My Experience at the Somatosensory Rehabilitation Center: Power and Positionality, Where do I Stand?

[Citation] : Chapdelaine, S. (2020). Guesteditorial My Experience at the Somatosensory Rehabilitation Center: Power and Positionality, Where do I Stand? e-News Somatosens Rehab 17(3), 79-85.

Sarah CHAPDELAINE

BSc OT, MSc OT(c), CSTP®

In January and February 2020, I had the pleasure of being welcomed by Claude Spicher and his colleagues at the Somatosensory Rehabilitation Centre (Freiburg, CH) to complete an occupational therapy placement as a McGill University Master’s program student, and to learn about the Somatosensory Rehabilitation of Pain method. Before attending the first part of the Somatosensory Rehabilitation Method (SRM) class, offered by the Réseau de Rééducaton Sensitive de la Douleur, I knew almost nothing about this method apart from what we briefly tackled in school. Today, I now understand that you have to take the plunge into the world of neuropathic pain to start grappling with the intricacy and the beauty of this method.

fFor me, writing this article is the perfect opportunity to gather my thoughts around my experience, and reflect on what I have learned. Reflecting on your practice is often very hard to do on the spot, especially as a student on the other side of the world. You find yourself very busy learning new things and adapting to a new environment. However, in order to improve the quality of our practice, one must take the time to engage in on-going learning by reflecting on our own strengths and weaknesses. In the following article, I will attempt to exemplify the reflection-on-action and critical reflexivity processes (Kinsella, 2012), by unpacking a reallife experience from both theoretical and practical perspectives. Within this example, I will be detailing a personal and professional situation with the aim of encouraging you to examine your own assumptions and how it impacts your daily practice.

In order to engage in reflective practice, it is important to acknowledge what made my experience unique. I have come to identify similarities between the Swiss and the French Canadian practices, but also identified some discrepancies, shared by both environments. Albeit most often hardly perceivable, they deserve attention because they contribute to inequities and injustices, as well as perpetuating oppressive practices within healthcare systems and societies. This is especially important in light of recent international events, namely anti-racism solidarity protests originating from North America. This paper does not claim to offer answers, but rather to elicit an individual and communal attempt to reflect on our own practice as healthcare professionals.

Preamble
Throughout my stay, I realized that Swiss practices share much resemblance with French Canadian practices. One particular thing I learned very early on is that both are grounded in scientific literature, although therapists are also committed to incorporate the patient’s personal expertise. The Certified Somatosensory Therapists of Pain (CSTP®s) nurture the “récit à deux voix [two voices narrative]” (Spicher et al., 2018) and leverage it as a way to establish the therapeutic relationship. They also make therapeutic education of the patient one of the practice’s core values, and this speaks about the importance they place on empowerment. The word empowerment is commonly defined as “the granting of the power, right, or authority to perform various acts or duties” (Merriam-Webster, n.d.). At the academic level, the traditional way to teach occupational therapy is to promote empowerment through our actions. We have a role to play in empowering patients through occupations, enabling them to act upon their life, by addressing disempowering environments and maladaptive behaviors. However, this idea introduces a relationship of power between a clinician and a patient; we must provide them with something for them to be or feel empowered. How does this affect the situation and how the patient perceives us? A growing number of professionals are incrementally starting to question themselves about how this notion of power influences the relationship between two or more individuals.

Clinical Example
Throughout my placement, one particular clinical situation prompted my reflection on social inequities and how they play out in therapy. It happened at the very beginning of the placement, so I remember not giving it too much attention at first because there were so many things going on. I was acting as an observer when I met a man, probably in his 30s, suffering from allodynia in his foot. The pain was so intense that he had to wear sandals inside and outside, even in the midst of winter. He was well-known at the clinic, as he was approaching his 36th session of occupational therapy at the center. Given his condition, the insurance would not allow for the coverage of more than 36 sessions, and this ultimatum was putting pressure on everyone. I remember the expression on his face, tired from trying and not making much progress. I recall being told he had trouble following the necessary recommendations, restricting him from touching and using his foot as much as possible, in part because he had to provide for his wife and children and could not stop working completely. I remember he had a very physically demanding job, thus conflicting with the therapy demands. He mentioned there was no way he could afford to pay the treatment sessions once he reached the 36th one. Any compromise regarding the treatment seemed elusive, and questions were being raised about how to keep him engaged in therapy when the end feels close and the results are not satisfactory. In this particular situation, disparities regarding the social class as well as cultural norms contributed to the impediment of the therapeutic relationship and treatment efficacy. On one side, the patient’s working class status was in conflict with the clinicians’ upper middle class status; the professional’s expectations did not match the client’s resources and opportunities. On the other side, the interpretation of pain, therapy and the role of a provider was different from one person to the other, making the therapeutic process a challenge if not being accounted for. This experience led me to interrogate why it turned out to be a reproduction of social norms, stipulating that the patient’s duty is to comply to the proposed treatment. One of the things that struck me was how the therapeutic relationship evolved. What lead to creating this feeling of inadequacy on my end? I remember sensing that the patient wanted something more, like an easy and straightforward solution to cure his neuropathic pain. But we are aware that somatosensory rehabilitation relies largely on the patient’s long-term and sustained engagement in the process. A little later, I started reading about power imbalance in the therapeutic relationship and realized how these can induce distress in a relationship (Atwood & Scholtz, 2005). More specifically, in certain situations, this power differential can be at the root of a client’s disengagement in the process as they may cause disruption in the alliance. How does the way we, as therapists, are perceived influence the process? What role does our stance play in all of this? Shaped by the social and political context, our positionality is closely related to the particular dynamics between a therapist and a patient. Through this article, I sought to explore issues around power and positionality but also how we can use these to promote more satisfactory outcomes in therapy.

