Patient Empowerment: Difference between revisions

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<div class="editorbox"> '''Original Editor '''- [[User:Michael Gallamore|Michael Gallamore]] [[Arkansas Colleges of Health Education School of Physical Therapy Musculoskeletal 1 Project]]. '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>  
<div class="editorbox"> '''Original Editor '''- [[User:Michael Gallamore|Michael Gallamore]] [[Arkansas Colleges of Health Education School of Physical Therapy Musculoskeletal 1 Project]]. '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>  


=== Patient Empowerment   ===
=== Introduction   ===
The intention of practicing physical therapists is to facilitate patients to successfully gain long-term independence and sustainable function. The facilitated long-term independence is empowerment. The recognition of a patient’s powerlessness or sense of powerlessness is where empowerment begins. A lack of self-efficacy poses a challenge to the patient asking for help to manage their recovery. The suffering of those in need of healthcare and rehabilitation exemplifies this relationship between patient/client and physical therapists, which is where the facilitation of empowerment begins. Empowerment as a process requires self-mastery and the ability to transcend through suffering by challenging adversity.<ref>Tedeschi, R. G., & Calhoun, L. G. (2004). " Posttraumatic growth: conceptual foundations and empirical evidence". Psychological Inquiry, 15(1), 1-18. </ref><ref>Walsh, F. (2007). Traumatic loss and major disasters: Strengthening family and community resilience. Family Process, 46(2), 207-227.</ref><ref>VanderWeele, T. J. (2019). Suffering and response: Directions in empirical research. Social Science & Medicine, 224, 58-66.</ref>
The intention of practicing physical therapists is to facilitate patients to successfully gain long-term independence and sustainable function. The facilitated long-term independence is empowerment. The recognition of a patient’s powerlessness or sense of powerlessness is where empowerment begins. A lack of self-efficacy poses a challenge to the patient asking for help to manage their recovery. The suffering of those in need of healthcare and rehabilitation exemplifies this relationship between patient/client and physical therapists, which is where the facilitation of empowerment begins. Empowerment as a process requires self-mastery and the ability to transcend through suffering by challenging adversity.<ref>Tedeschi RG, Calhoun LG. [https://www.tandfonline.com/doi/epdf/10.1207/s15327965pli1501_01?needAccess=true Posttraumatic growth: conceptual foundations and empirical evidence]. Psychological Inquiry, 2014;15(1): 1-18. </ref><ref>Walsh F. [https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1545-5300.2007.00205.x?sid=nlm%3Apubmed Traumatic loss and major disasters: Strengthening family and community resilience]. Family Process, 2017; 46(2): 207-227.</ref><ref>VanderWeele TJ. [https://www.sciencedirect.com/science/article/pii/S0277953619300413 Suffering and response: Directions in empirical research]. Social Science & Medicine, 2019; 224: 58-66.</ref>


The term 'empowerment' as a patient/client trait escapes formal definition and clinical application. The suggestion is that empowerment is a multifactorial trait and layered state that relies on multiple concepts, which will be briefly described.
The term 'empowerment' as a patient/client trait escapes formal definition and clinical application. The suggestion is that empowerment is a multifactorial trait and layered state that relies on multiple concepts, which will be briefly described.
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''' Empowerment Defined'''
''' Empowerment Defined'''


