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The power of THREE

Is treating mind and body at the same time the way forward for therapy? Joanna Lyall investigates

A fall in the cinema led to an unusual professional collaboration for psychologist, Veronika Cheasley-Rau. After undergoing several physiotherapy sessions for the resulting dislocated shoulder, she was surprised to find herself bursting into tears.

'It was the most sensitive of touches and I wondered how it could evoke such profound reactions,' she recalls. 'I felt very small, and abandoned. Afterwards I walked around Brecon crying, remembering feelings from my childhood.'

Having such a visceral emotional reaction to being touched in a healing environment is not unusual. As more studies show, mind and body, and emotions and pain are inextricably linked.

There is growing recognition that psychological factors may hamper healing, and increasing interest in how psychological approaches can enhance physical therapies.  And not surprisingly, physiotherapists are taking this on board: either by working side-by-side with psychologists, or gaining psychology qualifications themselves.

For Dr Cheasley-Rau, the emotional and physical experience led to discussions with her physiotherapist, Sally England, about the nature of mind-body interactions. Having worked as a chartered psychologist in the NHS for 14 years, Dr Cheasley-Rau was aware of a group of patients who were only partly responsive to psychological approaches.

 'I call them the talking heads – intelligent and thoughtful, but they just don't move on and seem somehow disengaged from their body.'  She felt these patients needed 'somebody to listen to their body'. 

On the other side of the professional fence, Mrs England, and her colleague, Sandie Lewis, who together have more than 60 years' physiotherapy experience, were aware of many patients whose emotional problems slowed, or prevented, the relief of their symptoms.

A common feeling was there was a psychological trauma their skills and hands could not reach, or, if they caught a glimpse of it in a session, they did not know how to treat it. 'What's become apparent is that it's very difficult to separate mind and body,' says Mrs England.


So in 2002, the professionals joined forces and started seeing patients jointly in their private practice in Brecon, Wales. Many of the clients suffer from chronic pain related to trauma, which can be the result of a variety of scenarios, such as a difficult birth, a car or riding accident, or physical or sexual abuse.

A typical session involves both psychotherapy and physiotherapy elements. Dr Cheasley-Rau talks to the patient, who may be sitting or lying down. Meanwhile, the physiotherapist listens to and works with the body using myofascial techniques and craniosacral therapy. 'One of the aims is to find physical and psychological barriers and assist patients to release them,' says Dr Cheasley-Rau.

'While I am talking the physiotherapist may start touching the patient's feet very gently, creating a sort of loop between the three of us. And the patient gradually becomes aware they have a body which links to what they think and feel.'

Five years on, they believe this way of working has enormous potential for patients and professionals alike. From the patient's perspective, the presence of both physiotherapy and psychology professionals gives the patient access to a greater range of healing possibilities, as well as the support of two professionals, and an implicit acknowledgement of the mind-body interaction. Because of this, says Dr Cheasley-Rau, they can now help clients they could not before, and can also speed up the process.

 Mrs England explains: 'We are the sum total of our experiences good and bad, and somewhere, we remember all of them. The body seems capable of storing memories, and locking them away, as efficiently as the mind. This locking down can be the cause of pain and disruption in any part of the body.' She adds: 'Working on body memory the process goes much more quickly with a psychologist in the room.' 

 Both professions feel they have learnt from each other. Dr Cheasley-Rau is more aware of the importance of touch as a conduit to emotions, while Mrs England notes the joint treatment sessions have made her more aware of the impact of language. 'As physios we need to be more aware of the power of our words when we are working, and the need to explain less and listen more to what our patients' symptoms are really trying to tell us.'


While it is still unusual for physiotherapists and psychologists to literally work side-by-side, it is increasingly common for the professions to work together as part of a multidisciplinary team with the aim of treating both body and mind. Also on the increase is the number of physiotherapists who seek further qualifications in psychology.

Zara Hansen is chair of the Physiotherapy Pain Association and a clinical research fellow at the University of Warwick. Her interest in chronic pain, and how it is influenced by emotional issues, led her to qualify as a cognitive behavioural therapist.

She describes her two-year postgraduate diploma course at the University of East Anglia as  'the most challenging thing I have ever done'.

However, it also enthused her; highlighting the importance to physiotherapists of exploring psychological approaches, such as cognitive behavioural therapy. 'Before I hadn't realised how much I was stuck in a biomedical model.'

Having a grounding in CBT, she says, 'gave me much more empathy into why people get into certain conditions and showed me the importance of exploring the patient's beliefs and expectations about their condition.'

It has also helped her understand her own limits. 'Now I feel it isn't completely my responsibility if a patient doesn't get better. And if they come back and say they haven't done their exercises, I see that as a challenge, and something to explore.'


Ms Hansen is now doing a PhD researching physiotherapists' competency to adopt CBT principles and is coordinating a large multicentre trial investigating the clinical and cost effectiveness of a cognitive behavioural approach to chronic low back pain. She also runs weekend courses for physios and other allied health professionals who want an introduction to CBT.

Speaking at the CSP's Congress last year,  Ms Hansen suggested ways in which therapists could apply CBT to their work through using exploratory questions to identify patients' unhelpful ways of thinking, as well as feelings and behaviours.

Marie Donaghy and Rosemary Payne chose to gain a second degree in psychology to complement their physiotherapy qualification. And both believe this extra string to their bow is of great benefit.

Now dean of the school of health sciences at Queen Margaret university, Edinburgh, Professor Donaghy is the author of a forthcoming book, Cognitive Behavioural Interventions in Physiotherapy and Occupational Therapy, and recommends CBT training for physiotherapists who want to broaden their scope.

CBT training, she notes, facilitates 'motivational interviewing' enabling health professionals to challenge patients' negative thinking and help them work towards realistic goals.  She welcomes wholeheartedly physios' increasing interest in pyschological factors in illness and rehabilitation.

Rosemary Payne, who works in private practice in Cardiff, believes knowledge of psychology has improved her understanding of patients. 'Studying psychology allows you to turn intuitive ideas into scientifically-backed ones. And it broadens your view of healthcare,' she says. 'It helps you understand thoughts and feelings, which play such an important part in the way patients respond to physiotherapy.'  


Looking to the future, Sally England believes the time has come for the professions to work far more closely together, particularly with more 'obstinate cases'. She says: 'Being able to work together turns us into very powerful therapists.'

A proper framework and training structure for the two disciplines to develop closer links is an exciting possibility, adds Dr Cheasley-Rau, and perhaps even a necessity for the modern therapist. 'We firmly believe no one profession can do it alone,' she says.

The big question is: are the two professions ready to become so intimately linked? But if they don't, who is going to heal the rift between psyche and soma in healthcare?

Childhood trauma correlates with surgical outcomeA study published in the journal Spine in 1992 found a highly significant correlation between childhood trauma and unsuccessful lumbar spine surgery.

Reviewing the progress of 86 patients with a mean age of 41, the research found that among those who had suffered three or more types of trauma as children, there was an 85 per cent surgical failure rate. (Traumas included physical and sexual abuse, abandonment, emotional neglect, and alcohol or drug abuse in a primary care-giver).

In contrast, for those patients who hadn't experienced such childhood traumas, there was a surgical success rate of 95 per cent.

The authors concluded continued pain after technically successful lumbar spine surgery can be partly due to the impact of childhood psychological trauma.

Schofferman et al, 'Childhood psychological trauma correlates with unsuccessful lumbar spine surgery', Spine (1992 Jun), 17 (6 suppl): S138


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Joanna Lyall

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17 October 2007

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