Therapeutic relationships and the
illusion of communication
Lisa Roberts PhD MCSP
Arthritis Research UK Senior Lecturer in Physiotherapy / Consultant Physiotherapist
University Hospital
• The challenge of communication
• Issues of truth telling
• Current research
• Opening clinical encounters
• Implications for practice
Communication is …..
‘The most important aspect that health
professionals have to master’
Weatherall (1998)
Importance of:
• Verbal communication
• Non-verbal (55-97%)
• Patient-therapist relationship
Poor communication
80% of patients’ complaints arise from a breakdown in
Towles BMJ;1998:301-4
Non-specific treatment effect
• Touch
• Showing interest (Hawthorne effect)
• Professionalism
• Actively listening
• Environment
• Technical equipment
• Placebo effect ….
The most important thing in communication is to hear
what isn't being said.
Peter Drucker
Why do we tell lies?
To reduce fear
To tolerate stress
To gain control over uncertainty
To enhance well-being
To protect privacy / confidentiality
To help others
To be malicious
Physiotherapists’ perceptions…
…of the most important factors in successful treatment
• patient-therapist relationship
• patients’ resources
More important to success than treatment techniques
Stenmar & Nordholm. Physical Therapy 1994;74:1034-9.
Aim of the pilot study
To measure the content and prevalence of the verbal and
non-verbal communication that occur between
physiotherapists and patients with low back pain in an
outpatient setting.
Roberts L & Bucksey SJ. Communicating with patients: what happens in practice?
Phys Ther 2007; 87: 586–94
Patients (n = 21)
Physiotherapists (n = 7)
Video recording: Initial treatment session (n=21)
Key findings
1. Verbal & non-verbal communication can be measured with
valid and reliable tools
2. Affective behaviours were more prevalent among
experienced physiotherapists
3. Video camera was perceived to influence communication,
planning and treatment
Roberts & Bucksey
Physical Therapy 2007;87(5):586-94
Communication and clinical decision making in
low back pain consultations
• Funded by Arthritis Research UK
• 'What communication and clinical decision making takes
place in consultations between physiotherapists and
people with back pain?'
Home visit
Observation of initial back pain
Physio interview
Patient interview
Wessex Medical Research:
Student Innovation Grant 2009
“Piloting an analysis of verbal communication using
Synote in consultations between physiotherapists
and people with back pain.”
Christopher Whittle
University of Southampton
• Grounded theory approach
• Data managed through ‘Framework’
27 home visits
25 initial consultations
25 interviews with physiotherapists
25 interviews with patients
Expectations data
• Knowledge:
• Skills:
• Personal attributes:
Opening questions
• ‘How can I help you today?’
• ‘Do you want to tell me your story’
• ‘I’ve had this referral through. Tell me what’s happened’
• ‘What problem are you having at the moment?’
• How long have you had back pain for?
• It’s your back pain that you’re here for is it?’
• The referral says you’ve got back pain. Is this correct?
• ‘What we’ll do today is just have a bit of a chat about your
back pain I believe it is. All right?
Clinical implications
• How do you open your clinical encounters?
• How often do you interrupt your patients?
• Do you tailor your communication to take account of
gender and age?
• When was the last time you told a ‘little white lie’?
• Have you spent time evaluating your communication
• How will you maximise your non-specific treatment

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