Intellectual Humility: How Recognizing the Fallibility of Our Beliefs and Owning Our Limits May Create a Better Relationship Between the Physical Therapy Profession and Disability

Abstract

 

Despite the many advancements over the history of the profession, physical therapy remains in a somewhat paradoxical relationship with disability. The physical therapist profession values disability as diversity but continues to focus on the normalization of body functions as the primary means to promote functionality in people with disability. This focus, consistent with a medicalized view of disability, may prevent physical therapists from empowering individuals with disability to explore alternative, yet effective, perceptual-motor strategies to achieve their functional goals. Additionally, recent research documents implicit, negative biases of physical therapists and physical therapist assistants toward people with disability, again consistent with the medicalized view that disability is the product of an imperfectly functioning body. Dominant underlying beliefs in any profession are often difficult to counter because they are so pervasive, and those beliefs can be reinforced and made stronger when challenged. The purpose of this Perspective article is to introduce physical therapists to a rising construct in psychology—intellectual humility—that may help to facilitate the profession’s relationship with disability. Intellectual humility is predicated on recognizing the fallibility of one’s beliefs and related practices. Intellectual humility is a promising construct for physical therapy to address the disability paradox and confront implicit attitudes that have served as the basis for many dominant ideas about disability. This Perspective synthesizes views and evidence from the behavioral and social sciences, philosophy, and critical disability studies to contribute to the ongoing evolution of the profession with respect to disability.

Impact

The development of enhanced intellectual humility in physical therapy may help to challenge long-held beliefs among physical therapists about disability—many of which are unnoticed, unquestioned, and difficult to counter.

Introduction

The advancement of any profession requires a consideration of professional ethos—the characteristics and beliefs governing a profession.¹ The physical therapist profession is guided by a foundational set of “core values” that support the provision of high-quality care.² Evidence suggests that the core values of compassion, accountability, and integrity are well integrated into physical therapist practice.³ Many physical therapists are also guided by clinical research evidence pertaining to intervention effectiveness,^4–7 and are increasingly being called upon to engage with theory to integrate and make sense of the body of available evidence, critical for its application in clinical practice.^8,9 Evidence from clinical research must always be considered through the prism of theory and its empirical basis.⁸ A theoretical understanding of a phenomenon supported by basic research provides the necessary context for interpretation of findings and appropriate selection of the best evidence to achieve the desired physical therapy outcomes.

Despite contemporary physical therapists synthesizing information from multiple quality sources to form their practices and beliefs, certain paradoxes in the profession persist,^10,11 particularly with respect to ideas and beliefs about disability.^9,10,12 For instance, it has been noted that the physical therapist profession values disability as diversity but continues to focus on the normalization of body functions as the primary means to promote functionality in individuals with disability.^11,12 This focus—consistent with a medicalized view of disability, which emphasizes the etiological factors that lead to context-independent pathological processes—often prevents physical therapists from empowering individuals with disability to explore alternative, yet effective, perceptual-motor strategies to achieve their functional goals.^13,14 Ideas about normality and independence remain central to physical therapy assessments and interventions despite people with disability expressing that these are not necessarily meaningful therapeutic endpoints.^15,16 Furthermore, these divides (normal/abnormal, independence/dependence) largely reflect Western ideals^14,17 and subscribe to medical models of disability, which have been criticized by many disability scholars, including scholars with disability and, increasingly, from those within the physical therapist profession.^12,18 Biopsychosocial models of disability, like the International Classification of Functioning, Disability and Health (ICF),¹⁹ have sought to address medical model shortcomings. However, it has been argued that biopsychosocial models continue to be implemented like medical models, decontextualized from the sociocultural, political, and physical environments that give rise to the disability experience.^9,14,20,21 Although respectable progress has been made in person-centric care in the past decade, there is evidence to suggest that physical therapists and recipients of care disagree on established therapy goals,²² and health care professionals—including physical therapists—often demonstrate implicit biases toward people with disability.^23,24

Critical disability and critical physical therapy scholars often note that the dominant ideas underlying physical therapist practices can be difficult to counter, or even notice, because they are so pervasive,^{9,11,14,25,26} and, subsequently, there can be an implicit resistance to challenging such long-held assumptions. There is a need for physical therapists and physical therapist assistants, as with all health professionals, to reflect on dominant ideas in the profession, including the sources, history, and evolution of these ideas and how they coalesce with multidisciplinary perspectives and disability justice. This reflection is critical to advance contemporary health care and policy, aligning them with the actual needs of those they are designed to serve. Specifically, there is a need for physical therapists and physical therapist assistants to critically examine the profession’s “complicated relationship” with disability¹³ and consider a future where we recognize and own the limits to our beliefs about disability. The purpose of this Perspective article is to introduce physical therapists and physical therapist assistants to the psychological construct of intellectual humility²⁷ and describe how the profession’s relationship with disability may benefit from intellectual humility. In what follows, we provide a brief overview of the principal issues between physical therapy and disability. We then describe intellectual humility and how the construct can be applied in physical therapy.

