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Basic clinical tactics
Basic clinical tactics This paper is the third in a series that Philip Latey has written specifically for JBMT, in which he explores psychosocial issues, knowledge of which is essential to all bodywork and movement therapists.
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P. J. Latey Abstract This paper aims to explore the everyday practical realities of clinical work. The reader is invited to consider various tools and guidelines to help in decision making. Severity of problem, the human side of the patient in context, and some important distinctions in technique are highlighted. Three key questions about home, work and relationships are emphasized, followed by contraindications and the support of the practitioner.
Introduction
Philip
Latey 1 Toongarh Road, North Sydney, NSW 2060, Australia
Correspondence to: P. J. Latey Tel: ++61 9929 6603; Fax: ++61 9929 8807 Received November 1996 Accepted January 1997
Journal of Bodywork and Movement Therapies (1997) 1(3), 163-172 © P.J, Latey 1997
This is the third discussion paper in a series designed to highlight key areas of interest to manual and movement therapists. The first paper set our work within a clinical formula, and a 'maxim' that governs the clinical setting: Always diagnosis, aetiology, prognosis and treatment agreement (ADAPTA). That paper continued with a brief 'diagnostic' look at the behaviour of muscles; seeking to bring out their sensory, emotional and experiential/subjective aspects. The author suggested that we might start with nine senses, four layers of typical postural behaviour, three regions of typical tension/compression patterns, and finished with a brief study of shock and withdrawal. The second paper, moving from general diagnosis towards the study of
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aetiology, explored the link between maturation and healing processes, with some of their physiology and psychology. Starting with a case history and more detailed look at adolescence, the paper used some aspects of migraines and asthma to show the possible effects of 'focal immaturities'. The author also suggested that many chronic stress syndromes are linked along the length of the body by a ruminative inner tube that digests, absorbs and rebalances tensions through some processes allied to 'fantasizing'. A range of social pressures working against maturation were mentioned in the conclusion. This paper, the third of these collections of themes for therapists, begins a study of treatment methods and clinical tactics. The author cannot produce a definitive guide to best practice such as one might hope to find in a good surgical manual, or in the indications for antidepressive
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Latoy medication. Nevertheless, there are many practical tips, simple models, 'tools', distinctions and broad classifications that may be very helpful for manual and movement therapists.
Simple models and distinctions Time management If our therapeutic schools depend on the innate self-rightingness of biological organisms and systems, we have to ask one very vital question. How much has our patient's capacity for self-restructuring been compromised? How ill are they? How ample and resilient are their current reserves of healthfulness? This judgement, often made intuitively in the first instant of our encounter with the patient or when we start to feel their body tissues, may determine many things. How much testing and elimination is needed? How urgent might this be? How much of our time will we be allotting to the case? We can simplify and formalize some of these elements into a 'spectrum of severity'. This spectrum also begins to place us in a proper continuum with orthodox medicine and indicates the gaps that the ordinary medical practitioner cannot encompass (Fig. 1). This spectrum has been discussed elsewhere (Latey 1983). But, briefly, category 'A' may represent perhaps two thirds of 'symptoms' in the community - but they are never presented to a health care practitioner. At these times people treat themselves, mostly by applying minimalism or faddism. As symptoms diminish or are adapted to, or the episode resolves, they are likely to believe that their methods and fads are effective or curative (post hoc propter hoe). The 'B' patient usually needs little more than a nudge in the right direction, with some reassurance and advice about management. In fact many of these problems may have
diagnosis into some sort of pattern of factors obstructing their return to health. This should give us as clear and simple as possible ideas about what has to be achieved in the clinical work. As an example, the author has described a scale of lesion patterns and complexity that we might look for in osteopathy (Latey 1992):
begun to resolve the moment they picked up the phone to call us making much of our treatment irrelevant. Here, also, we are likely to accept our own belief systems uncritically. The 'D' patient, on the other hand, is likely to have an urgent need for medication, surgery or asylum. Their illness is fixed in form; identifiable from the medical text book and we call on all of the resources of orthodox diagnosis straight away. The greatest challenge to the skill of the therapist, lies in the treatment of the 'C' patient. The 'C' patients' healthfulness has become so encumbered that they may only be able to proceed through small increments and stages of 'cure' that are hard fought. For the practitioner to survive work with these many-layered and often ill-defined areas of chronic health problems, they may need strong support or supervision with colleagues; sophisticated tactics, strategy and choreography; with the ability to sustain frustrations and the sense of futility. Above all they must have secured for themselves a position from which to rethink the case. So, there may be quite a lot of thinking that is set in motion by our initial impressions of the severity of our patients' problems, and how we are best able to manage our time.
(a) Specific tissue/joint lesion. Primary or secondary. Type one or type two. Acute or chronic. 'Compensatory'. Motion or position. (b) Somatic dysfunction. More broadly defined as musculoskeletal bind. Larger scale of biomechanical functional units in conflict. Opposing demands and directions. (c) Somatico-visceral and viscerosomatic dysfunctions. The facilitated segment, neurological lens, group lesions and cyclical feedback patterns. (d) Functional disturbances of fluid or pulsatile motility. Torsional/visceral. Breathing and involuntary movement patterns. (e) Compensatory failure. Large scale breakdown. Whole body lesion complexes. Postural - ergonomics - sports - exercise physiology/nutritional disorder. (f) Large pathogenic pattern of related factors. Include mental/environmental. Subjectivity. Social, emotional. Whole person in context. Current and history of group interactions. Mind matter and motion.
Fixing objectives Looking at the patient as they are now, with their set of symptoms or problems in the 'maintained' state, we have to try and crystallize the
A~ Health
Brief
Short-term
(Hoursof treatment prognosis)
Long-
Mediumterm term
Fig. 1 Spectrum of severity.
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These loose categories are like filters that we superimpose on the 'maintained' picture to look for the simplest model that will fit. They are not mutually exclusive, and likely to be found together; often nested or embedded within the clinical findings. And we have to choose at which level we will have to pitch our efforts. Only the last of these will require a really full holistic understanding of the problem; but this will be necessary for most of our more challenging cases.
Problem-solving or supportive work? With some idea of severity, and the complexity of the problem, we have to decide whether we are actually looking at a set of symptoms that really can be entirely and permanently cured. What are the patients themselves actually hoping for? It is quite common for us to find that our methods can help make a substantial improvement in the patients' health and quality of life, but that this is only partial and temporary. In these cases we may often be settling for an open-ended process that we would describe as long-term maintenance or supportive work. Although this is not aimed at cure, it may be of great value to the individual and community. Supportive and maintenance work is beyond the scope of this paper, but each practitioner needs to decide on the balance and proportion of their practice time to be taken up by the different sorts of work. When it is clear that the patients' hopes and expectations might be met, we have the beginnings of the prognosis and treatment agreement.