Empowerment is thought to have four (4) dimensions: Meaning, competence, choice, and impact.<ref>Spreitzer, G. M. (1995). Psychological empowerment in the workplace: Dimensions, measurement, and validation. ''Academy of Management Journal'', ''38''(5), 1442-1465.</ref> Choice may have the greatest impact on empowerment. The choice comes from realizing there is a way through an obstacle, which allows the individual to forge through a specific challenge. The competence to follow through is pivotal after recognizing the choice. Often a wavering competence and compromised internal locus of control are key obstacles to an impactful outcome. Self-efficacy and internal locus of control represent personal influence over the outcome, which reflects choice and competence. This indicates that self-efficacy is a prerequisite for empowerment.  
Empowerment is thought to have four (4) dimensions: Meaning, competence, choice, and impact.<ref>Spreitzer GM. Psychological empowerment in the workplace: Dimensions, measurement, and validation. ''Academy of Management Journal'', 1995; ''38''(5): 1442-1465.</ref> Choice may have the greatest impact on empowerment. The '''choice''' comes from realizing there is a way through an obstacle, which allows the individual to forge through a specific challenge. The '''competence''' to follow through is pivotal after recognizing the '''choice'''. Often a wavering competence and compromised internal locus of control are key obstacles to an '''impactful outcome'''. Self-efficacy and internal locus of control represent personal influence over the outcome, which reflects choice and competence. This indicates that self-efficacy is a prerequisite for empowerment.  


Empowerment is the expansion of freedom of choice and action. It means increasing one’s authority and control over the resources and decisions that affect one’s life: when we exercise real choice, we gain increased control over our lives and are able to change ourselves.<ref>Riva, G., Gaggioli, A., Gorini, A., Carelli, L., Repetto, C., Algeri, D., & Vigna, C. (2009). Virtual reality as an empowering environment for personal change: the contribution of the applied technology for neuro-psychology laboratory. Anuario de psicología, 40(2), 171-192.</ref>
Empowerment is the expansion of freedom of choice and action. It means increasing one’s authority and control over the resources and decisions that affect one’s life: when we exercise real choice, we gain increased control over our lives and are able to change ourselves.<ref>Riva G, Gaggioli A, Gorini A, Carelli L, Repetto C, Algeri D, et al. Virtual reality as an empowering environment for personal change: the contribution of the applied technology for neuro-psychology laboratory. Anuario de psicología, 2009; 40(2):171-192.</ref> Empowerment may be defined as a complex experience of personal change.<ref>Aujoulat I, d’Hoore W, Deccache A. Patient empowerment in theory and practice: polysemy or cacophony? Patient Education and Counseling, 2007; 66(1): 13-20.</ref> The process of empowerment is the discovery and development of one’s inherent capacity to be responsible for one’s own life.<ref name=":1">Funnell MM, Anderson RM. Empowerment and self-management of diabetes. Clinical diabetes, 2004; 22(3): 123-128.</ref> Patient empowerment is defined as helping patients discover and develop the inherent capacity to be responsible for one's own life.<ref>Funnell, MM, Anderson, RM, Arnold MS, Barr PA, Donnelly MB, Johnson PD, et al. Empowerment: an idea whose time has come in diabetes education. Diabetes Educ. 1991; 17:37-41.</ref>


Empowerment may be defined as a complex experience of personal change.<ref>Aujoulat, I., d’Hoore, W., & Deccache, A. (2007). Patient empowerment in theory and practice: polysemy or cacophony? Patient Education and Counseling, 66(1), 13-20.</ref>
=== Drivers of Patient Empowerment ===
 
The process of empowerment is the discovery and development of one’s inherent capacity to be responsible for one’s own life.<ref name=":1">Funnell, M. M., & Anderson, R. M. (2004). Empowerment and self-management of diabetes. Clinical diabetes, 22(3), 123-128.</ref>
 
Patient empowerment is defined as helping patients discover and develop the inherent capacity to be responsible for one's own life.<ref>Funnell, MM, Anderson, RM, Arnold MS, Barr PA, Donnelly MB, Johnson PD, Taylor-Moon D, White NH: Empowerment: an idea whose time has come in diabetes education. Diabetes Educ 17:37-41, 1991.</ref>


