THE IMPLICATIONS OF THE BEHAVIOUR OF PATIENTS IN THE ILLNESS-ROLE ON THE PSYCHOSOCIAL RELATIONSHIP OF PHYSIOTHERAPISTS WITH THEIR PATIENTS

INTRODUCTION The aim of patient treatm ent is to pro­ mote a return to health. The W orld Health O rganisation's definition.of health entails the concept of "w holeness". Health is a condition of com plete physical, mental and social well-being, and not merely one where disease or infirmity is absent1. Good health is a phenom enon both of the mind and body, and the therapist needs expertise and skills in both these areas in order to achieve h is/h er goals2. The question that then arises is, how much training does the physiotherapist receive in the developm ent of mechanisms to treat the "w hole" patient and is she taught to deal w ith her ow n em otions skillfully enough to help a patient to cope with his illness? Successful physiotherapy depends not only on physiotherapy techniques, but also on the psychosocial relationships which the therapist develops with h is/h er patient. This implies an openness to the patient's feelings and emotions, and a rec­ ognition that the patient and physiothera­ pist have similar needs. Raphael stated that the physiotherapist m ay be the only person in the medical care team with w hom the patient spends suffi­ cient time, over a reasonable period, to enable him to talk about his anxieties and fears, his sadness and disappointm ent, as well as his anger and guilt about w hat has happened to him3. " Man is a complex being, with among others, physiological, cultural, religious and social requirements. The interaction of these qualities with the individual's envi­ ronment, including people, will determine his behaviour, his reaction to his illness, to health care workers and to his experience of the illness-role. Lindesmith and Strauss feel that the pa­ tient identifies himself by seeing himself from the perspectives of the com m unity of social groups4. The physiotherapist must therefore critically evaluate the behaviour of the patient and also the influence of h is/h er ow n behaviour on the patient. The patient's reactions tow ards his ill­ ness-role and the adoption of w hat is deemed to be acceptablebehaviour, will be determined by society's perspectives. Pa­ tie n ts w ith p re v io u s e x p e rie n ce of physiotherapy trea tmen tw ill therefore be­ have differently from those patients who have no previous exposure4. A part from these complex social influences, the illnessrole will also be influenced by the patient's interpretation of the role.of the physiother­ apist in the total treatm ent plan. Parsons, who examined society's per­ spectives on the illness-role, reached the following conclusions: • the patient is exempted from all his social responsibilities • the patient cannot be cured by personal resolution • it is expected from the patient to have the desire to be cured • it is expected from the patient to seek medical help for his illness, as well as to co-operate with the treatment plan • in the case of a patient with chronic disease, it is expected that the patient will have a desire to function at his optimal level of "health" within his own limits4. In order to adopt a holistic approach, the physiotherapist must critically evalu­ ate the behaviour of the patient and also the influence of his ow n behaviour on the patient. Pain and illness behaviour are present to some extent in virtually every patient a therapist sees. It m ust never be overlooked that patients, first and fore­ most, are people who are entitled to feel and express emotions in different ways. The therapist m ay find it easier to tolerate the wide range of behaviours that a specific patient m ay demonstrate, if he considers for a moment w hat the patient is going through. Negative feelings and behaviour can be expected if the physiotherapist's role is negatively or incorrectly inter­ preted. Very often the patient will have diffi­ culty in protecting his self-image while coping with problems associated with the stress of handling the illness. H e m ay then present with a variety of reactions to re­ lieve the stress he is experiencing. A ccord­ ing to Kolb, the manner and degree to which these behaviours are exercised may vary am ong individuals4. Some patients need few psychological mechanisms in dealing with illness, while others require a host of mechanisms. There are some patients who, even with the use of all their adoptive mechanisms, never come to accept the illness-component of the wellness-illness role4. The physiotherapist should be familiar with the most important patterns and re­ actions of patients in order to be able to approach the patient correctly and holistically. The combination of assessment techfSUMMARY N In order for the physiotherapist to adopt a holis­ tic approach in the treatment of her patients, it is necessary for her to bear in mind the patient’s previous experience of the illness-role. This ex­ perience will influence the patient’s behaviour in any subsequent illness-role and thus his inter­ pretation of the role of the physiotherapist in the total treatment plan. It follows then that the physiotherapist should critically evaluate the be­ haviour of her patient in the illness-role while also evaluating the influence of her own beha­ viour on the patient in order to make treatment ^effective.________________________________ ^

these com plex social influences, the illnessrole will also be influenced by the patient's interpretation of the role.of the physiother apist in the total treatm ent plan.