The nature of the process In each therapeutic discipline there must be an underlying set of ideas, a philosophy and some basic principles. Our technique, tactics and overall strategy are derived from these - at
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least partially. In more complex modem osteopathy, for example, we look at the subtle recursive interactions between the structure and function of a system. Although this may be a somewhat artificial way of dividing things, it enables us to make a clear distinction between different forms of intervention. It became apparent in the 1960s and 1970s that there were two almost diametrically opposed approaches to techniques currently in use. There were practitioners succeeding in practice by the use of directive forceful methods that confronted and overwhelmed restriction in the bodies of their patients. Others succeeded by tuning in to intrinsic movements and enabling them to reach a new balance. There was, then, an opposition between extreme principles of 'confront bind' or 'pursue ease'. This could be compared to the unknotting of two radically different types of bind (Fig. 2). The slip knot shortening a piece of string can be released by a sharp pull away from the knot. If we pull in this way on a sheep shank it merely tightens. The release movement in this case is a slackening off of tension combined with rotation and lateral oscillation so that the knot can simply unwind. In the midst of these extremes we also had a group of 'technique
maxims' the usefulness of which cannot be exaggerated. For example, we might be attempting to: • Exaggerate the lesion. • Retrace the path of the lesion. • Loosen above and below; let the middle resolve itself. • Isolate the lesion. • Hold the lesion complex, compress it, and let everything else move: release very slowly. • Tune in to small differences and amplify them. • Find it, fix it, and LEAVE IT ALONE. e and so on. Various notions of this sort might come to mind during the most crucial moments of a therapeutic session, and help us enormously. Structural technique aims to confront bind in a system by the use of linear force. It aims to break down fibrotic areas and scar tissue, stretch and elongate tissues, restore or increase ranges of movement and so forth. It might do so by high velocity thrust, strong traction, deep friction, deep kneading, strong deep pressure, persuasion, exhortation and the like. Functional technique aims to pursue ease by the use of subtle multidirectional influence that is engaged and in tune with the system. It aims to release torsional patterns by
Shoed s~snk
Silo knot
STRUCTURAL release
Fig. 2 Slip knot and sheep shank.
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Latey facilitation/lysis/catalysis. A feeling of expectancy is established by setting and securing the boundaries within which changes can happen; waiting for them and helping to allow them to happen. Examples of functional work might be the dissolution of frozen traumatic shock patterns; the enabling of breathing and involuntary movements to rebalance. The techniques (low velocity stress types) might include gentle slow soft-tissue kneading of a very relaxing/calming/lulling type; listening to and following the involuntary movement patterns; minimal compression and release with torsional unwinding; diaphragmatic release; gentle moulding of the cranial and facial articulations and similar subtleties. To this we should add our exploratory techniques of simply playing around with an area or function. Both types of technique are designed to remove obstacles to health, and can be joined together into one scheme (Latey 1984). The aims of structural technique seem to be mostly in the direction of restoring homoeostasis; whereas functional work is more likely to provide opportunities for transformations and developmental metamorphoses. As we begin to expand our scheme to include the mental, emotional and social we may well find that this simple division of styles and approaches applies equally well to verbal interpersonal interactions, giving a very broad range of therapeutic choices.
various distances from them (Fig. 3). In the case of Sally (see Part 2 of this series) her treatment might have been interminable, or a total failure without careful thought to her participation in a broader field. Sally 'grew up' spectacularly during relatively brief manual treatment and general therapy. Sally' s practitioner took great care to reinforce the stability of her relationship with her husband. One crucial intervention clarified her relationship with her mother and the family of origin; making it innocuous. Sally was also helped to distance herself from her previous social group, who had equated success with easy money gained by cunning, ruthlessness and good luck. She was supported in this by the solid socioeconomic and political stance of her practitioner. So we can regard the levels of the expanded matrix as related systems with their own structure and function even to the point of imagining what an extra-species observer might make of the picture that emerges!
Practitioners' attitudes: preparation If we use words such as the 'stance, attitude, position or bearing' of the practitioner these could equally refer to something social, psychological or physical. How we view our patients will tend to reflect the common view of illness in the community, amongst our colleagues, what we think in our own minds, and how we feel about our own bodies and lives. With all complex problems we cannot have ready-made solutions. To try for the 'quick fix' straight away may well preclude more successful long-term work. We may not even be able to tell 'what is happening to what' with any great precision for quite a time. So, in the fine tuning of our clinical stance the first thing that we all have to cope with may well be something like acute stage fright.
'Stage fright'
-
Function
close grouping 'emotionals' ethnic/ etc social
We may have confidence in the capacity of our holistic approach to
general economics/
(e.g.
politics
climate)
? extra-species " observables
close 'emotionals' etc grouping ethnic/ social
economics/
politics
From manual to interpersonal The therapeutic interaction is a very special case, far removed from the everyday life of our patients. For the more complex cases we need some evolving picture of them engaged in the ebb and flow of human events. Again we can simplify this to set them within a matrix of relevant levels at
general (e.g. climate)
? extraspecies observables
Note: 'Close emotionale' including the immediate physical and mental/informational habits of the patient
Fig. 3 Expanded matrix: patient in context.
v
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meet and solve a wide range of health problems, but feel very anxious about our personal ability to apply the tools that it offers successfully. Faced with any new problem we all have to cope with our own worries - that we might overlook some crucial factor, fall to get a proper grasp of the situation, make people worse or no better, or start something that we cannot finish and our fear of the problem that might deteriorate catastrophically. Therapeutic work, at its best and most challenging is very high in stress and anxiety. On the other hand, if we can put up with those disturbing feelings of doubt and dread, futility, incompetence and ignorance (that are always liable to recur as we struggle towards maturity) there is much to gain. The unease that the author has labelled stage fright has to do with our awareness of the need for flexible but definite responses in an unpredictable field of interaction with the patient. By preparing to meet the unexpected in this way we encounter new aspects of the human condition almost daily. Alongside this acute unease or stage fright our lively interest, goodhumoured and patient optimism should be alerted to a very high degree of intensity, and focused on the problems brought to us by our patients. Part of our preparation to work lies in the mastery of a range of therapeutic simplifying hypotheses kept 'at our fingertips', and ready for use. It seems best to Use very simple contrasts to decide from moment to moment how to proceed.
P r a c t i t i o n e r s ' attitudes: tactical balances There are many tactical balances that we maintain while we are working. And, while we all find our way into these orientations quite naturally with experience, it helps to think about them. If we can define them more clearly we can at times make more defiberate choices, and alter our
approach more freely when it seems desirable.
Verbal and non-verbal There is a varying proportion of verbal and non-verbal interaction in our typical session. How much is said before the physical work; how much during it; and how much after? The quality and type of verbal communication during all three phases is quite different. We might aim to make language as adequate a therapeutic tool as the use of our hands and movements: and to integrate the use of them both. At this point it is vital that we realize that the verbal communication skills used in the ordinary course of our manual and movement work are radically different from those used in the various schools of counselling and psychotherapy. We are usually working on the physical unwinding of bodily seizures, and improving movement. In most cases our patients' distress is at least partially tangible and real to us and we are working directly with it. For the most part very little needs to be said but what actually is said is often crucial to the outcome! A well-timed question or comment can be as dramatically and lastingly effective as any of our physical manoeuvres.
Formal and informal There is a general tendency in our work to progress from formal towards informal interaction with our patients. It is crucial for our effectiveness that we never lose some of our 'formal reserve' (an overview of the progress of the case, our professional standing, ethics, aesthetics, etiquette, privacy and so forth). Nevertheless the very best physical and verbal tactics seem to happen most successfully when the practitioner has relaxed with the patient into a slow and easy rapport and empathy during and after the middle of the session.