===== Suffering =====
===== Suffering =====
The patient/client in need, presenting to the clinic, may be experiencing a sense of suffering. Suffering is an existential frustration associated with an unavoidable experience that threatens existence and loss of personal autonomy. A loss of personal autonomy is thought to be synonymous with a sense of powerlessness. Suffering can be defined as the state of severe distress associated with events that threaten the integrity of the person, which induces the perception of impending destruction.<ref>Cassell, E. J. (1998). The nature of suffering and the goals of medicine. ''Loss, Grief & Care'', ''8''(1-2), 129-142. </ref> Additionally, suffering is commonly associated with pain. People in pain frequently report suffering when they feel it as chronic, dire, out of control, overwhelming, or unknown.<ref name=":0">Cassell, E. J. (1998). The nature of suffering and the goals of medicine. Loss, Grief & Care, 8(1-2), 129-142.</ref> However, pain alone does not cause one to suffer. The perception of pain and how it demands more of the person than they can manage better defines the nature of suffering.<ref name=":0" /><ref>Trachsel, L. A., Munakomi, S., & Cascella, M. (2021). Pain theory. In StatPearls [Internet]. StatPearls Publishing.</ref>The implication is that the sense of suffering can become a driving and motivational force that enables empowerment.  
The patient/client in need, presenting to the clinic, may be experiencing a sense of suffering. Suffering is an existential frustration associated with an unavoidable experience that threatens existence and loss of personal autonomy. A loss of personal autonomy is thought to be synonymous with a sense of powerlessness. Suffering can be defined as the state of severe distress associated with events that threaten the integrity of the person, which induces the perception of impending destruction.<ref name=":0">Cassell EJ. The nature of suffering and the goals of medicine. ''Loss, Grief & Care'',1998; ''8''(1-2): 129-142. </ref> Additionally, suffering is commonly associated with pain. People in pain frequently report suffering when they feel it as chronic, dire, out of control, overwhelming, or unknown.<ref name=":0" /> However, pain alone does not cause one to suffer. The perception of pain and how it demands more of the person than they can manage better defines the nature of suffering.<ref name=":0" /><ref>Trachsel, L. A., Munakomi, S., & Cascella, M. (2021). Pain theory. In StatPearls [Internet]. StatPearls Publishing.</ref> The implication is that the sense of suffering can become a driving and motivational force that enables empowerment.  


===== Locus of Control =====
===== Locus of Control =====
Powerlessness is thought to come from a loss of internal and or external locus of control. Internal locus of control is the perception of one’s control over personal competence and motivation.<ref>Ajzen, I. (2002, January 1). Perceived Behavioral Control, Self-Efficacy, Locus of Control, and the Theory of Planned Behavior. JOURNAL OF APPLIED SOCIAL PSYCHOLOGY, 32(4), 665–683.</ref> Outside the parameters of the perception of personal competence and motivation is the external locus of control. A high internal locus of control is the foundation for creating intrinsic motivation that leads to self-efficacy. Intrinsic motivation and self-efficacy are both mediated by competence, autonomy, and locus of control.<ref>Deci, E. L., and Ryan, R. M. (2000). The ‘‘what’’ and ‘‘why’’ of goal pursuits: human needs and the self-determination of behaviour. Psychol. Inquiry 11, 227–268. doi: 10.1207/S15327965PLI1104_01</ref>  
Powerlessness is thought to come from a loss of internal and or external locus of control. Internal locus of control is the perception of one’s control over personal competence and motivation.<ref>Ajzen I. Perceived Behavioral Control, Self-Efficacy, Locus of Control, and the Theory of Planned Behavior. Journal of applied psychology. 2002; <big>3</big>2(4): 665–683.</ref> Outside the parameters of the perception of personal competence and motivation is the external locus of control. A high internal locus of control is the foundation for creating intrinsic motivation that leads to self-efficacy. Intrinsic motivation and self-efficacy are both mediated by competence, autonomy, and locus of control.<ref>Deci, EL, Ryan RM. The ‘‘what’’ and ‘‘why’’ of goal pursuits: human needs and the self-determination of behaviour. Psychol. Inquiry. 2000;11: 227–268. doi: 10.1207/S15327965PLI1104_01</ref>  


