Placebo: a study of persuasion and rapport

SERIES: THEMES FOR THERAPISTS

Placebo: a study of persuasion and rapport . . . . . . . . . . . .

Philip Latey

There may be as many ways of getting better as there are ways of getting ill. We cannot say that we know all there is to know about either of these. Part of the picture must always remain largely mysterious, but fascinating nonetheless.

Philip Latey 1 Toongarah Road, North Sydney, NSW 2060, Australia Correspondence to: Philip Latey Tel: ‡61 (02) 9929 6603, Fax: ‡ 61 (02) 9929 8785 Received October 1999 Revised December 1999 Accepted January 2000

........................................... Journal of Bodywork and Movement Therapies (2000) 4(2),123^136 # Philip Latey

The re¯ections in this paper come from 27 years of clinical experience in osteopathic private practice. Depending almost entirely on wordof-mouth referrals and fees paid by the patient, the author has sustained a reputation for good results in both brief treatments and in long-term complex cases. With a strong emphasis on methods that start from the somatic end of peoples problems, palpable change becomes clearer as our familiarity with the body grows. We become ®nely attuned to many sorts of di€erences in our patients. But why do these changes happen? Is there any way of knowing in our day-to-day practices? As we look for key factors that have helped the patient to turn the corner, we must inevitably consider whether some of them could be due to the operation of persuasion, suggestion, or some other form of `placebo response'.

During the author's years of training at the British School of Osteopathy (BSO) between 1969 and 1972 there was no place in the course to study the e€ects of placebo and persuasion. Mental, social and emotional factors of any sort were also hard to discuss. And yet many of the senior lecturers were without doubt extremely capable human `horse whisperers'. Among these were three men in their seventies who had all trained with John Martin Littlejohn, founder of the BSO, who had himself helped to set up osteopathy in Kirksville USA in the 1890s alongside its founder Andrew Taylor Still. Its importance to point out that prior to his conception of osteopathy Andrew Still had been both a `magnetic healer' and a `lightening bonesetter'.

Personal style Keith Blagrave was the only one of the BSO teachers with any professed knowledge of hypnotherapy, but he did not acknowledge any persuasive factor in his osteopathy. Nevertheless he would habitually hum little tunes at times, produce little practical jokes and stories with great aplomb; and engaged the patient with his one good eye in a

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Latey curiously riveting bird-like manner as he carried out his treatments. Clem Middleton had the misfortune to have had severe and lasting Bell's palsy. Behind this slight grimace he was highly intelligent, a great raconteur, and adept at turning any question into another question with great modesty: illuminating and shifting the area of inquiry. He seemed wonderfully enigmatic at times. Shilton Webster-Jones (Webber), who had been principal of the BSO since the 1940s, was an absolute master of in-close engagement with all sorts of dicult patients. When we students had ground to a halt, or didn't know how to manage `nutters', stubborn, surly or neurotic people, we would call for Webber. He would ask them a few extra questions while deftly maneuvering himself into their body space; appearing kind and respectful, but a ®rm and familiar ®gure to them. Within two or three minutes they were eating out of his hand. He would smile up at us from his bodywork as if to say `look Ð what's the problem Ð it's easy when you know how; but you've got to get them on side ®rst'. All three of these had a wonderful economy of ¯ow and movement. The choreography of their body handling and use of space in the treatment room was so graceful and captivating that their love of their work and care for people could not be doubted. These older men were very personable, with a de®niteness of enveloping and reassuring touch, tone of voice, and a respectful but somehow `knowing' acceptance of the person. They also had a sort of disrespectful way of handling the body; as if this could be any old specimen of humanity Ð without gender, status, class of any signi®cance at all, at any age and in whatever state we ®nd them; but treated still with some fondness and

familiarity. There could be no doubt about the persuasiveness of this second generation of osteopaths. In the next generation of BSO teachers, then aged thirty to fortyish, Audrey Smith, Bill Naidoo and Laurie Hartman were outstanding. Audrey had great depth of exploration, very patient discrimination, and understatement in her approach. Her sessions always felt secure and sensible; always `in her element' with bodies and clinical work with people. Bill had a combination of impeccable style and manners with an unerring touch for locating and releasing restriction in the body; and he never seemed to stop smiling altogether. Laurie has always had a very solid feeling of physical presence about him. This comes across in his posture and hands as an extreme but unobtrusive sense of con®dence: nonconfrontational, but de®nitely all-pervasive.

Therapy or therapist? In order to begin making sense of all this we can start by drawing a useful basic distinction. . Placebo responsiveness, we can make solely an attribute of the patient. . Persuasiveness, then, is a conscious and/or unconscious element in the practitioner's clinical repertoire. Additional di€erences between suggestion and clinical rapport will be brought out later in the paper. Unfortunately, the usual statistical type of clinical trial is not much help in this kind of qualitative study. We cannot ethically or practically use `dummy' treatments that are entirely impersonal; and our patients are usually strongly self-selecting. So we could never regard them as any sort of `random sample'.

Patient responsiveness Hard question Given the obvious attributes of these second and third generation osteopaths, is it odd that they were unable to decide which clinical results were due to persuasion? At the time they seemed unable even to discuss the topic without some evasion or dismissal. Unfortunately, this aversion also made psychosomatic studies unapproachable. The really hard question here is to decide how much of our real or apparent clinical e€ect is due to placebo and persuasion. How much is due to the real and lasting actual bodily change produced by the speci®c elements of the manual therapy? To complicate this issue, we would also need to distinguish the e€ects of the patients following helpful advice, and the various changes that they themselves make.

A great deal of responsiveness may be predicted from the way the patient comes to their initial consultation. In the very short term these may contribute to our success rates with uncomplicated problems (Box 1). In the ®rst place our personal reputation contributes a lot to these preconditions. If the patient has actually heard of our success and skills from two or more people, or even a whole social group who we

Box 1 Positives

Favourable preconditions . . . . . . .