This balance of formal and informal is most obvious with the new patient. We ask so many formal questions around the nature and dynamics of their current complaint, survey their current state of health and past history of illness and relevant events. We will often signal the end of this more formal phase by a more informal comment 'sorry about all the questions'. This helps them relax, but allows them to consider that we are not only very thorough, but preparing to adopt a more holistic understanding of their health and problems. We will then usually prepare them for physical examination, which has its own pattern of formalities. So, with the new patient it is only towards the end of the session when we are beginning some treatment, have begun to relax them, and have an idea of where to start that we will be able to ask in an informal way the three key questions (see next section) that are the most important kernel of this tactical paper.
Other technical balances Alongside the structural or functional, verbal or non-verbal, formal or informal balances that we maintain, we can describe many other important dynamic contrasts in our work. At times we can choose between setpiece tactics and those that are improvized ad hoc, between directive and interactive, provocative and contemplative action; between those methods that are highly determined and those that are open-ended, exploratory, and may just be making space for more manoeuvring.
Spontaneity Much that we do may, in fact, be something that we only understand after we have done it, if we understand it at all! A lot of the logic of osteopathy, for example, has probably arisen 'ex post facto', having done something that felt right at the time. Storing up these spontaneities and
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Latoy mulling them over is one of the ways that we improve with experience. Overall we can say that an awareness of these tactical dynamics in our work helps keep maximum flexibility while both feet are planted firmly on the ground.
What are we looking for? With each person or group we are trying to explore and recognize certain features and aspects of their lives and problems. We could say that we are looking for a pattern of patterns within patterns that are in some way coherently linked. As we oscillate between broader and narrower sections and areas we build up a picture something like a set of Russian dolls. We can assess dysfunction from the broadest of social bases down to the minutiae of a tiny localized disorder, and explore their relevance to each other. Like the faces, features and clothes of the nested Russian doll, it is the thematic consistency, familiarity and fit between these levels that is convincing in our more holistic study of pathology. With experience we also begin to be able to deduce or intuit features of the missing layers and links that we have not yet explored.
Thorough but minimal As we question and examine the patient it is extremely important that we are feeling our way between these levels only to discover which elements are going to be most useful in the resolution of their problems. As a general rule we never attempt to achieve more than they have asked. This is the nature of the clinical problem-solving contract; and we need it to set firm limits to our work. We also take great care to stay minimal and tactful in our interactions. It's a great mistake to be continually unearthing and dwelling on the past and present vicissitudes of the patient' s life, as these are reasons
to be ill and to stay i11. No. We are going to be always most interested in ways of getting better, of learning that certain stresses are over and finished; that there are better ways of relaxing; that bygones can be bygones eventually; and that ordinary life in the present has the potential to make everything available that is needed for health. And, as we work at the various levels that we can influence, we may find in our more successful work how people change fruitfully in ways we have not sought to influence or predict - and might also see how they bring their community to life! Luckily the questions that we will be asking in order to explore the ramifications of the problem are often the same ones that may stimulate its resolution. The simple fact of our asking (which is a form of intrusion into a system) requires them to formulate some sort of response making internal reformulations and a shift in attitude more likely. We cannot even look at a problem without acting on it! Nevertheless, in spite of our hopefulness about the effectiveness of our work we should not even try to emphasize only the positive in our work. The unflagging wishful thinking of the 'optimism police' in so much pop psychology is tiresome in the extreme: sacrificing long-term possibilities for a short-lived boost that wears thin very quickly. Overall the best attitude to convey is one of patient light-hearted hopefulness, with a measure of honest ignorance. We really don't know exactly how important each aspect of the case is likely to be. And, however much we might have guessed or already been told by the patient we cannot possibly know how they are themselves experiencing their lives, or the repercussions of their interaction with us. Some part of each person's version of things will always remain enigmatic, singular and unique to themselves. Our ways of including human subjectivity into our work
could never be as pragmatic as, for example, reading an X-ray.
Hope and despair So another balance that is subtle, but of great importance is our oscillation between optimism and pessimism. We naturally alternate between hopeful and encouraging views of the future, and a sort of global feeling of futility about the hard work, lack of results and seeming interminable impossibility of what we are attempting. This pessimism might emerge from the patient or practitioner's exasperation and frustration - ' W h y don't we just cut it off and throw it away?'. Often, if the situation seems very bleak it is only this light-humoured but rather 'black' sense of fun that can clear the air. By imagining and exaggerating the very worst we can somehow restore hope for something better, or restore a rapport that has begun to faker. The emergence and use of humour and imagination in our sessions is a very complex topic needing close study. It is enough here to note that its spontaneous appearance usually marks a substantial turn for the better.
Three key questions Given the scale of lesions 'a' to 'f' above, a loose categorization of what we might be looking for, we can now distinguish between the full use of holistic practitionership, and its lesser more restricted and limited use. We can do this in a very simple and decisive way. Towards the end of a first session when we and the patient are beginning to relax, or perhaps in the second or third session we ask these three key questions, or a close equivalent in a quiet conversational and relaxed way. •
'Are you settled ... in your place to live?' • 'Are you settled ... in your work?' • 'Are you settled ... in your relationships?'
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Unless they have already told us that they are moving house, work is stressful, or a relationship is foundering, this is the natural order for the three questions (Figs 4-6). We cannot really claim to be using modem holism fully unless we are making precisely this sort of openended enquiry. What a vast difference three questions make: between the practitioner open for the patient to tell them their distress and the stresses they're undergoing, and those practitioners with ready-made answers and schemes that preclude the emergence of the subjective human being. But we must be extra careful not to do much about what they tell us at least not straight away. -
Attribution and 'collusion' Patients, like all of us, are uneasy with aspects of life that are unexplained. They will have some view of the causation and remedy for their ills. This is usually simpler and much more linear than the clinical models that we are developing. In addition to this we also find that people who have converted unsolvable emotional and social stresses into physical symptoms ('somatizing' heavily) are generally unable even to imagine that there might be any such link (Latey 1987). In view of this we do best not to even try and connect things up for them - at least to start with. So we will usually start by explaining the somatic as caused somatically, with the emotional and social being something left entirely separate. This collusion with their preference in the form of the explanation that we agree on, will probably be somewhere along the lines of our lesions 'a' to 'e', or their equivalents, and leaves the more complex 'f' patterns unspoken. We are then free to continue physical work in the ordinary way, keeping our more personal enquiries sparse and conversational. We may also need to be careful not to disturb or challenge their own
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Fig. 4 'Are you settled ... in your place to live?'
beliefs in treatments that they feel have helped; however much we might recognize their faddist or unrealistic nature. If we simply remain noncommittal their interest generally subsides. Later on if things are not beginning to resolve well, we can introduce
general ideas of stress and tension, and link these to visceral upsets, exhaustion, muscular clenching and so forth. This can be an extremely tricky phase in work with severe and recalcitrant problems: most of the more successful tactics for this are beyond the scope of this introductory paper.
Fig. 5 'Are you settled ... in your work?'
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Fig. 6 'Are you settled ... in your relationships?'
We can later correct our original collusion very easily by saying: 'but there seem to be some other factors that I don't quite understand preventing the problem from clearing up'. We thus return to our position of interest with some ignorance and curiosity; perhaps wondering when they will start asking the interesting questions for themselves.
Communication skills There are many reasons why the various schools of thought in counselling and psychotherapy have only marginal relevance to manual and movement therapists. There are in any case at present no schemes modelling mental function as a part of visceral, respiratory and neuroendocrine or neuromusculoskeletal processes that are more than tentative hypotheses. Nevertheless, our good rapport and empathy enable us to question amiably about their personal life. This evolves into more of a conversation quite naturally. Our conversations with them, again can easily become discussions - and the discussions will often gather strength, interest and pertinence, to the point where we are actually helping them find a way past some key factor maintaining their problem.
