Bringing a Client-Centred Model into the Clinic
By Walt Fritz
One of the current trends in medicine is a movement toward a client-centred model of care, with recently published papers that describe the rationale for such a change.1 However, as both a student of manual therapy, as well as a myofascial release (MFR) educator, I see our shared fields lagging behind this trend. The basis for my theory as to why we lag behind revolves around the dissemination of information in the continuing education setting, with the fierce guarding of intellectual property and ideas in a manner that protects the financial interests of the educator. My cynical view was framed from years of first-person observations and as a long-time consumer of manual therapy continuing education. I speak at length to these issues on my blog, but I will move ahead with my topic and leave it to you to determine the validity of my cynicism.
While presented as science-informed, much of our work is based on adaptations of accepted science, reinforced and twisted a bit by experiences – our own and our clients’.
The Hierarchical-Based Model
(Excuse the generalising that follows – Walt.)
The norm in manual therapy is a hierarchical-based model that fosters a relationship that elevates the experience and opinions of the clinician over the views and feedback of the client. The client comes to the expert for help and gives up power in the hope that the clinician can help. The client becomes quite willing (some might say gullible) to believe what the clinician states as their findings and recommendations, in hopes of being relieved of their pain or movement issues. The opinions of the clinician become the determinant in treatment decisions, though hopefully framed by client goals. While listening to the client’s story happens during intake, the power shift from client to therapist occurs quickly as the initial session progresses, with the opinions of the therapist becoming more important than the client. The experience (ego) of the clinician takes hold quickly, driving the agenda.
While this model can be useful, I wish to offer an alternative.
A Place For Placebo?
Brian Fulton, RMT, in his excellent book, The Placebo Effect in Manual Therapy2 speaks to the power of the story we tell and that as our skill in telling that believable tale rises, so does the potential of placebo effects. Believing our story, on the part of the client, makes sense, as if we sound credible then we tend to be believed. To me, one problem with placebo effects rising as our story improves is that there is no provision in the scientific research that the story has to be true. The potential placebo effect increases as we become better storytellers. In short, we become beacons of believability, with, at times, grandiose claims and beliefs regarding what is wrong with our clients, based on evaluation methods that may lack validity across the full spectrum of manual therapy and medicine, with conclusions drawn based on those narrow beliefs.
My own MFR training framed problems to be a result of the fascial restriction and how it impacted the client’s function, regardless of how these beliefs conflicted with alternate models of manual therapy. My clinical outcomes seemed reasonable, but confirmation bias clouds objectivity in regards to these matters. As I gained experience, I tended to listen less to my client and more to what I thought I had uncovered. I saw their story as less important, as they didn’t understand the power of a fascial restriction as I did. And over time, I listened less.
Now I listen more.
What changed?
I had many years of experience under my belt, both as a physical therapist as well as a MFR therapist, but I saw that something was missing from my past.
My myofascial release treatment became entirely based on my vast experience and perceived knowledge, but no matter the level of my education and experience, there was a piece missing: I did not know what my client felt unless I asked.
Sure, I asked for feedback, “how’s my pressure?” etc., but it was merely an aspect of assuring that my treatment was not too aggressive. Feedback from my client had little to do with how I arrived upon a treatment plan.
Over the past few years, listening to my clients has become my passion, so much so that it has become my chief strategy in moving from evaluation into treatment. Not just listening to them during the intake but listening to them as I progress through evaluation and into treatment, allowing feedback to be the determinant for treatment decisions. Client feedback has become the primary means of how I frame the decision-making process for what and where to treat. It aligns well with the emerging trends in medicine and offers what I believe to be a more respectful perspective on the weighting in the therapeutic relationship between my client and myself.
Many clients baulk at being offered the chance to participate in treatment decisions fully, but over time I’ve become more adept at handing over power to them. To some therapists, handing over control to the client may seem as if they are admitting a lack of knowledge, but there is wisdom in knowing and realising what one does not know. We cannot understand what our clients are feeling, what they think might feel helpful or harmful, with no input of subtle or overt coercion, unless we ask.
Are you willing to ask?
Being willing to ask for input in decisions, to ask your client to partner with you in determining treatment decisions takes practice and can seem entirely foreign, both to the clinician as well as the client, but with practice becomes quite easy. Being comfortable with silence is vital. Ask, “what are you feeling” and allow them to process. Below is a current version of my process as I move from evaluation into treatment. Can you see this working?
(From Walt Fritz blog post “Synopsis in Synopsis of the Foundations Seminar Approach to Manual Care” July 2018.)
This video goes through my process. If exploring this approach appeals to you, I suggest you watch it more than once. My MFR methods, which use static engagement vs. movement, may make the process seem remote, but I see it as applicable to any massage/manual therapy style of engagement.
References
- Naming What We Do, by Brian Broom, MBChB MSc FRACP
- The Placebo Effect in Manual Therapy: Improving Clinical Outcomes in your Practice, By Brian Fulton, RMT
About the Author
Walt Fritz, PT owns the Pain Relief Center in Rochester, NY, USA and travels worldwide to teach his science-informed version of MFR, Foundations in Myofascial Release Seminars. His audiences include massage therapists, speech-language pathologists, voice professionals, physical therapists, and occupational therapists. He will be teaching his client-centered, science-informed version of myofascial release in August of 2019 in Bondi Junction through Terra Rosa, with MFR for The Upper Body and Lower Body. Each of these seminars is 2-days with some wonderful hands-on content presented in a context not typically seen in fascial trainings. You can learn more at www.FoundationsinMFR.com and his accompanying blog.
