Discuss the importance of the therapeutic relationship to clinical outcomes in herbal medicine
It is widely thought that the difference in the therapeutic relationship, within the context of a consultation with a complementary health practitioner, is one of the primary factors why people seek out this form of care as opposed to allopathic. Although seemingly little research has been done in this field, and in particular within the field of herbal medicine, this essay sets out to ascertain whether the quality of the relationship between practitioner and patient does have an effect on clinical outcomes.
At the heart of this issue is what is the best, most effective, way to treat patients to derive optimal outcomes, and the role of the practitioner within any given framework.
Conway (2011. p. 42) states that the focus on therapeutic relationship traditionally derives from the practice of psychotherapy and is a means of combining pharmalogical effects with psychotherapeutic effects. He maintains that a difference exists between the treatment of acute conditions which demand a rapid diagnosis and response, but that the current approach of treating, chronic illnesses especially, leaves a lot to be desired. That often practitioners in allopathic as well as sometimes in complementary disciplines tend to compartmentalise the symptoms of illness in order to quickly make a prognosis and arrive at a cure.
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When we factor in the wider environment in which healthcare professionals now work, it is often reported that healthcare is in crisis. That we are forced to focus more on targets rather than a quality delivery system (Kmietowicz, 2017).
This is an argument put forward by Toombs (1987. P. 222) who states that the allopathic physician is trained to see illness essentially as a collection of physical signs and symptoms which define a particular disease state. That he condenses a collection of symptoms in order to fit the disease paradigm and ‘one size fits all’ treatment of the modern healthcare system. We then become synonymous with our prognosis, labelled as our disease.
Of course there needs to be a rationalist approach to diagnosis and prescription. Douglas Model (2006 p.4) describes a framework of considerations for “accurate diagnosis” of a patient based on factors such as patients age, sex, race, past medical history and so forth, arriving at a hypothesis via “pattern recognition”.
However, as Mills (1991. pg 25) states “the human is a wilful vibrant idiosyncratic wonderful being, not to be divided into compartments…all living beings are self-regulating”. He maintains that we need to look at the overall processes unfolding rather than “mechanical functions”. There are also the effects of the therapist interaction in terms of considerations such as body language, building trust, positivity. In a time where patient wants are often at odds with evidence-based medicine (Conway, P. 2011), much has been written about the effect of mood and optimism on patient clinical outcomes, how in control patients feel and whether they feel heard.
Inherent in this approach is the argument that we need to move away from the ‘one size fits all’ approach to care and that in prescribing the polypharmaceutical nature of plants “diffuse, complex and wide-ranging”, Connor (2011. P. 11) argues that means that the key to successful practice is considering taking a dynamic view of the therapeutic relationship, rather than reductionist one.
This is reiterated by Cormack (1998) who proposes that most practitioners, whether orthodox or complementary in their approach, know that curing disease does not in itself necessarily render the patient healthy, and that with herbal medicine we need a more integrated way of looking at the wider variables of illness such as diet, lifestyle etc. We need to think about holism, that the whole is greater than the parts, often referred to as a ‘mind, body and spirit’ approach. This is also referred to by Hoffman (2003, p.9) when he talks about the “spiritual factors in human healing” and the motion of vitalism. In this, the body is always striving towards homeostasis and self-healing. The role of the herbalist and any prescribed plant medicine should be to facilitate the body’s own response mechanism.
So this then leads to a need for a different framework, a different standard of care from the Western norm, a highly individuated approach to the therapeutic relationship. One where it is more important to be patient-centred, rather than allowing the mind to jump in with preconceptions.
There are, of course, many other factors to take into account when looking at any model of therapist-patient interaction. Those such as empowering the client via building trust, receptivity, openness and active listening in the interaction itself.
Relationship is a two-way process and practitioners need a high degree of self-awareness of their role within the patient-therapist dynamic. With increasing demand for CAM and the possibility of inadequate resourcing within the allopathic model of care, there exists the possibility of burnout for the practitioner which Conway (2011. P. 48) warns of, with the occurrence of compassion fatigue impacting relationships.
There are also the complexities in trying to establish a balance between an approach of being more laissez-faire or more interventionist with patients. Conway (2011) cites the Emanuel model of 4 approaches from deliberative, interpretive, informative to paternalistic and highlights the difficulties of trying to strike the right balance therein. Mitchell (1998. P.129) also talks about the therapist as ‘wounded healer’, the need for self-care, boundaries and a high degree of self-awareness.
Nonetheless, the question remains whether the impact of taking a more holistic, patient-centred approach can be quantified. Without the benefits of large randomised studies in this field, it falls to an assessment of a qualitative assessment, patients’ self-assessment of the benefits.
So, one way of determining this is by looking at client expectations, managing those through a process of openness and flexibility (Conway, 2011). He also argues that this does not mean that we as healers take a passive role in the therapeutic relationship, that we can be “critical and radical, challenging and aiding the patient to develop a deeper and more vital sense of self” (2011. p.162).
Ultimately as herbalists we need to bring a multiplicity of skills to the table. We need to be able to engender a subtly nuanced patient-therapist relationship where we seek to place the patient at the heart of what we do. To neither be determined to be ‘right’ nor, conversely, too passive in empowering the patient to achieve better outcomes.
Word count: 1052
- Conway, P. (2011) The Consultation in Phytotherapy. Elsevier Limited.
- Hoffman, D. (2003) Medical Herbalism, Healing Arts Press
- Mills, S (1991) The Essential Book of Herbal Medicine. 2nd edn. Arkana.
- Mitchell, A, Cormack, M. (1998) The Therapeutic Relationship in Complementary Health Care. Churchill Livingstone.
- Model, D, (2006) Making Sense of Clinical Examination of the Adult Patient. Hodder Education
- Kmietowicz, Z & Gareth Iacobucci, G. Government fails to assuage doctors’ concerns over NHS crisis BMJ 2017; 356 doi: //doi.org/10.1136/bmj.j153 (Published 10 January 2017)
- Toombs,K.S. (1987) The Meaning of Illness; A Phenomenological Approach to the Patient-Physician Relationship pg 222 2011 jmp.oxfordjournals.org