About Language

Before we continue, we believe it is important to address disability language, both in general and as relates specifically to this Perspective. Individuals within the disability community have varied preferences about person-first and identity-first language, including differences in the language they use to describe themselves and the language they prefer to be used to describe them.²⁸ We wish to emphasize that each person’s disability language preferences should always be respected and supported. In this paper, as we are writing about disability more broadly, we have opted to use person-first language. However, it is important for readers to be aware that disability language is continuously evolving and specific to the individual. Consistent with the theme of this paper, disability language is an additional area where physical therapists may benefit from intellectual humility by recognizing that the popularity of person-first language in physical therapy may have unintended consequences (eg, separating the person from the disability with which they identify). An increasing number of people prefer identity-first language because it allows them to take ownership of their disability and express disability pride.²⁸

In this paper, we also use the term “not disabled” (as opposed to “able-bodied”) to refer to a person or a group of people who are the opposite of disabled. The adopted terminology is consistent with calls from people with disability and disability scholars to remove reference to “ability” in the terminology and simply describe who is or is not disabled.²⁹ Disability scholars and people with disability maintain that it is important to use the term “disability” and not erase the term with euphemisms.²⁸

Physical Therapy and Disability: Key Issues

Disability as a term has traditionally been conceptualized as the “inverse of ability” and as the “negative side” of an arbitrary dichotomy.^18,30 Most physical therapists and physical therapy assistants would likely eschew the perspective that disability is simply the inverse of ability and certainly recognize the importance of valuing disability as diversity.^11,12 However, the philosophical underpinnings of many of our interventions simply do not reflect this value. For instance, many physical therapy interventions are driven by conceptualizations of normality.^14,31,32 Physical therapists often look to minimize deviations in body functions in people with disability from the norms defined by people who are not disabled.³³ The unstated (and perhaps even unnoticed) assumption of this practice is that people who are not disabled demonstrate an idealized “correct” or “normal” body that expresses “correct” and “normal” movements, assumed to be the basis for successful activity and social participation.^14,34–37 “Normal” movement largely became associated with “good” movement in the last century due to shifting interpretations of statistical averages and the rise of the eugenics movement in the early twentieth century.³⁸ Thus, any variation from a “correct” standard represents an error requiring “normalization” through intervention.^14,39 This is in spite of evidence suggesting that “atypical” motor patterns found in people with disability may actually reflect adaptability, and interventions designed to “correct” these patterns interfere with adaptability for functional task performance.^9,40–43 Furthermore, people with disability have reported that an exclusive focus on performing a motor task “correctly” during a social interaction with a physical therapist can create experiences that are dissatisfying and awkward.⁴⁴ An objective focus on bodily functionality may even reinforce negative self-perceptions that can accompany disability, including objectification of the body.⁴⁵

Given that the conventionally understood role of rehabilitation professionals is to eliminate impairment or a disabled state,²³ and that “normality” has become a default way to shape practice,¹⁴ it is perhaps unsurprising that recent work focusing on the 2-dimensional model of prejudice (ie, implicit and explicit bias)²³ found that the majority of physical therapist assistants and occupational therapy assistants are aversive ableists. Aversive ableism⁴⁶ refers to people who are progressive and well intentioned, but they engage in implicitly biased thoughts or actions. They demonstrate low explicit prejudice but high implicit prejudice toward people with disability. Aversive ableists genuinely do not believe that they are prejudiced.²³ The tendency of physical therapist assistants and occupational therapy assistants to be aversive ableists is indisputably problematic, and it is extremely difficult to counter people’s prejudice when they do not believe they are prejudiced themselves.^23,24,46

In addition to aversive ableism, many decisions about clinical interventions, research, and disability have historically been made using an outsider-dominant approach without consulting people with disability.^18,43,47,48 Consider, for instance, the limited involvement of people with disability in the rehabilitation research that ultimately guides the interventions used in clinical practice.⁴⁹ Data collection, analysis, and translation are often undertaken exclusively by researchers who are not disabled.^49,50 As such, disability research often lacks relevance to people with disability, and it has been found that much published research in developmental disability, for example, does not lead to improvements in the health and well-being of children with disability.⁵¹