===== Intrinsic Motivation =====
===== Intrinsic Motivation =====
Intrinsic motivation is shaped by the perception of self-competency. Self-competency begins with the recognition that a new skill is needed to achieve a positive outcome.<ref>Deci, E. L., & Ryan, R. M. (1980). Self-determination Theory: When Mind Mediates Behavior. The Journal of Mind and Behavior, 1(1), 33–43.</ref> Successful attempts and acquisition of new skills and completion of tasks provide reinforcement of competency. The reinforcement and continued momentum fuel motivation, which remains a conscious decision to continue creating a cycle that proves to be autonomous.<ref>Di Domenico, S. I., & Ryan, R. M. (2017). The Emerging Neuroscience of Intrinsic Motivation: A New Frontier in Self-Determination Research. Frontiers in Human Neuroscience. <nowiki>https://doi.org/10.3389/fnhum.2017.00145</nowiki></ref>  
Intrinsic motivation is shaped by the perception of self-competency. Self-competency begins with the recognition that a new skill is needed to achieve a positive outcome.<ref>Deci EL, Ryan RM. Self-determination Theory: When Mind Mediates Behavior. The Journal of Mind and Behavior. 1980; 1(1): 33–43.</ref> Successful attempts and acquisition of new skills and completion of tasks provide reinforcement of competency. The reinforcement and continued momentum fuel motivation, which remains a conscious decision to continue creating a cycle that proves to be autonomous.<ref>Di Domenico SI, Ryan RM. The Emerging Neuroscience of Intrinsic Motivation: A New Frontier in Self-Determination Research. Frontiers in Human Neuroscience. 2017. <nowiki>https://doi.org/10.3389/fnhum.2017.00145</nowiki></ref>  


===== Self-efficacy =====
===== Self-efficacy =====
Self-efficacy is the actualization of one’s own competency with their skillset to achieve established outcomes with reliance on interaction with their environment.<ref>Howland, T. and McGuire, C. (2020). The development of intelligent behavior III: Robert W. White. Psychology in the Schools, 5, 230–239.</ref> An understanding of personal competence of control and locus of control is also self-efficacy. Self-efficacy takes active competency over that which is perceived as controllable and resourceful to the person.  A locus of control establishes the outcome expectancy while self-efficacy mobilized specific skills to accomplish the established outcome.
Self-efficacy is the actualization of one’s own competency with their skillset to achieve established outcomes with reliance on interaction with their environment.<ref>Howland T, McGuire C. The development of intelligent behavior III: Robert W. White. Psychology in the Schools. 2020; 5: 230–239.</ref> An understanding of personal competence of control and locus of control is also self-efficacy. Self-efficacy takes active competency over that which is perceived as controllable and resourceful to the person.  A locus of control establishes the outcome expectancy while self-efficacy mobilized specific skills to accomplish the established outcome.