So we do best not to describe any part of our work as counselling or psychotherapy, but to keep our view of these verbal interactive skills at the level of useful conversations or discussions, in our own minds and in the mind of the patient. That said, we can use some of the basics from 'verbal' schemes to very good effect. They all agree that we will always attempt to define the presenting problem very clearly, define what improvements can be expected, and have some way of monitoring improvement. We will also generally be working within a limited number of sessions, and will usually emphasize the limitations of our work; setting times for reassessment of progress. This much is held in common by all serious clinical disciplines.
General skills A range of simple guidelines are suitable for simple crisis intervention and can be extended towards our equivalent of brief counselling or psychotherapy work. One of the main differences is that we will be keeping the psychological, emotional and social as a low-keyed and peripheral aspect to our work. Only rarely and at crucial moments does it necessarily become central, and the main focus.
When some social/emotional stresses have come to a head, and may be precipitating florid symptoms, anger, despair or grief, our first job is to listen very carefully and attentively. Patients may express their narrative and dilemmas very emotively. It is absolutely crucial at this point for them to perceive that they have been heard. In crisis this expression of emotion, and being heard companionably or compassionately ('ventilation') may be all that is needed for them to begin to move on past the worst of their current emergency. With problems that are more ingrained we will be keeping up the attentive listening, but may begin to question carefully around the problem; prompting gently to help them approach things that are difficult to say. We will be aiming for them to have heard themselves say what has to be said at least two or three times, coming to it from slightly different angles. We hope also that they are developing an appreciation of wider connections and some practical grasp on what has to be done.
Contraindications Right from the very start we must not even think of doing this more extended work unless we are convinced in our own minds that the troubled patient is an agreeable ordinary person, living their life in a way familiar to us, with problems that are also ordinary and familiar. If we feel that there is anything even slightly odd, or threatening or seductive about the situation we do best to back off immediately and think how we can best refer them elsewhere. In a sense we cannot proceed confidently until they have already gained our own confidence. We also must be certain that we have at our fingertips all signs and presentations of depressive illness. At least one third of suicides have consulted a health professional in the
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weeks before their deaths; and this is commonly with physical symptoms. Again we need to know how to refer them urgently for proper care, and ensure that they are accompanied and kept an eye on. The work that we can undertake may also be severely limited by our own lack of support and balance (see below).
to suicide, alcoholism and addiction, impoverished relationships (marital breakdown etc.) and to the abuse of professional ethics. So we must keep asking ourselves some crucial questions: 1.
2.
Special techniques As we progress in this sort of work we begin to get a feel for the pacing, timing and manoeuvring that works best for us. The more advanced techniques that we can use will be discussed in further papers. But, broadly they could be described as ways of 'limiting', 'linking' and 'summarizing'; hypothesizing and planning 'interventions'. Their main aims are to contain the therapeutic process; keeping it efficient and on track; keeping boundaries drawn, firm and flexible; redefining patterns and building new ones; and with the use of very tactful provocation. There are also important ways of keeping the practitioner from becoming 'stuck' that are more advanced. In many ways these are bound to mirror the changes emergent in the patient at particular moments during their treatment. If we cannot unstick ourselves from a particular sort of log-jam, we can hardly expect to help them to do so!
3.
4.
5.
Practitioners' support It is very encouraging and supportive to have the satisfaction of doing our work well, with visible and palpable results. Experience adds confidence in our capabilities, our competence and our feelings of integration with human progress. But the more complex work can impose huge stresses on the practitioner. The solitary individual in one-toone practice can be extremely vulnerable. At the worst this can lead
6.
Is our workload too heavy? What breaks and variety do we always take time for? Are our expectations in line with what is reasonable and probable? Are we disappointing ourselves and our patients by setting the sights too high all the time? Are we attempting the improbable, expecting things to move along faster than an appropriate rate of change? Is our non-professional life at least as lively, vigorous, interesting and absorbing as our clinical life? Can we expect our own social matrix to put up with less than a 'whole' and vibrant person, capable of undistracted full engagement with them? Do we come back to our work refreshed and recharged? Are we meeting regularly with professional colleagues specifically to discuss the strains and difficulties inevitable in our work? Could this be something like a minimum of 3 hours per month? Could we also include practitioners not sharing our own viewpoint, so we can agree to disagree, and hear questions that arise from a fresh vantage point? Have we made a deeper study of some special topics? These might be of bereavement and loss, dependency problems and eating disorders, family and relationship problems, psychosexual disturbances, and perhaps the problems of social change and disadvantaged people generally. Are we pursuing our interests in broader human function on a broad scale so that we can see our work as part of a general development and exploration of new information and models?
So each time we ask our patients about their home, work and relationships we must ask ourselves the same questions. Are we ourselves really settled in our home, and in our work, and in our relationships?
Conclusion and implications Structural engineering is the art of modelling materials we do not wholly understand into shapes we cannot precisely analyse so as to withstand forces we cannot properly assess in such a way that the public at large has no reason to expect the extent of our ignorance (B eder 1991 ).
In a standard and conservative medical textbook of 25 years ago (Davidson & Macleod 1971) it was noted that in any 1 year at least 14% of the patient population would suffer from some minor psychiatric condition. More important for this paper was their estimate that, of problems presenting in practice, at the very least 40% have a strong psychosomatic component. Our view of the classification and management of illness need not necessarily coincide with that of orthodox medicine, although we must overlap each other in many important areas. In actual fact their recommendations for treatment by the ordinary general practitioner were in many respects similar to those discussed in this paper (Davidson & Macleod 1971). Given that the perfectly orthodox medical teaching of 20 years ago took this balance of factors into account, what was the teaching of our own disciplines doing then? What is our consensus now? What will it be in the immediate and long-term future? What practical changes have we made in our work together to become more holistic? What actions and acts do we really do that are different, and what is the direction of their development? The parallels between our work and good plays, theatre and performers can be extended a long way beyond just
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Latoy our experience of 'stage fright'. We can do a lot to enhance our awareness of plot and thematic development, and to enhance our ways of depicting life' s predicaments for our patients: bringing them to life. How much can we make use of our own imagination and good bumour (Latey 1987)? We are all well aware of the many aspects to our 'front' that we offer to the world, of our externalities and the impressions of ourselves that we put into our social and personal interactions. Making at least semideliberate use of our adaptability and flexibility of character can enliven many seemingly hopeless clinical
problems. Done well it will always refresh the therapeutic interaction in ways that are humane and beneficial to the patient - if we have the courage to imagine ourselves doing it! Perhaps we will arrive at a point where all of our work really will consist of mind, matter and motion.
ACKNOWLEDGEMENT Artwork by Maxwell John Phipps.
Davidson S, Macleod J 1971 Principles and practice of medicine. Churchill Livingstone, Edinburgh, pp 1071, 1084 Latey P 1983 An expansion of modern osteopathic diagnostic theory. British Osteopathic Journal 15:15-22 Latey P 1984 An expansion of modern osteopathic theory of technique. British Osteopathic Journal 16:51-56 Latey P 1987 Psychosoatic holism: an expansion of W.R. Bion's psychobiology. Hofistic Medicine 2 (4): 185-201 Latey P 1992 Some notes on basic clinical tactics. Australian Journal of Osteopathy. December.
