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Submit requests for reprints to: Matthew A. Davis, DC, Chiropractic Physician, Carlos G Otis Health Care Center Inc., P.O. Box 216, Townshend, VT 05353
Assistant Professor, Department of Anesthesia, Critical Care, and Pain Management, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
The following commentary discusses the concept of a chiropractic healer. A model is proposed to describe the elements of a successful chiropractic healer that includes knowledge and manual skill, specific interpersonal skills and attributes, and the attainment of a healing presence. The achievement of a healing presence, which represents the highest level of presence, is emphasized along with effective doctor-patient communication.
Evidence-based practice integrates the provider's own clinical experience, informed patient preference and values, and the most current scientific evidence.
The dichotomy between the 2 philosophical constructs may create a sense of disillusionment for the modern doctor of chiropractic as pressure grows to apply evidence-based practices in a patient-centered profession.
The strong doctor-patient relationship, a characteristic of patient-oriented health care, has historically distinguished the chiropractic profession from our medical counterparts
and potentially boosted our clinical outcomes. The complex interaction between physician and patient remains at the very core of the healing process. Research spanning fields of psychology, neurology, and immunology has made clear connections between emotions, immune function, and health.
The doctor-patient relationship has, and has always had, a pronounced impact on patient health and recovery. As early as the 4th century bc, Hippocrates recorded, “The patient, though conscious that his condition is perilous, may recover his health simply through his contentment with the goodness of the physician.”
Healing is defined as the process of becoming whole through the curing of disease (dysfunction). The physician or healer is a facilitator of the healing process within the patient, bringing about a positive health change. The healer has the opportunity to draw upon their own humanistic qualities of compassion and empathy to promote healing by responding to the biopsychosocial needs of the patient. The presence of the healer has been described as an intrapersonal, interpersonal, and transpersonal phenonomenon.
In an effort to “restore humanism in medical care” and create “physician-healers,” medical schools are beginning to address medical students' personal awareness and well-being.
The following commentary discusses the various factors that contribute to the healer-patient dyad, focusing on chiropractic implications. We describe the elements of what we consider to be a successful chiropractic healer.
Placebo and the Meaning Response
In clinical practice, placebos, defined as “fraudulent replacement of the real,” were popular when effective medical treatments were scarce.
Positive therapeutic effects were precipitated by the medical encounter itself, the caring and communication of the provider, and the use of strategic suggestion. The era of randomized controlled trials initially labeled placebos as nuisances, which resulted in a negative stance toward placebo in the literature. However, the marked improvement in untreated (control) groups remained, and interest grew. Recently, efforts have been made to better define, understand, and apply placebo effects in practice to maximize clinical outcomes in a safe, cost-effective manner.
One meta-analysis of 130 trials concluded that placebos have little clinical efficacy in many conditions but do have a beneficial effect in the treatment of pain,
The term caring effects has been used to replace the previous nomenclature, bringing attention to the profound impact of the nature in which health care is delivered by the provider.
This term was introduced to more positively describe the placebo response as the resultant effect of the particular meaning of a therapeutic intervention for an individual patient. This definition is important as it acknowledges the sometimes unpredictable complexities and specificity of an individual's reaction to a stimulus.
The effects of placebo responses are likely to be patient-specific. It is theorized that sickness must be investigated within the context of the psychobiological framework of the specific individual, including facets of social, emotional, and personal history.
Collectively, the term biopsychosocial is now used to describe the 3 realms (biological, psychological, and social) that pertain to comprehension of the delicate intricacies that impact a person's health and their response to treatment.
Identifying personality type(s) that are susceptible to placebo effect was a focus of early literature in hopes of excluding such individuals from clinical trials.
Early literature concluded that no “placebo-personality type” exists and that the nature of the placebo effect was a product of the context of the situation,
thus supporting the importance of contextual meaning. Personalities that use positive relationships as an active coping mechanism to adversity, called the “acquiescent personality type,” may be more receptive to placebo effects.
Vulnerability to hypnosis has been implicated as a predictive factor for placebo susceptibility characterized by one's ability to imaginatively dissociate, focus on a single theme, and remain open to new suggestions.
In this discussion, we define success not in terms of financial or practice patient volume but in terms of the provider's achievement in the relationship with their patients and their role as a healer. In this regard, a successful chiropractic healer is one who has mastered the ability to relate to patients of different biopsychosocial needs on a higher, at times spiritual, level. This evokes a positive health change in the patient. Categorically, we separate the components of a chiropractic healer into 3 domains: knowledge and manual skill, specific interpersonal skills and attributes, and the attainment of a healing presence (Fig 1). The acquisition of manual skills and clinical knowledge are areas where the profession has made great accomplishment
and need not be discussed here. Rather, we focus our attention to areas of touch, communication, empathy and compassion, and the development of healing presence in clinical practice.
Fig 1Proposed components and developmental scheme of a chiropractic healer. Clinical skills, interpersonal skills, and partial presence are requisite for all practicing chiropractors. The development of a healing presence coupled with clinical and interpersonal skills allows maturation into a chiropractic healer.
before and during the application of therapies that involve touch. The intimate nature of this interface creates an environment conducive to healing by promoting a physical and emotional connection, and often exceeds patients' expectations.
impact. This is important because 30% of chiropractic patients report coexisting moderate to severe emotional distress, and 50% report their emotional stress as contributing to their musculoskeletal condition.
The nature of intention-driven touch as administered during treatment communicates the confidence and healing intention of the chiropractor. Intention is “a mental state directed toward achieving a goal.”
One study that showed reductions in psychological stress with physical contact described the intervention as “lingering, firm, but gentle, non-invasive touch.”
