A number of years ago, I gradually and almost imperceptibly began to have lower back problems. Eventually, simple daily activities caused me great pain: lifting a grocery bag, taking a casserole out of the oven, rolling over in bed, getting out of a chair, vacuuming the house (that last one I didn’t really care about). I had to give up things I loved, such as swimming laps and working in my garden. The more my back hurt, the less I did.
As it turns out, that’s one of the worse things you can do in situations like mine, but I didn’t know that at the time. I had been through an extreme amount of stress not long before my back started acting up. As anyone who has a health condition (ranging from a cold to cancer) can attest, friends, family and even perfect strangers feel free to provide you with unsolicited diagnoses and treatment suggestions. So, people kept telling me that my condition was stress related, emotional. I think there may have been some truth to that, but I also knew deep down that there was a structural element that needed to be addressed.
Eventually I got X-rays, which showed that I had not only long-term scoliosis but also erosion at the sites of a couple discs and some arthritic changes in my spine. I didn’t want to relegate my existence to painkillers or a reduced quality of life, so I accepted a referral for physical therapy. I was fortunate to find a wonderful practitioner to whom I returned again and again in the years that followed for a variety of issues — not only my lower back but also an injured shoulder, a knee problem and an unstable cervical area in my neck.
Upon conducting the initial assessment of my back situation, my physical therapist announced, “Jane, you have no core!” She meant physically, not psychologically, but nonetheless the pronouncement sounded dire, so I really took her words to heart. And, indeed, I had been using my back muscles inappropriately because no one had ever explained to me how to strengthen core muscles and why it was important to do so. To this day, I still do most of the exercises my physical therapist taught me as a way to manage my back condition, and I have resumed all the activities I was unable to do previously, including (unfortunately) vacuuming.
So, why this essay about what I learned from physical therapy? Because I believe the lessons and approaches presented in the PT model of conducting therapy, albeit in the physical realm, apply in very concrete ways to our work as professional counselors. Here are my takeaways.
- A thorough initial assessment sets the frame for successful treatment. In physical therapy, there was paperwork but not too much. A good portion of the evaluation was my own self-report, along with some objective measurements and observations on the part of the therapist. The preassessment consisted not only of rating my level of pain but also a functional analysis of my ability to perform tasks of daily living. This set the stage for an accurate post-treatment assessment.
- In terms of diagnosis, instability can be just as concerning as outright pain, but it doesn’t get as much attention. We often hope that those initial warning signs, whether physical or emotional, will go away. However, stabilizing a condition before it becomes painful can help avoid serious problems down the line.
- In my various experiences with physical therapy, the goals of our work together were very clear and established by me during that first intake session, thus creating a contract for therapy. Usually, one or two goals were sufficient and were completely measurable. Sometimes a goal was merely to reduce (not eliminate) pain and to regain my ability to engage in a particular activity again. My physical therapist estimated the number of sessions I would need, so the work had a beginning and an end, but it always included an invitation to return for a consult if needed.
- Trust is essential and was developed through the therapist’s active listening and sincere invitation to provide her with feedback. She had the expertise but understood that I was the expert on myself. Encouragement and honesty went hand in hand. If something wasn’t helping, we decided together to regroup and start fresh. I never really liked anything that involved props such as big rubber balls or elastic bands. She didn’t judge me for this but instead worked with my preferences.
- My physical therapist was not just a good listener but also genuinely wanted to know how I was doing. In my most recent round of physical therapy for a neck condition, I wasn’t experiencing the results that either of us would have liked. I was feeling discouraged and frustrated that I wasn’t making progress. No problem. She instructed me to forget all the exercises I’d been given so far so that we could start all over at the beginning. We began anew with a different approach and set of practices, and they worked. It’s important to note that, to switch gears like this, total honesty on my part was essential, but it was her nondefensive response that allowed us to find a more effective approach.
- A little goes a long way. We started very slowly. Each week my physical therapist introduced one or two exercises that I was to practice in between sessions. In fact, my participation and practice outside the sessions were where the real work happened (just like in psychotherapy). The requirements and expectations were so minimal — most exercises involved only 10-15 repetitions one or two times a day — that it was easy to do them, and this led to a sense of accomplishment. My therapist gave me handouts with written instructions and diagrams so that I could refer back to them if needed. I came to understand that when humans are confronted with change on a big scale (even if the change is something we invite into our lives), the organism can set up resistances in both subtle and significant ways. When change is small and gradual, the protective functions of the amygdala don’t get activated, and barriers to change don’t have a chance to develop.
- Visualization was a primary tool for the physical therapist. When she asked me to locate and tighten muscles I didn’t even know I had, she used imagery and mental practice to get me started. “Just see yourself in your mind’s eye doing the exercise.” “Imagine guy wires attached to your abdomen pulling the muscles tight.” “Bend from the waist, keeping your back straight, like a waiter taking a bow.” “Press your feet to the floor as if trying to keep an egg from rolling away without breaking it.” “Try this with a light touch, like kitten whiskers.”
- The results of physical therapy were not instantaneous, but changes became evident in a few short weeks. Stabilization came first, and then strengthening. Small gains were encouraging and kept me motivated. Armed with a menu of exercises to practice on my own, I felt resourced with an increased sense of agency. Slowing down and paying attention with mindfulness became solidified as tools that were readily available (these tools were also transferable to other life situations).
- If something can’t be cured, at least it can be managed, functioning can be restored, and quality of life can be enjoyed. I felt empowered to continue the maintenance work on my own but also encouraged to come back if past problems resurfaced or new ones arose later on.
Each of the concepts and suggestions I incorporated from physical therapy can be applied to our work in mental health counseling. Some of them are common sense, whereas others reflect what is established as best practice. But organizing them into a frame that is parallel to physical therapy provides a different portal into our therapeutic work.
I have used all of these ideas with clients and found them to be useful. My back continues to be stable, and I have discovered that I do have a core after all.
This essay is dedicated to BB with gratitude.
Jane E. Buckingham is a licensed clinical mental health counselor, national certified counselor, certified clinical mental health counselor and mental health consultant in Brattleboro, Vermont. Contact her at firstname.lastname@example.org.
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