Western healthcare since the sixteenth century has been structured on the theory proposed by French philosopher, scientist and mathematician, Rene Descartes, that body and mind are separate. Modern medicine is now recognising the importance of a whole person non-dual approach to health issues, dualistically categorized as ‘physical’ or ‘mental’ health. This cannot come quickly enough. The Australian National Study of Health and Wellbeing (2020 – 2022) states one in five adults (21.5%) live with mental illness. The Australian Institutes of Health and Welfare (2022) found that nearly half of all ages (46.6%) have one or more chronic conditions.
A non-dual approach is a philosophical viewpoint that challenges 600 years of medical structure and cultural beliefs, and over 200 years of physiotherapy as a structured profession with a skill base centred around the functioning of the body.
An example of a first non-dual physiotherapy treatment for a person with persistent back pain could be 1-2 movements that create the conditions for the person to increase the mobility of their lower back, reduce sympathetic nervous system arousal, and new insights into their rigid belief that ‘pain never changes’.
A perceptual shift of some magnitude is required for this approach. Perhaps this is also what is needed for the physiotherapy profession in the future. This is an important topic and one that this article introduces and explores through a series of questions and responses. The invitation is to read slowly and pause often.
Question: Is there a way to work with clients that honours and expands the physiotherapy skillset to address not just the physical aspects of illness but also the cognitive and emotional aspects?
Response: From a non-dualistic viewpoint any physiotherapy intervention affects emotional or cognitive responses that can lead towards or away from health and wellness. We mostly are not aware of these effects.
Question: Does the body-mind connection mean that I can be providing optimal manual or exercise therapy but my patient might not be getting better because of how they are thinking and feeling?
Response: What is your experience of this? Do you ever provide great treatment but don’t get the outcome that you hope and expect?
Question: How can we be more aware of the effect we have and deliver treatment in a targeted way to help guide the person towards health and wellness?
Response: This learning invites clinical reasoning to expand out to a whole person perspective that also includes you as the therapist. Information gathered may include your own and your patient’s body language, protective patterns, non-verbal and verbal communication patterns, cues of trauma in a patient’s storytelling and the signs and symptoms of sympathetic hyper and hypoarousal. This lays the foundation of a treatment intervention that creates the conditions for an experience that creates positive change such as increasing safety, reframing an unhelpful belief, empowerment, self-mastery, calming stress.
Question: A whole person approach sounds complex. How would this work in the clinic?
Response: It does take effort with a turning of existing physiotherapy skills in a different direction. The complexity is simplified. For example, when a person with pain in many areas and other stress related symptoms, a simple movement practice can integrate breathing, grounding and curious attention to help calm the body, better regulate the sympathetic nervous system, create better mental clarity and help generate positive emotions.
Question: What is the first step to bringing mindfulness into my work to deliver a body-mind approach?
Response: Understanding the inter-relationship between the body and mind is the first step. It is difficult to learn from theory. Fortunately, you have a body-mind to experiment with! Being curious about what happens in the sensory world of your body when you are worried, when you are angry, when you are in pain, when you are peaceful, when you are joyful.
Question: Is mindfulness and acceptance-based interventions the training pathway?
Response: Yes. Mindfulness is the human trait and skill of bringing attention to the present moment without judgment. Mindfulness offers a way of better understanding ourselves and the human body-mind experience. It is a way of seeing more clearly the learnt patterns of moving, holding tension or letting go, avoidance or acceptance, thinking clearly from a broader perspective or getting stuck in old patterns of catastrophising or narrow view. Mindfulness enables clearer insight into patterns that enhance health and those that create more pain, disfunction and distress.
An important aspect of mindfulness are attitudes of acceptance, non-judgement, curiously and kindness. We don’t judge our patterns. They are human and understandable. When we see them clearly with these attitudes they begin to shift.
Question: I’ve heard that I need to practice mindfulness myself before I share it with others. Is this correct?
