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Research Reports |
Teresa J Clark, PT (TC), is Staff Physical Therapist, Functional Rehabilitation and Sports Theraphy (FRST) and Health Optimization for Pain Education (HOPE), Palo Alto, Calif
Joan McComas, PhD, PT, is Associate Professor, Physiotherapy Program, University of Ottawa, Ottawa, Ontario, Canada
Cynthia Potter, DPT, PT, PCS, is Associate Professor, Slippery Rock University, Slippery Rock, Pa. She is a member of APTA's Advisory Panel on Women
 | Introduction |
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JR: Patients in this study were recruited through social service agencies and support groups. Would you expect these patients to be different from those with a history of sexual abuse who don't have a support network—that is, the patients whom physical therapists are more likely to see in everyday practice?
JM: These participants were aware that they had been sexually abused, and they were able to talk about it. In that sense, they aren't representative of the total population of survivors of sexual abuse, many of whom would not be able to articulate why they feel uncomfortable during a physical therapy session. They might not realize that a touch in a certain place brings back a memory of abuse. One of the patients interviewed in this study said that she could not do any exercises "that had to do with...spreading my legs." If the physical therapist is not aware of the reason for this type of behavior, the patient might not come back for the next appointment. The therapist would never know why.
CP: The physical therapist has to be very astute to detect the behaviors and nonverbal cues among patients who aren't in a support group and who aren't able to articulate why something is bothering them. These patients could easily be missed. A patient's passivity may lead the physical therapist to have even more of a more "take charge" attitude, which could be detrimental to the progress of therapy and could even cause the patient to abandon therapy altogether.
JR: Physical therapists who deal with victims of torture also have observed that there are things certain patients can't do, and the therapist doesn't know why until the history is revealed. There are inexplicable "blocks." Perhaps the inexplicable is one of the cues.
CP: That's why physical therapists have to become aware of the possibility of sexual abuse as the reason for some of the "blocks" they see—for what they perceive as the inability of the patient to cooperate with them or adhere to the program.
JR: These study participants were a relatively well-educated group compared with the general population. The majority had a college or university education. Would that give them an advantage in articulating their feelings?
JM: People who are more educated are likely to find resources—such as a support group—more easily, and that is reflected in the sample used in this study.
JR: The education level also may suggest the socioeconomic level, which in turn may relate to the health care options that patients have. Theoretically, the patients in this study are in a position to say, "I'm not comfortable, so I'm going to try somewhere else."
CP: Some patients have a bad experience with physical therapy and then that's the end of it, because they don't have the resources to go to another physical therapist. That group is likely to be lost to physical therapy forever.
JM: A number of the participants in this study did not go back to physical therapy after a bad experience. Some had decided not to go for physical therapy again even though they did have resources and a referral elsewhere. So I don't think that we can make generalizations about the role of socioeconomics.
| How Well Do PTs Respect Patients' Boundaries? |
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 TopIntroduction How Well Do PTs... To What Extent Is...Is There Any Danger...Under Managed Care, Don't...How Can We Better...Should PTs Meet Every...Sexual Abuse: A Routine...References |
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TC: Much depends on the environment in which we practice. I struggle with this because I practice in an open setting. Confidentiality is hard to maintain in a busy practice that doesn't have separate treatment rooms. As physical therapists, we need to ensure confidentiality and a place where patients can feel comfortable talking about something that's taboo in our culture. It's a difficult task to ask questions about sexual abuse, respect patient privacy, and help patients feel safe enough to express themselves. We need to be comfortable asking questions, and we need to have the right environment in which to ask them. Sometimes our coworkers may not comfortable asking about sexual abuse. We have to respect them, too.
CP: Many of the patients in this study talked about safety in the clinic. That really struck me. Most physical therapists probably feel that their clinics are "safe" places. We are comfortable touching people's bodies and working in an open clinic. We need to remember that we should embody the concept of informed consent. Consent is an important ongoing process for survivors of sexual abuse.
JM: Not everyone grasps the concept of boundaries—and of how boundaries are violated. Whenever we move a hand from one place to another, we should seek consent. If we're touching a patient's back and start to move our hands down lower, we should ask, "Is that alright?" Consent is not simply seeking a signature at the beginning of a session. Of course, patients can violate our boundaries, too. All of these issues are important to teach both students and clinicians.
JR: Consent, then, is an ongoing, interactive process, rather than a momentary event.
JM: Exactly. An ongoing dialogue of consent and collaboration.
