I’m impressed at the way the COVID-19 virus has taken the global community by storm in unexpected ways across every sector of society. There’s no one who’s been left unaffected by its spread and it continues to transform the way we feel and respond to this new situation.
Many outpatient physiotherapy services have been altered drastically, including my own. The decision to practice ‘physical distancing’ (I prefer it to ‘social distancing’) has meant suspending all face-to-face contact in the clinic and redirecting all of our services online.
The wonderful thing about physiotherapists is we offer a wide range of skills that can be used to continue supporting our clients in this unique moment of separation. Skills such as; assessment, diagnostic and exercise advice and coaching where appropriate, creating a therapeutic alliance that meets the needs of our clients.
I started thinking about the idea of ‘distancing’ and how that could be examined more closely; in what ways does it matter if there’s physical/geographical space between a clinician and client?
What does distance signify for the client (or the therapist)? Does the knowledge of non-contact hold meaning to the client’s expectations of the therapeutic encounter? If it does hold meaning, in what ways might I, as the therapist close the gap?
What follows is an outline of some of those reflections which could be used to think differently about the therapeutic encounter and how that might be applied in practice.
As an aside note, when we think about distance, we may also think about different notions of space which carry different textures and meaning. ‘Distance’ could translate to ‘separation’, which may include ideas around safety, isolation, withdrawal or hiding.
For other’s it may also mean freedom, restoration and safe boundaries. It’s worth remembering each person brings their unique understanding to these ideas and consequently may respond more positively or negatively to it.
As therapist’s we may not necessarily ‘know’ the client’s position on certain ideas, but holding it in mind means you’ll hold for the client the possibility for exploration in the therapeutic encounter. Where appropriate, it’s useful to get to know our client’s story; who they are; what motivates or drives them. Being interested in somebody is part and parcel of building trust and learning to relate to each other’s humanity.
‘Contact’ or more specifically manual therapy, as an effective component of service delivery for certain conditions and has been challenged within the profession in recent years. Historically, massage was the core skill of physiotherapy. Adopting a hands-on or hands-off approach has polarised some quarters of the musculoskeletal world; perhaps emphasised by the different demographics of the private or public spheres within the profession.
Considering our contemporary times, the shear client load and pressures within NHS outpatient departments has meant a drastic reduction of individualised time with clients. Parallel to these evolving changes, there continues to be necessary, ongoing dialogue concerning the evidence-base of our treatment techniques that physiotherapists employ.
Manual therapy and other combined interventions such as education and exercise have been suggested to produce favourable outcomes that justify our efficacy for particular conditions and in different population groups. At the centre of these discourses is whether service delivery remains client-centred and at the same time supported by clinical evidence.
Non-contact also brings to mind the possibilities that touch may be problematic for some clients. Without complete histories, there may be trauma, current or historical abuse, shame from body image or body dysmorphia and/or cultural nuances that restrict the use of touch for particular individuals.
Whether within our individual practice we choose to use touch (manual therapy) or not, the challenge is can we remain connected to our clients in meaningful ways that delivers compassionate and person-centred care? And can we continue to do this when using video tools or telehealth as a model for service delivery?
So what are the conditions that might best achieve this, particularly where face-to-face interactions have been suspended?
From an embodied perspective as a somatic practitioner and physiotherapist, there’re central themes that emerge as core skills that enhance the therapist-client interaction or therapeutic alliance.
Therapeutic Presence
This describes the experience of being ‘conscious’ of one’s bodily responses in relationship to another person. In other words, you’re ‘present’ with yourself and able to recognise information coming from different sensing channels (mental activity, sensations from the body, sight, hearing etc.).
Therapeutic presence helps you make more informed decisions about how to respond more compassionately both towards yourself and your client.
There are a number of ways to help achieve this, but it takes practice to feel comfortable. Somatic practitioners have a method to achieve this by means of ‘grounding’ the body using the breath and their skills of awareness.
