Personality, temperament, “soft-skills…”
There is a good amount of chatter in the world of pain science about these topics right now, related to both patients and to those who treat them. As we seek to determine who may benefit most from interventions like Pain Neuroscience Education (PNE), there very well may emerge certain personality traits, such as openness to change or optimism in addition to diagnosis-specific traits like central sensitization, which bode well for positive outcomes. It is well-established that patients who have high fear-avoidance and catastrophization struggle greatly to overcome pain and get on with their lives, and thanks to Dr. Vlaeyen and Dr. Linton we understand that negative affectivity is continuous fertilizer for keeping someone in the fear-avoidance cycle (Vlaeyen and Linton, 2000):
But what about physical therapists’ personality characteristics?
The more we understand and develop the characteristics that make an effective PT, and in particular, the characteristics which help foster therapeutic alliance, theoretically, the better outcomes we can expect, since therapeutic alliance is a predictor of patient outcomes (Hall, et al., Phys Ther, 2010). In a recent podcast, Doctors Kory Zimney, Tim Flynn and Jeff Moore had a thought-provoking conversation about the importance of trust as a fundamental element of therapeutic alliance. They spoke in particular about the soft-skills PTs must develop to create enough safety for the patient to be willing to risk changing behaviors to climb out of a cycle of chronic pain. After all, as Tim eloquently noted, patients are logical human beings, and when movement causes pain, they learn to avoid said movement.
How can we convince them that the very thing that scares them the most is what they will ultimately need to confront to move beyond their pain?
Clearly, trust is a cornerstone. And when we look at the soft-skills that build trust, is there a disconnect between the metrics that allow students to be accepted into PT school (good grades, high GRE scores, etc.) and the interpersonal skills requisite to connect on a human level to develop that kind of trust?
Being a non-Twitter-bug, I missed out on the terrific conversation that likely followed, but the podcast really got me thinking: what personality traits foster trust and facilitate success as a PT? Obviously, this is not a novel question. A quick perusal of Google yielded a few ideas. Justphysio.co.uk listed Team Player, Confidence, Adaptive, Patience and Drive as essential traits to succeed as a PT. Jobs.net described Cool and Determined, Supportive and Compassionate, Confident and Resilient, Fit and Health Conscious, and Sociable and Cooperative as essential characteristics. Their description of “Supportive and Compassionate” resonated with my own bias for crucial ingredients: “Individuals who maintain control of difficult sessions with empathy, tenderness and a sense of humor are among the most successful therapists.” Other sites listed qualities such as openness, life-long learner, competence and kindness.
As I pondered this further, I asked a good friend and colleague of mine, who has an amazing ability to make patients feel heard, important and safe what she thinks. “What makes the most trust-worthy PT?” Her answer:
“Presence. The ability to be truly present with the patient; to look them in the eyes; to hear what they are saying with both their words and their body-language; to have unconditional positive regard for them as a fellow human being.”
As I watched the passion in her expression while she said these things, and as I reflected on her interactions with patients, I thought, no wonder her patients do so well. She truly sees them, honors their dignity, and connects with them on a personal level. She has deep reverence for that “sacred space” we are given the privilege to enter when we come alongside a person who is going through one of the most difficult things known to humankind: suffering. And as I reflected on my observation of her personality, the first word that entered my mind was humility.
While these are all interesting, touchy-feely ideas and observations, I also had to consult the literature a bit, and in doing so I stumbled upon an intriguing little cohort study by a group of Dutch physiotherapists. The authors explored physiotherapists’ personality traits that may influence treatment outcome in patients with chronic diseases. They used The Big Five personality traits to see if there was a correlation between PT personality and patient outcomes.
While we might expect a correlation between some of these categories (particularly agreeableness, due to the elements of sensitivity and warmth), what these researchers found was rather interesting:
“Of the Big Five traits, Neuroticism [LOW scores on the neuroticism parameters] was the only personality trait that was associated with better treatment outcomes. This suggests that treatment by therapists who tend to be calmer, more relaxed, secure and hardy, may produce better treatment outcomes in patients with chronic diseases…The indication of the possible relevance of Neuroticism corresponds with evidence found in the field of psychotherapy, showing that being treated by secure therapists predicts a better outcome.”
The authors cited several limitations, including the fact that the majority of therapists in the sample were male, and that the Big Five Inventory lacks precision and is merely a measure of broad personality characteristics. Never-the-less, the idea that our own mental and emotional well-being as PTs may enhance the health of our patients is compelling.
Being low on neuroticism really struck me, and it reminded me of quotes from two PTs who I know and respect a great deal. One is a hero of pain science education and research, Adriaan Louw, who often tells PTs in his courses, “Keep your placebo cool. You freak out, they freak out. Stay calm.” The other is a good PT friend of mine locally, Bob Johnson, who has never taken a pain science class in his life, yet has over 30 years of experience and has phenomenal outcomes. Bob once told me, with kindness and gentleness in his voice, “I’ve come to think of myself not as Bob Johnson PT, but rather, Bob Johnson, queller of fears.” He views his job as a calling: to calm patients’ fears, to provide them with a sense of safety, and ultimately, to offer hope. As I look at the common thread between these two fantastic PTs, I see a characteristic that I think is essential, and is in line with the Dutch physio study: security. Adriaan and Bob are both secure in who they are and what they stand for. That sense of integrity, self-awareness and security allows them to interact with people (not just patients, but people in general) in a way that extends acceptance and grace to others regardless of their circumstances. They are able to keep it “about the patient,” instead of allowing themselves (i.e. their egos) to get in the way.
So, after pondering all of these ideas, I’m trying to decide what I would rank as my own “Big Five” personality traits for a PT, particularly a PT treating a patient population predominantly struggling with chronic pain. Trust-worthiness, humility, presence, security, and hopefulness? Empathy?
Maybe kindness, warmth, or emotional stability (i.e. anti-neuroticism)? So many options! What is your BIG FIVE list for characteristics of a relationally-successful PT? Is there a difference between those characteristics depending on the environment and/or patient population a therapist works with? And, not to open a whole new can of worms, but how on earth can we screen for those characteristics for admission into PT schools, develop them, and nurture them? I look forward to hearing your thoughts, and thank you Kory, Tim and Jeff for getting this conversation started!