JR: How could we best convey to our patients that consent is an ongoing activity in which they can participate by declining and judging?
CP: The tone is set at initial contact. Because so much of their past experience has been the result of a lack of control, it's important for the physical therapist to be sensitive and to convey that patients do have control at every step of the therapeutic process—starting with the questioning. The therapist should listen and reflect back the patients' opinions and thoughts so that they know they are being heard and they can feel more comfortable speaking up. When patients feel that they can't voice their opinions, they may withdraw and revert to some of the defense mechanisms that were helpful to them in surviving abuse.
TC: Before I begin an examination, I usually say to the patient, "If you feel that anything is not safe or if you're not comfortable, you have the right to let me know." I also assess the patient's body language and observe whether the affect changes as I work with the patient. If it does, I know that I might need to back off or ask more questions, such as, "Do you feel that this is causing harm?" or "Is this too difficult for you?" and then go from there. Patients usually are receptive to that approach.
JM: There are so many signals—body language, eye contact, verbal cues—that a physical therapist should pick up on. Asking "Is this okay?" or "Is this hurting you?" or "Do you feel comfortable?" along the way should be part of daily practice.
JR: How many physical therapists get into the habit—out of necessity or presumed necessity—of accepting a lack of privacy? Patients have to overcome their fear just to say, "I need to see you in private."
JM: This study points out that the requirement changes for every patient. Some patients might need the privacy; others might need the openness. Although your physical plant might not be able to accommodate perfectly every patient, you can't assume that someone with a history of childhood sexual abuse will want to be treated in a private cubicle. The physical therapist has to check it out and then try to make the best of the physical plant for the individual patient.
JR: Still, it's ironic that the patient who is in a public space has to assert, "I want to be private"—something that, based on the vivid dialogue quoted in this paper, would require a substantial amount of effort. How could physical therapists sense this need for privacy early on or develop some kind of technique to ascertain this need in a functional and patient-friendly way?
CP: Giving the patient a choice initially would be one strategy. For the first visit—assuming that you practice in a clinic that has some private rooms and some curtained areas in an open gym area, which I think is fairly typical—ask the patient, "Would you prefer to go into the gym or this room?" Right from the start, get a feel for what the patient prefers. Then assess the patient's response to your initial approach, asking further questions or adopting your behavior.
| To What Extent Is Safety an Issue for All Patients? |
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TopIntroductionHow Well Do PTs...To What Extent Is...Is There Any Danger...Under Managed Care, Don't...How Can We Better...Should PTs Meet Every...Sexual Abuse: A Routine...References |
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CP: The authors pointed out that strategies for managing patients with a history of sexual abuse are strategies that should be used for all patients. The difference lies in the consequences for people who are survivors of sexual abuse versus the consequences for those who may be vulnerable as patients but don't necessarily have severe emotional reactions to experiences in the physical therapy setting. It may be more important to use these strategies among patients who have been sexually abused, but we should use them for all patients.
JM: It's not a matter of "I've got to be able to identify survivors of sexual abuse and then treat them in a special way." This article raises awareness of what constitutes good practice regardless of whether a patient is a survivor.
JR: But are the strategies practical in today's health care setting?
JM: When I talk to clinicians about boundaries, at first they are reticent about using these strategies: "I couldn't possibly do that!" But then after they practice using the strategies, they realize that it's not so bad—"Yes, I think I could do it like that." The thought of it is more difficult than the actual implementation. Sensitivity is an important part of practice. Technique isn't the only thing that matters. Students are so concerned that they've got their hands in the right place to perform this or that examination. But it takes more than that to make a good therapist! Students don't value interpersonal skills. They view this area as "soft."
TC: This is an area that is not objective or measurable. The kinds of things that we cling to in scientific research can't be applied to the psychosocial issues. There are no clear-cut solutions: "Here's something I can't fix by mobilizing a joint." These issues are infinitely more complex, and they are what make human beings so interesting.
JR: The irony, however, is that some of our psychosocial interactions with patients have a greater research foundation than our classic physical therapy interventions do. But many therapists don't hesitate to use those interventions, even though there are no data to support them.... Have we stumbled on something about the personality of the physical therapist or health care practitioner in general?
JM: I'm generalizing—I'm not being scientific—but physical therapists tend to be very concrete. They want to see very definite results to what they do. The psychosocial part of practice therefore has not been valued as much.