Intentionality is a vital component of therapies such as healing touch, therapeutic touch, and distant healing. The few studies on these therapies suggest mild efficacy.
In the healer-patient dyad, the healer must have the ability to recognize and relate to the experiences of the patient. The significance of empathy in healing dates back to Greek mythology and the concept of the “wounded healer.”
In this regard, the path to becoming a healer is “that of being wounded in body, mind, or spirit, and through one's own healing process to emerge with a commitment to share deep empathy, insights, and loving energy with others in need of healing.”
Connectivity is achieved when the healer can better understand and offer genuine compassion to the nature of the patient's suffering. Compassion involves openness and emotional movement by another's suffering with the subsequent desire to ease their pain.
Levels of charisma lend attraction to different personalities of patients and may prove more beneficial to patients requiring motivation.
Effective Communication
The ability to conjure empathy and compassion in clinical practice entails active listening. Listening is an acquired communication skill, and is an important aspect of the healer-patient relationship. There is a large disparity between hearing and listening.
Listening “involves taking in all elements of a patient's message including verbal and nonverbal signs” and requires “reflection, interpretation, and understanding.”
Both the provider and the patient are respective experts: the physician an expert of clinical sciences from their training, and the patient an expert of their own experiences and expectations.
One study found less than 50% congruence between chiropractors' and patients' health-relevant perceptions, which suggests practitioners could improve on discussing patients' expectations and opinions before treatment.
Asking appropriate questions and responding promptly to patients' expectations and concerns is critical. Given the uniqueness of each patient encounter, adaptability is an essential component of the art of healing.
Patients inevitably will have their own notions and perceptions about their health status. It is not the job of the healer to change these notions, unless destructive in nature, but rather to communicate within the conceptual framework of them. For instance, if a long-standing chiropractic patient understands his low-back pain as “L5 going out of place,” it is not the responsibility of the new chiropractor to convince the patient his back is not “misaligned” and that the pain is a case of “facet-syndrome.” To do so may give the chiropractor professional satisfaction in bringing the patient up to date but could negate a previous meaning response. In this situation the chiropractic healer would be better to agree with the patient to reinforce that the treatment will correct the dysfunction.
Because much of the chiropractic consultation focuses on musculoskeletal dysfunction, diagnostic explanations often include simplified and not necessarily scientifically supported concepts that relate the body to a machine (eg, “misalignment,” “joint dysfunction,” “nerve interference,” and “myofascial tightness”). In our mechanically based culture, such comparisons elicit a strong meaning response in patients. Historically, the description of “misalignment” of the spine had a powerful meaning effect because it was easy to understand by patients and clearly connected the dysfunction with the proposed treatment. Many chiropractors continue to use this description despite a far superior understanding of the complexities of spinal mechanics and pathophysiology. Although spinal manipulative therapy is a well-evidenced intervention in the treatment of low back pain and neck pain,
the application of a meaning response in clinical practice seems likely to intensify the therapy.
Allotting sufficient time for doctor-patient interaction is imperative. This is a significant advantage of patient encounters with naturopaths, massage therapists, and acupuncturists.
detailed a framework describing 4 levels of presence including presence, partial presence, full presence, and transcendent presence. We have adapted this framework into our model, considering healing presence as full presence, and the chiropractic healer as one possessing transcendent presence to some degree (Fig 1). In this scheme, presence is defined simply as physically being with another, lacking psychological interaction. Partial presence is when the caregiver is physically present yet focuses energy on a task and not the individual for which the care is being provided. Healing (full) presence is achieved when mind-to-mind interaction occurs between the healer and patient with the embodiment of compassion, empathy, and caring. The chiropractic healer (transcendent presence), the highest level of interaction of this model, is when an exchange of energy occurs between caregiver and patient in a spiritual-like quality. During transcendent communication the healer must be aware of “fusion” and the “danger of taking on recipient's problems” as possible negative outcomes of this level of interaction.
Current efforts toward practice development concentrate on improving and validating technical skills. In the eyes of the patient, this may inadvertently shift our perceived clinical presence toward merely presence or partial presence. Fostering a strong healing presence must be emphasized in chiropractic education and research if our profession is to maintain its autonomy.
Spirituality, “the belief in a power apart from one's own existence” contributes to the centeredness and openness of the healer.
Spirituality must be differentiated from religiosity. Spirituality is unique and personal; although it may be associated with specific religious beliefs, it is often constructed outside the constraints of formal religions. Research on the impact of the healer's spirituality has received little attention in the literature, although a substantial amount of literature has investigated the patient's spiritual beliefs.
We postulate that a chiropractic healer who has come to terms with their own spirituality may be more likely to achieve the level of transcendent presence.
Conclusion
The chiropractic profession must not lose sight of altruistic beliefs while we strive to improve patient care by implementing evidence-based practices. The powerful impact of the doctor-patient relationship on clinical outcome suggests that the healer is evidence-based. We propose that the optimization of patient care lies in chiropractic healers incorporating evidence-based practices. This concept is as amenable to scientific inquiry as other practice parameters. Efforts to more clearly quantify elements of the chiropractic healer should become a focus of chiropractic education and research.
We should acknowledge the complexities and uniqueness of each patient and adapt our skills to address their clinical and emotional needs. To be successful in this challenge means to master interpersonal skills of effective communication, empathy, and compassion in an effort to connect with our patients on a higher emotional level. Clinically, the meaning response should be maximized to heighten the effect of therapeutic intervention as these responses are powerful in practical application. To practice chiropractic in a manner that promotes the self-healing capacities of the patient maintains the chiropractor as a true physician and healer.
References
Delaney PM
Fernandez CE
Toward an evidence-based model for chiropractic education and practice.
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