REFERENCES Beder S 1991 The fallible engineer. New Scientist 2 Nov
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P. J. Latey Abstract This paper aims to explore the everyday practical realities of clinical work. The reader is invited to consider various tools and guidelines to help in decision making. Severity of problem, the human side of the patient in context, and some important distinctions in technique are highlighted. Three key questions about home, work and relationships are emphasized, followed by contraindications and the support of the practitioner.
Introduction
Philip
Latey 1 Toongarh Road, North Sydney, NSW 2060, Australia
Correspondence to: P. J. Latey Tel: ++61 9929 6603; Fax: ++61 9929 8807 Received November 1996 Accepted January 1997
Journal of Bodywork and Movement Therapies (1997) 1(3), 163-172 © P.J, Latey 1997
This is the third discussion paper in a series designed to highlight key areas of interest to manual and movement therapists. The first paper set our work within a clinical formula, and a 'maxim' that governs the clinical setting: Always diagnosis, aetiology, prognosis and treatment agreement (ADAPTA). That paper continued with a brief 'diagnostic' look at the behaviour of muscles; seeking to bring out their sensory, emotional and experiential/subjective aspects. The author suggested that we might start with nine senses, four layers of typical postural behaviour, three regions of typical tension/compression patterns, and finished with a brief study of shock and withdrawal. The second paper, moving from general diagnosis towards the study of
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aetiology, explored the link between maturation and healing processes, with some of their physiology and psychology. Starting with a case history and more detailed look at adolescence, the paper used some aspects of migraines and asthma to show the possible effects of 'focal immaturities'. The author also suggested that many chronic stress syndromes are linked along the length of the body by a ruminative inner tube that digests, absorbs and rebalances tensions through some processes allied to 'fantasizing'. A range of social pressures working against maturation were mentioned in the conclusion. This paper, the third of these collections of themes for therapists, begins a study of treatment methods and clinical tactics. The author cannot produce a definitive guide to best practice such as one might hope to find in a good surgical manual, or in the indications for antidepressive
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Latoy medication. Nevertheless, there are many practical tips, simple models, 'tools', distinctions and broad classifications that may be very helpful for manual and movement therapists.
Simple models and distinctions Time management If our therapeutic schools depend on the innate self-rightingness of biological organisms and systems, we have to ask one very vital question. How much has our patient's capacity for self-restructuring been compromised? How ill are they? How ample and resilient are their current reserves of healthfulness? This judgement, often made intuitively in the first instant of our encounter with the patient or when we start to feel their body tissues, may determine many things. How much testing and elimination is needed? How urgent might this be? How much of our time will we be allotting to the case? We can simplify and formalize some of these elements into a 'spectrum of severity'. This spectrum also begins to place us in a proper continuum with orthodox medicine and indicates the gaps that the ordinary medical practitioner cannot encompass (Fig. 1). This spectrum has been discussed elsewhere (Latey 1983). But, briefly, category 'A' may represent perhaps two thirds of 'symptoms' in the community - but they are never presented to a health care practitioner. At these times people treat themselves, mostly by applying minimalism or faddism. As symptoms diminish or are adapted to, or the episode resolves, they are likely to believe that their methods and fads are effective or curative (post hoc propter hoe). The 'B' patient usually needs little more than a nudge in the right direction, with some reassurance and advice about management. In fact many of these problems may have
diagnosis into some sort of pattern of factors obstructing their return to health. This should give us as clear and simple as possible ideas about what has to be achieved in the clinical work. As an example, the author has described a scale of lesion patterns and complexity that we might look for in osteopathy (Latey 1992):
begun to resolve the moment they picked up the phone to call us making much of our treatment irrelevant. Here, also, we are likely to accept our own belief systems uncritically. The 'D' patient, on the other hand, is likely to have an urgent need for medication, surgery or asylum. Their illness is fixed in form; identifiable from the medical text book and we call on all of the resources of orthodox diagnosis straight away. The greatest challenge to the skill of the therapist, lies in the treatment of the 'C' patient. The 'C' patients' healthfulness has become so encumbered that they may only be able to proceed through small increments and stages of 'cure' that are hard fought. For the practitioner to survive work with these many-layered and often ill-defined areas of chronic health problems, they may need strong support or supervision with colleagues; sophisticated tactics, strategy and choreography; with the ability to sustain frustrations and the sense of futility. Above all they must have secured for themselves a position from which to rethink the case. So, there may be quite a lot of thinking that is set in motion by our initial impressions of the severity of our patients' problems, and how we are best able to manage our time.
(a) Specific tissue/joint lesion. Primary or secondary. Type one or type two. Acute or chronic. 'Compensatory'. Motion or position. (b) Somatic dysfunction. More broadly defined as musculoskeletal bind. Larger scale of biomechanical functional units in conflict. Opposing demands and directions. (c) Somatico-visceral and viscerosomatic dysfunctions. The facilitated segment, neurological lens, group lesions and cyclical feedback patterns. (d) Functional disturbances of fluid or pulsatile motility. Torsional/visceral. Breathing and involuntary movement patterns. (e) Compensatory failure. Large scale breakdown. Whole body lesion complexes. Postural - ergonomics - sports - exercise physiology/nutritional disorder. (f) Large pathogenic pattern of related factors. Include mental/environmental. Subjectivity. Social, emotional. Whole person in context. Current and history of group interactions. Mind matter and motion.
Fixing objectives Looking at the patient as they are now, with their set of symptoms or problems in the 'maintained' state, we have to try and crystallize the
A~ Health
Brief
Short-term
(Hoursof treatment prognosis)
Long-
Mediumterm term
Fig. 1 Spectrum of severity.
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These loose categories are like filters that we superimpose on the 'maintained' picture to look for the simplest model that will fit. They are not mutually exclusive, and likely to be found together; often nested or embedded within the clinical findings. And we have to choose at which level we will have to pitch our efforts. Only the last of these will require a really full holistic understanding of the problem; but this will be necessary for most of our more challenging cases.
Problem-solving or supportive work? With some idea of severity, and the complexity of the problem, we have to decide whether we are actually looking at a set of symptoms that really can be entirely and permanently cured. What are the patients themselves actually hoping for? It is quite common for us to find that our methods can help make a substantial improvement in the patients' health and quality of life, but that this is only partial and temporary. In these cases we may often be settling for an open-ended process that we would describe as long-term maintenance or supportive work. Although this is not aimed at cure, it may be of great value to the individual and community. Supportive and maintenance work is beyond the scope of this paper, but each practitioner needs to decide on the balance and proportion of their practice time to be taken up by the different sorts of work. When it is clear that the patients' hopes and expectations might be met, we have the beginnings of the prognosis and treatment agreement.