CP: Physical therapist students don't like ambiguity, and their difficulty with psychosocial issues is part of that intolerance. Tolerance for ambiguity comes only with experience. Somehow we need to make them value the establishment of a trusting relationship as the key to success with any patient, and in particular with the types of patients that we're talking about today. I hear students say, "We're not going to have the time under managed care to talk to patients." In the long run, it may take less time to communicate well with patients and empower them than it would take to struggle through therapy because trust hasn't been established.
JR: That's a researchable question: In a managed care environment, do physical therapists who are more sensitive to patients have to spend less time developing strategies to overcome problems? I'm not sure that students are all that different from practicing therapists. Perhaps nothing teaches better about the importance of psychosocial issues than repetitive failure with patients.
TC: Or personal experience. If you have a friend or a family member who has been sexually abused, that makes the issue real, makes you more compassionate and more aware, and encourages you to do something about it. But students may not have that body of personal experience to build from.
| Is There Any Danger That We'll Misinterpret the Signals? |
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TC: We're not trained as psychotherapists or social workers. We shouldn't be afraid to refer patients, saying, "This is something that I'm not very knowledgeable about, but there are other resources in the community that could better help you with this issue."
JM: Referring is something that physical therapists traditionally have not done as well as some other health care professionals. It's very important to have a list of community resources and to feel comfortable enough to say, "These are the people who can help." We can't provide counseling. But our sensitivity to the problem will help.
JR: Body language does not necessarily make a perfect linkage to a history of sexual abuse. How do we know that we're assessing correctly? How do we know when we've gone too far?
JM: We know that we should be asking about history of abuse. If we sense that something is amiss and ask about it in a sensitive way, does that mean we're going too far? No.
JR: So again the emphasis is on "checking it out."
TC: Yes. You can't assume anything until the patient actually says, "Yes, this is what happened to me." There are so many other psychosocial issues that could be going on. Maybe the patient has already come to terms with past sexual abuse and therefore it's no longer the main problem.
CP: Depending on the patient's level of comfort, we may never know that sexual abuse is part of his or her history; however, based on the reactions that we observe, if we use some of the suggestions made in the article, we can't go wrong. The danger is in labeling the person. We should respond to the behavior and not necessarily label the person based on why that behavior might be occurring.
JR: Would the better strategy be to use an open-ended question—"Are you uncomfortable?"—rather than to suggest that the person volunteer specific information?
TC: During the initial evaluation for all patients, you might ask, "Are you currently in an abusive relationship—physical, emotional, or sexual?" Make it a routine question. That way, you're opening the door.
JR: About 3 years ago I had to go to an emergency department that happened to have a grant to study family violence. They started asking about family violence. "Did somebody beat you? Did you beat someone?" As a patient with an emergency condition, I couldn't imagine answering positively in that situation! So timing and context have a bearing.
JM: As does safety. Patients are not going to answer honestly if they feel unsafe. In an emergency department, the patient may never feel safe! There are certain interventions, however, that may require us to be more "up-front" with our questioning. A physical therapist who works with urinary incontinence has to ask about a history of abuse before starting the examination. It has to be done in a very sensitive way—"Sometimes patients who come to me with this problem have had this kind of history. Has sexual abuse ever happened to you?" We have to adapt our way of questioning to what we're doing as physical therapists.
| Under Managed Care, Don't We All Feel We Lack Control? |
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TopIntroductionHow Well Do PTs...To What Extent Is...Is There Any Danger...Under Managed Care, Don't...How Can We Better...Should PTs Meet Every...Sexual Abuse: A Routine...References |
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JM: In the patient-professional relationship, the physical therapist is the one with the power, and, because of that, a patient may behave differently. But physical therapists often don't view themselves as powerful: "I'm not in power, I'm being controlled by my employer," or "I'm a woman and therefore I have less power in the workplace." As a profession, we need to consider these issues. Even if you yourself as a health care professional don't feel as though you are in control, your patients certainly perceive you that way.
TC: I routinely say, "What do you want to accomplish in therapy? What are your expectations?" If patients respond, "The doctor sent me here," I have to spend some time educating them, letting them know what they can expect, and giving them the choice to participate or not. That establishes a much more trusting relationship, and the patient feels less like a pawn in the system—less like "it's" being done to them, and more like they're an active participant. They feel that "this is where I'm going to get my needs met, and this is where I can learn how to meet my own needs."
CP: Under managed care, we also need to consider the issue of delegation to a physical therapist assistant or a physical therapy aide. When we see that there may be some difficulties relating to the patient, that there isn't a lot of trust established, or that the patient is uncomfortable, we may need to ignore the administrative or fiscal pressures to delegate, because delegation would only slow progress down.
