The New South Wales branch of the APA Mental Health national group has been exploring how physiotherapy contributes to mental health and wellbeing. 

This work recognises that mental health physiotherapy is applicable across all care settings. In this complex arena, where physical and mental health are deeply intertwined, we encounter numerous challenges when dealing with patients in distress, including looking after our own wellbeing.

The New South Wales branch of the Mental Health group is eager to share insights from research and personal experiences and to offer some innovative strategies that are guiding us towards a more empathetic, relational approach to care.

Ryan McGrath reflects on his recent research, which suggests that physiotherapists feel unprepared for this emotional aspect of their work, with multiple interactions linked to empathy fatigue. 

This points to an urgent need for a more comprehensive approach to healthcare, integrating both physical and mental health competencies within physiotherapy practice.

Tracey Clark then offers a personal perspective on the challenge, sharing her own experiences in promoting wellbeing in the workplace. 

Given the rise of ‘survival mode’ among colleagues, she advocates for the establishment of a healthy workplace environment that supports staff as well as clients. 

Her work underscores the necessity for staff training on mental health, which would equip health professionals with knowledge on how to recognise changes, how to provide support and when to refer to specialists.

Finally, Shelley Barlow’s doctoral thesis provides valuable insights into physiotherapy’s transformation to better accommodate the distress inherent in our work. 

Shelley draws attention to the ‘in-between’ space— the intersubjective realm—between patient and clinician, emphasising the importance of understanding our own responses to patient distress. 

She proposes a framework for working with distressed patients, focusing on a relational approach and emotional self-development.

These insights bring us closer to a more comprehensive understanding of mental health in physiotherapy practice. 

As we continue to navigate this evolving field, we aim to incorporate these perspectives into a more holistic, compassionate and trauma-informed approach to care.

Physiotherapist encounters with patients in distress

Ryan McGrath recently published the third paper from his ongoing PhD study. Ryan’s three papers explore the interactions that physiotherapists have with patients experiencing psychological distress and call for a comprehensive approach to health and wellbeing, informed by trauma-informed care (McGrath et al 2022a, McGrath et al 2022b, McGrath et al 2023).

According to a survey of 340 physiotherapists, 36.1 per cent of all patients were perceived to be
experiencing psychological distress, with 15.6 per cent believed to be experiencing severe psychological distress. 

The results from the survey support the qualitative research preceding it, which found that encounters between physiotherapists and patients experiencing psychological distress were seen to be common.

All three papers indicate that the nature of patient distress varies greatly, including sadness, grief, anger, anxiety and worry. 

Physiotherapists reported that patient psychological distress often goes beyond physical health issues, sometimes manifesting as fear of the future, emotional loss, trauma and a loss of hope. 

Interestingly, while physiotherapists felt that identifying distress was within their scope of practice, they also felt unprepared for this emotional aspect of their work. 

They said that their undergraduate study had not equipped them with the necessary skills to navigate this area effectively and that frequent encounters were linked to empathy fatigue. 

They emphasised the importance of developing and maintaining a therapeutic alliance with patients, which involves becoming emotionally attuned to them.

While physiotherapists are trained experts in movement and physical health, the findings suggest a need for a more holistic skill set that includes mental health competencies. 

This broader understanding should encompass factors contributing to both physical and mental wellbeing and those that may lead patients to experience health-related psychological distress.

While physiotherapists are trained experts in movement and physical health, the findings suggest a need for a more holistic skill set. - Ryan McGrath

Acknowledging and addressing these psychological factors not only benefits the patients, but also contributes to the wellbeing of the health professionals themselves. 

It can enable physiotherapists to sustain their careers more effectively. 

In summary, the research findings underscore the need for increased recognition of the emotional components in physiotherapy practice and of the vital role of mental health training within physiotherapy education.

Starting in our own backyard

Where can we start, as individual therapists? Tracey Clark reflects on her experiences.

As a physiotherapist, I am passionate about supporting client and staff wellbeing and this approach underpins my role at Physio Inq. 

When we conducted an engagement survey, unpacking it gave me the opportunity to take a close look at how staff rated their own wellbeing. 

I found that therapists had a sense of ‘just getting through work’ without a clear definition of how wellbeing could be experienced and how we could effectively support working towards it.

The Centers for Disease Control and Prevention describe wellbeing as including the presence of positive emotions and moods, the absence of negative emotions, satisfaction with life, fulfilment and positive functioning. 