Reputation Expectations Precise problem Self-motivation Hurdles Self payment Timeliness

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Placebo: a study of persuasion and rapport have been looking after, this is strongly favorable. Helpful also are a set of expectations that ®t with our capacities; their problem is relatively clearly identi®able, they are likely to have been referred by someone with a similar complaint. They are prepared to undergo an appropriate course of treatment, and to participate in their own rehabilitation. This `self motivation' factor is often crucial to anything longer than the very briefest interaction. And, in the case of the more stress-related conditions, a preparedness for some dicult self-examination is also very helpful. Where there is chronic pain, compliance issues may be crucial to the outcome (Liebenson 1999). It helps also if the patient has had to surmount some diculties in order to get to see us. . A bit of a wait for an appointment at a time that is not easy for them. . Some directions to follow if we are slightly o€ the map of their usual movements. . The e€ort of organising their account of the problem. . Preparing to be questioned, examined and probably treated in the ®rst session. These are all quite important hurdles to get over. The fact that they are prepared to pay for themselves, however small a contribution that is, makes a considerable di€erence in private practice. Except in some longer-term work where budgeting is dicult, people naturally expect to pay more for the best, and do not count the cost too greatly when their health is at stake. The timeliness of their consultation is also crucial. It helps when it is clear to them that the problem is not going to clear up without help, and they have reached a point where it has got to be sorted out. They have also abandoned

previous attempts at treatment and management; with enough time for it to be obvious that these have failed. If all of these positive factors are in place, the actual details of our clinical work might not be crucial provided we ®t reasonably well with their set of expectations. In fact it is not uncommon for the symptoms to vanish quite suddenly just before the ®rst consultation! We have only then to examine them and advise about recurrence and about any preventative measures.

Box 2 Negatives

Unfavorable preconditions . . . . . . . . . .

Unaware of therapist's reputation No hurdles Not self-initiated Not paying for self Any current or anticipated compensation claim Unreasonable expectations Unhelpful diagnostic labels Multiple failures to date Multiple current therapists No bene®cial or adverse e€ects reported

Reputation On the cautionary side of things we must be a bit careful about how we assess our own reputation. A patient comes in who we saw ®ve years ago. `I came in here in terrible pain and all bent over. After the ®rst session I walked out straight and completely pain free Ð you're wonderful; I'm sure you can do that again'. But we look at the old case records and ®nd that we struggled for 6 weeks to get them out of trouble: and weren't really sure of the result at the end of treatment. Somebody's memory has been severely edited!

Self cure What we are seeing here, and calling `placebo' is de®nitely a form of self cure when it is successful. In part this could be regarded as a form of auto-suggestion. In this sort of case the author would guess that at least 80% of the curative e€ect occurs spontaneously as part of some natural process in the patient. Our contribution may have been neutral or have added or taken away 20%. Beyond the clues we can gather from the bodily responses that we monitor, we just don't know how to assess our ecacy in cases where results have come quickly. Assuming that we do no cutting or poisoning it is actually possible to

ascribe all of our apparent successes to placebo e€ects. We could call this patient-produced sort of placebo responsiveness a favourable momentum towards spontaneous or assisted self cure.

Lack of momentum (Box 2) There are an opposing set of unfavorable preconditions that can make any self-cure increasingly unlikely. If the person has just drifted in from the street on the o€chance that they can be seen, or has picked us out of the yellow pages we are not someone of particular importance to them or to their social contacts. We may also seem considerably less important when someone else is footing the bill for them. Success also seems much harder when they have been bullied and coerced into coming to see us Ð and would not have done so under their own steam. Success is sometimes impossible when there is any legal, occupational, social or medical advantage from staying ill, from staying symptomatic or maintaining some disability. Unfortunately, this e€ect can be operable even when the patient is consciously entirely honest and honorable. The secondary gain from the illness may defeat us.

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Latey It is not helpful when they have unreasonable expectations as to what might be achieved. Nor if they have arrived with unhelpful diagnostic labels. There is a subtle di€erence between the person who asks if we can help cure the label (they have grown rather attached to it) and the person who asks `please can you help me?' The di€erence in body language, eye contact and eagerness to meet us is usually very marked. We often notice in retrospect that the initial case history was in fact very blurred, with factors missing, and had no clear descriptions and dynamics to the particular symptoms. The way the illness is labeled can make a huge di€erence and is subject to all sorts of vagaries in medical fashion (Shorter 1992). The intermeshing of labels like chronic fatigue syndrome, post-viral myalgic encephalitis, and ®bromyalgia syndrome, is always hard for us to unravel. Leon Chaitow points to a picture of `allostasis', following Hans Selye, where homeostatic processes are so poorly formed that any slightest perturbation is automatically responded to as noxious: making therapy virtually impossible (Chaitow 2000). We often erect a `cautionary ¯ag' if they have seen a chain of other therapist Ð some of them of good repute and skills Ð and don't even mention a temporary or slight improvement, or recount e€orts they have made themselves on good advice. This is often much worsened if they are involving multiple current therapists. The ancient Egyptians employed special doctors for every function Ð including Irij who cared exclusively for Pharaoh's anus. This would be far more a question of vanity, status and faddist belief; but `therapy hopping', therapy collecting and `name dropping' are on the increase. Often these people are actually in very sound and unstressed health;

but self-obsessed and socially indolent. We may be just indulging a rather pointless hobby and leisure activity! This cautionary ¯ag is amply con®rmed when they make no reference at all to our initial attempts at treatment. `How are you doing?' elicits the same word-forword vague description of unclear symptoms; as if they were a spur to urge the practitioner into increased e€orts, or to emphasise our ine€ectual impotence. Did they at the outset really convince us that they were determined to get better? These are broad generalizations only, and must not be allowed to colour our decisions in the individual case. There is a danger that they might become synergistic self-ful®lling prophecies if they undermine the practitioner's con®dence and optimism. Of course any person su€ering from long-term chronic pain and disability is likely to be depressed, broke, dependent, despondent, and half-hearted in their grasping at many straws. It is actually the most splendid challenge to us when we choose those very dicult and hopeless-seeming jobs; and have been able to help them function better and manage their problems with less diculty.