The outsider-dominant approach can also be observed by the way in which people with disability are often presented as background figures in nondisabled narratives. Pointedly, the visibility of people with disability is profoundly lacking in professional roles in physical therapy.^10,13,52 Hinman and colleagues⁵² found that people with physical disability constitute a lower percentage of students in physical therapist educational programs (~5%) than in other graduate programs (7%) in the United States. Institutional policies, discriminatory practices, lack of knowledge about accommodations, and societal attitudes have been identified as barriers to physical therapist education for people with disability.¹³ It is interesting to consider, given the previously discussed findings about aversive ableism, whether this is an additional factor limiting the recruitment, enrollment, and retention of students with disability in physical therapist education programs. Hinman and colleagues⁵² similarly note the importance of considering instructor perceptions of disability that might influence the limited opportunities for people with disability in the profession. Research focused on health care professionals with disability has also raised the important consideration that assumptions about disability from health care professionals who are not disabled themselves largely limit the participation of people with disability in health care careers more broadly.⁵³ It is also important to acknowledge that there are likely many people with disability within the physical therapist profession who have invisible disabilities or who have felt uncomfortable with disability disclosure due to the abovementioned factors related to ableism in the field.

In summary, we agree with Sharp and Herrman¹³ that the relationship between physical therapy and disability has been complicated. As identified in this section, many of the factors underlying this complicated relationship, however, are likely unnoticed and unknown because they are so pervasive. It is important to emphasize that physical therapists are, overall, not explicitly biased toward people with disability,^23,24 and most therapists genuinely want to do good for people with disability. The problem is that many of our complicating beliefs about disability are unintentional and reflective of aversive ableism. These implicit beliefs are extremely resilient and can actually be strengthened when explicitly confronted.⁵⁴ Furthermore, implicit beliefs may even preclude the wider integration (in both education and practice) of alternative disablement models, such as the diversity model⁵⁵ and relational models,^43,56–58 which consider disability as a celebrated part of a person’s identity and as both situated (context-dependent) and embodied (shaped by the body and its capabilities), respectively. We thus turn to intellectual humility as a character trait to develop and potentially use to counter the implicit beliefs contributing to the field’s “uncertain path forward” with disability.¹³ The development of intellectual humility may also serve as an important precursor for a deeper understanding of alternative disability models.

Intellectual Humility

Intellectual humility is rapidly gaining traction across philosophy and the social and behavioral sciences,^59–62 often in relation to civil discourse.⁶³ Definitions of intellectual humility subtly differ but generally converge on the recognition that one’s beliefs may be incorrect.^{27,60,61,64–66} A consensus definition developed by psychologists and philosophers posits that intellectual humility involves “recognizing that a particular personal belief may be fallible, accompanied by an appropriate attentiveness to limitations in the evidentiary basis of that belief and to one’s own limitations in obtaining and evaluating relevant information.”^27,(p4) In short, intellectual humility invites us to welcome the idea that our beliefs might be wrong, and that the evidence we use to support our beliefs might itself be limited. Intellectual humility should be distinguished from a lack of confidence or uncertainty.⁶¹ Individuals in possession of high intellectual humility do not hold low self-confidence, per se, but rather, they hold their beliefs tentatively because they are cognitively and reflectively aware that their beliefs—and the evidence used to support a belief—might be flawed, or that they have limited information or expertise to fully evaluate the evidence forming a belief.²⁷

Intellectual humility has been associated with the characteristics of reflective thinking, curiosity, openness and open-minded thinking, and intrinsic motivation to learn.⁶⁷ The construct is also related to less social vigilantism⁶⁷—the tendency of individuals to resist the perspectives of others because they believe that their opinions are superior.⁶⁸ Intellectual humility goes far beyond compassion and empathy—which are areas where physical therapists already excel,^3,69 and it challenges physical therapists to acknowledge that people with disabilities are the experts of their own experiences. Physical therapists (nondisabled) are outsiders, and thus, there are limits to what physical therapists can possibly know about disability. This is in contrast to the idea that physical therapists “know disability.”¹² As part of our professional evolution in thinking about disability, we must come to terms with the reality that we are often incorrect about disability, and, more importantly, that how we think about disability might not be reflected in how we actually practice. Identifying our implicit biases in practice will require careful analysis of our practices and what “hidden” beliefs these practices actually reflect.