Parsons, w ho exam ined society's p er spectives on the illness-role, reached the following conclusions: • the patient is exem pted from all his social responsibilities • the patient cannot be cured by personal resolution • it is expected from the patient to have the desire to be cured • it is expected from the patient to seek medical help for his illness, as well as to co-op erate w ith the treatm ent plan • in the case of a patient w ith chronic disease, it is expected that the patient will have a desire to function at his optimal level of "health" within his ow n limits4. In order to adopt a holistic approach, the physiotherapist m ust critically evalu ate the behaviour of the patient and also the influence of his ow n behaviour on the patient. Pain and illness behaviour are present to som e extent in virtually every patient a therapist sees. It m ust never be overlooked that patients, first and fore m ost, are people who are entitled to feel and express em otions in different w ays. The therapist m ay find it easier to tolerate the w ide range of behaviours that a specific patient m ay dem onstrate, if he considers for a m om ent w hat the patient is going through. N egative feelings and behaviour can be expected if the physiotherapist's role is n eg ativ ely o r in co rrectly in ter preted.
V ery often the patient will have diffi culty in protecting his self-image while coping with problem s associated w ith the stress of handling the illness. H e m ay then present w ith a variety of reactions to re lieve the stress he is experiencing. A ccord ing to Kolb, the m anner and degree to which these behaviours are exercised m ay v ary am ong individuals4.
Some patients need few psychological mechanism s in dealing with illness, while others require a host of m echanism s. There are som e patients w ho, even with the use of all their adoptive m echanism s, never com e to accept the illness-com ponent of the wellness-illness role4.
The physiotherapist should be familiar with the m ost im portant patterns and re actions of patients in order to be able to approach the patient correctly and holistically. The com bination of assessm ent tech-fSUMMARY N In order for the physiotherapist to adopt a holis tic approach in the treatment of her patients, it is necessary for her to bear in mind the patient's previous experience of the illness-role. This ex perience will influence the patient's behaviour in any subsequent illness-role and thus his inter pretation of the role of the physiotherapist in the total treatment plan. It follows then that the physiotherapist should critically evaluate the be haviour of her patient in the illness-role while also evaluating the influence of her own beha viour on the patient in order to make treatment ^effective.________________________________f

DPSOMMING D
ie pasient se gedrag in die siekrol word deur vorige ervaring daarvan en die rol van die fisioterapeut daartydens bei'nvloed. Die fisioterapeut moet die gedrag van die pasient in die siekrol en haar eie reaksie daarop krities ondersoek om pasiente in totaliteit te behandel. v ______ ;_______________________________n iques of behaviours together w ith the traditional skills of the therapist can pro d uce a very exciting and pow erful tool for rehabilitation and on -going good health. The m atter-of-fact, crisp, objective ap p ear ance of m an y physiotherapists is often called "p rofessionalism " w hich m ay p re vent the therapists from being total per sons and from treating the w hole patient, as it m ay distance them from their patient5.
M any patients will fear the unknow n aspects of their illness, thus experiencing a fe e lin g o f e x p e c ta tio n , d is c o m fo r t o r a n x ie ty a s so cia te d w ith an u n k n o w n source of possible danger. Patients of the sam e sex, age and socio-econom ic back g ro u n d s m ay re a c t d ifferently to fear. Their reactions will be influenced by p re vious experiences of the illness-role, as well as by the p atient's em otional m a tu rity. The p h y sio th erap ist will find a m odera te d egree of fear in a pa tien t benefi cial for his adjustm ent to his' treatm ent plan, because the patient is w ary and ad justs m ore easily. On the con trary, a very frightened patient b ecom es disorientated and tends to over-react. A fearful patient can be helped by recognising his fear, by answ ering his questions, and thus his un spoken fears, in a sim ple m anner and by respecting his privacy. This will help the patient to adjust to the changed environ m ent and to changed relationships6.
V ery often, a patient will have conflict ing em otions about seeking medical help and following the advice given to him. This can cause em otional lability because of the co-existence of opposing em otions, atti tudes and desires tow ards his illness. The p hysiotherapist can, after recognising this b ehaviou r p attern , reassu re the patient that conflicting em otions are not uncom m on and m ay help the patient to vocalise his feelings. R eflexive reassu ran ce is a spontaneous reaction w hich occurs in the therapist to cou n teract feelings o f anxiety, uncertainty or w o rry about the circu m stances in w hich the p atient finds himself. This resp on se reflects the p h y sio th era pist's attem p t to balance the p atient's feel ings and to calm the patient by using ver bal assurances in a tone of voice w hich is not unlike that of a p aren t7.