Persuasion So there are patient-determined factors that are active from the outset. Persuasion, on the other hand, is something that the practitioner does to the patient. This is to some extent a completely normal part of manual and movement therapies, and begins as soon as the patient starts to hand over direction of the session. What use we make of the phenomenon of persuasion may be crucial to the outcome; especially in very brief prognoses. Persuasion may also be very complex: `Another important set of technique variables belongs to the dynamics of the physical work itself and are intersubjective. They require a conscious and/or unconscious contribution from both parties in order to work. Under favorable conditions some patients can allow the practitioner almost total in¯uence over their pain sense, proprieceptive sense, pressure sense, location in space, body image, sensations of temperature, and sense of the passage of time itself. We often ®nd ourselves using variants of simple hypnotic technique, as in distraction techniques Ð occupying the patients' attention

Fig.1 Domination. 126

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Placebo: a study of persuasion and rapport

Fig. 2 Animal magnetism.

elsewhere while doing otherwise painful work, or when we need an instant's relaxation. But this is not an adequate explanation. We do not know how the patient is induced into the acceptance that our technique is lighter or more painless or less deep or quicker or slower than it really is. There is some sort of useful non-verbal collusion available to us that is unique to physical contact'. (Latey 1984) Animal magnetism was the `force' or in¯uence that Anton Mesmer thought he was using back in the 1760s (Wilson 1996). The illusion that some magical ¯uids and esoteric energies are responsible for cure is still with us in spite of all evidence to the contrary. There has been so much study of the e€ects of persuasion and suggestion (Bowers 1976) that we should by now be able to say how this contributes to mainstream therapies. But, apart from those who make deliberate and stated use of hypnosis and

hypnotherapy, few are willing to question the type of in¯uence that may be at work in their own practice. In order to look at the persuasive elements in our sessions we might look ®rst at the hypnosis of animals, since this is largely non-verbal. The manipulation of language to produce delusion and illusions through suggestion is not an

ordinary part of most manual and movement therapies. This distinction will be discussed later. Domestic animals and livestock are quite easily hypnotised. An excellent method is described in `dog's hypnosis' (Wilson 1996). The owner or trainer can use these techniques to enhance responsiveness, remedy bad habits, and for more advanced training. First a special mat or piece of carpet is produced that is only used for the hypnosis sessions, and is put away out of sight and access afterwards. The dog is allowed to play with the mat for a while till the enthusiasm wanes, then called onto the mat and made to sit or stand. With much reassurance and soothing voice the dog is told to respond to familiar commands in a relaxed way until tuned in to the trainer. New material, for example to reduce fears or aggression, is introduced calmly and gradually, with return to reassurance and routine whenever the dog seems confused or agitated. The session is ended with a couple of familiar movements, an alerting tone of voice, rewards if it has gone well, and putting away the mat.

Fig. 3 Good-dog mat. 127

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Latey Within this sequence we can see several features that are common to most clinical work. The time and place are de®ned as clinical and therapeutic, with the treatment table or exercise mat ready to con®ne the movements and attention of the patient. Special clothing or states of undress further de®ne the interaction. Wilson also makes use of special smells to mark the hypnotic session for the dog. We all of us know the smell of the hospital; but many other therapy rooms have a highly distinctive odour. With cooperation from the patient the practitioner takes over their movements, with directions to stand and move in particular ways. The movements themselves tend to be rhythmical and repetitious; the teacher/practitioner using steady non-alerting voice tones for their instructions. The end of the session is often marked by encouragement, conveying a sense of achievement, and the return to a more matter-offact voice tone reminding the patient of helpful advice, homework, and the ®xing of a next session (Box 3).

The setting There are many lesser details that can make a di€erence to the type and intensity of persuasion that we use. We might have a very formal authoritarian type of setting, with white coats, therapist at a desk,

anatomy wall charts and impressive appearing bit and pieces. An egalitarian emphasis with informal clothing, free from medical paraphernalia, and with equal chairs to sit on may suit the more secure practitioner and those patients who approach life with a healthy skepticism. The gender and age of the therapist might also make a di€erence. But this is o€set by many good therapists seeming to be somewhat ageless, and having quite an overlap of traditional gender qualities. Some are also able to combine a chameleon-like responsiveness with a very de®nite sense of self.

Limiting persuasion When the patient hands the direction of the session over to us they are submitting some aspects of themselves to our ministrations. As their responsibility for themselves lessens, so our responsibility must necessarily increase. We actually do best if we make a great e€ort to minimize persuasion, so as not to produce arti®cially distorted results. We need to be careful not to exceed the limits that the patient would normally feel comfortable with Ð both ethically and aesthetically. Even though we are inevitably in charge we must diminish their sense of vulnerability and our tendency to dominate; overwhelming no aspect of them at all Ð however, much it might seem that they want this. No aggression, no violence, no bullying.

Box 3 Animal Hypnosis

. . . . . . .