Power
To try to understand power, one must look at the context in which it is in play. We must explore and define how it is hindered, but also how power dynamics are upheld. There are types of power that we acquire by our position (such as by being healthcare professionals), but also that we inherit. Power is multidimensional; anyone may be powerful in some places or situations, but vulnerable in others. Particular to the therapeutic relationship, the patient may portray us as the all-knowing therapist, which we must challenge (Brown, 2007).

This starts by acknowledging power differentials, along with challenging narratives that are grounded in dominant discourses (Brown, 2007). This traditional power dynamic continues to survive in part because of the longstanding influence of the medical model, but also because of all parties’ background and experiences. One useful example to illustrate this though is to introduce the concept of beneficial coercion. Simply think about how we present the different options to a patient, and how easy it is to emphasize the one we believe to be the best. Ultimately, this comes down to a situation in which “yes involves forces but is not experienced as force” (Ahmed, 2014).

Too often, analytical questioning regarding the interests and inequalities that exist in the therapist-patient relationship is lacking (Harley, Jolivette, McCormick, & Tice, 2002). We, as healthcare professionals, have the power to undermine or reduce the narratives and expertise of our clients to mere symptoms and pathologies (Harley et al., 2002). Power and force are often understood as an ability to influence, oppress or coerce, rather than being seen as never just constraining (Brown, 2007). Indeed, power and empowerment should be understood and explored together, as a springboard for action. Power is a concept embedded in everything we do, whatever the context is. Flaskas and Humphreys (1993; in Brown, 2007) suggest that power is an intrinsic part of all human relationships, and cannot be considered separate. The important thing remains to understand its extent and implications, in order to use it skillfully within a relationship. Because, “the therapeutic alliance is a potent curative factor in all forms of treatment” (Marziali & Alexander, 1991).

In certain clinical situations, I had to be careful not to fall in the trap of portraying the knowledgeable therapist, situations in which I make it seem like I have all the answers and I know what is best for the patient at a given time. This, while being common practice in certain settings, contributes to reinforcing the struggle for power. Here, I need to insist on the fact that the goal is not to escape power or to equalize it, but rather to acknowledge each other’s position, depoliticize the notion and use it to promote the client’s wellbeing.

Positionality
Our actions as occupational therapists have relational-ethical implications within the patienttherapist relationship. One of the ways to bring these to light is to become aware and acknowledge our positionality. Positionality is a concept that has been around for a while (Harley et al., 2002), but that has never been part of a shared vocabulary among our community of practice. Positionality categorizes individuals. It shapes your identity with regard to your class, gender, race or any social construct that determines if you are on the margin or at the center of the society. A very obvious and publicized example is the fact that women in Quebec were not allowed to vote because of their gender, until they received full suffrage in 1940. A more modern Canadian example is that Indigenous people, because of their status, still do not benefit from an equal access to healthcare services as compared to non-Indigenous people (Truth and Reconciliation Commission of Canada, 2015). Our multiple positionalities are intersectional and “possess rank, have value, and are constructed hierarchically, particularly those that are visible and discernible” (Robinson, 1999). But more importantly, positionality contributes to highlighting how one’s identity impacts your understanding and perspective of the context, while providing room for significant bias.

We position ourselves, and get positioned by others, consciously and unconsciously. Each status carries advantages and disadvantages; think about how you expect a low-income patient versus a high-income patient to be before even meeting them. Or how our education, shaped by Western middle-class standards, has emphasized health promotion and independence as some of the most important goals. Among our community of practice, there exists a noticeable lack of critical reflexivity on how the terms, concepts and practices we use and promote in therapy are shaped by exclusionary standards. We cannot deny that issues around positionality have implications for our practice, both at the individual and societal level.

