispositionalism and the multi-dimensional nature of pain, Christine began her journey of understanding pain and how to manage it.

It is Christine’s example from the book that I wish to share and attempt to reconcile the parallels between dispositionalism and process based therapy.

If you are interested to learn more I encourage you to read the following open access book ‘Rethinking Causality, Complexity and Evidence for the Unique Patient.’

Christine’s Analogy

In order to understand causality and dispositionalism Christine created a smallholding analogy. She referred to the causal powers of her persistent pain as “9 young friends” that club together to buy a smallholding in a beautiful part of the UK.

Christine described how the 9 friends would help grow food, care for their animals and look after the smallholding with the aim of living a vibrant, happy, hardworking, outward looking commune with plenty of food. Each of the friends had one disposition

Carl = catastrophising

Henry = hypervigilance

Amy = anxiety

Debra = depression

Sue = sleep difficulties

Patricia = positivity

Rebecca = resilience

Tammy has experienced trauma

Danny has low blood pressure

Christine points out that some dispositions may have been present from birth such as anxiety, whilst other have been affected by upbringing such as resilience. Others may be related to physical factors such as low blood pressure.

Based on the book by Mumford & Anjum, (2013), Christine was able to conceptualise the dispositions in the form of a vector diagram as shown in Figure 2 and 3. Dispositions represented by vectors to the left of the centre line are ‘negative and are likely to cause the friends difficulty, whilst powers to the right are positive. The stronger the power (longer the arrows) would indicate more of a tendency for/against symptoms to manifest and decreased/increased capacity for coping.

Figure.2. Dispositions on a good day (courtesy of C. Price & Anjum et al, 2020)
Figure.3. Dispositions on a difficult day (courtesy of C. Price & Anjum et al, 2020)

Therefore the more of the friends that appear on the vector model, depending “on their disposition” and the strength of the power will determine a good day or a difficult day. See images for further details.

What is important to note is how the disposition of one friend may evoke the disposition of another. Such as Tammy, Amy and Sue may evoke each other’s dispositions when they are overwhelmed by the change in context. This may result in a tendency towards a difficult day.

How does PBT fit with Dispositionalism?

The proponents of PBT discuss a “functional first” approach, referring to function as processes of change found in 6 dimensions:

  1. Affect and emotional regulation
  2. Cognition/reappraisal
  3. Attentional processes
  4. Sense of self
  5. Motivation
  6. Overt behaviour

Let’s take a look at the “causal powers” of Christine’s analogy and see if we can fit them into the 6 dimensions as outlined above. See table below for comparisons between processes of change and causal factors.

Processes of change (as per Hayes et al, 2020)Causal factors (as per Low, 2017)
Affect and emotional regulationAnxiety, catastrophising, Hypervigilance, trauma
Cognitive/reappraisalTrauma, Depression
Attentional processesAnxiety, catastrophising, Depression
Sense of selfHypervigilance, Depression, positivity
MotivationDepression, resilience
Overt behaviourHypervigilance, catastrophising
Other (biophysiological processes)sleep, low blood pressure

I guess one of the issues I have about causal factors is the narrowing down to specific labels and categories, whereas the domains in processes of change (whilst categorical) are… more flexible.

Now, I agree it could be argued that I am merely arguing semantics, but by focusing on signs and symptoms (causal factors) that lead to a tendency for symptoms to manifest, could well result in a protocol driven approach that has lead to a significant number of problems within psychological diagnoses and treatment approaches (Hayes & Hofmann, 2020).

The dimensions outlined above relate to processes of change that are multidimensional, dynamic, and ever changing. Now, if I’ve understood dispositionalism and PBT correctly, both approaches are targeting more of a humanistic approach to “function” rather than a primarily tissue based focus, where all aspects of a person’s life contribute to the dis-ease of the person living with a chronic condition.

It is important to examine both adaptive and maladaptive processes because health is more than the removal of pathology; intervention needs to be focused on building human prosperity not just eliminating pathology.

Acceptance and Commitment Therapy (ACT) adopts a process based (or transdiagnostic if you want to think in CBT terms) approach to working with people living with chronic health/pain problems.

From a psychological perspective we can see the parallels between the approaches, particularly when we consider the dimensions above. These dimensions are functionally important because they are highly dependent on context. Perhaps what is lacking is how we might add some additional dimensions if we were to adopt PBT within physiotherapy?

Both are dynamic process that are highly dependent on context, which means that as health professionals we need to begin to think more dynamically, provide explanations that capture an ever changing picture based on context and be able to provide workable ways for people living with persistent problems to live well.

Both capture and request a wider knowledge and reasoning framework that can help health professionals and people living with chronic conditions to step back and consider a broader perspective when faced with head scratching challenges.

Finally, through the evidence base we can draw upon multiple influencing factors including culture and context, treatment utility, client needs and goals and place them within these dynamic approaches that intend to provide a person-centred rather than disease-centred approach to healthcare.

Thanks for having a read

TNP

References

Anjum, R. L. (2020). Dispositions and the Unique Patient. In R. L. Anjum, S. Copeland, & E. Rocca (Eds.), Rethinking Causality, Complexity and Evidence for the Unique Patient. Gewerbestrasse: Springer Open.

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