Chapter 29 Clinical reasoning to facilitate cognitive–experiential change
Healthcare practitioners across all disciplines, areas of practice and practice settings assess and collaboratively manage (independently and in conjunction with other health professionals) patients’ physical impairments, environment and psychosocial status. This holistic approach to understanding patients and their problems is consistent with the World Health Organization (WHO) model of health and disability (WHO 2001). Healthcare management regularly includes facilitating patients’ learning, including understanding of their health condition and factors either predisposing or contributing to the maintenance of their health problems, understanding management options and understanding prognosis. An example of learning commonly required within physiotherapy is patients’ awareness of habits in body posture and movement and alternative or more effective strategies, and their understanding and performance of general and specific exercises and self-management strategies. Ideally, clinicians’ approach to promoting patient learning is tailored to the individual patient (in terms of expectations and goals, clinical presentation, cognitive and physical capabilities) and to the nature of the learning desired (e.g. technicalities of a specific exercise versus construction of a revised health and disability belief). However, the skill and effectiveness of clinicians in this important aspect of management varies enormously (Payton et al 1998). Ineffectiveness in facilitating patient learning can stem from a multitude of clinician, patient/family/carer, resource and policy factors. Here we focus on factors relating to the clinician, particularly clinicians’ understanding and philosophy of health and disability and their approach to promoting patient learning, especially with respect to changing beliefs regarding health and disability.
Healthcare practitioners’ philosophy of practice and their world view in general influences their perceptions and their approach to practice (Cusick 2001, Higgs et al 1999, Hooper 1997, Jensen et al 2000, Unsworth 2004). For example, based on research into expert physical therapy practice, Jensen and colleagues’ model of expert practice in physical therapy has the therapist’s philosophy of practice as the core ingredient of expert practice that both influences and is influenced by four additional integrated dimensions of expert practice: a dynamic, multidimensional knowledge base; a clinical reasoning process embedded in a collaborative, problem-solving approach; a central focus on movement assessment linked to patient function; and consistent virtues seen in caring and commitment to patients. The patient-centred expert practice evident in the findings of this research (see Chapter 11 for further details) is consistent with the intent and requirements of practising within a biopsychosocial as opposed to biomedical philosophy of health care (Borrell-Carrió et al 2004; Engel 1977, 1978; Waddell 1987).
The biopyschosocial model as it was originally proposed ‘dispenses with the scientifically archaic principles of dualism and reductionism and replaces the simple cause-and-effect explanations of linear causality with reciprocal causal models’ (Engel 1978, p. 175).
The WHO model of health and disability (WHO 2001; see also Chapter 22) reflects this biopsychosocial perspective whereby patients’ clinical presentations (their body functions and structures or physical status; their capacity and performance of functional activities of life; and their subsequent ability to participate in their family, work and leisure roles) are portrayed as the result of influences (both positive and negative) of their health condition, environment and personal factors. Importantly, the contributions of the physical/biomedical, environmental and psychosocial influences to a particular patient are individual and complex. That is, the individual factors not only combine in determining a patient’s disability experience, they also directly influence each other (Borrell-Carrió et al 2004).
However, some clinicians’ personal and professional philosophies of practice are clearly more biomedically than biopsychosocially based, leading either to a lack of attention to these influences on patients’ presentations (for example the view that ‘psychological’ aspects of patients’ problems are separate from the physical and it is not the clinician’s role to manage psychological issues) or to an overly superficial and hence less effective assessment, reasoning and management of psychosocial barriers. This may also be associated with a view that psychosocial factors only become relevant when working with patients in chronic pain and disability and are not relevant to the more acute patient presentations. Further, while health professionals may claim to be biopsychosocially oriented in their assessment, reasoning and management, espoused philosophies of practice do not always reflect actual practice attitudes and behaviours (Argyris & Schön 1978, Jorgensen 2000, Mattingly & Hayes Fleming 1994). In a critical review of cognitive-behavioural theory and practice, Sharp (2001) argued that the cognitive dimension of cognitive-behavioural therapy for chronic pain as reported in the literature is inadequate and that behavioural management inappropriately dominates the cognitive-behavioural interventions. The conception of biopsychosocial for some remains dualistic, in that either (a) the patient’s presentation is viewed as a combination of biomedical and psychosocial problems, rather than construing biopsychosocial as a genuine integration of mind and body where each influences the other (Borrell-Carrió et al 2004, Duncan 2000, Engel 1978, Pincus 2004), or (b) appreciation and focus are given to psychological factors without appropriate recognition and attention to the social circumstances that have contributed to shaping those cognitions and that remain as barriers to change (Osborn & Smith 1998, Sim & Smith 2004).
