A tale of two couches

In the second of a series highlighting surprising career moves, Sandra Hempel looks at how unanswered questions in physiotherapy led to a shift from treatment to counselling couch

Britt Tajet-Foxell is in demand around the world. A psychologist who spent the first 20 years of her career as a physiotherapist, she’s developed an innovative and successful rehab programme addressing the psychological effects from injury on elite athletes. In doing so, she has helped some of the most famous names in ballet, football and athletics to get back on top after injury. She is passionate about her work, enthusing; ‘I must have the most exciting career in the world.’ While Britt is clear her practice now lies firmly within psychology, she is keen to point out her pioneering work in the psychology of rehabilitation is underpinned and informed by her long experience in physiotherapy. ‘I use my background as a physiotherapist all day,’ she comments. ‘Being a physiotherapist I learnt to listen to people’s feelings, moods and situation. It taught me to communicate, to see beyond the words, which is, of course, the most important tool of psychology... I wouldn’t be where I am now, by any stretch, if I hadn’t been a physiotherapist.’ Britt grew up in Norway in the 1960s without any clear idea of what she wanted to do. ‘A friend was planning to study physiotherapy in London and suggested we apply together,’ she explains. ‘I wasn’t even sure what physiotherapy was.’ Nevertheless, she was accepted on the course and did her training at St. Thomas’ Hospital in London. She was in her first job, working with geriatric patients in Worthing, when she spotted an advertisement for part-time physiotherapists to the Royal Ballet. Britt applied, attracted in part, she says, by the huge contrast between the two worlds. ‘I love old people but I was starting to feel in danger of becoming one myself. This job sounded wonderful, so exciting.’ The role of physio was a new one for the ballet company and, as far as anyone could tell, it was the first for any dance company. Britt was one of two part-time physios. ‘This was the early 1970s and it was pioneering stuff. We had to get all our information and knowledge from sport and transfer it across. We were developing dance physio at the coal face.’ While the dancers welcomed her with enthusiasm, some of the teachers took more convincing. ‘It was a bit of an uphill struggle to start with,’ Britt says. ‘But because ballet is such a high-risk profession for injuries, people did cotton on fast.’ Such was the job satisfaction, she might well have carried on for the rest of her working life, but for having a baby at the age of 40. Touring the world with the company proved incompatible with the demands of a family. ‘I tried for a couple of years but it just didn’t work out. By that time, though, I didn’t want to do any other kind of physiotherapy. Dancers are so motivated, so fulfilling to work with. They are desperate to get better and to get back on the stage. I thought I might find working in other situations a bit frustrating.’ As she pondered what to do, Britt found herself thinking about a phenomenon that had long puzzled her. ‘I could have two dancers with the same type and degree of injury. They might be the same sex, same age, at the same stage in company, and they might have injured themselves in the same rehearsal or performance. They would have the same physiotherapy, but while one would get better, the other might never get back on stage again.’ This unanswered question led her to the world of psychology. The only psychology element in her physiotherapy training had been a brief introduction to eating disorders. ‘I decided to go back to university, do a degree in psychology and see if I could identify what made the difference between who recovered and who didn’t. I hadn’t got anything in mind in terms of a career. I thought I’d just do something different and be inspired. I thought that perhaps when my daughter started school I might go back to physiotherapy, possibly set up my own private practice.’ Britt didn’t find studying easy. ‘I’d forgotten how to learn. I really struggled for the first six months. The other students would spend their evenings getting drunk, and I would go home and cry and work all night. So I went to see my tutor and she said: “Britt you are just getting used to using your brain differently. Don’t change anything, just keep working and all of a sudden it will all come together.” I walked out not believing a word of it but I’d gone to her for advice and I felt honour-bound to take it. Then, all of a sudden, it began to make sense.’ The effort paid off, and she finished top of her group. Even so it was a tough learning curve. ‘If I’d known how hard it was going to be I would never have done it, but it’s turned out to be the best thing I have ever done in my whole life. Sometimes you have to follow your intuition.’ No sooner had she qualified as a chartered psychologist than the director of the Royal Ballet got in touch. They had a problem. A talented young woman had been off for a long time and they were desperate to get her back on stage. Would Britt see her? The dancer had had several injuries in quick succession and while she was now finally fit, she was overwhelmed with fear and depression. ‘When she arrived for rehearsal, she was physically sick and couldn’t remember how to tie her shoes,’ Britt recalls. After just two weeks with Britt, however, the dancer was back on stage and her performance got better and better. The company began sending Britt other dancers, before going on to create a permanent post for her. ‘This was fantastic because it enabled me to put in place a multidisciplinary model of expertise. And the Royal Ballet’s then physiotherapist really embraced the concept.’ The company now has two full-time physiotherapists, a nutritionist, a Pilates instructor and a massage therapist. A sports doctor also runs a clinic. Soon, word of Britt’s achievements spread into another high pressure, high injury field: world-class sport. She was asked to see footballers, rugby players, skiers and other elite athletes who were having trouble with rehab, even though their physical injuries seemed to have healed. She is now consultant psychologist to the Olympic Medical Institute. Britt’s CV is impressive. She worked with the England rugby team before they won the world cup in Australia in 2003, and she’s also involved with various premier division football clubs. In the vast majority of cases, Britt uses her physiotherapy experience to do an assessment. ‘My 20 years as a physio mean I understand how people function through dealing with their physical injuries. It’s given me an incredible insight, and I would never, ever have become the kind of psychologist I am if I didn‘t have that physiotherapy background. It’s unique.’ Her point is well illustrated by her work with Olympic rower James Cracknell, who suffered a stress fracture in his rib three months before the Athens games. Cracknell had been moved from the right side of the boat to the left side three years before but had never felt comfortable in that position. As Cracknell has recalled in interviews, he was concerned there was something wrong, although a scan showed his injury had healed. As he describes, after taking him through the mechanism by which the brain tells the muscles to row a stroke, Britt asked him to visualise the process. His mental picture for right strokes was clear and strong, but, that for left strokes was fuzzy and he became agitated when he thought about it. ‘Here I am using physio skills in terms of rhythm patterns and anatomy, but at the same time I am foremost being a psychologist,’ Britt says. ‘If anything is wrong I have to go in and rescue it.’ She then asked Cracknell to imagine his muscles and ribs. When he pictured the broken rib, he described it as welded together. ‘He was carrying an image in his subconscious mind that the rib had a weakness, which meant a devalued performance, which meant he was less likely to get a gold medal,’ Britt explains. ‘So we changed his mental picture of a rib that was welded together to one that looked like the other side.’ Cracknell went on to win gold in Athens. When Britt went back to the Royal Ballet as a psychologist instead of a physiotherapist, she felt it important to make clear her new role. ‘I was still known as a physio to some of the dancers. The physiotherapist herself was very relaxed about it, but to avoid any conflict I cancelled my CSP membership for a while. I wanted to create a boundary.’ She resumed her membership a couple of years later when she felt firmly established as a psychologist, but is still very clear about her practice. ‘I am a chartered psychologist, albeit with a very strong physiotherapy background. It’s easier for me to work within a multidisciplinary team if I only practise psychology. It’s a conscious professional decision. ’Nevertheless, in the future, she sees an opportunity for the two disciplines to develop close links, each informing the other, with a proper framework and training structure in place. ‘It’s a very exciting possibility,’ she says. Britt also observes her model of the psychology of rehab would transfer easily from dance and sport into general rehabilitation: ‘We are so much more aware now of treating the whole person.’ Newly qualified physiotherapists particularly encourage her. ‘I am bowled over by them. They are so much better trained than I was. They manage a process in a much more sophisticated way, they see the larger picture and they have so many areas of expertise that they can pull in.’ Britt believes her pioneering career has come about largely thanks to the open minds of individuals like the director of the Royal Ballet. ‘It’s about timing and people who dared to think a bit differently,’ she notes. While this is true, it is only half of the story. It is also about her, a woman who dared to think a bit differently too, and who wasn’t afraid to start again at 40. As Britt says: ‘You’re never too old.’ FL A meeting of mind and body? What do you think? Are physiotherapy and psychology complementary disciplines? Do you envisage a future where the two work more closely together? Does this scenario excite or disturb you? Frontline would like to hear from you. Email your comments to features editor Catherine Blackledge: blackledgec@csp.org.uk   The princess and the pea Britt explains her psychology of rehab approach in the following way. ‘When you get injured, the brain develops programmes to protect you from yourself. Pain and anxiety stop you doing stupid things. But because dancers and athletes are so focused on being dancers and athletes, those programmes can become riddled with gremlins. Unanswered questions run through the brain in the early hours of the morning: “Oh my god, will I ever get back? I know someone who had this injury three times and they never danced again”.’ As she explains, for elite athletes, whether dancers or sports people, personal identity is closely linked to their identity as an athlete. This means when they are injured they feel their very survival is threatened. Britt uses psychological strategies to help clients picture the normal physical mechanisms involved in what they do. An accredited cognitive behaviour therapist, she employs cognition to challenge some of the negative thinking around injury. She works with the client to identify any anxieties getting in the way of their normal physical performance. For example, she notes dancers may say they can’t possibly go up en pointe. Britt gets them to pull out on their mental screen the specific memory files or mental programme of going en pointe. The aim is then to replace the clogged up programme, distorted bymemories of the injury, with a more appropriate one. ‘It’s the memory files that are faulty,’ Britt stresses. ‘We can then begin to differentiate between what’s a real response to their injury and what is a memory response. They then use that as a tool to facilitate their rehab. My aim is to ship people out of injury mode and into performance mode as fast as possible.’ She adds: ‘Someone recently said that what I do reminded them of the fairy story of the princess and the pea. I find the pea and pull it out from under the mattress.’

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