The nature of the process In each therapeutic discipline there must be an underlying set of ideas, a philosophy and some basic principles. Our technique, tactics and overall strategy are derived from these - at
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least partially. In more complex modem osteopathy, for example, we look at the subtle recursive interactions between the structure and function of a system. Although this may be a somewhat artificial way of dividing things, it enables us to make a clear distinction between different forms of intervention. It became apparent in the 1960s and 1970s that there were two almost diametrically opposed approaches to techniques currently in use. There were practitioners succeeding in practice by the use of directive forceful methods that confronted and overwhelmed restriction in the bodies of their patients. Others succeeded by tuning in to intrinsic movements and enabling them to reach a new balance. There was, then, an opposition between extreme principles of 'confront bind' or 'pursue ease'. This could be compared to the unknotting of two radically different types of bind (Fig. 2). The slip knot shortening a piece of string can be released by a sharp pull away from the knot. If we pull in this way on a sheep shank it merely tightens. The release movement in this case is a slackening off of tension combined with rotation and lateral oscillation so that the knot can simply unwind. In the midst of these extremes we also had a group of 'technique
maxims' the usefulness of which cannot be exaggerated. For example, we might be attempting to: • Exaggerate the lesion. • Retrace the path of the lesion. • Loosen above and below; let the middle resolve itself. • Isolate the lesion. • Hold the lesion complex, compress it, and let everything else move: release very slowly. • Tune in to small differences and amplify them. • Find it, fix it, and LEAVE IT ALONE. e and so on. Various notions of this sort might come to mind during the most crucial moments of a therapeutic session, and help us enormously. Structural technique aims to confront bind in a system by the use of linear force. It aims to break down fibrotic areas and scar tissue, stretch and elongate tissues, restore or increase ranges of movement and so forth. It might do so by high velocity thrust, strong traction, deep friction, deep kneading, strong deep pressure, persuasion, exhortation and the like. Functional technique aims to pursue ease by the use of subtle multidirectional influence that is engaged and in tune with the system. It aims to release torsional patterns by
Shoed s~snk
Silo knot
STRUCTURAL release
Fig. 2 Slip knot and sheep shank.
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Latey facilitation/lysis/catalysis. A feeling of expectancy is established by setting and securing the boundaries within which changes can happen; waiting for them and helping to allow them to happen. Examples of functional work might be the dissolution of frozen traumatic shock patterns; the enabling of breathing and involuntary movements to rebalance. The techniques (low velocity stress types) might include gentle slow soft-tissue kneading of a very relaxing/calming/lulling type; listening to and following the involuntary movement patterns; minimal compression and release with torsional unwinding; diaphragmatic release; gentle moulding of the cranial and facial articulations and similar subtleties. To this we should add our exploratory techniques of simply playing around with an area or function. Both types of technique are designed to remove obstacles to health, and can be joined together into one scheme (Latey 1984). The aims of structural technique seem to be mostly in the direction of restoring homoeostasis; whereas functional work is more likely to provide opportunities for transformations and developmental metamorphoses. As we begin to expand our scheme to include the mental, emotional and social we may well find that this simple division of styles and approaches applies equally well to verbal interpersonal interactions, giving a very broad range of therapeutic choices.
various distances from them (Fig. 3). In the case of Sally (see Part 2 of this series) her treatment might have been interminable, or a total failure without careful thought to her participation in a broader field. Sally 'grew up' spectacularly during relatively brief manual treatment and general therapy. Sally' s practitioner took great care to reinforce the stability of her relationship with her husband. One crucial intervention clarified her relationship with her mother and the family of origin; making it innocuous. Sally was also helped to distance herself from her previous social group, who had equated success with easy money gained by cunning, ruthlessness and good luck. She was supported in this by the solid socioeconomic and political stance of her practitioner. So we can regard the levels of the expanded matrix as related systems with their own structure and function even to the point of imagining what an extra-species observer might make of the picture that emerges!
Practitioners' attitudes: preparation If we use words such as the 'stance, attitude, position or bearing' of the practitioner these could equally refer to something social, psychological or physical. How we view our patients will tend to reflect the common view of illness in the community, amongst our colleagues, what we think in our own minds, and how we feel about our own bodies and lives. With all complex problems we cannot have ready-made solutions. To try for the 'quick fix' straight away may well preclude more successful long-term work. We may not even be able to tell 'what is happening to what' with any great precision for quite a time. So, in the fine tuning of our clinical stance the first thing that we all have to cope with may well be something like acute stage fright.
'Stage fright'
-
Function
close grouping 'emotionals' ethnic/ etc social
We may have confidence in the capacity of our holistic approach to
general economics/
(e.g.
politics
climate)
? extra-species " observables
close 'emotionals' etc grouping ethnic/ social
economics/
politics
From manual to interpersonal The therapeutic interaction is a very special case, far removed from the everyday life of our patients. For the more complex cases we need some evolving picture of them engaged in the ebb and flow of human events. Again we can simplify this to set them within a matrix of relevant levels at
general (e.g. climate)
? extraspecies observables
Note: 'Close emotionale' including the immediate physical and mental/informational habits of the patient
Fig. 3 Expanded matrix: patient in context.
v
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meet and solve a wide range of health problems, but feel very anxious about our personal ability to apply the tools that it offers successfully. Faced with any new problem we all have to cope with our own worries - that we might overlook some crucial factor, fall to get a proper grasp of the situation, make people worse or no better, or start something that we cannot finish and our fear of the problem that might deteriorate catastrophically. Therapeutic work, at its best and most challenging is very high in stress and anxiety. On the other hand, if we can put up with those disturbing feelings of doubt and dread, futility, incompetence and ignorance (that are always liable to recur as we struggle towards maturity) there is much to gain. The unease that the author has labelled stage fright has to do with our awareness of the need for flexible but definite responses in an unpredictable field of interaction with the patient. By preparing to meet the unexpected in this way we encounter new aspects of the human condition almost daily. Alongside this acute unease or stage fright our lively interest, goodhumoured and patient optimism should be alerted to a very high degree of intensity, and focused on the problems brought to us by our patients. Part of our preparation to work lies in the mastery of a range of therapeutic simplifying hypotheses kept 'at our fingertips', and ready for use. It seems best to Use very simple contrasts to decide from moment to moment how to proceed.
P r a c t i t i o n e r s ' attitudes: tactical balances There are many tactical balances that we maintain while we are working. And, while we all find our way into these orientations quite naturally with experience, it helps to think about them. If we can define them more clearly we can at times make more defiberate choices, and alter our
approach more freely when it seems desirable.
Verbal and non-verbal There is a varying proportion of verbal and non-verbal interaction in our typical session. How much is said before the physical work; how much during it; and how much after? The quality and type of verbal communication during all three phases is quite different. We might aim to make language as adequate a therapeutic tool as the use of our hands and movements: and to integrate the use of them both. At this point it is vital that we realize that the verbal communication skills used in the ordinary course of our manual and movement work are radically different from those used in the various schools of counselling and psychotherapy. We are usually working on the physical unwinding of bodily seizures, and improving movement. In most cases our patients' distress is at least partially tangible and real to us and we are working directly with it. For the most part very little needs to be said but what actually is said is often crucial to the outcome! A well-timed question or comment can be as dramatically and lastingly effective as any of our physical manoeuvres.
Formal and informal There is a general tendency in our work to progress from formal towards informal interaction with our patients. It is crucial for our effectiveness that we never lose some of our 'formal reserve' (an overview of the progress of the case, our professional standing, ethics, aesthetics, etiquette, privacy and so forth). Nevertheless the very best physical and verbal tactics seem to happen most successfully when the practitioner has relaxed with the patient into a slow and easy rapport and empathy during and after the middle of the session.
This balance of formal and informal is most obvious with the new patient. We ask so many formal questions around the nature and dynamics of their current complaint, survey their current state of health and past history of illness and relevant events. We will often signal the end of this more formal phase by a more informal comment 'sorry about all the questions'. This helps them relax, but allows them to consider that we are not only very thorough, but preparing to adopt a more holistic understanding of their health and problems. We will then usually prepare them for physical examination, which has its own pattern of formalities. So, with the new patient it is only towards the end of the session when we are beginning some treatment, have begun to relax them, and have an idea of where to start that we will be able to ask in an informal way the three key questions (see next section) that are the most important kernel of this tactical paper.
