Sunday, September 04, 2011

About treatment boundaries

Yesterday, I commented about treatment boundaries in this post. I want to elaborate. I want to explain how explaining pain to a patient can be woven straight into the constructing a safe psychological, social, therapeutic container to work within, while utilizing physical contact.

Guys, especially, seem very reluctant to take on gentle manual therapy. They are concerned they could be misinterpreted. (Maybe this is why they seem to head off in large droves toward ortho and other structural, manipulative technical approaches and away from physiological change approaches - they don't want their physical contact to be misunderstood.)
I say, then, make the situation be completely transparent. Ask for and get permission every step of the way. 

Let's say you had a patient with some kind of pain problem. Let's make you a guy, and the patient female. Let's make her a tough case: anxious, known drug user/abuser. Chances are, you are scared of using gentle manual therapy. You worry that she might cling, rapidly become dependent.

You can avoid any danger of creating dependency by setting a simple but firm treatment boundary: Something like:

"We could try to help the part of the brain that is making the pain figure out a way to stop. I'd like to try some hands-on work, if that would be OK with you. (Pause and wait for an indication the patient is interested.)

"It may help, although I wouldn't know for sure, without us trying it first - it helps most people in a pretty straightforward way; what I am sure about is that if it we do a few sessions and it hasn't helped yet (changed the pain significantly right away, so that it is less severe, less bothersome, less frequent, stays away for longer periods of time, one of those things or some combination of those things) then it wouldn't be worth pursuing further. 
"I'm saying, it's something we could try, and see what happens, and if it doesn't help, we haven't really lost anything by trying. So, what do you think? Would you be interested in seeing if it could help your brain to stop giving you this foot (or back, or leg, or arm) pain?" (Pause and wait for an indication the patient is interested)
The next set of treatment boundaries involves explaining the patient's nervous system and how it mounts a pain presentation. This does a number of things:
1. It explains pain to the cognitive part of the patient's brain, which will give her the idea that you consider her worthy of learning it and capable of understanding it (respect).

2. It creates a conceptualization that "she" is something apart from the rest of her own brain, that you would ask for her cooperation in helping you, so that together, you (plural) can detach from the pain, watch the nervous system (with minimal input from you) solve the "problem" which is something in the rest of the nervous system (recruitment of patient's cooperation, mostly her dorsolateral prefrontal cortex).

3. It also gives her non-conscious brain time to mount reward expectation mechanisms and dopamine (if she has any of her own left), all that anticipation stuff. This wouldn't be a bad place to reassure her that you aren't going to hurt her with your handling, that you want her to tell you if anything you do, any grip, feels uncomfortable to her, because you aren't in there and can't feel her nervous system the way she can, and you certainly can't feel her pain experience, only its manifestations. So you are relying on her to help. You don't think it's prudent to have her nervous system, which is a learning machine, learning to have to deal with more pain, associated with you - your job, as you see it, is to help it learn how to feel less pain.(You are assigning her a job, a role, and indicating that she has locus of control over your handling, are giving her veto control over it, and therefore over all your physical contact with her.)
The third set of treatment boundaries involves explaining the actual physical contact, what position you would like her to lie down in, what you are going to touch, how you are going to land, then what you're going to do once you've landed, what she can expect, what you'd like her to pay attention to, to breath, etc. Then before you actually touch her, ask her permission one more time.

These are little things, mostly good manners, but they add up into setting a treatment relationship/contract that is OK for either of you to walk away from at any time. It's egalitarian and fair. It should not give her any opening to become a cling-on.  It permits the dance between nervous systems to develop to the point of helping the patient get out of the way such that his or her nervous system can resolve its problem, can fix itself, all the while, as you provide it with clear, boundaried messages and feedback, both verbal and kinesthetic, and ask for the same from the patient.

You have the right to end the (manual) treatment relationship if you sense it's not helping, and she knows from what you've said, that she has to carry a lot of responsibility for any success, and her nervous system carries the rest; if she doesn't get this, then I'd recommend stop manually treating her and move to other management methods.

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