A Brief History of Psychotherapy and Physical Disability

Article excerpt

The task of providing even a brief history of psychotherapy with the physically disabled is difficult. This is primarily because there is very little that has been written that refers to a generic psychotherapy with physical disability. There is ample literature on psychological intervention with specific disabilities, for example, blindness, neurologic disease/brain dysfunction, renal disease, and chronic pain. A number of reasons can be given for the paucity of literature on psychotherapy and physical disability.

First, psychotherapists who work with the physically disabled are usually identified with their original area of training, for example, psychiatry, clinical or counseling psychology, clinical social work or nursing and only secondarily do they identify with physical rehabilitation. Traditionally, rehabilitation psychology has emphasized somatopsychological processes and ecologic-environmental approaches to the reactive psychological difficulties of the congenitally and adventitiously disabled. Early in the history of rehabilitation psychology, this disproportionate focus on the environment appeared to be a reaction against the then-popular psychoanalytic approaches to human behavior that implied "psychopathology" if one had difficulties coming to terms with one's disability. We believe that argument to be misleading and we will elaborate on that later.

Second, the majority of literature on intervention in physical rehabilitation has focused on behavioral approaches. Diller pointed out a fundamental philosophical difference between rehabilitation medicine and psychotherapy. He noted that rehabilitation medicine is action oriented whereas psychotherapy is insight oriented.(1) Consequently, behavioral approaches with their focus on behaviors, including physical ones, were a logical adoption for rehabilitation psychologists.(2-5) The point we want to emphasize throughout this brief review is that psychotherapy with the physically disabled does not differ in any substantive way from psychotherapy with the able-bodied and, therefore, the entire history of psychotherapy becomes germane to work with physically disabled individuals. While some psychotherapists focus on either conflict or deficit, it should be noted that, philosophically, rehabilitation specialists have always placed more emphasis on the patients' remaining assets and their optimal utilization than on dealing with matters of premorbid personality, psychopathology or character.

DEFINING PSYCHOTHERAPY FOR THE PHYSICALLY DISABLED

We will restrict our review to the theory and practice of psychotherapy with the physically disabled. Psychotherapy needs a broad generic definition. Moore and Fine define psychotherapy as "Literally, psychological treatment. It refers to any method used by a professionally trained therapist regardless of the disorder being treated. The term is applied to a wide variety of mental illnesses of varying severity, to somatic disorders thought to be of psychological origin, and to behavioral adaptations for which the patient seeks treatment (p. 158)."(6) We would emphasize the importance of including adaptation to physical limitations, be they congenital or acquired. Frank has defined the components of psychotherapy as including a socially sanctioned healer, a sufferer who seeks relief, and a circumscribed series of contacts that are designed to afford the sufferer relief.(7) In addition to reviewing psychotherapy as it is considered in the context of physical disability, we will also highlight certain areas that we believe to be important for the psychotherapist working with physically disabled individuals, specifically, issues of loss, mourning and trauma.

PREPSYCHOANALYTIC CONCEPTIONS

In the early history of medical psychology one finds few references to physical disability per se or its psychotherapeutic management. Often, spirits and demons were believed to be the cause of a variety of physical afflictions and one finds in the history of psychotherapy many references to shamans, faith healers, exorcists, religious healers, and magicians. …