Becoming resilient


Rehabilitation professions are about helping people recover from illness to return to what matters in life. Sometimes as I read the myriad social media posts on ways to help people with pain, I wonder what kind of life rehabilitation professionals live themselves. Does our focus on what’s done during rehabilitation represent the way people live in everyday life?

I suspect that because rehabilitation has emerged from a medical model, much of our expectations and the framework for our work has remained in a “fix-it” or “there you go, good as new” mindset. A kind of short-term, out the door and back home lens, exacerbated by hospital adminstrators and policy developers needs to get people to leave hospital so as not to clog the beds.

Rehabilitation is often provided for people recovering from accidental injury, at least in NZ. These services consist of lots of physiotherapy – mainly exercise prescription; vocational rehabilitation – mainly time-frame expectations for the number of hours a person should be working, with adjustments made to tasks and some equipment; psychology – possibly cognitive behavioural approaches, but no specialist rehabilitation psychology yet in NZ.

The main problems with rehabilitation for persistent pain is that while provision for people receiving compensation is available (very little for those not receiving ACC), it’s often located away from where people live their lives. Even in the workplace, much vocational rehabilitation is undertaken by clinicians who are focused on helping the person return to this job only, not respond to future developments.

I think rehabilitation professionals could take a few leaves out of an approach promoted by Steven Hayes, Professor of Psychology at University of Nevada. In a recent paper he and Stefan Hofmann and Joseph Ciarrochi wrote, he proposes an “extended evolutionary meta-model” (EEMM) could provide unity to a process-based approach to therapy (Hayes, Hofmann & Ciarrochi, 2020). Much of the paper addresses concerns about the DSM V and its abysmal record of identifying underlying aetiologies for common mental health problems – and I would argue that similar concerns apply to problems inherent in attempting to treat pain. The aetiology of a pain problem probably has little in the way of influencing how a person responds to the experience.

What appeals about the EEMM is that it builds towards recognising that “defined processes of change are biopsychosocial functions of the
person in context, as distinguished from the procedures, interventions, or environmental changes that engage such functions.”

When the human genome was first mapped, I remember the enthusiasm had for finally, finally, we’d find “the genes for…” [name your disease].

Sad to say, behaviour isn’t as straightforward as that – as Hayes and colleages point out “behavior results from a diverse set of evolving dimensions and levels that include not only genes, but also many other processes. As a result, behavioral phenotypes that clearly involve genes are not necessarily genetic in a process of change sense.” Actually, many chronic diseases aren’t nearly as straightforward as we’d hoped (think type II diabetes, for example).

So what does an EEMM approach do for rehabilitation? I think we can begin to frame rehabilitation according to the foundations of evolution: to evolve, organisms need to have variability (otherwise the whole species dies out). To be resilient, and respond to what life throws at us, humans also need to have a wide repertoire of responses. This is one part of rehabilitation – to help people develop new response repertoires that fit their new circumstances. How well do we enable people to develop a broad repertoire of ways to do things?

Rehabilitation processes work to help people choose the most useful response for what’s needed in function: selection. Selection is a key part of evolution, because it allows the organism to choose a response from their repertoire to suit the circumstances. Translating to humans, given a context, people can choose a response that enables them to do what matters in their life. For example, knowing a range of ways to move an object from A to B means humans have learned to build the pyramids, and to construct Faberge jewelry. In rehabilitation, do we enable people to develop a range of responses, and do we help them work through a process of choosing well for a given context and purpose? Is a clinic the best place to learn how to choose well? Do our rehabilitation approaches incorporate motivational factors to engage people, so they can work out what’s important for their own life and values?

Retention is another process of evolution – people need to learn a range of responses, choose appropriately and know those responses well enough for them to be used when needed. Rehearsal, practice, habits and routines are the way humans have developed patterns that enable more brain space to be dedicated to choosing the best way to achieve a goal. Being able to effortlessly vary a response because it’s well-practiced is how elite sports athletes, professional dancers, musicians and performers do what they do despite the very different places they may need to do it. I think we possibly begin to do this, but often omit the patterning, the habitual practice in many different contexts that is needed to really retain variety.

Finally, evolutionary processes are about context. When the context changes, the most adaptive beings survive because they have a range of behavioural options to choose from, they know how to choose them, and the options are well-learned – and the choices they’ve made suit the new context. In rehabilitation, how well do we vary contextual demands? How often do we help people engage in what matters in their life in the person’s real world? Do we go walking across a range of different flooring surfaces, like the slippery shopping mall, the sandy beach, the rocky river-bank, the rugby field, the park? Do we mix it up with pace – fast and slow? Do we consider time of day? Do we think about the presence of sensory stimuli? Or the absence of sensory stimuli? Do we include contexts where there are lots of people – or very few, but they’re all focused on the one person? Do we think about the size, shape, fragility, wriggliness or preciousness of an object we’re hoping the person will lift?

