The Therapist Effect

Hello again! Welcome back to the PhysioDirect blog. This months topic is a slightly more abstract one; looking at the subtleties of the relationship between therapist and patient and how this can actually influence pain and recovery!


The idea for this article came after reading a book on psychology and social interactions called ‘Popular’; with one chapter specifically focusing on how being popular and sociable can have a real tangible impact on your health in the long term. It also inversely mentioned how being socially isolated can have as much of a negative impact on your health as smoking.. Damn!


A Good Relationship

The theory from the book suggests that just being around people can influence your health because of how it makes us feel. Human’s have evolved to be social beings that live in communities. We are hardwired to thrive off social interaction, with the release of the feel-good chemicals from the brain when working as part of a team or when we’re around people we get on well with. This can even effect things on a cellular level, activating certain genes and turning others off.

So is there a link between generally being in good company and having a good working relationship between the therapist and patient? As a physiotherapist working in private practice, the idea of building a positive relationship with a patient has always been seen as a priority. This is something I’ve been taught all the way through my career, in all the different private clinics over my working life.

On the surface it just seems like common sense; all part of providing good quality care, but is there more to it? The effect of a good relationship has actually been shown in the research to have a significant positive effect on the outcomes of treatment, but why is this the case?

Humans are Complicated.

If we were to think of injured people in the same way we think of broken cars (as mechanical things that needs bits fixing) then you might be forgiven for thinking that the only important part of treatment is the exercises and advice given or other adjuncts used. Things however aren’t that simple.

How we feel (i.e. our perceptions) can make a as much of a difference to our recovery as our general health. Firstly being in a positive therapeutic environment has the same positive effects as just being in a positive social environment; feel good chemicals released, being more relaxed, reduction of stress hormones. The knock on effect of this positive environment is our perceptions of pain can be dampened down. Getting on with your therapist also means you’re also more likely to view the treatment in a positive way, which can ultimately leading to a more positive outcome.

In the medical world, this is referred to as the ‘non-specific therapeutic effect’, and the size of this effect can be small or large, and even negative depending on the interaction between the therapist and patient.

What can Enhance Treatment?

Although this seems like a rather grey area, there is a general consensus on a few things that can help get the best out of treatment. Here are some of the most important ones:

  • Getting to know someone! – often referred to as ‘building rapport’ when I was training. Going deeper than asking the basic level of questions about work and hobbies and finding common ground, thinking about the person as a whole and trying to understand where they’re coming from. Giving time and attention so the patient feels you’re on their side and genuinely trying to help can build that sense of teamwork and lead to a better outcome.
  • Being an expert! –  being an authority, appearing knowledgeable and coming across as an expert gives people confidence in your abilities. This can change the whole outlook on treatment, make people feel more comfortable and supported knowing they are getting great treatment. If someone is confident what you’re asking them do to is right, it can improve compliance and I think ultimately lead to greater improvements.
  • Positivity! – taking a positive approach to a problem can really help (as long as you’re not giving false expectations). The way you say things and even body language can all affect the way someone views and approaches their recovery. Communicating the right message and providing encouragement could make the subtle difference, helping to reduce fear of movement and reduce stress which as mentioned can be a big part of someones pain experience.
  • A good reputation – at it’s extremes this is known as ‘the guru effect’, where people have such high expectations of their medical professional that they are already more likely to view things as going well before even stepping through the door for an assessment. Not something you can do much about in the short term, but if you treat people well, with the above points in mind, then you can slowly start to gain this attribute and have an advantage from the start.


When it Goes WRONG

Obviously taking all the above positive effects and doing the opposite could have a very detrimental effect on treatment. Not building rapport, showing lack of empathy and making it feel like its you vs. them, and can be a big barrier to treatment. Seeming unsure or not knowledgable about the the problem someone is having can be very disconcerting. Not having a positive approach or even if you’re dealing with stresses outside of work can even come across in your body language.

One area that can cause a particularly negative impact is how therapists put across information, and the language used. This is often referred to as a ‘nocebo’. An example of this is the discussion around back pain, where in the past there has been too much focus on structural damage. Telling people how discs have ‘popped out’ or ‘leaked’ (generally using terrifying words to describe things) can hugely increase their apprehension, cause them to avoid movement, tense up and ultimately lead to a much poorer recovery.

Final Thoughts…

Reading the book Popular brought things home to me, and reminded me again of the importance of a good relationship between a therapist and patient (even if this wan’t the books main purpose). In the modern world of physiotherapy it’s all too easy to become consumed by outcome measures, statistics and what the research is telling you to do. 

I fear sometimes we’re in getting close to handing out sheets of paper with the most well researched exercises and saying ‘see you in a months time’ to cut time and save costs in the name of efficiency. Less focus on the human side of things and not giving people the time and attention they need may mean we lose part of what has made physiotherapy so special in the past. 

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