JM: The issue of power surfaced when my colleagues and I did a study on inappropriate patient sexual behavior.1 It was evident that physical therapists felt they did not have any power. This may be changing, however. For instance, our college is working to educate physical therapists in Ontario about issues related to power and boundaries in the patient-provider relationship.
| How Can We Better Understand Our Power? |
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TopIntroductionHow Well Do PTs...To What Extent Is...Is There Any Danger...Under Managed Care, Don't...How Can We Better...Should PTs Meet Every...Sexual Abuse: A Routine...References |
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TC: Interaction style is the key. Physical therapists can come across as authoritarian—"This is what you need to do"—or they can inform and interact with the patient, which would give the patient more control. But interaction style is hard to teach.
JM: In 1990, Payton published Patient Participation in Program Planning.2 That was the first time I had seen these ideas so concretely put. We need to involve our patients in all aspects of therapy, not just prescribe; we need to involve them in identifying their goals and in deciding what treatment is most appropriate.
CP: The quotes of the study participants show physical therapists the impact that they can have on patients. They show the power that physical therapists do have. Consider what happened when one therapist didn't respond well as a patient began to cry. Many therapists don't know how to react when a patient "freaks out."
JR: Not giving patients the freedom to make us feel uncomfortable is part of the problem: "You don't have a right to cry or express other emotions because I can't deal with it."
CP: Right. We need to educate ourselves about the strategies that we can use when patients respond in certain ways and about the referrals that we could make in those situations.
JR: In the 1980s, Echternach and I published the hypothesis-oriented algorithm for clinicians [HOAC], in which the patient and the physical therapist discussed their goals before the examination to ensure that the patients' goals were considered before they were "medicalized."3 No one argued with the concept of patient participation, but it was criticized as being "impractical." Again, is this type of patient participation practical?
TC: Certainly! It's not a problem when you see a sense of relief come over a patient's face. It's extremely rewarding when patients feel that they've been listened to and that they are in an empathetic health care relationship. To me, that's almost more important than range of motion.
CP: Sensitive practice doesn't have to be time consuming. You can integrate it into your own style of working with patients. Occasionally you may need to take more time when you recognize a particular issue, but how do we evaluate time efficiency in the long run? How do we define success? We should not leave issues hanging for a patient at the end of a session.
JM: In the end, it's going to save time. If somebody "tightens up" and turns away because you haven't been communicating properly, then you've got to figure out the problem—which will take more time than if you had been communicating properly in the first place! Just as we need research on what's more efficient, we need research that compares the outcomes of patients whose physical therapists spend more time communicating and the outcomes of patients whose physical therapists don't. But that would be a difficult study to do, because it would require the delivery of inferior practice.
| Should PTs Meet Every Patient Need? |
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TopIntroductionHow Well Do PTs...To What Extent Is...Is There Any Danger...Under Managed Care, Don't...How Can We Better...Should PTs Meet Every...Sexual Abuse: A Routine...References |
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JM: No. But we can hear out their needs and desires and then explain, "This is what I can offer within the scope of my practice." Through good communication, we can come to a mutual agreement about what should be done.
CP: Patients may not be able to foresee the triggers that might set off a bad memory. We won't be able to prevent all unpleasant situations. But we can be prepared to deal with whatever happens, offering patients some choices that might help them feel comfortable again.
JR: Sometimes patients express a preference for a male or a female therapist, which may not be something we can accommodate, based on our staffing. What should we do in that case?
JM: We should try to meet the need if we can, and, if we can't, explain why, and then give the patient the choice of going elsewhere.
CP: The gender limitation is going to occur sometimes. We have to leave that to the patients' choice. And just as we would transfer care to another therapist, we should do whatever it takes to allow the patient to obtain care in another setting.
JR: Speaking of gender, when we look at early data from other sources, we see that, on average, there seems to be twice as much sexual abuse of women as of men. This paper focuses on women. What about men who have been sexually abused? Many of the behaviors that were described as "watch signs" in this article are behaviors that we socialize men not to have, such as vulnerability. So it might be even more difficult to pick up cues from men.
TC: The response may be different along gender lines, but men certainly deserve the same resources and opportunities for help. As providers, we need to consider sexual abuse when dealing with both men and women, even though one group may have a higher frequency of sexual abuse than the other.
