It’s not you, it’s me…

Relationships are hard work. They require effort, commitment, and sacrifice from all involved to succeed. However there are times when it’s clear that this is is not happening and the relationship isn’t working. Being able to recognise this takes honesty and courage, and taking action to address it sooner than later is usually best for everyone, and sometimes this means ending a relationship.

The professional relationship between a patient and therapist is on many levels not much different from a personal relationship. They both require everyone to work together to achieve a successful outcome. The therapeutic relationship you have with a patient is also more important than many would care to admit, with many therapists still believing that successful outcomes are due to their extended skills in manual therapy or exercise prescription.

This is bull shit, and I often highlight this on social media and on my courses much to the annoyance of many. To put it simply a therapists interaction reinforces their intervention, regardless of what they do. In fact it can be at times only the therapists interaction and not their intervention that gets the results and successful outcomes which is why a lot of shitty interventions appear to work.

Interaction IS intervention

Don’t believe me, well lets consider two therapists giving the SAME treatment to patients with the SAME problem, lets say some crappy interferential treatment for chronic low back pain. The first therapist demonstrates to their patients that they are listening, caring, understanding, and empathising, the second therapist not so much. Who do you think will get the better results despite using the same crappy treatment?

Well this has actually been studied. Fuentes randomised 117 patients with chronic low back pain to receive either active or sham interferential electrotherapy treatment, BUT with either a limited or an enhanced therapist interaction. In the limited interaction the patients were told that the therapist was just there for safety reasons and so just strapped the machines on them for 30 minutes and sat in the room quietly with them.

However, in the enhanced interaction group the therapists used the 30 minutes of crappy interferential treatment to also talk to the patients about their back pain demonstrating active listening, asking for further information, using a soothing tone of voice and other non-verbal behaviours such as eye contact, and physical touch. Empathy was also demonstrated by the therapists by using phrases such as “I can understand how difficult this must be for you”.

Guess what… The enhanced interaction groups all had significantly improved outcomes (see above chart) even in the sham group where the crappy interferential machine wasn’t even switched on. In fact, the enhanced interaction achieved nearly double the pain reducing effect of the crappy interferential treatment regardless if it was switch on or off.

Its’s not what you do, it’s how you do it

So just by being a decent, caring human being you can double the effect of your treatment, even if its a shitty one, and it doesn’t matter what the treatment is. Ferreira did a similar study looking at the effect of the therapeutic relationship on the effects of three different treatments for low back pain. Patients where randomised to receive 12 sessions of either general exercise, specific motor control exericse, or spinal manipulation. They found that regardless of the treatment the patients who reported a greater theraputic alliance with their therapist had the greatest success.

So the relationship between you and your patient is vital to their outcome. As the saying goes it really isn’t about WHAT you do, more about the WAY you do it.

However, this doesnt mean for one second you can suddenly become a smooth talking bar steward and start applying snake oil treatments or what ever the hell you like to your patients. Although, unfortunately this does happen the world over, and as I already mentioned explains why a lot of dubious treatments appear to work for a lot of people.

Maximise it

But for all the remaining non narcissistic, honest, sensible, rationale, and decent therapists out there it does make sense to maximise your therapeutic relationship with your patients, you would be daft not to. Hall in her review discusses the many factors found that make a successful therapeutic relationship, and its all pretty straight forward simple stuff. Things like listening more, talking less, showing that you care and empathise, not rushing, being clear and concise, and having a good sense of humour.

These personal humanistic traits and communication skills are where the true skill of a good therapist lie, not in the latest fad of manual therapy, or exercise rehab. Any therapist can treat a stiff back or weak shoulder, but it takes a great therapist to treat a person with a stiff back or weak shoulder.

However, being brutally honest building relationships with patients can be hard bloody work at times, and there are many times when I feel the relationship with a patient is strained, awkward, uncomfortable, and frustrating, and no matter what I try it doesn’t seem to improve.

This can be due to a host of different reasons, such as cultural, personal, enviromental, and it can be due to anything from a simple a lack of rapport, a mis-communication, a mis-understanding, a clash of personalities, or simply just not liking the look of each other.

Ending a relationship

Humans are highly variable in personality, and human interaction is complex. It would be naive to think that we as therapists can get a good effective relationship with everybody we see, all the time. I have learnt that when I feel the relationship is not maximised, and I can not see it improving, rather than continuing on with an awkward uncomfortable non productive relationship I will now end it sooner rather than later.