Territory and place Restriction of movement Direction of movement Voice tone Repetitions Reassurance Rewards

Initiating rapport To a certain extent we have to capture and engage attention, limit movement, and usually pitch some of our directions without alerting critical examination and second thoughts. But for useful sustainable work it is much better that the

patient stays as alert as possible; with the minimum of passivity. When we are aiming for change across important linked aspects of the person it is best if they have all their wits about them. They can then synthesize and integrate much of what we are doing as we go along in the session. They will also remember and re¯ect on interesting parts of it later with a clearer mind. About two minutes into the case history we can often sense patients hurrying us to get on with the bodywork. We cannot collude with this. Some ®rm minimum conditions must always be met before we can safely start treatment. On the table some want to switch o€ altogether and become putty in our hands, and to wake up cured after we've done whatever we have to do! It is often a great challenge to keep them thinking about their tenseness, and where the tensions are coming from and going to. Putty is very dull stu€. We can keep them from doing this by keeping some tactful questioning and leisurely discussion going. In this way most components of their personality stay intact and active; and we become gradually more real to them as they get to know us. We also come to appreciate them more as they are out in the real world and ®nd them much more interesting as they gather the con®dence to express themselves with us. As so much of our work is de®nitely `psychosomatic' we can keep the physical body central to our clinical work; with the emotions, minds, and psycho-social being attended to lightly and tactfully in the periphery. Recognition of this ®gure-ground relationship is crucial. From time to time the gestalt reverses, the body becoming peripheral to other pressing needs: often just to stay clothed and talk. But that does not require us to call ourselves counselors or psychotherapists. If we are careful to

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Placebo: a study of persuasion and rapport acknowledge limitations and gradually expand our capacities, the `mind' that emerges from our bodily understanding may be very di€erent from previous models (Latey 1996, 1997). In longer term work, then, the good manual and movement therapist often becomes someone with whom discussions are very useful when supported by a robust and unhurried rapport: without psychobabble or sermonising. This would not be possible if we had been using more than the minimum of persuasion.

Suggestibility Adding to the two original categories of placebo and persuasion, we can draw two more distinctions that are useful, and distinguish between suggestion and rapport. As an extension of persuasion, suggestions are speci®c attempts to over-ride and alter the perceptions and underlying assumptions that the patient brings to their inner and outer milieu. Persuasion, on the other hand can be viewed as just temporarily allowing themselves to do as they are told: much simpler. Suggestibility is extremely variable between people (Bowers 1976). It is a measure of the extent to which people make themselves available to external authority to govern their lives and thoughts, and to govern how they feel their own feelings. It is essentially passive and uncritical Ð and may have nothing to do with common sense at all. Looking again at how Steve Wilson trains his dogs (Box 3) we can see that these conditions cover a far wider range of phenomena than just the one-to-one relationship. From the crowds in the sports stadium to the religious congregation, military parade and Nuremberg rallies we can see conditioning by suggestion, or mass

`brainwashing', as a widespread social phenomenon (Latey 1998). We could say that the tendency to trust, sometimes against our own better re¯ective judgment, is hardwired into the behaviour of the group or herd; and part of the glue that tends to bind us together. In the presence of group pressure and strong suggestion we are being coerced into agreeing to agree; and never allowed space to question what we are being required to agree with. We naturally suspend our disbelief to engage with a piece of good storytelling, theatre, cinema, a novel, and even newspapers Ð that recreate re¯ections of some aspects of living. It is a triumph of the human imagination that wishful thinking and make-believe can almost become truth and fact to us Ð at least temporarily. But suggestible people's perceptions are so easily in¯uenced and overwhelmed that they can only see evidence for the convictions that they have been sold. They lose touch with common sense and healthy questioning far too readily. These are the cannon fodder in the battle for people's hearts and minds; in¯ating the wallets and egos of

those willing to exploit their gullibility. A 50-year-old patient had been working with the osteopath for some months to ease and improve her severely arthritic hip. On impulse she went to a `faith healer' of grandiose repute. He used strong suggestion to convince her that her hip was pain-free and could move fully. She abandoned her stick and walked all the way home in a state of euphoria and religious ecstasy. Next morning she was unable to move from bed. In extreme pain she was taken to hospital and, due to bony collapse, had to have a complete arthrodesis: permanently fusing the joint. (Case report from UK colleague) Results due to the application of strong suggestion to suggestible people are often dramatic and extreme. Rapid responses producing high levels of pain relief, altered perceptions and other strong bodily e€ects are not at all unusual. The pain threshold is the human subjective variable that is most particularly labile. Hypnotherapists use numbering of parts of the body as part of some common `inductions' (Calof 1997).

Fig. 4 Abject submission. 129

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Latey

End results Longer term e€ects of strong suggestion are much more variable. Patients of the author who have responded to acupuncture analgesia (administered elsewhere) usually report pain relief that lasts between two hours and a week or so. Unfortunately for patient and practitioner these responses are highly fatigueable, and su€er from the law of diminishing returns. By about the third session the e€ects of suggestion on the suggestible are exhausted; which is why the snakeoil salesman and apocalyptic preacher have to move on so quickly. The end is not nigh; we are not saved; the symptoms return. Some of these initial e€ects may be recoverable after a month or so; but never to the strength of the original. This may be part of the appeal of regular treatments that are repeated at wider intervals; and really achieving very little. This also helps to explain the army of patients migrating from modality to modality, and from fad to fad.

Suggestion and belief General belief systems are often more durable. But when they have been instilled by the usual combination of suggestion, repetition and auto-suggestion they may have to be renewed by frequent reminders. This `compulsion to repeat' staves o€ the pangs of disillusionment and the intrusion of common sense realisations. We none of us wish to appear naõÈ ve and stupid, especially to ourselves. Some attrition of treasured illusions, unfortunately, is part of growing up. The massively over-responsive person in unlikely to tell the practitioner that the results of their treatment were transient or illusory. Once their besotted and blinkered state begins to evaporate they may feel foolish, abused and remorseful

or depressed. Their condition may be worse. We have every good reason, then to be wary of the more charismatic quick ®x `healer', whatever versions of therapeutic practice, religious or social philosophy they espouse. Many practices and reputations have been built on their success with problems that are spontaneously remitting and episodic. It is also likely that some practitioners themselves become addicted to the quick ®x, to the appearance of dramatic cure and to instant results. Excessive zeal and fervent belief render them blind to people's real needs and the possibilities for longer-term success. Their indecent haste and inappropriate intensity usually make this clear. Nevertheless more sober and modest practitioners are used to estimating the severity, complexity and chronicity of problems that will take time to sort out. They sense the momentum of the patient carefully. (Boxes 1 and 2), and use only enough persuasion to enable the patients to participate voluntarily in the work. Having studied the problems presented to us we consider ®rst a very thorough di€erential diagnosis, and whether to refer them elsewhere. We develop our ideas of aetiology, and discuss the prognosis and treatment agreement with the

patient. The real degree of diculty, if we take on the patient, is represented by the length of the prognosis; the complexity of technique; and whether its aims are actually met. Problems that are going to take many weeks, months or even years to get right (Box 4) will depend less on the e€ects of persuasion and suggestion, and more on the skill of the practitioner and the ability of both them and the patient to sustain the momentum through dicult phases. There will always be a need for changes in tack, strain on the rapport, and much rethinking in review sessions to make an honest measure of progress.

