Ending a relationship

A 7-minute read

All relationships are hard work. They require effort, commitment, and sacrifice from all involved to succeed.

However, there are times when it's clear that a relationship is not working.

Being able to recognise this takes honesty and courage, and taking action to address it sooner rather 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 that different from a personal relationship.

They both require everyone to work together to achieve a successful outcome, and sometimes they don't always work.

The relationship therapists have with their patients is more important than many care to admit, with many therapists believing that their success as a clinician is due to their extended skills in manual therapy or exercise prescription when in fact its due to their skills in building a therapeutic relationship.

I often highlight this on social media and in my courses, much to the annoyance of many therapists who feel I am belittling their skills or undermining their experience.

I am not.

I am simply being open, honest, and realistic and highlighting how many patients get better, not because of WHAT therapists do, but far more by HOW they do it.

To put it simply, often it's the act of treatment that works, not the treatment itself, and therapists' interactions often reinforce their interventions.

In fact, it can sometimes be only the therapist's interaction and not their intervention that gets the results, which is why a lot of shitty interventions can appear to work.

Interaction is intervention

Don't believe me, well let's consider two therapists giving the SAME treatment to a patient with the SAME problem, let's say interferential treatment for chronic low back pain.

However, one therapist does it whilst showing care and empathy and listening to the patient, the other doesn't.

Who do you think will get the better results from using the exactly  same treatment?

Well, this is what Fuentes studied in their paper. They 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 group, the therapist was instructed to be 'professional but distant' just there for safety reasons, and so they just strapped the machines on and then sat quietly in the corner of the room for 30 minutes while the interfential did or didnt do its thing.

However, in the enhanced interaction group, the therapists were asked to be warm, friendly, empathetic during the 30 minutes of interferential treatment, and engage in conversation, demonstrate some active listening.

And guess what... The enhanced interaction groups all had significantly greater results (see the chart below ) 

The enhanced interaction achieved nearly double the pain-reducing effect of the same interferential treatment, regardless of whether it was switched on or off.

It ain't what you do, it's the way that you do it

So just by being a caring human being, you could double the effect of your treatment, even a shitty one like interferential.

And it doesn't matter what treatment you use; this applies to all. Ferreira did a similar study looking at the effects of the therapeutic relationship on three different treatments for low back pain.

Patients were randomised to receive 12 sessions of either general exercise, specific motor control exercise, or spinal manipulation.

They found that regardless of the treatment, the patients who reported a greater therapeutic alliance with their therapist had the greatest improvements.

So the relationship between you and your patient is vital to their outcome.

However, this doesnt mean for one second you need to suddenly become a smooth-talking snake-oil salesman to start getting good outcomes.

Although, unfortunately, this does happen a lot in the world of therapy, and as I've 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, rational, decent therapists out there, it does make sense to maximise your therapeutic relationship with your patients.

Hall, in her systematic review, discusses the many factors that make a successful therapeutic relationship, and it's all pretty straightforward, common-sense 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 are where the true skill of a good therapist lies.

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 stressed, anxious, annoyed, or worried person with a stiff back or weak shoulder.

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

This can be due to a host of different reasons, such as cultural, personal, and environmental factors. Or it can be due to something as simple as a lack of rapport, a miscommunication, a misunderstanding, a clash of personalities, or just not liking the look of each other.

Ending the relationship

Humans are extremely variable, and human interaction is extremely complex, so it would be extremely naive to think that we as therapists can develop an effective relationship with everybody we see, all the time.

Over the years, I have learnt that when a professional relationship is not maximised, and I can not see it improving, rather than continuing on with an awkward, uncomfortable, non-productive situation, I will now look to end the relationship... sooner rather than later.

Again, being brutally honest here, this can also be awkward and uncomfortable to do, but it has gotten easier over the years, the more I do it.

Ending an unproductive relationship with a patient can be tricky, but I find being completely open and honest with them is best.

I find simply, clearly, and calmly explaining that it feels like we are not connecting or working well together, and I try to make them feel that there is no fault or blame associated to anyone for this, and that it's just one of those things. I also try to stress that I wish to cause no offence or disrespect by saying this.

I then ask them for their thoughts, to which I find that often they are either in agreement or sometimes it can be a complete surprise or shock to them.

If it's a surprise to the patient, it allows us to talk more about the issues and feeling and sometimes can actually help overcome any obstacles and barriers that were hindering an effective working relationship.

If its agreement, then I often suggest finding someone else to work with them.

Now, I know I am likely to get some negative reactions from this. Some see it as our duty as physios and therapists to work with everyone and anyone who needs our help and assistance. And I kind of agree, and I am not saying we are just going to give up immediately at the first difficult encounter we have.

This is not an excuse to give up, pass the buck, or duck out of complicated or difficult work.

But the realities are that not all relationships work well, and if there are other people and options to consider that could help someone better, why should I restrict that from happening?

I am fortunate to work with 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, and this happens both ways.

Getting the right therapist in front of the right patient at the right time, I think, is essential for success, and thats not just about a therapist's experience or knowledge, but also their personality and style.

Summary

So that's my views on professional therapeutic relationships. As I said at the beginning, successful relationships are hard work and require effort and commitment from all involved.
 

However, when it comes to successful relationships, I will always remember my Grandad's advice to a long, happy marriage to my Nan for over 60 years, which he told me was all about making time to talk regularly.

But he also used to joke about how it didnt always have to be to each other.

I think there is a lot of truth in this!

As always, thanks to you for reading this far.

Adam