Again being brutally honest here, this can be awkward and uncomfortable to do, but it has got easier over the years. I find being completely open and honest with the patient is best. I ensure I make them aware that this is in no way any reflection on them, or me, and that there is no fault associated. I stress that I wish to cause no offence or disrespect, but I explain that it feels we are not communicating or working well and that I think that I am not the best therapist for them. I then suggest that it is in their best interests to work with someone else.

This onward referral is not me giving up, passing the buck, or ducking out, and I know this isn’t always an option for some therapists who work alone. I am extremely fortunate that I work within a great team of therapists, all with unique and different personalities, styles, and mannerisms. This means there is always someone who I can pass a patient onto who I feel would be better suited for them. This process happens both ways, I pass patients to other therapists, other therapists pass patients too me.

Simply put getting the right therapist in front of the right patient is essential for success, and thats not just about experience or knowledge, but also personality and style.

So there we go, a review of therapeutic relationships, which are not as simple as they may seem. As I said at the beginning, successful relarionships are hard work, and require effort and commitment from all involved.

When it comes to successful relationship advice I always remember my Grandad telling me the secret to his long and happy relationship to my Nan. He told me it was all about making time to talk and that they went out for dinner twice a week to do this. He went out on the Friday night and my Nan went out on the Saturday, and that it was talking to others that was the secret to their success!

Thanks for the advice Grandad!

And as always, thanks to you for reading this far.



9 thoughts on “It’s not you, it’s me…

  1. Another top blog Adam. I’ve done 20 years as an MSK physio,10 in pelvic health and absolutely concur. Getting rid of narcissistic tendacies and replacing them with a genuine focus on the patient gives the best results.
    Thanks for writing!

  2. Thank you for this excellent post. One of the reasons I went back into private practice was to have control over how much time I spend with clients pre- and post-treatment. In addition to the positive effect on the treatment outcome, after 13 years in practice I find managing the nuances of the therapeutic relationship to be the most fascinating and professionally fulfilling part of my work.

  3. Excellent, Adam , one of your top blogs in my opinion . This would never happen in health care but yesterday we had our chimney swept by a great character ..deer stalker , sweep, wood cutter and all round fearless judge of character . He said he was up at some house where the B+B owner needed a certificate for insurance but the guy had installed it himself and it was dangerous etc and kept our man waiting in his van…. an air of hostility ensued pretty quickly . He informed the punters that its pretty obvious that I really don’t like you and you clearly don’t like me and if I were twenty my immediate reaction would have been to deck you and move on. I am not suggesting this is a good way of going about life but sometimes he has a point . Many times people with a completely mechanical view of life with absolutely no nuance or greyness will never get ‘pain education’ , metaphors or even simple rehab ideas …I encourage them to see Mr White coat for often futile tests ( I know this is medicalisation but this is the culture we are in and I am usually King Canute in many situations ….) . I think massage therapy is excellent for some people who are in stressed out situation and can afford it for example and with the right therapist the support is invaluable. I agree with you regarding horses for courses and one of the reasons why a diverse range of personalities should be employed in health care settings (rather than a bland homogenous group perhaps ?? ) .

  4. Another great post, Adam. There is an old saying “if you listen closely enough, your patient will usually tell you what is wrong”. I really believe that. I have always said that one of the least technically knowledgeable therapists I know is also one of the most effective. He REALLY listens.

  5. Thanks for another thought provoking post Adam.
    The relationship is everything! I recommend reading Paul Watzlawicks 5 axioms of communication which includes a definition of relationships as either complimentary or symmetrical. In summary; either consisting of power or equality. It is a difficult stance we take as therapists in treading the fine line between empowerers and educators!

  6. Totally agree! That’s why you find juniors get lots of presents from patients because they’re fresh and still have lots of patience!

    Who also finds that when they’re in a good mood all your patients seem to get better? Then when you’re having a bit of a rubbish day and don’t really want to be at work, the patients all seem to be worse? I also notice the same with the clinic I’m in… When I’m in a depressing room with no windows, the patients appear much more complex, yet when I’m in a brand new sports centre surrounding by fields, patients seem to be much more positive!

  7. Great post Adam!

    Another recommended read among this topic is “Skills for Communicating with Patients” 3rd ed. by Jonathan Silverman. Content is excellent.

    Looking forward to more posts!

Please leave your comments here...

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )


Connecting to %s