===== Therapeutic Alliance =====
===== Therapeutic Alliance =====
The therapeutic alliance (TA) refers to a sense of collaboration, warmth, and support between a client and their practitioner. TA is associated with a combination of emotional flexibility, interpersonal communication, and trust.<ref name=":2">Crom, A., Paap, D., Wijma, A., Dijkstra, P. U., & Pool, G. (2020). Between the Lines: A Qualitative Phenomenological Analysis of the Therapeutic Alliance in Pediatric Physical Therapy. Physical & Occupational Therapy in Pediatrics, 40(1), 1–14. <nowiki>https://doi.org/10.1080/01942638.2019.1610138</nowiki></ref> Building trust through communication creates patient/practitioner collaboration and builds a relationship that inspires personal motivation toward the goals of therapy. The therapeutic alliance enables a motivating vicarious experience through the coaching and standards set by the physical therapist. Goal flexibility is centered around the needs of the patient and allows for appropriate modifications that support those needs. TA enables the physical therapist to transfer knowledge and power to the patient/client and enables the patient to receive the shared knowledge and power.<ref>Unsgaard-Tondel M, Soderstrom S. Therapeutic Alliance: Patients’ Expectations Before and Experiences After Physical Therapy for Low Back Pain--A Qualitative Study With 6-Month Follow-Up. PTJ: Physical Therapy & Rehabilitation Journal [Internet]. 2021 Nov 1 [cited 2023 Apr 1];101(11):1f. Available from: <nowiki>https://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,shib&db=edsgao&AN=edsgcl.697168676&site=eds-live</nowiki></ref> Patient education emphasized with empathy that is directed toward personal choices and ideas help patient empowerment.  
The therapeutic alliance (TA) refers to a sense of collaboration, warmth, and support between a client and their practitioner. TA is associated with a combination of emotional flexibility, interpersonal communication, and trust.<ref name=":2">Crom A, Paap D, Wijma A, Dijkstra PU. Pool G. Between the Lines: A Qualitative Phenomenological Analysis of the Therapeutic Alliance in Pediatric Physical Therapy. Physical & Occupational Therapy in Pediatrics. 2020; 40(1): 1–14. <nowiki>https://doi.org/10.1080/01942638.2019.1610138</nowiki></ref> Building trust through communication creates patient/practitioner collaboration and builds a relationship that inspires personal motivation toward the goals of therapy. The therapeutic alliance enables a motivating vicarious experience through the coaching and standards set by the physical therapist. Goal flexibility is centered around the needs of the patient and allows for appropriate modifications that support those needs. TA enables the physical therapist to transfer knowledge and power to the patient/client and enables the patient to receive the shared knowledge and power.<ref>Unsgaard-Tondel M, Soderstrom S. [https://pubmed.ncbi.nlm.nih.gov/34339506/ Therapeutic Alliance: Patients’ Expectations Before and Experiences After Physical Therapy for Low Back Pain--A Qualitative Study With 6-Month Follow-Up.] PTJ: Physical Therapy & Rehabilitation Journal. 2021;101(11):pzab187. doi: 10.1093/ptj/pzab187</ref> Patient education emphasized with empathy that is directed toward personal choices and ideas help patient empowerment.  


===== Conclusion =====
===== Conclusion =====

Revision as of 17:15, 13 August 2023

Original Editor - Michael Gallamore Arkansas Colleges of Health Education School of Physical Therapy Musculoskeletal 1 Project. Top Contributors - Michael Gallamore, Tony Varela, Uchechukwu Chukwuemeka, Ewa Jaraczewska, Kenzie Friday and Kim Jackson

Introduction  [edit | edit source]

The intention of practicing physical therapists is to facilitate patients to successfully gain long-term independence and sustainable function. The facilitated long-term independence is empowerment. The recognition of a patient’s powerlessness or sense of powerlessness is where empowerment begins. A lack of self-efficacy poses a challenge to the patient asking for help to manage their recovery. The suffering of those in need of healthcare and rehabilitation exemplifies this relationship between patient/client and physical therapists, which is where the facilitation of empowerment begins. Empowerment as a process requires self-mastery and the ability to transcend through suffering by challenging adversity.[1][2][3]

The term 'empowerment' as a patient/client trait escapes formal definition and clinical application. The suggestion is that empowerment is a multifactorial trait and layered state that relies on multiple concepts, which will be briefly described.

Empowerment Defined

Empowerment is thought to have four (4) dimensions: Meaning, competence, choice, and impact.[4] Choice may have the greatest impact on empowerment. The choice comes from realizing there is a way through an obstacle, which allows the individual to forge through a specific challenge. The competence to follow through is pivotal after recognizing the choice. Often a wavering competence and compromised internal locus of control are key obstacles to an impactful outcome. Self-efficacy and internal locus of control represent personal influence over the outcome, which reflects choice and competence. This indicates that self-efficacy is a prerequisite for empowerment.

