“A Middle Way”: Psychologically Informed Physical Therapy Practice

One day in PT school, one of my professors gave a strong case for why anatomical factors are less predictive of persistent pain than are psychological factors. My classmates were a bit speechless. I couldn’t blame them. We just spent several months — and an unbelievable amount of tuition money — learning anatomy under our assumption that pain in a certain anatomical location is related to injury to a certain anatomical location. That day in class, it felt like the air was let out of the room.

But I was thrilled.

After class, I asked my professor a few questions about psychology in physical therapy. I wondered whether cognitive-behavioral therapy was within our scope of practice as physical therapists. I questioned whether physical therapists are open to psychological interventions. I asked what psychological treatments look like in a physical therapy setting. He answered my questions graciously, and told me that he had something that would probably interest me.

He brought me to his office and showed me a special issue of the Physical Therapy Journal on “Psychologically Informed Practice.”  I was still thrilled, with my excitement getting increasingly geekier. I read every paper in the issue, word for word.

That day altered the course of my training as a student. As I’ve said before, my background is in psychology. Over the course of several years, though, I drifted away from the field of clinical psychology and toward the field of physical therapy. I thought that I had moved to other side of the planet as far as health professions are concerned. Finding out about an approach to physical therapy that embraces psychology tied my two primary academic interests together.

In that special issue of PTJ, Chris Main and Steven George elaborate on the definition of psychologically informed practice (PIP). They write,

Psychologically informed practice is offered as a “middle way” between narrowly focused standard physical therapist practice based on biomedical principles and the more cognitive-behavioral approaches developed originally for the treatment of mental illness.

The authors describe standard practice as having the primary goal of reducing symptoms, with the core philosophy of addressing physical impairments based on biomedical concepts. On the other end of the spectrum, mental health practice carries the primary goal of minimizing the impact of psychological disorder on quality of life, with the core philosophy of identifying and treating mental illness. Main & George suggest that the primary goal of psychologically informed practice is secondary prevention of disability, with the core philosophy of incorporating patients beliefs and emotions into patient management based on a biopsychosocial approach.

In simpler terms, standard practice cares about physical problems in order to reduce physical symptoms. Psychologically informed practice cares about physical problems and the psychosocial parts of their problem, and PIP aims to reduce the impact of a condition or injury even if the symptoms remain. A logical extension of this approach is that PIP may involve a physical therapist providing something like cognitive-behavioral therapy in order to manage factors that contribute to the pain experience.

For many physical therapists, awareness of the psychosocial component of pain is nothing new. In my experience, though, many PTs have never heard the term “psychologically informed practice,” and they have no intention to learn how to use psychological interventions. (Unless they say that exercise is a psychological intervention, which appears partially true for some people, but probably not true for serious mental illness.)

Thus, there is likely a wide range of responses to PIP. I’m particularly interested in those who are either students or fresh PTs. Do you feel confident in providing something like cognitive behavioral therapy? If not, then would you want to learn how to do it? From the many conversations I’ve had about PIP, it seems that the longer a PT has been practicing, the less willing they are to provide PIP.

I have no interest in trying to convince someone to take a specific view about PIP. Rather, I’m interested in working together to find out (1) whether PIP is actually more effective than standard care and (2) how to use PIP in a specific, repeatable way.

So far, the answers to these questions are complicated. Every year, though, the research literature sheds more light on PIP. In an upcoming post, I’ll focus on a study published last year by two of my PT school professors: Jason Beneciuk & Steven George.