Other technical balances Alongside the structural or functional, verbal or non-verbal, formal or informal balances that we maintain, we can describe many other important dynamic contrasts in our work. At times we can choose between setpiece tactics and those that are improvized ad hoc, between directive and interactive, provocative and contemplative action; between those methods that are highly determined and those that are open-ended, exploratory, and may just be making space for more manoeuvring.
Spontaneity Much that we do may, in fact, be something that we only understand after we have done it, if we understand it at all! A lot of the logic of osteopathy, for example, has probably arisen 'ex post facto', having done something that felt right at the time. Storing up these spontaneities and
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Latoy mulling them over is one of the ways that we improve with experience. Overall we can say that an awareness of these tactical dynamics in our work helps keep maximum flexibility while both feet are planted firmly on the ground.
What are we looking for? With each person or group we are trying to explore and recognize certain features and aspects of their lives and problems. We could say that we are looking for a pattern of patterns within patterns that are in some way coherently linked. As we oscillate between broader and narrower sections and areas we build up a picture something like a set of Russian dolls. We can assess dysfunction from the broadest of social bases down to the minutiae of a tiny localized disorder, and explore their relevance to each other. Like the faces, features and clothes of the nested Russian doll, it is the thematic consistency, familiarity and fit between these levels that is convincing in our more holistic study of pathology. With experience we also begin to be able to deduce or intuit features of the missing layers and links that we have not yet explored.
Thorough but minimal As we question and examine the patient it is extremely important that we are feeling our way between these levels only to discover which elements are going to be most useful in the resolution of their problems. As a general rule we never attempt to achieve more than they have asked. This is the nature of the clinical problem-solving contract; and we need it to set firm limits to our work. We also take great care to stay minimal and tactful in our interactions. It's a great mistake to be continually unearthing and dwelling on the past and present vicissitudes of the patient' s life, as these are reasons
to be ill and to stay i11. No. We are going to be always most interested in ways of getting better, of learning that certain stresses are over and finished; that there are better ways of relaxing; that bygones can be bygones eventually; and that ordinary life in the present has the potential to make everything available that is needed for health. And, as we work at the various levels that we can influence, we may find in our more successful work how people change fruitfully in ways we have not sought to influence or predict - and might also see how they bring their community to life! Luckily the questions that we will be asking in order to explore the ramifications of the problem are often the same ones that may stimulate its resolution. The simple fact of our asking (which is a form of intrusion into a system) requires them to formulate some sort of response making internal reformulations and a shift in attitude more likely. We cannot even look at a problem without acting on it! Nevertheless, in spite of our hopefulness about the effectiveness of our work we should not even try to emphasize only the positive in our work. The unflagging wishful thinking of the 'optimism police' in so much pop psychology is tiresome in the extreme: sacrificing long-term possibilities for a short-lived boost that wears thin very quickly. Overall the best attitude to convey is one of patient light-hearted hopefulness, with a measure of honest ignorance. We really don't know exactly how important each aspect of the case is likely to be. And, however much we might have guessed or already been told by the patient we cannot possibly know how they are themselves experiencing their lives, or the repercussions of their interaction with us. Some part of each person's version of things will always remain enigmatic, singular and unique to themselves. Our ways of including human subjectivity into our work
could never be as pragmatic as, for example, reading an X-ray.
Hope and despair So another balance that is subtle, but of great importance is our oscillation between optimism and pessimism. We naturally alternate between hopeful and encouraging views of the future, and a sort of global feeling of futility about the hard work, lack of results and seeming interminable impossibility of what we are attempting. This pessimism might emerge from the patient or practitioner's exasperation and frustration - ' W h y don't we just cut it off and throw it away?'. Often, if the situation seems very bleak it is only this light-humoured but rather 'black' sense of fun that can clear the air. By imagining and exaggerating the very worst we can somehow restore hope for something better, or restore a rapport that has begun to faker. The emergence and use of humour and imagination in our sessions is a very complex topic needing close study. It is enough here to note that its spontaneous appearance usually marks a substantial turn for the better.
Three key questions Given the scale of lesions 'a' to 'f' above, a loose categorization of what we might be looking for, we can now distinguish between the full use of holistic practitionership, and its lesser more restricted and limited use. We can do this in a very simple and decisive way. Towards the end of a first session when we and the patient are beginning to relax, or perhaps in the second or third session we ask these three key questions, or a close equivalent in a quiet conversational and relaxed way. •
'Are you settled ... in your place to live?' • 'Are you settled ... in your work?' • 'Are you settled ... in your relationships?'
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Unless they have already told us that they are moving house, work is stressful, or a relationship is foundering, this is the natural order for the three questions (Figs 4-6). We cannot really claim to be using modem holism fully unless we are making precisely this sort of openended enquiry. What a vast difference three questions make: between the practitioner open for the patient to tell them their distress and the stresses they're undergoing, and those practitioners with ready-made answers and schemes that preclude the emergence of the subjective human being. But we must be extra careful not to do much about what they tell us at least not straight away. -
Attribution and 'collusion' Patients, like all of us, are uneasy with aspects of life that are unexplained. They will have some view of the causation and remedy for their ills. This is usually simpler and much more linear than the clinical models that we are developing. In addition to this we also find that people who have converted unsolvable emotional and social stresses into physical symptoms ('somatizing' heavily) are generally unable even to imagine that there might be any such link (Latey 1987). In view of this we do best not to even try and connect things up for them - at least to start with. So we will usually start by explaining the somatic as caused somatically, with the emotional and social being something left entirely separate. This collusion with their preference in the form of the explanation that we agree on, will probably be somewhere along the lines of our lesions 'a' to 'e', or their equivalents, and leaves the more complex 'f' patterns unspoken. We are then free to continue physical work in the ordinary way, keeping our more personal enquiries sparse and conversational. We may also need to be careful not to disturb or challenge their own
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Fig. 4 'Are you settled ... in your place to live?'
beliefs in treatments that they feel have helped; however much we might recognize their faddist or unrealistic nature. If we simply remain noncommittal their interest generally subsides. Later on if things are not beginning to resolve well, we can introduce
general ideas of stress and tension, and link these to visceral upsets, exhaustion, muscular clenching and so forth. This can be an extremely tricky phase in work with severe and recalcitrant problems: most of the more successful tactics for this are beyond the scope of this introductory paper.
Fig. 5 'Are you settled ... in your work?'
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Fig. 6 'Are you settled ... in your relationships?'
We can later correct our original collusion very easily by saying: 'but there seem to be some other factors that I don't quite understand preventing the problem from clearing up'. We thus return to our position of interest with some ignorance and curiosity; perhaps wondering when they will start asking the interesting questions for themselves.
Communication skills There are many reasons why the various schools of thought in counselling and psychotherapy have only marginal relevance to manual and movement therapists. There are in any case at present no schemes modelling mental function as a part of visceral, respiratory and neuroendocrine or neuromusculoskeletal processes that are more than tentative hypotheses. Nevertheless, our good rapport and empathy enable us to question amiably about their personal life. This evolves into more of a conversation quite naturally. Our conversations with them, again can easily become discussions - and the discussions will often gather strength, interest and pertinence, to the point where we are actually helping them find a way past some key factor maintaining their problem.