When entering the clinic for the first few times, I realized that, as a Canadian student, I do not enter the setting as a blank canvas. Rather, I carry with me a range of experiences, knowledge, as well as a status. This was evident when I entered treatment rooms for the first time. I remember one patient who immediately noticed my French Canadian accent, which he associated to a memorable experience of his own, and started telling me about how he loves Canada and how welcomed he felt during his time here. As well, being a Canadian student brought up different challenges. An obvious particularity would be to say that treatment options for neuropathic pain disorders vary from one country to another, such as the application of local anesthetic being forbidden in Canada whereas used daily in Switzerland. It was thus not intuitive for me to use it at first. A less obvious challenge is that the interpretation of pain is different. My approach to it is shaped by what I have learned in my home country and, inversely, my position probably was interpreted differently. The important thing here not being to identify exactly what is different and how, but rather to focus on how these differences shape the context. One of the things I believe makes much sense on paper but find complex to apply is to start by acknowledging where I come from and what I carry with me, because I will never get rid of it (not that this is my goal). Thus, on every opportunity that I have, I ought to interrogate my positionality as a means to establish authenticity between the client and myself.

Earlier, I mentioned that our positionality implicitly carries some form of bias. Indeed, with chronic pain patients, we inevitably interpret patients’ stories through our own position, our own lens. We bear the presumed competence of understanding their lived experiences from an objective standpoint which, in fact, could not be further from the truth. Above and beyond recognizing the role it plays within a relationship, Brown (2007) argues that we must be “clear and up-front about the positions we adopt, rather than hiding under the veil of absolute neutrality”.

It is deemed that the more the professional resembles the client, the more successful outcomes will be. When treating a patient, being an insider can contribute to enhancing trust and openness, as the homogeneity can contribute to creating a sense of community (Merriam, Johnson-Bailey, Lee, Kee, Ntseane & Muhamad, 2001). Being identified as an insider can bring its share of familiarity and comfort, thus contributing to facilitate relationship-building. In contrast, being qualified as an outsider (i.e. sharing more differences than similarities with the client·s) is often assumed to be detrimental (Hopkins, 2007). In that respect, I am questioning whether this form of non-neutrality must always be interpreted as a negative thing. Merriam and colleagues (2001) stated that, throughout a data collection process regarding the investigation of a specific phenomenon, her outsider status turned out to be an asset as it elicited more complete explanations from the participants. She believes that fuller information and details would be given to her as opposed to an insider, who is presumed to ‘already know’. Being an outsider can help make explicit what is implied, or hidden. And even address things that normally would not be discussed, and as a result we can obtain a deeper understanding of the situation. Moreover, Hopkins (2007) associated his position as an outsider as a factor that helped him in alliance formation with the participants involved in his research. Indeed, it can be used productively by catalyzing the sharing of experiences.

Now what?
First, think about how you sit with the word power. If you struggle with the word itself, I suggest you start with examining your connection to the situation, and what that means for you. To disarm both others and yourself, acknowledging your power is often the right way to go about it. However, one of the most important lessons I learned throughout this whole journey is that we all need to understand the extent and repercussions of it. Because, power remains relational and contextual. Hereon, I argue that we have to move away from the binary idea that one has power or does not; the answer is rather situated on a continuum. It is conceivable to acknowledge our power, in relation with our stance, while skillfully deploying it. Thereon, there are different ways of using this power, tied to different ends. Try putting aside the vocabulary and actions stemming from dominance, such as: “I believe option A is best for you considering all the facts”. Instead, try: “option A has been beneficial to other patients, and option B is also available if you prefer a less invasive alternative”. Note the subtle difference between putting forward our therapeutic knowledge, without implicitly suggesting a better answer.

Power is inevitably supported by resources. We can assume that the more one has power, the more resources they possess. Besides, the structures within our system can be understood as governed by the dynamics of power. That being said, wherever you stand, you must benefit from at least some form of power in a particular context. Once you find how that notion shapes your own situation, reflect on how you could use it to intervene and drive change. Power can and should be perceived as a tool that is capable of making a difference (Allen, 2008). Going back to the illustrative example provided at the beginning, some additional actions could have helped to empower the client. For healthcare professionals, contacts are an integral element of our day, as they permit us to help the client navigate the healthcare system. Providing him with information about available financial support resources, a colleague to help him deal with challenging emotions, or home support services would probably have been worth giving a try.

When intervening with a client, small changes can trigger big repercussions. The very core of someone’s own story stems from their narratives. Learn to listen and listen to learn. Creating an environment conducive to free and deliberate expression can be encouraged by small gestures, such as contributing to a safe atmosphere, ensuring confidentiality, or promoting cultural safety. Throughout the years, I have also started to learn the importance of becoming aware of what is happening inside my body. I am learning how to interpret it, and what information it provides me about the situation. I am learning how to sit with my emotions, with the unexpected. Cultivating receptive and embodied reflection is one efficient way to unveil things that can hardly be put into words. Pay attention to details, such as how you feel at a particular moment or the specific words the client uses. To conclude, there is no recipe for being a considerate and knowledgeable healthcare practitioner, but engaging in reflective practice is the first step towards improving patients’ health experiences and outcomes.

Special thanks to Claude Spicher, who generously offered me this space to deepen my reflection.

Thank you to Laurence Roy, assistant professor at McGill University, and Hilary Byrne, who
helped me along the way of writing this article.

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