Useful suggestion The patient allows themselves to be persuaded in a limited way Ð so that we can work with them. In addition to this a small amount of carefully metered suggestion is often useful in the short term. In acute pain and in the initial stages of work reassurance and supportiveness are often vital. Speci®c suggestions can be a great help to the patient here. Reassurance alone is often enough to solve many problems if major anxieties are relieved. `Imagine this sudden nasty back pain you have had is just like a joint strain. We've positioned it on

Box 4 Typical long-term case

At the initial consultation a potential patient has symptoms that might suggest irritable bowel and spastic colon of many years' duration, combined with some sort of hip rotator and sacroiliac dysfunction. Unprompted they mention being very stressed and unhappy at work, and feel a failure at relationships. In their response to routine general questions it emerges that they had a serious fall from a horse in their mid-teens, their parents are divorced and both ill, they are avoiding many foods, used to have severe migraines, have mild urogenital symptoms and sleep very poorly. Without adding further detail, this rather generalized presentation would not be particularly uncommon. What sort of minimum and maximum prognosis would we be contemplating; assuming a sound treatment agreement can be reached? 130

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Placebo: a study of persuasion and rapport your side here to relieve pressure on it as you breathe and relax. That's it, that's better. Let the breathing go slower and relax. It's like a strained ankle, when it hurts really badly at ®rst and you cant put much weight on it at all for a while. Most of what you feel here is muscle spasm from the strain, and I'm just using very slow stretching and easing to relieve some of the muscular spasm around the strain. No sudden movements. And that leaning to the side you feel is just you spine's way of limping to keep your weight away from the strained part. It will be very sore again when you stand up, but I'm really con®dent that it will be clearing up Ð (tentative prognosis and management plan)'. More complex suggestive work (e.g. Haley 1973) can also be a great help in manual therapy when addressing speci®c fears, impulses, anxieties and phobias that so often emerge. Combinations of suggestion with behavioural modi®cation, guided imagery, dramatic enactment, narrative development, and thought experiment are quite natural extensions from our ordinary conversations and bodywork. But these may require considerable further training, and will usually need the fully informed consent and cooperation of the patient. Ordinary good humour may be most helpful (Latey 1997).

From persuasion to rapport When working with long-term complex problems the author has found that there is a very familiar repeating pattern that occurs in many of them. If the complex patient has, say ®ve predominant symptoms and aspects to their complaint, they might start with a quite dramatic improvement in as many as four of them during the opening phase. The ®fth remains

stubborn and recalcitrant throughout these early sessions. In the next phase very little seems to happen to symptoms while the patient and therapist adjust to each other and ®nd ways of relating. Gradually the symptoms return, perhaps during a brief trial of `no treatment'. In the third phase each symptom or area of complaint will tend to move into prominence as the bodily regions, functions and subject matter in discussion start to come to a focus. As we expect all aspects of the person to be interdependent it is quite usual for one or two of the symptoms to be forgotten about and resolve out of sight in this phase; but it is also likely that transient extra symptoms emerge as the pattern starts to shift. Our irritable bowel patient (Box 4) may have become much more comfortable round the hip and groin, with less bowel spasm and less food sensitivity. But a persistent sacral ache has failed to respond, and dominates the symptom picture for quite a while. As they begin to discuss their dented adolescent optimism round the time of their fall from their horse, the hip pain comes back and they remember that their parents were divorcing at that time. Food avoidance and gut spasms increase also in this third phase, and they recall a school camp when they had diahorroea and the food was awful. The change in appetite that accompanies the teenage growth spurt also gave them much trouble. All of this comes from the leisurely conversation that surrounds the body work. We also discover they have been having sore eyes for a week or so, with increased urinary discomfort and some foot pain (possibly transient Reiter's syndrome). They su€er one isolated migraine, but have been sleeping very much better ever since their early sessions.

This third phase is very satisfying when the symptoms, bodily work and other ®ndings begin to make sense. But the main symptoms do not disappear altogether. There usually follow at least two periods of relapse and reworking Ð as if the body refuses to let go of its position till the third time around. This fourth stage is by far the longest: a severe challenge to the practitioner. They have to be very patient themselves, and surmount their own frustration and boredom to look for missing elements, avoid repetition, and invent fresh ways of covering the same ground. In the ®fth phase there is a combination of quiescence and complacency alongside a sort of searching around for more work to do. As sessions are spaced further apart the symptom-free periods lengthen to the point where they are hardly mentioned; but recur in a minor form just before each session. This is a clear sign that the therapeutic process is coming to an end. The patient and practitioner are nearly ready to disengage. In the sixth and ®nal phase, the ending of the work, there is often a brief return to the need for reassurance. We will nearly always feel it helpful to o€er continuing support if it is needed from time to time, say that we will miss the patient we have got to know so well, and set the scene for follow-up. Something quite similar to this sequence often happens during a single session. The way we choreograph our work, and expect changes to happen can take advantage of this, making an easier ¯ow to the rhythm of our sessions and of our longer prognoses. This sequence is also mirrored in many other forms and human interaction. The e€ects of the patients' initial momentum, the persuasiveness of the therapist and the setting, with any initial suggestions that have been used are usually exhausted by

