Understanding the dynamics of the practitioner-patient relationship in the manual therapies can improve treatment outcomes.

In a series of video interviews, Danny Sher of the Programme for Advanced Learning of Manual Medicine & Osteopathy (PALMM) and Dr Mannie Sher of the Tavistock Institute of Human Relations discuss the nature of practitioner-patient relationships in the manual therapies and how to strengthen them through a deeper understanding of the psychodynamics and emotions inherent in those relationships. They suggest that in many instances, a traditional bio-mechanical approach may ignore deeper underlying psychological and emotional reasons for the patient’s presenting condition, and consequently, lead to a less than adequate outcome for the patient. They offer a number of easily adopted suggestions that could enhance the practice of practitioners of manual therapies who rely on very specialized physical methods of diagnosis and treatment. An understanding of dynamics, they suggest, could lead to improved prognosis and increased professional satisfaction for practitioners. They describe five key dynamics that characterize practitioner-patient relationships in the manual therapies: (i) pain as a form of communication; (ii) the ‘heart-sink’ patient; (iii) dependency; (iv) the erotic transference; (v) endings and loss.

The videos are the result of two series of seminars for osteopaths entitled: What is the patient really telling me? The programmes were provided under the auspices of the Tavistock Institute of Human Relations’ Professional Development initiatives and aimed at (i) addressing gaps in understanding the relationship between patients’ symptomatology and their mental states, and (ii) improving practitioners’ application of psychodynamics in their work. The videos challenge the training institutions in the manual therapies to seriously consider the relevance of ‘psychodynamics’ in their education and training programmes.

Practitioners of manual therapies are often puzzled by the nature of their patients’ presenting problems that may mask deeper underlying emotional and relationship conflicts. Understanding the mind-sets of patients during consultations, processing the practitioners’ own feelings, identifying patterns of patients’ behaviour, feelings, thoughts and physiological responses will increase diagnostic and treatment capability. The psychology of the patient and practitioner, and importantly, the interaction between the two, will affect not only how the patient behaves (e.g. adherence to treatment and following advice), but how they feel emotionally and physically in response to their clinical treatment.

The video interviews discuss how patients may obtain psychological benefits such as reduced fear and a positive mind-set from an improved understanding of their emotional states. The videos challenge the proposition that any benefits of psychodynamic understanding are simply due to a placebo effect of clinical contact, treatment preference or the caring attitude of the practitioner. Rather, Danny Sher and Mannie Sher assert that the integrated (or holistic) approach of combining appropriate manual treatments with empathic understanding and therapeutic relationship between practitioner and patient, is the major contributor to clinical improvement and psychological wholeness. The ‘therapist effect’ should not be discounted; it lies at the core of the recovery process.  Orthodox clinical methods rest upon ‘either-or’ epistemologies; manual holistic methods rest upon ‘both-and’ epistemologies – integrating the body and the mind. The direction of ‘holism’ is away from studying smaller and smaller fragments to the integration and organisation of small parts into intelligibly patterned wholes.

Patients may appear at consultation fearful and worried about their conditions. Patient and practitioner sometimes ‘dance’ around each other, juggling their individual perspectives on the ‘condition’, its causes and treatment. Practitioners may concentrate on technical methods and techniques and ignore the psychodynamics and emotions at play in various personality structures. Practitioners understand pathology, physiology and diagnosis. But the reality is that in many practices, presenting cases have strong psychological elements which require more than the application of techniques. Practitioners often have to reassure and guide patients away from obsessive preoccupations with their symptoms. They can do this by providing opportunities for patients to verbalise worries, face fears and gain understanding of themselves.

Patients stir emotions in their practitioners. Some patients are a delight to treat; others not. Some patients make one feel good and others a failure. Poor outcomes, increased dissatisfaction, ethical problems and burnout of the manual therapist are more likely to occur through ignoring emotional dynamics and attending only to the technical aspects of the problem. The awareness of the presence of potentially troublesome emotions – sometimes referred to as transference and counter-transference – is vital to a holistic approach to healthcare.

Many psychological therapists understand that the body speaks in a language of its own. Joyce McDougall (1989) says patients who are accustomed to “speaking through their bodies” present enormous challenges to physicians, psychoanalysts and practitioners of physical therapies. Patients’ physical distress is often disconnected from its emotional component; and they have no words to reconnect the two, even in the context of talking therapies. McDougall writes about patients who seem trapped in a pre-verbal merger with their mothers, which she calls ‘one body for two’. McDougall describes alarming psychosomatic maladies that seem to serve mainly as confirming their owner’s existence. Through the use of insight and gentle guidance, words are given to the body’s messages and the pre-verbal trauma is addressed. All patients ‘talk with their bodies’. The body may be seen to have a language of its own which the patient is asking to be decoded and understood. The manual therapist can play a crucial role in this decoding.

Video Interviews: Danny Sher & Mannie Sher

1. Introduction: What is the patient really telling me?
2. Methodology
3. About the workshops
4. How the osteopath feels
5. Paediatrics
6. Treating the Elderly
7. Osteopathy and the Balint Approach
8. The Placebo Effect
9. Dependency and the ‘Heart-Sink’ Patient
10. Boundaries and Roles 
11. Boundary, Authority, Role and Task
12. Identity
13. The Erotic Transference
14. Conclusion

A paper on the subject was also published in the Journal of Bodywork & Movement Therapies (2015) details can be found here.

Dr Mannie Sher
TIHR, Principal Consultant/ Researcher, Executive Coach and Board Evaluator