To get everyone kickstarted back in to the new academic year, here is a really interesting research piece from one of UCO’s bright sparks, Maria Larrain, who previously guested on osteofm with her essay about placebo. She looks at the experience of touch in an osteopathic treatment, and the concordance between patient and practitioner.
Note: Research purists amongst you might balk at the use of ‘I’ in a supposedly academic context. This is because it is an ethnographic study so the ‘I’ is always present rather than being an objective observer.
“Can You Feel What I Feel?” – a phenomenological exploration of an osteopathic therapeutic relationship.
The evidence base using randomly controlled trials (RCTs) has been difficult to achieve in osteopathy, partly because of the non-specific effects of touch (Cerritelli et al., 2016). Only one study was identified that explored touch in osteopathic practice using phenomenology (Consedine, Standen and Niven, 2016).
This research project set out to explore the phenomenon of what it feels to touch and be touched in the therapeutic process and where there is concordance of sensations between osteopath and patient. In the medical anthropology literature, I identified only two ethnographies that described concordance of touch in reading of pulses in Siddha medicine (Valentine, 1991) and between chiropractor and a Filipino hilot (O’Malley, 2004). Sociologist Lee-Treweek (2002) studied patients of a cranial osteopath to look at the construction of trust. However, she did not explore the embodied feeling of the treatment process itself in the people she interviewed.
The phenomenology of touch
‘Embodied cognition’ is the multisensory experience combined with the practitioner’s cognitive faculties which leads to diagnosis and treatment and identified in other manual therapies (Øberg, Normann and Gallagher, 2015).
Phenomenologist Max Van Manen (1999) distinguishes between ‘pathic’ touch, the emotionally aware, caring touch that conveys concern, confidence and reassurance (Kneebone, 2018) and ‘gnostic’ touch which comes from (dia)gnostic and is procedural, brief, one-directional and a more probing kind of touch. Our hands are uniquely suited to this kind of touch, but the phenomenology of touch is subtle and complex (Van Manen, 1999). To touch and to be touched by something can be two completely different experiences, which Merleau-Ponty (1962) calls a kind of physical reflection (p.166). The type of ‘pathic’ touch used by osteopaths such as myself that produce a therapeutic effect in the patient, I experience as a form of embodied empathy. It requires an open, afferent sensing of the other person in order to feel for the subtle changes that occur in their body.
The neurobiology of gentle touch
Therapeutic touch may be an evolutionary development from grooming of the skin, known as allogrooming, which helped strengthen kinship bonds (Silk, 2002). Humans may have evolved to respond to interpersonal affective touch (Crucianelli and Fillippetti, 2018) and the exchange of grooming services for food may have helped establish some of the early patient-doctor relationships (Benedetti, 2013).
Neuroscientists increasingly understand the positive neurophysiological and nurturing effects of touch on health and well-being (Craig, 2009; McGlone et al., 2017; Elbrecht & Antcliff, 2014; Field, 2010). Some distinguish between ‘discriminate’ touch, essential for our survival, and ‘affective’ touch which may provide the neurobiological substrate for the development and function of the social brain and is detected in the anterior insular cortex (AIC) via the C-Tactile sensory nerve fibers (CTs) (McGlone, Wessberg and Olausson, 2014). Contextual factors influence the perception of pleasantness of CT mediated affective touch, such as positive expectations (Ellingsen et al., 2014) and the quality of the relationship between “touchee” and “toucher” (Gazzola et al., 2012). The AIC may be the area of the brain that engenders the human capacity to be aware of themselves, others and the environment (Craig, 2009). Studies have found that slow touch produced higher levels of subjective embodiment than fast touch (Crucianelli et al. 2013) and that interoception may contribute to body ownership, and thus our embodied cognitive “self” (McGlone, Wessberg and Olausson, 2014). Interpersonal affective touch helps homeostatic regulation and making sense of our body as our own (Crucianelli and Fillippetti, 2018). The relationship between the osteopath and the patient when using gentle, affective, ‘pathic’ touch may have the potential to create meaningful changes in the well-being of the person receiving treatment through this neurobiological mechanism.
When does ‘giver’ (osteopath) of touch concord with the ‘receiver’ (patient) of touch and vice versa and what is this phenomenon’s significance to the therapeutic relationship?
A voice recorder was used to record a treatment encounter between my osteopath and myself, the researcher. It was transcribed and analysed using Colaizzi’s (1978) descriptive phenomenological method, which is widely used in healthcare sciences and is valuable in areas where there is little existing research (Morrow, Rodriguez and King, 2015; Consedine, Standen and Niven, 2016).