W illiam s how ever, cautions us to be careful of "th e p aren t trap ". This occurs w hen patients, feeling m iserable, turn to us, as if to parents, for sym p ath y, u nd er standing, com fort and w isd om , in the hope that w e can resolve their problem s for them2.
A d elib erate m o v e b y the th erap ist a w a y from the trad ition al professional "carin g-exp ert-in -ch arge"-role, to a rela tionship w here the patient is seen as an equal adult w h o has a problem he is teach ing himself to tackle and cope w ith, m ust be m ade. It m ust be expected of a patient to take responsibility for his ow n share of the effort and to m ake his ow n decisions; only then can a patient retu rn to norm al behaviour.

Suspicious and hostile patients are dif ficult to handle. The p hysiotherapist m ay perceive such a p atient as irritable, sarcas tic, dem anding, critical, uncom pliant or q uarrelsom e. It is im p ortan t to rem em ber that w hen a patient d irects anger at the therapist, he is usually an gry at w h at the therapist represents, nam ely health and the health care system , both of w hich he m a y feel h a v e b e t r a y e d h im 5. T h e physiotherapist m ay feel threatened by the hostile behaviour of the patient, since this behaviour endangers the therapist's posi tion of authority o v er the patient. This can lead to transferral of negative feelings to w ard s the patient, especially through the body-language of the therapist. The pa tient m ust be encouraged to verbalise his hostile feelings in ord er to preserve his self-esteem . The p h y sio th e ra p ist m u st learn to cope w ith this type of hostility and not to over-react. A rgu in g is of no benefit; w h at is needed is understanding and a willingness to share6.
A patient m ay react to the illness-roleby taking on a role suitable to earlier stages of developm ent. These could include with d raw al from all responsibility, an inability to feed himself, wilfulness and changed in terp erso n al relationships. H e will d em onstrate this behaviour because it is easier for him to regress to an earlier stage of d evelopm ent than to ad apt to the stressful situation in the illness-role. This reaction can be a natural one, because it can p ro m ote the healing process, for exam ple, w hen a post-op erative patient allows the health care w orkers to turn him on the first post-operative day. In the early days fol lowing traum a, the patient receives intens ive m ed ical, surgical and p h y sio th era peutic intervention aim ed at preventing further com plications and if possible, re storing function. The focus of rehabilita tion is on the patient's physical needs. It will be difficult for the patient to under stand w hat is happening to him , even if he has had the nature and extent of his injuries exp lain ed to him . H e m ay exp erien ce shock, denial, num bness and despair. H ere the physiotherapist has a vital role to play in facilitating h is /h e r patient's transition from the well-to the illness-role by p rovid ing hope, counselling and support . Ther apists m ust en courage their patients to tak ep artin the treatm ent. E very successful attem p t m ust be encouraged and praised, but care should be taken not to expect too m uch from the patients. The benefits of hum our have been ac cep ted th rou gh ou t hum an h istory, for exam ple in Proverbs 17:22, "A cheerful heart is a good medicine, but a dow ncast spirit dries up the bones". Robert Burton, Plato and Freud also w rote about laughter. Success w ith hum our is based on the per sonality of and the relationship between the therapist and the patient involved. H u m our and laughter can be useful in helping a patient to balance a stressful situation by focusing on a less serious aspect of it. Tim ing of hum our, receptiveness of the patient and the context of the hum our are all fac tors that m ust be evaluated to determ ine if hum our and laughter are appropriate in a given situation. Inappropriate hum our can result in hurt feelings, anxiety, hostility and em barrassm ent8 CONCLUSIONS A lexa n d e r said that the m ost disturbing em otion w h ich the p h ysio th erap ist wiil h ave to cope w ith is anger, w hich is often provoked by the failure of a patient to respond to treatm ent, despite d evoted and prolonged care9. N ot only m ay the anger g iv e r is e to f r a g ile a n d in a d e q u a te defences, provoking guilt on the p art of the physiotherapist, but w h at m ay be w orse, is that this anger m ay be com m un icated to the patient.
It is im p ortant to rem em b er that the physiotherapist is hum an, and is allowed to feel anger at the health care system , the patient and at himself. A balance m u st be kept by recognising h is /h e r ow n stress and by finding w ays to deal w ith stress as it occurs. O nly then can the physiothera pist ha ve a posi ti ve im pac t on the pa tien t's ability to cop e w ith his stress in the illnessrole. Perhaps the greatestcon trib ution that ou r profession will h ave to m ake in this increasingly technological age, will be the hands-on caring for the individual.
A s W einberg says: "Successful physical therapy depends not only on p hysiother apy techniques, but upon the psych o-so cial relationships w hich the therapist de velops w ith the p atien t"10.