The Potential Promise of Intellectual Humility in Physical Therapy

When we approach disability through the lens of intellectual humility and recognize that our beliefs lack a full evidentiary basis (eg, research, lived experience) for a complete understanding of disability, we may become more inclined to seek alternative and additional sources of information. Importantly, possession of intellectual humility may facilitate the translation of critical appeals to involve people with disability in research studies as co-creators and collaborators^43,47 and may challenge ableist ideas that have historically limited the representation of people with disability in physical therapist education programs and professional roles.^10,13,52,70

Increased intellectual humility may allow physical therapists to see and value people with disability as the resources that they are.¹⁸ For example, increasing the number of physical therapists with disability (as well as more explicitly recognizing and celebrating the contributions of physical therapists with disability already in the profession) may improve clinician–client encounters, and there is evidence to suggest that people with disability (as recipients of care) anticipate a positive impact from receiving services from a clinician with disability.⁷⁰ Thus, increasing the number of physical therapists with disability may have a positive impact on clinical outcomes because physical therapists with disability are in possession of first-hand experiences of health care and are able to relate to recipients of care who have disability in a way that nondisabled physical therapists cannot.⁷⁰

Intellectual humility might allow us to recognize that we are not as “disability literate” as once thought.¹³ Approaching a clinical encounter with the openness that is characteristic of intellectual humility may help to mitigate power dynamics inherent to the clinician-recipient of care interaction. Intellectual humility may facilitate therapists moving past an exclusive focus on function (functionalistic attitude) during a clinical encounter to achieve a more personalistic attitude—an attitude in which one is open to another’s experiences.⁴⁴ Positively, there is evidence that physical therapists (compared to strangers) tend to already demonstrate more personalistic attitudes during interactions with people with disability; however, the “functionality trap” remains prevalent in rehabilitation, and it may be very easy for physical therapists to slip into this “normalizing” mindset.⁴⁴ Achieving a balance between the functionalistic and personalistic attitudes has been hypothesized as a necessity for more person-centered care in rehabilitation.⁴⁴ In short, possession of intellectual humility may allow a physical therapist to confront the implicit attitudes that have served as the basis for many dominant ideas about disability that have long evaded confrontation. Furthermore, we may become increasingly motivated to address the disability paradox and consider the broader disability context, including the lived experiences and priorities of people with disability while concurrently addressing the barriers and attitudes that often devalue disability.

Future Research and Conclusion

Intellectual humility is a relatively new term and construct, but it is an extraordinarily promising idea for advancing education and practice within the field. In this paper, we sought to introduce physical therapists and physical therapist assistants to the concept and provide potential implications. For instance, by invoking intellectual humility, we might find ourselves more open to exploring alternative perspectives of disability such as diversity and relational models. Conversely, if we do not consider our limits and biases, we may perpetuate potentially harmful disability narratives and diminish possible physical therapy impacts. To date, there has been very little empirical research conducted to evaluate how to change one’s intellectual humility,²⁷ and there is no research in this specific area in physical therapy. It is hypothesized that in order for someone’s intellectual humility to change, they must first perceive that there is a benefit to changing their beliefs and then accept that their beliefs are fallible.²⁷ This is a first step that every physical therapist and physical therapist assistant desiring to improve their intellectual humility can take.

Future research is certainly warranted to find specific approaches to help foster intellectual humility in physical therapists and physical therapist assistants and help counter aversive ableism. In our own line of work, we plan to combine our interdisciplinary expertise in physical therapy, joint action, and experimental psychology to determine (1) if there are specific environmental contexts (naturalistic vs clinical) in which physical therapists and physical therapist assistants demonstrate more or less implicit biases during interactions with people with disability, and (2) if they could thus benefit from higher intellectual humility to improve interactions across environmental contexts. We also intend to examine interpersonal interaction strategies that may help foster intellectual humility among physical therapists and physical therapist assistants. There is some evidence in social psychology⁷¹ to suggest that embodied engagement (eg, physically performing a task together) may be more effective in reducing disability prejudice than more passive engagement (eg, watching a theatrical performance) with a person who is disabled. These results offer exciting possibilities for ways to foster intellectual humility among physical therapists and physical therapist assistants, and we look forward to others in the profession joining us in the study of intellectual humility.

Author Contributions

Concept/idea/research design: S.M. Schwab, P.L. Silva

Writing: S.M. Schwab, P.L. Silva

Funding

This project was funded in part by a Foundation for Physical Therapy Research Promotion of Doctoral Studies (PODS) Level I Scholarship supported by the American Physical Therapy Association Scholarship Fund and a PODS Level II Scholarship supported by the Rhomberger Fund. The funder played no role in the writing of this work.

Data Availability Statement

Data availability is not applicable to this Perspective as no new data were created or analyzed.

Disclosures

The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.

References