I identified 13 events and used ‘bracketing’ to reflexively describe the event as I was experiencing it as a patient. The process of bracketing originates from Husserl’s (1931/1982) concept of the phenomenological reduction. It is a multilayered process meant to access the researcher’s presuppositions and assumption through their consciousness, when studying the phenomena, but there is a lack of consensus of how it is done (Tufford and Newman, 2010). I used bracketing from my point of view as an osteopath as I have experience in both ‘giving’ and ‘receiving’ treatment. Through describing the events, and as I am not able to read my osteopath’s mind, I used my own experience as ‘giver’ to describe hers. Our treatments are usually in silence and our own ‘inner-world’ experiences are simply felt in a normal treatment, but this time, to get data, we verbalised our sensory experience as the treatment unfolded from moment-to-moment.
The events that I identified I clustered into themes and marked them as either concordant or non-concordant and underlined the evidence statements from osteopath and patient:
Describing the phenomena:
In the beginning of the treatment (events 2, 3), awareness of the osteopath and patient will invariably be in different places, which is why there is no concordance of sensations. The osteopath has her attention in settling the patient into the treatment, which feels different to both. The osteopath is applying concepts from her osteopathic training and she is observing phenomena in the body that she is treating while the patient’s awareness is in the pleasant sensations in her body (event 2):
(I take a deep breath as my body feels like it sinks deeper but I am not able to relate to what she says to me as the ‘tide’ but I just feel a deep sense of calm and connection with my body at this point)
The patient’s awareness is in her legs that feel like they are ‘stuck in a shallow pool’ which the osteopath takes as a verbal cue that she needs to move on to this part of the body (event 3). The patient has sensations in her hip and the osteopath thinks it may be referred pain using her sensory findings for clinical reasoning (event 8). During the stages of settling into treatment there is no concordance between osteopath and patient.
P: You see, now that you’re holding my feet…I get a sense of release in the pelvis. (I have guided her to the place where her hands will be of help to my body where they will be most helpful).
O: Aha…that’s good to hear…(I interpret this as she is hearing it from me but not feeling it herself as her awareness is in some other process in my body)
As the treatment progresses (event 12) there is concordance, although the patient’s focal awareness is on her tooth, while the osteopath’s is on the whole myofascial connection that is causing the tooth sensation.
In the beginning of the treatment, the osteopath diagnoses what she feels is happening in the patient’s body (event 1) which initially validates her disembodied feeling:
P: ‘it doesn’t feel like it’s my leg’.
They both agree the importance of validation and how that feels reassuring to patients:
O: ‘They like to know that what they’re feeling you can feel. Validate it. And you can talk to them in a different way that makes sense to them’.
The validation seems important to the therapeutic relationship that is unfolding, but also ongoing between osteopath and patient.
When there is most concordance between osteopath and the patient is when there are feelings of embodiment, where the patient is aware of the ‘inner-world’ in her body:
P: ‘I’m definitely feeling something changing in there’
and the osteopath is paying attention to this process, which for her is also an ‘inner-world’ experience:
O: ‘And it’s a sort of ‘goldy-ney’ sort of light shifting around’.
It is a meaningful and multisensory experience for both as they are observing the therapeutic changes taking place. It is an embodied empathy for the patient and how she feels. The process also provides reassurance for the patient:
P: ‘It’s funny the jaw pain, I started to sense it right now. I hope it’s not a tooth’.
‘I can feel the tension of all that coming up but I think I will go to your jaw’ , the osteopath reassures.
P: ‘Yes, my jaw, I can feel that into my right shoulder there’.
The patient thought her jaw pain was an infection, but the connection of sensations she feels in her shoulder is reassuring, because it is a sign of a musculoskeletal strain rather than the prospect of a root canal.
The fundamental structure of phenomena:
The concordance of sensations during this osteopathic treatment using gentle touch is important in the therapeutic relationship because it allows the patient’s distress or disembodied sensations to be validated by the osteopath. Healing takes place when the body is allowed to ‘be seen’ and sensations validated, which also helps to reassure the patient by providing a narrative to why the body feels the way it does (e.g. the tooth).
The osteopath has embodied empathy and the patient trusts the osteopath to allow her to enter her ‘inner-world’. This happens through a process that intensifies during the treatment as the osteopath and patient are more synchronised with each other, evident by the progression and degree of concordance in their sensory experiences.
Both osteopath and patient have an embodied multisensory experience during the treatment process.
The process of verbalising our sensations during the treatment confirmed our shared experiences as osteopaths who work in the same way using gentle touch. There is concordance in how we perceive treatment, perhaps as a result of similar training, which means that we have a similar understanding of the treatment process.
As osteopath and patient we have concordance of sensations during the treatment process and the function of concordance is two-way. It validates the patient’s state of health and well-being, but also the osteopath’s diagnostic and therapeutic skills.
Plausible neurobiological explanations of how touch may heal are emerging, but how it is experienced can only be studied phenomenologically. This study is a very small and therefore a limited contribution to the study of touch in osteopathy. It would be interesting to expand the study of concordance and the role of embodied empathy in a group of osteopathic and patient dyads.
By Maria Larrain BSc, BOst, DPO, PgC ACE
References and bibliography
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