To really help people flourish and respond to the future demands they’ll face, rehabilitation professionals might want to consider the EEMM, and begin to adopt a process-based approach to what we do. While some of the physical rehabilitation principles we use might not change, I think we could be far more creative and responsive to the processes involved in learning to adapt to altered circumstances. Maybe psychosocial flexibility is as important as muscle strength and control?

Hayes, S. C., Hofmann, S. G., & Ciarrochi, J. (2020). A process-based approach to psychological diagnosis and treatment:The conceptual and treatment utility of an extended evolutionary meta model. Clinical Psychology Review, 82. doi:10.1016/j.cpr.2020.101908

4 comments

  1. “I suspect that because rehabilitation has emerged from a medical model, much of our expectations and the framework for our work has remained in a “fix-it” or “there you go, good as new” mindset. A kind of short-term, out the door and back home lens, exacerbated by hospital administrators and policy developers needs to get people to leave hospital so as not to clog the beds.”

    Bronnie, your suspicion is correct but I do not think you have understood the concept and subsequent development of medical rehabilitation.

    Here is a recent brief review that sets the record straight:

    https://journalofethics.ama-assn.org/article/history-physical-medicine-and-rehabilitation-and-its-ethical-dimensions/2015-06

    Please note the final comment, which is in line with the main thrust of your otherwise excellent blog article.

    1. Yes, there is a proud tradition of rehabilitation – amongst rehabilitation physicians, who are, from what I’ve seen, wonderful clinicians. Considered by many in the medical profession, however, to be rather lowly beings. Hospital administrators are most likely to need patients to leave hospital quickly – and in some cases for good reason – but without appropriate rehabilitative support, the outcomes are not nearly as wonderful as they could be.

      1. Bronnie, I am surprised and disappointed to hear that many in the medical profession consider rehabilitation physicians as “rather lowly beings”. On what do you base your opinion?

      2. Norredam, M., & Album, D. (2007). Review Article: Prestige and its significance for medical specialties and diseases. Scandinavian Journal of Public Health, 35(6), 655–661. https://doi.org/10.1080/14034940701362137

        Phillips, J. P., Wilbanks, D. M., Rodriguez-Salinas, D. F., & Doberneck, D. M. (2019). Specialty income and career decision making: a qualitative study of medical student perceptions. Med Educ, 53(6), 593-604. doi:10.1111/medu.13820
        Olsson, C., Kalén, S., & Ponzer, S. (2019). Sociological analysis of the medical field: using Bourdieu to understand the processes preceding medical doctors’ specialty choice and the influence of perceived status and other forms of symbolic capital on their choices. Advances in Health Sciences Education, 24(3), 443-457.

        Matteson, M. T., & Smith, S. V. (1977). Medical specialty choice: A note on status rankings. Social Science & Medicine (1967), 11(6-7), 421-423.

        Rosoff, S. M., & Leone, M. C. (1991). The public prestige of medical specialties: Overviews and undercurrents. Social science & medicine, 32(3), 321-326.

        Album, D., & Westin, S. (2008). Do diseases have a prestige hierarchy? A survey among physicians and medical students. Social science & medicine, 66(1), 182-188.

        To summarise: “Our interpretation of the data is that diseases and specialities associated with technologically sophisticated, immediate and invasive procedures in vital organs located in the upper parts of the body are given high prestige scores, especially where the typical patient is young or middle-aged. At the other end, low prestige scores are given to diseases and specialities associated with chronic conditions located in the lower parts of the body or having no specific bodily location, with less visible treatment procedures, and with elderly patients.” Album & Westin (2008)

        Album, D., Johannessen, L. E. F., & Rasmussen, E. B. (2017). Stability and change in disease prestige: A comparative analysis of three surveys spanning a quarter of a century. Soc Sci Med, 180, 45-51. doi:10.1016/j.socscimed.2017.03.020

        “The top three diseases in all three surveys were leukaemia, brain tumour and myocardial infarction. The four lowest ranked were fibromyalgia, depressive neurosis, anxiety neurosis and hepatocirrhosis. The most notable change concerns apoplexy (brain stroke), which moved from a rank of 33 to 29 and then to 23 over the three rounds. We argue that the stable pattern, as well as this change, substantiate the interpretation of previous research, i.e. that the prestige of a disease is affected by the localization of the affected organ or body part, the effect and style of its typical treatment, and the social attributes of the typical patient.”

        Rosoff & Leone (1991) “The results affirm that a stable prestige hierarchy exists among medical specialties, with certain ones, such as surgery and cardiology, consistently ranked at the top, and others, such as dermatology and psychiatry, consistently resting at the bottom.”

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