JM: Awareness is growing about women who are survivors of childhood sexual abuse, but there is little information available about male survivors. But sensitive practice for both male and female patients seems only logical.
| Sexual Abuse: A Routine Question? |
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TopIntroductionHow Well Do PTs...To What Extent Is...Is There Any Danger...Under Managed Care, Don't...How Can We Better...Should PTs Meet Every...Sexual Abuse: A Routine...References |
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TC: Ideally, physical therapists should routinely address this issue. The first step, however, is for us to become educated about the extent of the problem. APTA guidelines3 provide resources so that physical therapists can both ask the question and deal with the answers.
CP: The question should be a routine part of the interview, but it will be successful only if therapists are comfortable with it. This is true not only for sexual abuse but for domestic violence. As these kinds of questions become more routine, patients eventually will realize that they're not being singled out. Physical therapists also should expect that not all patients will be able to give an honest answer the first time and that there may be a time—as more trust develops—when the patient becomes more able to talk about his or her history.
JM: In principle, it's essential to ask the question. But I can think of so many circumstances when either the patient is not going to feel safe or the therapist is not going to feel comfortable because of the lack of knowledge in the greater physical therapy community. If physical therapists are uncomfortable asking the question, patients won't be as likely to answer appropriately. We've got to educate our profession before this question can be routinely asked.
JR: If a physical therapist were to say to you, "Tell me what I ought to do differently based on this paper," how would you respond?
JM: I would refer the therapist to the appendix at the end of the article by Schachfer et al., which lists essential items, such as a positive rapport and a trusting therapeutic relationship. That includes communication, paying attention to body language, listening to clients, telling clients that it's alright to talk about their experiences, sharing the control and development of the anticipated goals, and obtaining ongoing consent.
CP: The paper also encourages us to recognize the range of reactions to physical therapy that survivors may have and notes that we need to be comfortable with patients, regardless of their reactions—and that we need to learn what is not helpful.
JR: What would be the benefit of changing our practice based on what we've learned from this paper?
TC: If a patient feels better about the outcome, I automatically feel better about it. That in itself is rewarding. Identifying a problem that the patient has never before identified, for which the patient needs help, also is rewarding. It reaffirms the place of the physical therapist within the entire healthcare community and within society at large.
CP: Many people who were abused as children have dissociated their bodies from their thinking. Physical therapists are in an excellent position to help them reestablish that connection, which will lead to more effective treatment and also to better long-term outcomes and quality of life.
JM: Your clinic's reputation may be enhanced as patients start talking about the sensitive practice that they receive. You also may not lose as many patients for unknown reasons—the ones who don't come back after their first session. It also will establish more trust with a community of people who have had a rough beginning in their life, and that's good for our profession as a whole.
JR: Knowing what you know now and what you've learned from this paper, what do you wish educators would have told you before you graduated?
CP: I wish they would have told me about the profound impact that some early experiences have on people's lives and all of their further experiences. That sounds simplistic to me now, but it's difficult to impress on students.
JM: The psychosocial aspects of practice tend to be a surprise to new graduates—this may have been especially true for those of us who graduated a while ago. We were not taught about these aspects of practice. Students need to know that they will not be able examine, evaluate, treat, reexamine, and reevaluate without incorporating other aspects that involve interpersonal communication and sensitive practice.... This study is the first one to look at survivors of childhood sexual abuse and their experiences with physical therapy. It will make people stop and think. The words of the study participants were very, very powerful. Those words can't help but affect you.
TC: I graduated in 1995, and by then educators were bringing up the need to evaluate for psychosocial concerns. Education is becoming oriented not only to exposure to the issues but to what we can do about them. The next step is more research. What is the incidence of past sexual abuse among people who come for physical therapy? What is the best way to accommodate these patients? I'm thrilled that the study by Schachter et al was conducted and published. It's great to see clinicians going forward into uncharted areas of our profession.
JR: Material on sexual abuse and domestic violence is now required in curricula based on accreditation standards promulgated by the Commission on Accreditation of Physical Therapy Education and based on the normative model of physical therapist professional education.5 Applying sensitivity in practice is like using evidence in practice, however. Until we integrate the concepts of evidence and sensitive practice into every course, they will be viewed as optional—as adornments to practice rather than the heart of practice. The person who could most powerfully illustrate the importance of sensitive practice—and of evidence-based practice—is the same person who's teaching the manual therapy techniques or the therapeutic exercise techniques or the wheelchair transfers. The more we link these issues to application in practice, the more real they are, and the more likely they are to be applied.
| Footnotes |
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| References |
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