Empowerment is the expansion of freedom of choice and action. It means increasing one’s authority and control over the resources and decisions that affect one’s life: when we exercise real choice, we gain increased control over our lives and are able to change ourselves.[5] Empowerment may be defined as a complex experience of personal change.[6] The process of empowerment is the discovery and development of one’s inherent capacity to be responsible for one’s own life.[7] Patient empowerment is defined as helping patients discover and develop the inherent capacity to be responsible for one's own life.[8]

Drivers of Patient Empowerment[edit | edit source]

Suffering[edit | edit source]

The patient/client in need, presenting to the clinic, may be experiencing a sense of suffering. Suffering is an existential frustration associated with an unavoidable experience that threatens existence and loss of personal autonomy. A loss of personal autonomy is thought to be synonymous with a sense of powerlessness. Suffering can be defined as the state of severe distress associated with events that threaten the integrity of the person, which induces the perception of impending destruction.[9] Additionally, suffering is commonly associated with pain. People in pain frequently report suffering when they feel it as chronic, dire, out of control, overwhelming, or unknown.[9] However, pain alone does not cause one to suffer. The perception of pain and how it demands more of the person than they can manage better defines the nature of suffering.[9][10] The implication is that the sense of suffering can become a driving and motivational force that enables empowerment.

Locus of Control[edit | edit source]

Powerlessness is thought to come from a loss of internal and or external locus of control. Internal locus of control is the perception of one’s control over personal competence and motivation.[11] Outside the parameters of the perception of personal competence and motivation is the external locus of control. A high internal locus of control is the foundation for creating intrinsic motivation that leads to self-efficacy. Intrinsic motivation and self-efficacy are both mediated by competence, autonomy, and locus of control.[12]

Intrinsic Motivation[edit | edit source]

Intrinsic motivation is shaped by the perception of self-competency. Self-competency begins with the recognition that a new skill is needed to achieve a positive outcome.[13] Successful attempts and acquisition of new skills and completion of tasks provide reinforcement of competency. The reinforcement and continued momentum fuel motivation, which remains a conscious decision to continue creating a cycle that proves to be autonomous.[14]

Self-efficacy[edit | edit source]

Self-efficacy is the actualization of one’s own competency with their skillset to achieve established outcomes with reliance on interaction with their environment.[15] An understanding of personal competence of control and locus of control is also self-efficacy. Self-efficacy takes active competency over that which is perceived as controllable and resourceful to the person.  A locus of control establishes the outcome expectancy while self-efficacy mobilized specific skills to accomplish the established outcome.

Therapeutic Alliance[edit | edit source]

The therapeutic alliance (TA) refers to a sense of collaboration, warmth, and support between a client and their practitioner. TA is associated with a combination of emotional flexibility, interpersonal communication, and trust.[16] Building trust through communication creates patient/practitioner collaboration and builds a relationship that inspires personal motivation toward the goals of therapy. The therapeutic alliance enables a motivating vicarious experience through the coaching and standards set by the physical therapist. Goal flexibility is centered around the needs of the patient and allows for appropriate modifications that support those needs. TA enables the physical therapist to transfer knowledge and power to the patient/client and enables the patient to receive the shared knowledge and power.[17] Patient education emphasized with empathy that is directed toward personal choices and ideas help patient empowerment.  

Conclusion[edit | edit source]

A goal directed physical therapy is insufficient for sustainable and comprehensive recovery.[16] Patient empowerment begins with patient education and ends with the active participation of the patient in their physical therapy. Empowerment takes place with the transcendence and sustainable management of the patient’s impairment or dysfunction by the patient being giving autonomy and authority over their own rehabilitation and life.

Empowerment is complex and multidimensional. The Takeaway message is

  1. Self-efficacy is a prerequisite for empowerment.
  2. Engagement toward empowerment must explore areas outside of one's comfort zone.
  3. Choice and competence must be specifically directed to increase an internal locus of control and motivation
  4. Vicarious experiences offered by physical therapists and other patients reinforce self-efficacy and empowerment.
  5. Social support and reinforcement complete the transcendence of empowerment
Patient interview[edit | edit source]

A patient/client interview was conducted to exemplify the complex nature of empowerment. The patient/client, Ellen, demonstrates empowerment through her resilience, self-efficacy, and a positive mindset. Ellen exemplifies the importance of self-efficacy, which was established prior to her diagnosis of Parkinson's. Her commentary that she controls her diagnosis rather than the diagnosis controlling her reveals that sense of empowerment. Ellen was able to push outside of her comfort zone and engage in a HIIT/CrossFit research program for patients/ clients with Parkinson's and Spinal Cord Injuries, which is conducted at the Arkansas College of Health Education Physical Therapy Program. The variability and intensity of the program along with the group dynamic reinforced Ellen's empowerment. This interviewee was handpicked by the researchers as someone who exemplifies empowerment.