Response: Yes. To teach anything we need to understand it from our own personal experience. For example, teaching a person to swim you need to understand what’s it like to be in the water, how it feels to float and move through the water. Mindfulness is like this. Experience mindfulness also allows you to decide whether it’s a helpful wellbeing strategy in your own life.
Mindfulness of the therapist has also been found to enhance therapeutic relationships and prevent burnout.
Question: Can I learn mindfulness on my own?
Response: Yes. Many people, however, find they learn and are better able to integrate practices into their life with training with a qualified teacher individually or by attending a recognised training course.
Question: Are mindfulness and acceptance interventions evidence-based?
Response: Yes. In the 1970s the Mindfulness-Based Stress Reduction (MBSR) program was taught by Jon Kabat-Zinn at the University of Massachusetts. This is the most researched program with a combination of theory, mindfulness practice, mindful movement and personal reflective practices. There is now a range of Mindfulness and Acceptance-Based Interventions (MABIs) that aim to help people cope with stressful thoughts, emotions and physical sensations. They are associated with improved health outcomes for a range of health issues including pain, stress-related illnesses, anxiety, and depression. Improvements are mediated through improved sleep, physical functioning, stress regulation, body awareness and cognitive flexibility with changes in brain, hormonal and immune functioning.
Question: Isn’t mindfulness teaching only for psychologists? What does this mindfulness in the clinic look like for physiotherapists?
Response: Mindfulness was brought into healthcare as a secular practice adapted from Buddhism. Many other cultures have similar practices within their teachings.
Mindfulness is a human trait of awareness available for everyone.
In healthcare, psychologists have led the way in integrating MABIs, creating programs that meet their skill sets. The most recognised and researched is Acceptance and Commitment Therapy (ACT).
This is an emerging field for physiotherapy. Training is required to teach mindfulness to others but there is not a requirement to be a psychologist. The first foundation of mindfulness is the body and this is the territory of physiotherapists. Mindfulness of movement may provide a shift from standard physiotherapy teaching, however, as an inside-out approach, guiding people to explore their sensory, interoceptive and proprioceptive experience with curiosity and acceptance.
Mindfulness of the body in combination with movement provides a unique clinical body-based pathway that builds on the physiotherapy skillset.
Question: What is the uptake of mindfulness practices in physiotherapy?
Response: Change is slowly happening, but MABI’s are underutilised in the physical therapy profession (Tatta et al 2022). This is understandable in the absence of MBI interventions that specifically highlight and expand on the body-based skillset of physiotherapists. Other potential reasons for this include lack of training, limited awareness of evidence of potential benefits and lack of clarity regarding the scope of practice.
Question: Where do I start?
Response: Be curious. Acknowledge the wonderful work that you do.
Pause, breathe, move with awareness and be kind. Seek out resources and opportunities to engage in body-mind practices such as mindfulness courses such as the MBSR course, mindful hatha yoga and Tai Chi.
Conclusion
Now is the time to piece the body and mind back together, and to recognise that any body-based intervention always affects the whole person. Let’s take charge to better understand the non-dual nature of human experience and provide an informed whole-person approach. Don’t leave it to chance.
Mindfulness and Acceptance Based Interventions are existing evidence-based practices that provide a first-step training option for physiotherapists. We need, however, to take a closer look at a creative and innovative physiotherapy model that integrates whole-person interventions to enhance therapeutic outcomes and reduce the risk of chronic physical and mental health disorders.
References
Australian Institute of Health and Welfare (2022). Chronic conditions and multimorbidity, accessed 22 June 2023.
Mindfulness and acceptance-based interventions in physical therapist practise double Colin time is now. Tatta, J., Willgens, AM., Palombaro K M. Physical Therapy, Vol (102): 3 pzab 293.
Georgie Davidson
APA Titled Pain and Musculoskeletal Physiotherapist
Certified Mindfulness and yoga teacher
Director Mindful Movement Physiotherapy