So we do best not to describe any part of our work as counselling or psychotherapy, but to keep our view of these verbal interactive skills at the level of useful conversations or discussions, in our own minds and in the mind of the patient. That said, we can use some of the basics from 'verbal' schemes to very good effect. They all agree that we will always attempt to define the presenting problem very clearly, define what improvements can be expected, and have some way of monitoring improvement. We will also generally be working within a limited number of sessions, and will usually emphasize the limitations of our work; setting times for reassessment of progress. This much is held in common by all serious clinical disciplines.
General skills A range of simple guidelines are suitable for simple crisis intervention and can be extended towards our equivalent of brief counselling or psychotherapy work. One of the main differences is that we will be keeping the psychological, emotional and social as a low-keyed and peripheral aspect to our work. Only rarely and at crucial moments does it necessarily become central, and the main focus.
When some social/emotional stresses have come to a head, and may be precipitating florid symptoms, anger, despair or grief, our first job is to listen very carefully and attentively. Patients may express their narrative and dilemmas very emotively. It is absolutely crucial at this point for them to perceive that they have been heard. In crisis this expression of emotion, and being heard companionably or compassionately ('ventilation') may be all that is needed for them to begin to move on past the worst of their current emergency. With problems that are more ingrained we will be keeping up the attentive listening, but may begin to question carefully around the problem; prompting gently to help them approach things that are difficult to say. We will be aiming for them to have heard themselves say what has to be said at least two or three times, coming to it from slightly different angles. We hope also that they are developing an appreciation of wider connections and some practical grasp on what has to be done.
Contraindications Right from the very start we must not even think of doing this more extended work unless we are convinced in our own minds that the troubled patient is an agreeable ordinary person, living their life in a way familiar to us, with problems that are also ordinary and familiar. If we feel that there is anything even slightly odd, or threatening or seductive about the situation we do best to back off immediately and think how we can best refer them elsewhere. In a sense we cannot proceed confidently until they have already gained our own confidence. We also must be certain that we have at our fingertips all signs and presentations of depressive illness. At least one third of suicides have consulted a health professional in the
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weeks before their deaths; and this is commonly with physical symptoms. Again we need to know how to refer them urgently for proper care, and ensure that they are accompanied and kept an eye on. The work that we can undertake may also be severely limited by our own lack of support and balance (see below).
to suicide, alcoholism and addiction, impoverished relationships (marital breakdown etc.) and to the abuse of professional ethics. So we must keep asking ourselves some crucial questions: 1.
2.
Special techniques As we progress in this sort of work we begin to get a feel for the pacing, timing and manoeuvring that works best for us. The more advanced techniques that we can use will be discussed in further papers. But, broadly they could be described as ways of 'limiting', 'linking' and 'summarizing'; hypothesizing and planning 'interventions'. Their main aims are to contain the therapeutic process; keeping it efficient and on track; keeping boundaries drawn, firm and flexible; redefining patterns and building new ones; and with the use of very tactful provocation. There are also important ways of keeping the practitioner from becoming 'stuck' that are more advanced. In many ways these are bound to mirror the changes emergent in the patient at particular moments during their treatment. If we cannot unstick ourselves from a particular sort of log-jam, we can hardly expect to help them to do so!
3.
4.
5.
Practitioners' support It is very encouraging and supportive to have the satisfaction of doing our work well, with visible and palpable results. Experience adds confidence in our capabilities, our competence and our feelings of integration with human progress. But the more complex work can impose huge stresses on the practitioner. The solitary individual in one-toone practice can be extremely vulnerable. At the worst this can lead
6.
Is our workload too heavy? What breaks and variety do we always take time for? Are our expectations in line with what is reasonable and probable? Are we disappointing ourselves and our patients by setting the sights too high all the time? Are we attempting the improbable, expecting things to move along faster than an appropriate rate of change? Is our non-professional life at least as lively, vigorous, interesting and absorbing as our clinical life? Can we expect our own social matrix to put up with less than a 'whole' and vibrant person, capable of undistracted full engagement with them? Do we come back to our work refreshed and recharged? Are we meeting regularly with professional colleagues specifically to discuss the strains and difficulties inevitable in our work? Could this be something like a minimum of 3 hours per month? Could we also include practitioners not sharing our own viewpoint, so we can agree to disagree, and hear questions that arise from a fresh vantage point? Have we made a deeper study of some special topics? These might be of bereavement and loss, dependency problems and eating disorders, family and relationship problems, psychosexual disturbances, and perhaps the problems of social change and disadvantaged people generally. Are we pursuing our interests in broader human function on a broad scale so that we can see our work as part of a general development and exploration of new information and models?
So each time we ask our patients about their home, work and relationships we must ask ourselves the same questions. Are we ourselves really settled in our home, and in our work, and in our relationships?
Conclusion and implications Structural engineering is the art of modelling materials we do not wholly understand into shapes we cannot precisely analyse so as to withstand forces we cannot properly assess in such a way that the public at large has no reason to expect the extent of our ignorance (B eder 1991 ).
In a standard and conservative medical textbook of 25 years ago (Davidson & Macleod 1971) it was noted that in any 1 year at least 14% of the patient population would suffer from some minor psychiatric condition. More important for this paper was their estimate that, of problems presenting in practice, at the very least 40% have a strong psychosomatic component. Our view of the classification and management of illness need not necessarily coincide with that of orthodox medicine, although we must overlap each other in many important areas. In actual fact their recommendations for treatment by the ordinary general practitioner were in many respects similar to those discussed in this paper (Davidson & Macleod 1971). Given that the perfectly orthodox medical teaching of 20 years ago took this balance of factors into account, what was the teaching of our own disciplines doing then? What is our consensus now? What will it be in the immediate and long-term future? What practical changes have we made in our work together to become more holistic? What actions and acts do we really do that are different, and what is the direction of their development? The parallels between our work and good plays, theatre and performers can be extended a long way beyond just
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Latoy our experience of 'stage fright'. We can do a lot to enhance our awareness of plot and thematic development, and to enhance our ways of depicting life' s predicaments for our patients: bringing them to life. How much can we make use of our own imagination and good bumour (Latey 1987)? We are all well aware of the many aspects to our 'front' that we offer to the world, of our externalities and the impressions of ourselves that we put into our social and personal interactions. Making at least semideliberate use of our adaptability and flexibility of character can enliven many seemingly hopeless clinical
problems. Done well it will always refresh the therapeutic interaction in ways that are humane and beneficial to the patient - if we have the courage to imagine ourselves doing it! Perhaps we will arrive at a point where all of our work really will consist of mind, matter and motion.
ACKNOWLEDGEMENT Artwork by Maxwell John Phipps.
Davidson S, Macleod J 1971 Principles and practice of medicine. Churchill Livingstone, Edinburgh, pp 1071, 1084 Latey P 1983 An expansion of modern osteopathic diagnostic theory. British Osteopathic Journal 15:15-22 Latey P 1984 An expansion of modern osteopathic theory of technique. British Osteopathic Journal 16:51-56 Latey P 1987 Psychosoatic holism: an expansion of W.R. Bion's psychobiology. Hofistic Medicine 2 (4): 185-201 Latey P 1992 Some notes on basic clinical tactics. Australian Journal of Osteopathy. December.
REFERENCES Beder S 1991 The fallible engineer. New Scientist 2 Nov
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