References

  1. ↑ Tedeschi RG, Calhoun LG. Posttraumatic growth: conceptual foundations and empirical evidence. Psychological Inquiry, 2014;15(1): 1-18.
  2. ↑ Walsh F. Traumatic loss and major disasters: Strengthening family and community resilience. Family Process, 2017; 46(2): 207-227.
  3. ↑ VanderWeele TJ. Suffering and response: Directions in empirical research. Social Science & Medicine, 2019; 224: 58-66.
  4. ↑ Spreitzer GM. Psychological empowerment in the workplace: Dimensions, measurement, and validation. Academy of Management Journal, 1995; 38(5): 1442-1465.
  5. ↑ Riva G, Gaggioli A, Gorini A, Carelli L, Repetto C, Algeri D, et al. Virtual reality as an empowering environment for personal change: the contribution of the applied technology for neuro-psychology laboratory. Anuario de psicología, 2009; 40(2):171-192.
  6. ↑ Aujoulat I, d’Hoore W, Deccache A. Patient empowerment in theory and practice: polysemy or cacophony? Patient Education and Counseling, 2007; 66(1): 13-20.
  7. ↑ Funnell MM, Anderson RM. Empowerment and self-management of diabetes. Clinical diabetes, 2004; 22(3): 123-128.
  8. ↑ Funnell, MM, Anderson, RM, Arnold MS, Barr PA, Donnelly MB, Johnson PD, et al. Empowerment: an idea whose time has come in diabetes education. Diabetes Educ. 1991; 17:37-41.
  9. ↑ 9.0 9.1 9.2 Cassell EJ. The nature of suffering and the goals of medicine. Loss, Grief & Care,1998; 8(1-2): 129-142.
  10. ↑ Trachsel, L. A., Munakomi, S., & Cascella, M. (2021). Pain theory. In StatPearls [Internet]. StatPearls Publishing.
  11. ↑ Ajzen I. Perceived Behavioral Control, Self-Efficacy, Locus of Control, and the Theory of Planned Behavior. Journal of applied psychology. 2002; 32(4): 665–683.
  12. ↑ Deci, EL, Ryan RM. The ‘‘what’’ and ‘‘why’’ of goal pursuits: human needs and the self-determination of behaviour. Psychol. Inquiry. 2000;11: 227–268. doi: 10.1207/S15327965PLI1104_01
  13. ↑ Deci EL, Ryan RM. Self-determination Theory: When Mind Mediates Behavior. The Journal of Mind and Behavior. 1980; 1(1): 33–43.
  14. ↑ Di Domenico SI, Ryan RM. The Emerging Neuroscience of Intrinsic Motivation: A New Frontier in Self-Determination Research. Frontiers in Human Neuroscience. 2017. https://doi.org/10.3389/fnhum.2017.00145
  15. ↑ Howland T, McGuire C. The development of intelligent behavior III: Robert W. White. Psychology in the Schools. 2020; 5: 230–239.
  16. ↑ 16.0 16.1 Crom A, Paap D, Wijma A, Dijkstra PU. Pool G. Between the Lines: A Qualitative Phenomenological Analysis of the Therapeutic Alliance in Pediatric Physical Therapy. Physical & Occupational Therapy in Pediatrics. 2020; 40(1): 1–14. https://doi.org/10.1080/01942638.2019.1610138
  17. ↑ Unsgaard-Tondel M, Soderstrom S. Therapeutic Alliance: Patients’ Expectations Before and Experiences After Physical Therapy for Low Back Pain--A Qualitative Study With 6-Month Follow-Up. PTJ: Physical Therapy & Rehabilitation Journal. 2021;101(11):pzab187. doi: 10.1093/ptj/pzab187
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