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Box 5 Overall patterns in long-term work

1. Opening Patient momentum. Auto-suggestion. Practitioner persuasion and speci®c suggestion (minimal in complex cases). 2. Refractory Patient unresponsive. Gradual return of symptoms. Gains lost. Practitioner frustrated. Quick ®x measures fail. 3. Rapport Good working relationship. Con®dence in e€ectiveness: focused e€ort is worthwhile. 4. Recurrence Con®dence is strained as the same areas recycle for second and third time. 5. Quiescence Calming down, increasingly symptom-free for longer. Casting around for new work. 6. Discharge and follow-up Patient unsure if ready to disengage. Practitioner retreat to more `distance'; slight reassurance and suggestion.

the end of the second phase. From the third phase onwards it is the clinical framework and setting, the rapport and the joint e€orts of practitioner and patient that does the work. Only in the ending might we have to return to a more stylised and formal way of working (Box 5).

Building rapport Modern clinical skills able to tackle dicult problems depend a lot more on the quality of the interpersonal rapport than used to be thought. There is much evidence that good results from therapy depend far more on the rapport than the supposed theories and schools of though of the practitioner (Roth & Fonagy 1996). There are also areas where the `untrained' may do best of all (Spinelli 1999). What matters most is that we and the patient ®nd some gradual way of tuning in to each other as people. If this is working all sorts of good humour, imagination and invention can be brought into play gently; and can bring the whole process to life. When we are able to separate the e€ects of persuasion and suggestion

from lasting results that have been hard to achieve in the long term, the importance of rapport becomes very clear. But clinical rapport is extremely dicult to teach (Box 6). In interactions where there is no need for a durable rapport there is always an imbalance between activity and passivity, dominance and submissiveness, giving and receiving; and so forth. But in phase three of the therapeutic pattern (Box 5) both participants are present in a more equal form. Control and direction of the interaction is passed back and forth. Questions, ideas, topics, pauses, wry comments and tentative answers ¯ow freely Ð with

lots of requests aimed at expansion of each others' viewpoint in particularly interesting areas. While the good therapeutic rapport is not part of normal everyday life, it needs to have a close relationship to it. As close, perhaps as a work of art, novel, movie, poem or song in it's evocative qualities. This means that we have been able to reach an accord and resonance with the patient where they really can feel that we `take it to heart', whatever emerges. Experienced practitioners will not take on a longer-term case unless they feel that this sort of rapport will be likely to emerge. The main parts of the work in phases three and four are like musical ®gures: with statements of theme, subject and counter subjects, developments, restful and energetic passages. Our job is partly to keep steady progress, with the ability to introduce refreshing di€erences; and partly to maintain an exquisite sensitivity to `¯inch'. In conversation with them we can be watching for sings of recoil. . Have they suddenly gone very silent for a moment? . Did they suddenly withdraw for a second, and freeze their smile? . Do we know when we have overstepped the mark in some way, and must change tack and o€er prompt apology?

Box 6

The artist's dilemma is of a peculiar sort. He must practice in order to perform the craft components of his job. But to practice always has a double e€ect. It makes him, on the one hand, more able to do what he is attempting; and, on the other hand, by the phenomenon of habit formation, it makes him less ware of how he does it. If his attempt is to communicate about the unconscious components of his performance, then it follows that he is on a sort of moving stairway (or escalator) about whose position he is trying to communicate but whose movement is itself a function of his e€orts to communicate (Bateson 1972). 132

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Placebo: a study of persuasion and rapport

Physical rapport In physical work we are used to monitoring the responses of tissue tone and muscles. . Are they able to relax with what we are doing without disconnecting? . Do their muscles contract back against us? . Do we notice a slight catch in their breathing? . Are their hands or feet curling? . Is there a slight ¯icker or grimace at the side of their face? . Are we checking how sore they feel in areas we are working on? This `¯inch' boundary, where we are carefully monitoring the impressions we are making, and the responses evoked, is a very precise line of demarcation in the sustaining of rapport. It is equally critical in the work of physical contact. When physical work is part of the process there is a very rich mixture within which the two parties can attune themselves to each other at many levels simultaneously. Towards the end of the 1880s Andrew T. Still was bringing osteopathy together from his work as a bonesetter and magnetic healer. At the same time Sigmund Freud was himself using hypnosis, massage and head pressure while he discussed with the patient what memories and images came to mind. There was much interest in therapeutic suggestion at that time (Bernheim 1888). Sadly, just as psychoanalysis retreated from physical rapport, so did osteopathy retreat from psychological awareness; to the great loss of both professions. Physical work with their bodies can often help produce marked psychological, emotional and social improvements for people. When we are in close physical engagement with the patient's body we are moved by their inner movement. They are moved by ours.

This attunement reaches deeper than just to their proprieceptive and locomotor senses and muscularity (our sixth sensory system?). Here lie an additional three systems; the emotional, visceral and `mental' patterns of muscle sensation, movement and embodiment that express to us the essential subjective person in all of it's complex layering (Layer 1979, 1996). To the author it seems clear that we connect with these seventh, eighth and ninth senses when we engage with the other in a process of change, transformation and evolution. From the bodywork we can often tell far more about them than the person themselves may be aware of. To what extent are covert emotional strictures, torment and painful or numb paralyses keeping them from progressing? The impacts, longings and bending to group pressures that we feel give us strong evidence of most useful areas to explore in our tactful conversation with them. Very simple tactics are often all that is needed to broach new areas of inquiry as we progress (Latey 1992). Attachment and separation from the practitioner may also be a key factor here.

