Monday Memo 4/20/2020

The Monday Memo

April 20th, 2020                                                                       PITT DPT STUDENTS

Psychologically Informed Care

For many people across the globe, 2020 has been a particularly challenging year thus far.  With the COVID-19 Pandemic, a sequala of stressors are arising in conjunction with anxiety, depression, increased incidence of domestic violence, alcohol/substance abuse, PTSD, and other mental illnesses throughout the world.  With social distancing in effect in many areas of the United States, many people are feeling alone and fearful in the midst of uncertainty.  It is CRITICAL during this time to be aware of signs and symptoms consistent with mental illness when we are interacting with those around us.  Then, you must be aware of ways to support yourself, your loved-ones, and your patients through this challenging time. Although, as students, we are not seeing patients currently, these are key points to take with you as future clinicians.

Stress has many physical manifestations that mirror common impairments we see in the clinic such as muscle pain, fatigue, spasms, tightness, and high blood pressure.  It is important to be aware of psychological triggers for the pain the patient is feeling, as well as physical causes.  As physical therapists, we often see patients for longer durations over an extended period of time.  Due to this length of treatment, patients share information with us that they have not yet shared with other medical professionals.  Listen to each patient when they talk, because they could provide you with a wealth of knowledge regarding how to best support them.  For example, Mr. Covid is a 52-year-old man referred to you for chronic low back pain.  You evaluate him, and it appears that he has a standard flexion-preference.  You treat him for five visits, he misses a week of treatment, and when he returns for visit six, he states that his pain “just doesn’t seem to be getting any better.”  You start talking to him about his home exercise program, and he tells you:

“To be honest, I just have not found any time to do it.  I was laid off because of this pandemic and have been spending four hours a day sitting in front of my computer trying to find a new job.  My wife is an ER doctor who has been working 12 to 14-hour shifts, and we have four children that I am taking care of and homeschooling alone.  I just am not doing so well right now.  I’m stressed, I’m eating everything in my house, I miss my friends, family, and coworkers, I’m not sleeping enough; this back pain just makes it all so much worse!” 

This patient report, although fiction, doesn’t seem very unrealistic, right?  It could be easy to write “no progress noted.  Pt. non-compliant with HEP” on their chart and move on with your treatment plan as scheduled.  Using psychologically informed care, the information that Mr. Covid shared could be critical for his mental AND physical progress.  Being the skilled-PT you are, you say to Mr. Covid:

“I hear you are going through a lot right now between losing your job, caring for your children, and this back pain that just doesn’t seem to go away.  Unfortunately, the stress you are under could be contributing to your back pain.  I really would like you to start working on some mindfulness techniques at home to help you destress; I will show you them at the end of the session.  If your wife is feeling stressed as well, these could be great to teach her, and you could practice together!  Every thirty minutes that you are at the computer or homeschooling your children, I would love for you to integrate some sort of activity break in – such as dancing with your children, doing a lap around your house, or some other form of activity for 5-10 minutes to break up those long intervals of sitting.  Today in the clinic, let’s do some milder activities to calm your back down, and modify your home exercise program so they are activities that you will have time to complete throughout your day.  This pandemic is incredibly challenging for everyone, and I want you to know that you are not alone.  Do you think you want to talk to a mental health professional about your stress?  If so, I know someone great who I could refer you to!”

               As Pitt Physical Therapy students, we often discuss the term “psychologically informed care”, but what does that term mean to each of us future clinicians?  According to 2nd Year DPT student Paige Paulus, psychologically informed care means being aware of the patient’s perspective; “Sometimes it isn’t about pushing what you want to do on them, it is adapting their treatment so that they can heal to the best of their ability.”  Christina White, a 2nd Year DPT student stated that it means “being in tune with the psychological factors that could be a barrier to care, but also aware of aspects that could promote care.  For example, if someone is motivated and ready to go, that is psychologically informed, but so is the opposite side of that continuum where a patient is not motivated.”  To 1st Year DPT student Nikki Ray, it means “recognizing when a patient is struggling mentally and noticing when they have their guard up and not pushing them past their boundaries.  They could have their guard up because they don’t want to get reinjured, or something else may be going on.”  2nd Year DPT student Kalli Seibert stated that, “for me, the psychological piece of treating patients is one of the most important parts; if you aren’t listening to what the patient needs to be successful, your outcomes will not be as great.  You could heal their body, but you will not leave a lasting impact.  In Women’s Health, we get a lot of patients who have many factors affecting their physical and mental health.  In my experience in this area of PT, using psychologically informed care is a key part of every treatment.  Patients may not remember the exercises you gave them, but they will remember what you said to them and how you made them feel.  You are not just treating them so they get better musculoskeletal-wise, but that they are also getting better emotionally and have more confidence in themselves after each session.”  2nd Year DPT student Kara Kaniecki stated “to me, psychologically informed care means being an active listener. Listen to your patients when they talk and listen to the way they say things. Listen to your patient’s body language. Observing how they present themselves can be so important when trying to understand how your patient is truly doing. Psychologically informed care means that your patients may have so many things going on outside of your therapy session. Their spouse could have just passed away. They could have just been fired from their job. They might have just failed an important exam. We need to take into account how their mental health is affecting them and how our treatment sessions can improve their health both mentally and physically. We need to keep our patience and empathy at all times. We need to do what we can to make our patients feel comfortable with us. PT shouldn’t be another stressor in a patient’s life! We are trustworthy and great communicators. Let us show our patients that as well.”

The Pandemic will come to an end, and we as a society will move through this… but some of the psychological complications of COVID-19 could last a lifetime.  As future healthcare professionals, it is crucial to listen to our patients, support them, and make appropriate referrals as necessary.  Be open to talking to your patients about their mental health as well as physical health.  Use your motivational interviewing and listening skills early and often for each patient that you encounter.  Additionally, just as the SBIRT training suggests, screen each patient, provide a brief intervention, and refer to treatment (whether that be for alcohol/substance abuse or mental health resources) as necessary.

As far as what we can do RIGHT NOW to make a difference: reach out to those around you who may be feeling alone during this time, be kind to each other, and most importantly—take care of yourself and stay healthy.  Our future patients are counting on us.

Mental Health resources posted by the University of Pittsburgh Counseling Center:

-Mariah Callas, SPT

Special Thank you to Paige Paulus, Christina White, Nikki Ray, Kalli Seibert, and Kara Kaniecki for their valued input.