Grounding increases the opportunity to further attend to inner sensations arising in the body through interoception; a part of the nervous system that functions to inform us how we feel. It gives representations of our internal state, more broadly our emotions and internal physiological state of the body.
This helps increase the awareness of one’s physical body in space; ‘I feel my body supported by the floor/chair’ and ‘I’m aware of the soles of my feet on the ground’, as well as information about how you feel; ‘I feel anxious’ or ‘I feel safe’. This allows more choice about how to respond from a place of authenticity.
This approach is shared with mindfulness-based practices. It utilises our internal sensing skills (interoception) that support the regulation of our emotional responses, offering a broader perspective on our experience helping to foster clearer communication.
Active Listening
Most of our communication is through non-verbal communication, in particular through our body language.
Nonverbal phenomena are most important in the structuring and occurrence of interpersonal communication and the movement-to-movement regulation of a particular interaction.
However, not being in the same room as someone potentially reduces the ability to pick-up on body language where we may be less likely to view the entire person on a screen.
Paying more attention to what is being said or ‘active listening’ is a way to ensure we’re most attentive to the client’s needs.
It’s been argued to be an essential part of a set of our clinical reasoning skills.
Repeating or affirming what has been said, helps to clarify the information received and engenders more trust from the client that they’ve been heard. Although this skill in theory should be implicit in all therapeutic interactions, not having to rely so heavily on bodily clues in face-to-face interactions, brings it more into focus as an active skill to use.
Being present in the body as described above, further enhances the capacity to listen carefully to what is being said. It serves to redirect our attention from any thoughts processes that may be trying to construct a reply before the other person has finished speaking. Our response is from a more embodied position, that’s present to the therapist’s experience and present to what the client is actually saying.
Tracking
As an extension to both therapeutic presence and active listening, tracking is the dynamic way in which you’re able to follow signals in your own body. It gives moment-by-moment information regarding the interaction.
These include registering in the body both non-verbal and verbal cues that give a more comprehensive meaning to the dialogue. How the therapist responds from this informed place is vital to remain compassionate and as authentic as possible.
Tracking supports the emotional response of the therapist by helping them monitor more closely if for example, there’s material shared in the interaction that has high affect. It allows them to choose how to respond appropriately to better regulate their response.
Language
How we use language in interactions with clients must be carefully considered to avoid judgements or projections about them. A projection used here is a psychological term where one ascribes one’s own traits, emotions or positions onto someone else.
An example would be, “you look like you’re sad when you rubbed your cheek”. The other person may be feeling something completely different but hasn’t stated it explicitly as to verify that assumption.
As therapists we have to be cognisant of dominant narratives and certain expectations that influence our ideas regarding models of ideal health which include; particular attributes relating to body size, shape and ability, as well as behaviours and other socioeconomic factors.
These unconscious and conscious biases inform how we process information that informs our thinking and thus the assessments that are made about our clients.
It can’t be assumed as a given that somatic training automatically eliminates these biases or blind spots. This always needs constant reflexive work and active attention. However somatic practice does specifically focuses on bringing conscious language and embodied awareness to the therapeutic relationship that help minimise judgements or projections.
Summary
Connecting compassionately with clients, whilst at the same time meeting their needs using novel video technology, can be a daunting task for physiotherapists.
Clients may be experiencing increased levels of anxiety for a variety of reasons. Their dysregulation may include how they navigate the unfamiliar conditions of their physiotherapy interactions that are delivered in this novel form. The therapist too may also be experiencing a degree of dysregulation for similar reasons.
Utilising these specific skills can support any dysregulation clients or the therapist may experience helping to facilitate a greater degree of connection in spite of any physical distancing.
Bringing a somatic perspective can add value to the therapeutic relationship by being more conscious about how the interaction is taking place which remembers the body as central resource to the exchange.
Maintaining the client-centred connection and not just delivering a product/service remotely is perhaps most fundamental to clients, especially those experiencing vulnerability and an unusual disconnection from service providers.