The cognitive-behavioural approach situated in the biopsychosocial model is increasingly put forward as the preferred approach for the management of chronic pain and disability and associated psychosocial influences (e.g. Main et al 2000, Morley et al 1999, Turk & Flor 2006). The evolution of this approach is described elsewhere (Gamsa 1994a, 1994b), but in general it is based on the theory that patients’ thoughts, feelings and behaviours are interrelated in their pain or disability experience. Turk & Flor (2006, p. 340) explain that the cognitive-behavioural perspective is based on five central assumptions:
Based on individual patient assessment, cognitive-behavioural management then draws on a combination of explanation and education directed at facilitating restructuring of unhelpful or maladaptive thoughts and associated feelings, and operant behavioural techniques to strengthen patients’ constructive thoughts, self-efficacy and active coping behaviours while discouraging the reverse (Jones & Edwards 2006). The aim is to assist patients in gaining control over the effects of pain and disability while also modifying the actual affective, behavioural, cognitive and sensory aspects of the experience (Turk & Flor 2006).
In the biopsychosocial and WHO models of health and disability, patients’ thoughts, feelings, self-efficacy and coping strategies contribute (positively and negatively) to their disability experiences (Craig 2006, Flor & Turk 2006, Gottlieb et al 2001, Jones & Edwards 2006, King et al 2002).
Psychosocial factors, of course, involve more than just the patient’s own thoughts and feelings; the expressed or perceived thoughts and feelings and the behaviour of others (healthcare practitioners, family, friends, acquaintances and service representatives such as insurers and resource providers) also influence an individual’s disability experience. For example, in a qualitative study investigating the personal experience and psychological processes involved in maintaining pain, distress and disability in subjects presenting with benign chronic low back pain, Osborn & Smith (1998) used an interpretative phenomenological analysis to identify four themes common to the participants: (a) searching for an explanation; (b) comparing this self with other selves; (c) not being believed; and (d) withdrawing from others. The frustrations regarding inadequate explanation from the medical system reported by these participants is well recognized as an iatrogenic contributing factor to maintained disability (e.g. Main et al 2000, Main & Watson 2002). The effect of these subjects’ self-image was evident in their continuing comparisons to others and to their memory of their past selves while also projecting who they were likely to be in the future (Osborn & Smith 1998, p. 72):
Their contemporary self-regard contrasted with a nostalgic recall of their past and those around them, and their comparisons served almost inevitably as an index of their sense of threat and loss. Attempts to buttress self-esteem by comparison with those more unfortunate often proved counterproductive and served only to remind participants of their own gloomy prognosis.
Sim & Smith (2004) noted that this loss of a former self is a common finding in people suffering with chronic disability and pain, and described the circumstances that leave these people with a fundamental choice of trying to maintain their former self in spite of the pain, to suspend the former self in the hope that it can be regained once the pain is gone, or to come to terms with a new painful self.
The third theme identified by Osborn & Smith (1998) of not being believed created for the participants a continual need to justify their pain, and the incongruity of being mobile or appearing healthy created a sense that they should appear ill in order to conform to the expectations of others. The participants’ tendency to withdraw from others was the final theme. The researchers related this to participants’ fear of misunderstanding and rejection, highlighting the various and complex forms which fear-avoidance may take (Phillips 1987). In other words, fear-avoidance may have a social basis and not just a biomedical one.
With recognition that the thoughts, feelings and behaviours of patients and others influence disability, healthcare practitioners clearly need strategies and skills in assessing and managing these influences within the limits of their professional training. The level of education health practitioners receive in this area varies enormously, both across and within professions. Although it is not realistic to refer all patients to healthcare practitioners with more extensive education in psychosocial assessment and management (e.g. psychologists), superficial assessments leading to superficial judgements and inappropriate management are equally inappropriate. All healthcare professions have their own body of literature to assist their members’ understanding and application in this important area. For example, there is now very helpful physiotherapy literature providing suggestions on assessment and management strategies specifically targeting patients’ unhelpful thoughts, feelings and behaviours (e.g. Harding 1998, Johnson & Moores 2006, Keefe et al 2006, Kendall & Watson 2000, Main & Watson 2002, Muncey 2002, Strong & Unruh 2002). However, as discussed above, many clinicians either have not incorporated this approach into their philosophy and application of practice or have acknowledged its importance but take a superficial approach to psychosocial assessment and management.
It is not uncommon to find recommended management strategies that selectively ignore patients’ maladaptive coping behaviours while reinforcing their adaptive responses without providing practitioners with explanation as to how judgements of adaptive versus maladaptive should be made. It is as though there is an assumption that maladaptive thoughts, statements and behaviours can be defined out of context and some sort of universal truth exists that defines for everyone what is normal versus abnormal. For example, praying is classically given as an example of a passive coping behaviour that should be challenged and ideally replaced with something more active. However, judgements such as this simply cannot be made out of context. Whereas for one person praying may well be a passive coping behaviour linked to an excessively negative perspective, for another it may function as an active coping mechanism with links to positive thoughts, providing a source of strength and conviction to fight on. We certainly take issue with such a positivist position regarding judgements about normality and motivation. Any assessment of a patient’s beliefs, emotions and behaviours cannot be made without a deeper understanding of the person (including personal perceptions and social influences) and the basis for their perspectives. Kleinman et al (1992, p. 6) highlight the challenge this creates to the epistemological premise that underpins traditional biomedical theory and research, ‘namely that there is objective knowledge, knowledge apart from subjective experience’. Although it may not be the intent of those promoting cognitive-behavioural therapy, it is very common to see such superficial judgements being made in practice.