When I spoke to colleagues, they described a feeling of ‘just surviving’, which was echoed in a review of the literature on burnout post COVID-19 in healthcare (Centers for Disease Control and Prevention 2018, Diener & Seligman 2004, Diener 2009, Diener et al 2009).

I felt disheartened and could see that burnout was leading staff to change companies, to change professions and to go travelling to recover and reflect on their next steps.

I wondered how we could both support clients’ wellbeing and prevent the attrition of staff.

So what could I do, as an individual? I started by thinking about what makes up a healthy workplace and noted that the literature not only explains how this may be achieved, but also offers effective pathways. 

I was encouraged by the ideas presented about how to support this systemic and organisational change.

In New South Wales, one approach was particularly relevant.

This approach encouraged an assessment of how our company was understanding the factors that were essential to a ‘healthy workplace’.

The structured survey was completed and presented to upper management and, with the support of the CEO and my state manager, I developed a work plan that would start to build a mentally healthy workplace. 

The free workplace mental health coaching was funded by the state government and delivered by Transitioning Well. 

Coaching allowed an unfiltered sounding-board, a broader understanding of resources and the
creation of a plan. But where to focus?

I selected staff training as the initial focus and confirmed that, as Ryan McGrath’s papers had indicated, health professional staff wanted training on mental health for themselves, colleagues and clients so they could recognise changes and know how to support each other as well as being familiar with referral options when outside their clinical knowledge and boundaries.

The project applied training available from the Black Dog Institute over a six-month time frame. 

Further feedback from staff and colleagues advised that the greatest distress came from not knowing what to do when clients presented with severe distress, self- harm and/or suicidal thoughts.

We proceeded by developing a suicide/self-harm prevention pathway for use in the clinical setting and supported therapists with training that addressed clinical practice, professional boundaries and self-care for the clinician.

So what have I learnt? This is a journey, not an end destination. 

It did provide a platform to discuss staff distress and burnout and gave us a pathway for directing staff towards existing referral options within our company as well as developing links to external supports for both themselves and their clients.

The suicide/self-harm prevention pathway was developed with the support of colleague and PhD candidate Ryan McGrath, Transitioning Well coach Tess Collins and Physio Inq People and Culture Manager Caroline Rimington. 

The overall project was also supported by my manager David Shearer and by Physio Inq CEO Jonathan Moody, who recognised the importance of listening to staff and embracing organisational change.

I was prompted to regularly consider my own wellbeing along the journey to a mentally healthy and sustainable workplace. 

Part of this process involves therapists building mental health skills for their clients, including through the APA Mental Health Physiotherapy Level 1 and Mental Health First Aid courses, through reflecting on their own wellbeing and through learning when to refer on to specialists.

Transforming practice

The challenge of working with people experiencing distress is significant. Shelley Barlow has considered how physiotherapy practice may be transformed to better recognise the impact of distress. 

The investigation identified the components of such an approach in her doctoral thesis and offered the New South Wales branch of the Mental Health group a greater understanding of how our previous and current experiences affect our client relationship and our therapeutic approach with our clients.

Within the community of physiotherapists, our individual experiences as we react and respond to the uncertainty, complexity and ambiguity of working with people experiencing distress often raise our own distress and discomfort. 

Such responses can emerge from within the existing situation—that is, a clinical encounter—or may be enacted based on our previous experiences. 

These previous and current experiences make up our lifeworld, everything we bring to the relationship we have with our patients, as they bring everything they have experienced to each clinical encounter.

To understand and honour our lived experience, we need to recognise the value of this component of physiotherapy practice despite the potential for distress. 

This gives clinicians extra information on what might be going on in the ‘in-between’ space, known as the intersubjective realm.

Our willingness to pay attention to ‘how we are’ in relation to people experiencing distress can elucidate many aspects of how our lifeworld has been shaped to meet vulnerability. 

How we are shaped and what lens we use to perceive situations can emerge and evolve through every encounter. 

Confronting and understanding our own responses allows us to transform and transcend any previous negative experiences, with the support of awareness-raising, supervision and guidance of practice.

A framework for working with people experiencing distress that recognises the value of a relational approach and the importance of emotional self- development, as a parallel process to content knowledge, will help to transform and transcend the inherent challenges of working in this field.

Click here for references.