It's not you, it's me…

All relationships are hard work. They require effort, commitment, and sacrifice from all involved to succeed. However, there are times when it’s clear that a relationship is not working. Being able to recognise this takes honesty and courage, and taking action to address it sooner than later is usually best for everyone, and sometimes this means ending a relationship.

The professional relationship between a patient and therapist is on many levels not that different from a personal relationship. They both require everyone to work together to achieve a successful outcome, and sometimes they don’t always work. The relationship therapists have with their patients is more important than many care to admit, with many therapists believing that their success as a clinician is due to their extended skills in manual therapy or exercise prescription when in fact its due to their skills in building a therapeutic relationship.
I often highlight this on social media and on my courses much to the annoyance of many therapists who feel I am belittling their skills or undermining their experience. I am not. I am simply being open, honest, and realistic and highlighting how many patients get better, not because of WHAT therapists do, but HOW they do it.
To put it simply as I can often its the act of treatment that works, not the treatment itself, and therapists interactions often reinforce their interventions. In fact, it can be at times only the therapist’s interaction and not their intervention that gets the results which is why a lot of shitty interventions appear to work.

Interaction IS intervention

Don’t believe me, well let’s consider two therapists giving the SAME treatment to a patient with the SAME problem, let’s say interferential treatment for chronic low back pain. However, one therapist does it whilst taking and listening to the patient, the other doesn’t. Who do you think will get the better results from using the same treatment?
Well this has actually been studied. Fuentes randomised 117 patients with chronic low back pain to receive either active or sham interferential electrotherapy treatment, BUT with either a limited or an enhanced therapist interaction. In the limited interaction the patients were told that the therapist was just there for safety reasons and so just strapped the machines on them and sat quietly in the corner of the room.
However, in the enhanced interaction group the therapists used the 30 minutes whilst the same interferential treatment was on to also talk to the patients about their back pain, demonstrating some active listening, using a soothing tone of voice and other non-verbal behaviours such as eye contact, and physical touch. Empathy was also demonstrated by the therapists by using phrases such as “I can understand how difficult this must be for you”.

And guess what… The enhanced interaction groups all had significantly greater results (see the above chart) even in the sham group where the crappy interferential machine wasn’t even switched on. In fact, the enhanced interaction achieved nearly double the pain-reducing effect of the crappy interferential treatment regardless if it was switch on or off.

It ain’t what you do, it’s the way that you do it

So just by being a caring human being, you could double the effect of your treatment, even a shitty one like interferential, and it doesn’t matter what the treatment is this applies to all treatments. Ferreira did a similar study looking at the effect of the therapeutic relationship on the effects of three different treatments for low back pain.
Patients where randomised to receive 12 sessions of either general exercise, specific motor control exericse, or spinal manipulation. They found that regardless of the treatment the patients who reported a greater theraputic alliance with their therapist had the greatest improvements.
So the relationship between you and your patient is vital to their outcome, however, this doesnt mean for one second you can suddenly become a smooth talking bar steward and start applying snake oil treatments or what ever the hell you like to your patients. Although, unfortunately, this does happen a lot the world over, and as I already mentioned explains why a lot of dubious treatments appear to work for a lot of people.

Maximise it

But for all the remaining non narcissistic, honest, sensible, rationale, and decent therapists out there it does make sense to maximise your therapeutic relationship with your patients. Hall in her systematic review discusses the many factors found that make a successful therapeutic relationship, and its all pretty straight forward simple stuff. Things like listening more, talking less, showing that you care and empathise, not rushing, being clear and concise, and having a good sense of humour.
These personal humanistic traits and communication skills are where the true skill of a good therapist lie, not in the latest fad of manual therapy, or exercise rehab. Any therapist can treat a stiff back or weak shoulder, but it takes a great therapist to treat a stressed, anxious, annoyed, or worried person with a stiff back or weak shoulder.
However, being brutally honest here building therapeutic relationships with patients can be at times exhausting, frustrating, and hard bloody work, and there are many times when I feel the relationship with a patient is strained, awkward, and uncomfortable and no matter what or how hard I try it doesn’t seem to improve.
This can be due to a host of different reasons, such as cultural, personal, environmental, and it can be due to anything from a simple a lack of rapport, a miscommunication, a misunderstanding, a clash of personalities, or just not liking the look of each other.