Practitioners' feeling Less predictable are the experiences and reactions of the manual therapist with the transforming patient. This is a much neglected and under-reported area. The author can sometimes feel deeply moved Ð as if swirled slowly in a massive tidal undercurrent in the sea, or as if caught in the ®eld of powerful interweaving magnetic ®elds. In discussion with colleagues feelings of melting, ¯uidity and drift are most common. Having poor di€erentiation of these muscular senses, and even less language for them, these experiences tend to be `synaesthetic'. They induce strong echoes in senses that are otherwise

disengaged. So we may experience colours, vibrations and resonant shapes that are not there, or more rarely sounds, music, tastes and smells. In the author's opinion this goes a long way towards explaining why people have needed to invent esoteric energies, magical auras, chacras and so on. A better understanding of the mutual rhythmicity of our therapeutic `dance' with the patient should also reduce the confusions surrounding involuntary movement patterns, putting their clinical usefulness into better perspective (Latey 1979, 1985). This type of experience may not necessarily be associated with speci®c emotions for us, but it is usually well clear to us and the patient that a major shift has taken place. We may afterwards feel shaken and weak, or very much in tune with ourselves and the world. Sometimes we may feel exhilarated, sometimes extremely peaceful, or near to tears of happiness. Musicians might report the same range of feelings after an exceptional performance. While relatively rare in ordinary daily practice, these very moving experiences make our more routine work much easier. They deepen and broaden our body awareness. And like an experienced deep sea diver, any brief plunge under the surface of life holds no further fears for us. We can also learn to skim under large waves that would otherwise seem quite threatening. We also understand better how patients may feel disorientated and di€erent after a `moving' session. A fruitful phase of integration and revision will usually follow for them quite naturally.

Structural coupling Chilean biological philosophers Francisco Varela and Humberto Maturana make an extremely useful

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Latey set of distinctions about interactions between cells and organisms. These concepts ®t well with the author's understanding of clinical rapport in bodywork. Instructive interaction, where an organism can be expected to respond to some perturbation in an exact and predictable way cannot happen. Each organism can only respond in a way that is predetermined by it's own history of idiosyncratic self-structuring. They call this self-structuring `autopoiesis' (Maturana Varela 1980). Structural coupling, on the other hand, happens when two organisms in close contact begin a process of mutual recursive change. Here they undergo a sharing of each other's restructuring processes achieved by tuning in to each other. Multicellular organisms could not have evolved without some such process. Maturana and Varela call this `second order autopoiesis'. This is not the mechanical joint coupling that we study in spinal movements. It is closer to the ideas of `entrainment' that come from physics and complexity or chaos theory (Davies 1989). In `social' organisms structural coupling would seem to be either more intermittent or less intense. In any case there are obvious parallels in bodywork, where we are faced with the di€erence between trying to make things happen, and tuning in to engage in such a way as to allow changes to happen. This is a highly signi®cant distinction for us, when we recognise that structural coupling cannot possibly be unidirectional. Our own personal plasticity and mutability are an essential element in clinical structural coupling.

Sexual parallels The slow upheaval or lurch that we could call `clinical structural

coupling' does not ®t well with our previous more linear views of persuasion, suggestion and placebo responsiveness. Something di€erent is happening here; and is happening to both parties; though they will perceive it di€erently. These phenomena (previously called `inter-transference', Latey 1979) seem completely beyond the scope of the non-touching psychotherapist's models. They fear regression, fragmentation and sexual abuse. Whereas we will commonly perceive a subtle integration and emergence of the renewed person: with boundaries intact; softer and more resilient when they were brittle; healing where they were broken or illformed; ®rmer where they were blurred. There are very close parallels here to sexual coupling. Two people alone in a warm room, with undressing, ¯eshy contact and handling of parts make this undeniable. Using sex as a very close analogy for physical therapy we could say that the hypnotherapist is metaphorically seducing compliance, or that the faith healer (above) sexually overpowered the woman and in doing so mutilated the integrity of her pelvic structure. A meeting of the minds is more like a `mating' when fruitful new ideas are generated. When any of this works well we could say that there is therapeutic conception and gestation: new life has been gained. A close relationship is necessary for clinical structural coupling. In fact it is unlikely to work or even happen at all unless it is a metaphorically interpenetrative relationship; at least in the intimate interaction of motile muscular sensation. The `sensory systems that sense the senses' (Latey 1997) may be uncoupling and rebalancing here Ð perhaps ¯owing upwards towards higher functions from the

reticular activating systems and cerebellum. Imagine a widow and a widower. They have known each other for years, but are not a couple. They dance together at a reunion party, ®nding they can jive and quickstep passably well with each other. In the last slow waltz at the end of the evening you observe them very close, leaning in to each other. Their swaying movement is no longer in time to the music: it slowly wanders chaotically around a small area. Looking at them you sense a deep warmth of a€ection, sadness, happiness and compassion. A few minutes later they have parted, feeling fuller and more contented. They leave for their separate homes hoping they might meet again next year; feeling perhaps some healthy tiredness and a little heartache. Something has unfrozen for them; they can breathe more easily Ð even if it is just a sigh. Clearly there is a mature intimacy of ordinary life here: without sex. Lust, passion, desire, arousal, foreplay, all can be entirely unnecessary to episodes of very close structural coupling. They may well be antagonistic to it, temporarily shelved, or totally irrelevant. Although clinical structural coupling has a di€erent history and social setting, it has identical qualities to the couple at the reunion dance. Our secure ethics of un-sexualised compassion also make this a safe area of practice for both patient and practitioner. It is likely that lesser degrees of clinical structural coupling are an ordinary everyday characteristic of good manual therapy practice. In which case this is a major aspect of the empathy that we bring to our daily work.

Conclusion There are many e€ects of touch and movement not mentioned in this

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Placebo: a study of persuasion and rapport work with complicated patients dawns very slowly in today's hurried society. With most dicult patients, and for most of the time, the author is accustomed to waiting hopefully; with considerable optimism about our human capacities for selfrighting.

