From Drama to Empowerment
Traditional manual therapy has been biomechanically based with only a recent sprinkling of neurophysiology and pain science. The beliefs and expectations of the patient have often been ignored. The biopsychosocial-spiritual nature of care is what ultimately drives change. N=1. The patient’s unique functional impairment will never follow a recipe of care.
Traditional manual therapy places the ultimate story in the hands of the therapist. The therapist feels impaired movement and attempts to correct it for the patient before typically reinforcing “the fix” with education and home exercises. We unknowingly have become a rescuer as a clinician and have unknowingly placed the patient into the role of a victim.
The Dreaded Drama Triangle
The way we look at things is the most powerful force in shaping our lives. Our stories matter!
The Dreaded Drama Triangle (DDT) is the toxic interplay of three distinct roles; Persecutor, Victim and Rescuer, which was first articulated by American psychiatrist Dr. Stephen Karpman in the 1960’s. Healthcare often follows this narrative. The patient plays the role of the Victim with situations such as health acting upon them often beyond their control. This situation or condition may be seen as a Persecutor. The clinician plays the part of the Rescuer, the one who intervenes on behalf of the Victim, to deliver the Victim from harm by the Persecutor. While the Rescuer may have the best of intentions, their actions remove the Victim from responsibility, thereby reinforcing their Victim mindset.
David Emerald wrote about The Empowerment Dynamic (TED) in 2005. TED shifts the story in the DDT. I feel that this is the perfect analogy to the power of narratives. The TED flips the DDT 180 degrees. The Victim becomes a Creator. The Persecutor becomes a Challenger. The Rescuer becomes a Coach. Patients tell us they want autonomy and to be a part of a team, relatedness. The TED lens places patients in the role of the hero in their own journey. This shifts and transforms their story from reacting to creating. A Creator has choices that lead to growth and resiliency. Possibilities. Creators take responsibility and action toward desired outcomes. A Challenge is something that can be overcome and can be seen as an opportunity to grow. We as clinicians take on the role of a Coach. We walk beside the Creator. We do not need to carry them. We focus on the need to understand versus the need to fix. We provide therapy with a coaching edge. Guiding empowerment, finding, and creating meaning. Coaching embraces whole-person care. We are a co-creator. Confluence.
The Mulligan Concept Creates Confluence
In The Mulligan Concept, the patient has the locus of control, not the therapist. We do therapy with our patients as opposed to them or on them. Our patients are doing the impaired activity while we are providing an accessory movement/glide. We are in constant communication with the patient as they decide what is working not us. We alter the treatment direction/force/location accordingly. The patient can see and feel if treatment is successful, and we adapt as guided by them. The outcome is created together as a team. This fuels patient self-efficacy and motivation that change is possible and shows them that they have an autonomous role. The new story moving forward is created together as a team. It is a confluence.
Intrinsic motivation is the key to any change and opens the door to adherence. Behaviour change strategies such as cognitive behavioural theory, self-determination theory, social cognitive theory, and motivational interviewing all intersect at the themes of autonomy support, a sense of team (relatedness), and self-efficacy (competence). All of these themes are born out of empathy, connection, and trust. The Mulligan Concept is a living example of how this works in practice. Fixing somebody does little for their intrinsic motivation.
Therapy with a coaching edge is built on these same foundations of empathy, connection, and trust. Change is not imposed on the patient. Options are considered, readiness to change is assessed and the narrative speaks to possibilities. Once autonomy support and relatedness are truly present, then self-efficacy, competence, and confidence emerge in the arms of enhanced intrinsic motivation. Physical therapy is an agent of change. Therapy with a coaching edge shifts the story for us as clinicians to that of partner and co-creator. Narratives are healing and transformative for the patient and the clinician.
Stories matter. Are we creating sanctuaries or are we creating prisons by the words we use? Are we creating challenges for our patients or introducing them to persecutors? Do we invite them to be the creators of their own hero’s journey, or do we unknowingly place them in the role of victim?
Stories matter. Do we tell them the story we want for them or are we creating a shared story together? Finding and creating meaning collaboratively is a skill. It is a practice. It is the confluence of being a clinician.
The Mulligan Concept lives at the intersection of manual therapy and pain science but it also is an effective example of the confluence of care. It is a therapeutic alliance fueled by autonomy support and gives the patient the role of the creator. The Mulligan Concept allows the patient to be the hero of their own journey!
Creative writing and poetry have played a big part in my own self-reflection process. The writing and study of stories and poetry build empathy and narrative competence to not only get to know ourselves but to meet others where they truly are. Poetry has assisted me in navigating the uncertainty of being a clinician as it embraces the mystery of just being alive. We can never trade mystery for mastery. I shared this journey as a poetic odyssey in my book, Cuoreosity: The heArt of Being. Please reach out to me if you are interested in where coaching and therapy connect to help create a more fulfilling practice or how poetry/creative writing can transform the resilience of ‘being” a physiotherapist.