Ending the relationship

Humans are extremely variable, and human interaction is extremely complex, so it would be extremely naive to think that we as therapists can develop an effective relationship with everybody we see, all the time. Over the years I have learnt that when a professional relationship is not maximised, and I can not see it improving, rather than continuing on with an awkward uncomfortable non-productive atmosphere I will now end the relationship sooner rather than later.
Again being brutally honest here, this can also be awkward and uncomfortable to do, but it has gotten easier over the years the more I do it. How to end an unproductive relationship with a patient can be tricky, but I find being completely open and honest with them is best.
I ensure I make them aware that this is in no way a reflection on them, or me, and that there is no fault or blame associated to anyone. I stress that I wish to cause no offence or disrespect, but I explain that it feels that we are not communicating or working well together.
I then ask them for their thoughts, to which I find it can be either a surprise or shock to them or they are in agreement. If its a surprise to the patient it allows me to explore the issues further and can actually help overcome any barriers and actually help improve the relationship. If its agreement then I suggest that I think its best if we find someone else to help them.
Now, this is not giving up, passing the buck, or ducking out, and I know this isn’t always an option for some therapists who work alone. I am fortunate that I work with a great team of therapists, all with unique and different personalities, styles, and mannerisms. This means there is always someone else who I can pass a patient onto, and this process happens both ways, I pass patients to other therapists, other therapists pass patients to me.
Simply put getting the right therapist in front of the right patient at the right time is essential for success, and thats not just about experience or knowledge, but also personality and style.


So that’s my review of therapeutic relationships which are not as simple as they may seem. As I said at the beginning, successful relarionships are hard work, and require effort and commitment from all involved.
However, when it comes to successful relationships I will always remember my late great Grandad’s advice. He told me the secret to the long and happy relationship he had with my Nan was due to them making the time to talk, and so they went out for dinner twice a week to do this… he went out on Friday and my Nan went out on Saturday.
And as always, thanks to you for reading this far.



  1. Another top blog Adam. I’ve done 20 years as an MSK physio,10 in pelvic health and absolutely concur. Getting rid of narcissistic tendacies and replacing them with a genuine focus on the patient gives the best results.
    Thanks for writing!

  2. Thank you for this excellent post. One of the reasons I went back into private practice was to have control over how much time I spend with clients pre- and post-treatment. In addition to the positive effect on the treatment outcome, after 13 years in practice I find managing the nuances of the therapeutic relationship to be the most fascinating and professionally fulfilling part of my work.

  3. Excellent, Adam , one of your top blogs in my opinion . This would never happen in health care but yesterday we had our chimney swept by a great character ..deer stalker , sweep, wood cutter and all round fearless judge of character . He said he was up at some house where the B+B owner needed a certificate for insurance but the guy had installed it himself and it was dangerous etc and kept our man waiting in his van…. an air of hostility ensued pretty quickly . He informed the punters that its pretty obvious that I really don’t like you and you clearly don’t like me and if I were twenty my immediate reaction would have been to deck you and move on. I am not suggesting this is a good way of going about life but sometimes he has a point . Many times people with a completely mechanical view of life with absolutely no nuance or greyness will never get ‘pain education’ , metaphors or even simple rehab ideas …I encourage them to see Mr White coat for often futile tests ( I know this is medicalisation but this is the culture we are in and I am usually King Canute in many situations ….) . I think massage therapy is excellent for some people who are in stressed out situation and can afford it for example and with the right therapist the support is invaluable. I agree with you regarding horses for courses and one of the reasons why a diverse range of personalities should be employed in health care settings (rather than a bland homogenous group perhaps ?? ) .

  4. Another great post, Adam. There is an old saying “if you listen closely enough, your patient will usually tell you what is wrong”. I really believe that. I have always said that one of the least technically knowledgeable therapists I know is also one of the most effective. He REALLY listens.

  5. Thanks for another thought provoking post Adam.
    The relationship is everything! I recommend reading Paul Watzlawicks 5 axioms of communication which includes a definition of relationships as either complimentary or symmetrical. In summary; either consisting of power or equality. It is a difficult stance we take as therapists in treading the fine line between empowerers and educators!

  6. Totally agree! That’s why you find juniors get lots of presents from patients because they’re fresh and still have lots of patience!
    Who also finds that when they’re in a good mood all your patients seem to get better? Then when you’re having a bit of a rubbish day and don’t really want to be at work, the patients all seem to be worse? I also notice the same with the clinic I’m in… When I’m in a depressing room with no windows, the patients appear much more complex, yet when I’m in a brand new sports centre surrounding by fields, patients seem to be much more positive!

  7. Great post Adam!
    Another recommended read among this topic is “Skills for Communicating with Patients” 3rd ed. by Jonathan Silverman. Content is excellent.
    Looking forward to more posts!

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