Further reading For studies of synaesthesia in other ®elds the author recommends Baron-Cohen S, Harrison JE 1997 Synaesthesia. Oxford: Blackwell Artwork: Maxwell John Phipps. REFERENCES

Fig. 5 Structural coupling.

paper (Nathan 1999). Touch restores some of people's `felt' identity. In opposition to the unreality and instabilities of nontouch methods, touch can defuse the excesses of transference and counter transference. But touch on it's own may be deeply addictive; it is so sorely needed in our alienated society. The degree of separation at which we must live our lives is sometimes painful and always emotionally distressing. Hopefully we can now begin to see some di€erences between persuasion, suggestion, the patient's momentum, and their suggestibility; and look at some of the realities of the treatment rapport in dicult cases. Our very careful work of trying to understand their problems and to work out some treatment agreement and prognosis with them provides the only real and reliable

measure of success. With better understanding we can rethink those processes that are foundering. But, to some degree, all of our successes could be ascribed to one form or another of placebo. It is up to us to decide which form; and to confess with honesty that attention to these areas is long overdue; and only just at a tentative beginning for most of us. We might begin by distinguishing between rapid results from brief procedures, and the complex patterns and phases that we meet in longer-term work. The author's `Muscular Manifesto' started from the premise that impressive and satisfying `cures' can come from a palpable consensual condensation between osteopath and patient when the problem can be viewed simply (Latey 1979). The depth of understanding, compassion and skill that will enable this to

Bateson G 1972 Steps to an ecology of mind. New York: Ballantine Bernheim H 1888 Suggestive therapeutics: a treatise on the nature and uses of hypnotism. New York: Putnam's Bowers K 1976 Hypnosis for the Seriously Curious. New York: Norton Calof D 1997 The couple who became each other. UK: Century Chaitow L 2000 Fibromyalgia Syndrome. Edinburgh: Churchill Livingstone Davies P 1989 The cosmic Blueprint. London: Unwin Haley J 1973 Uncommon therapy. New York: Norton Maturana H, Varela F 1980 Autopoiesis and cognition. Holland: Riedel Latey P 1979 The Muscular Manifesto (2nd edn 1982) London: Osteopathic Publishing Latey P 1984 An expansion of osteopathic theory of technique. British Osteopathic Journal 19: 51±56 Latey P 1985 Cranial Osteopathy: a divisive alternative. Journal of Alternative Medicine 3: 6±7 Latey P 1992 Some notes on basic clinical tactics. Australian Journal of Osteopathy 4: 4±12 Latey P 1996 Feelings, muscles and movement. Journal of Bodywork and Movement Therapies 1: 44±52 Latey P 1997 Complexity and the changing individual. Journal of Bodywork and Movement Therapies 1: 270±279 Latey P 1998 The pressures of the group. Journal of Bodywork and Movement Therapies 2: 115±124 Liebenson C 1999 Motivating pain patients to become more active. Journal of Bodywork and Movement Therapies 3: 143±146

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Nathan B 1999 Touch and emotion in manual therapy. Edinburgh: Chruchchill Livingstone Roth A, Fonagy P 1996 What works for whom: A critical review of psychotherapy research. New York: Guilford

Shorter E 1992 From Paralysis to Fatigue Ð a history of Psychosomatic illness in the Modern Era. New York: Free Press Spinelli E 1999 If there are so many psychotherapies how come we keep

making the same mistakes? Psychotherapy in Australia 6: 19 Wilson Steve FT 1996 Dog's Hypnosis. Australia, Bankstown: BluePrint

BOOK REVIEW

Book review Harmonic technique Eyal Lederman Churchill Livingstone,1999 ISBN 0-443-06162-9, Price: »60 Eyal Lederman is a leading osteopathic theoretician and clinician who, in this text and video, draws together and describes the mechanisms which he claims can, when applied appropriately, move rhythmicity beyond purely mechanical in¯uences, allowing it to achieve a harmonic interaction with bodily tissues. Rocking and pulsating, cyclical actions are common basic massage methods, and few manual therapists, whether they work in massage therapy, physiotherapy, osteopathy or chiropractic do not already use some form of rhythmic movement, albeit in an unstructured, almost intuitive manner. Lederman has evolved an approach which he suggests lifts these basic approaches to a level which `produce therapeutic e€ects that are beyond the physical

phenomenon.' He maintains, and o€ers evidence to support the assertions, that during application of harmonic technique the patient's own oscillatory frequencies can be induced to in¯uence local tissue, neurological, as well as psychophysiological organizations, a€ecting repair processes, ¯uid dynamics, pain re¯exes, proprioception, autonomic functions, motor responses, as well as emotion and behaviour. These are large claims and Lederman attempts to back them up with detailed discussion of the concepts, as well as by means of research evidence. One explanation for the bene®ts of harmonic technique relates to the virtually hypnotic (and therefore profoundly relaxing) e€ect of any rhythmic movement. This may in fact be enough to provide a powerful placebo in¯uences, along with whatever e€ects are resulting on the physical level, in terms of alterations in tissue tone and function, neurological modi®cation and ¯uid interchange.

A curious omission (which could be recti®ed in a second edition) involves a lack of mention of osteopathic researcher T. J. Ruddy DO, whose `rapid rhythmic resisted duction' method (commonly now called `pulsed muscle energy technique') has distinct echoes in Lederman's work.1,2 The video which accompanies the book (they cannot be purchased separately) is very instructive and competently produced, and should allow the application of these gentle, economical (in energy terms) and potentially e€ective measures. Ruddy TJ 1962 Osteopathic rhythmic resistive technic. Academy of Applied Osteopathy Yearbook 1962, pp. 23±31 Chaitow L 1996 Muscle Energy Techniques. Edinburgh: Churchill Livingstone, pp 56±57

Leon Chaitow Senior Lecturer, Centre for Community Care and Primary Health, University of Westminster, UK

........................................... Journal of Bodywork and Movement Therapies (2000) 4(2),136 # 2000 Harcourt Publishers Ltd

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