PLACEBO

Prévia do material em texto

Placebo:
complex cases.
With a strong emphasis on
methods that start from the somatic
alongside its founder Andrew
Taylor Still. Its importance to point
out that prior to his conception of
osteopathy Andrew Still had been
. . . . . . .
Journal of B
4(2),123^13
# Philip La
Philip L
1Toonga
Correspo
Tel: ‡61
Received
Revised D
Accepted
S E R I E S : T H E M E S F O R T H E R A P I S T S
end of peoples problems, palpable
change becomes clearer as our
familiarity with the body grows. We
become finely attuned to many sorts
of di€erences in our patients. But
why do these changes happen? Is
there any way of knowing in our
day-to-day practices?
As we look for key factors that
have helped the patient to turn the
corner, we must inevitably consider
whether some of them could be due
to the operation of persuasion,
suggestion, or some other form of
‘placebo response’.
both a ‘magnetic healer’ and a
‘lightening bonesetter’.
Personal style
Keith Blagrave was the only one of
the BSO teachers with any professed
knowledge of hypnotherapy, but he
did not acknowledge any persuasive
factor in his osteopathy.
Nevertheless he would habitually
hum little tunes at times, produce
little practical jokes and stories with
great aplomb; and engaged the
patient with his one good eye in a
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
odywork and Movement Therapies (2000)
6
tey
atey
rah Road,North Sydney,NSW 2060,Australia
ndence to: Philip Latey
(02) 9929 6603, Fax: ‡ 61 (02) 9929 8785
October 1999
ecember 1999
January 2000
123
JOURNAL OF BODYWORK AND MOVEMENT THERAPIES APRIL 2000
a study of
and rappor
. . . . . . . . . . . .
Philip Latey
There may be as many ways of
getting better as there are ways of
getting ill. We cannot say that we
know all there is to know about
either of these. Part of the picture
must always remain largely
mysterious, but fascinating
nonetheless.
The reflections in this paper come
from 27 years of clinical experience
in osteopathic private practice.
Depending almost entirely on word-
of-mouth referrals and fees paid by
the patient, the author has sustained
a reputation for good results in both
brief treatments and in long-term
persuasion
t
During the author’s years of
training at the British School of
Osteopathy (BSO) between 1969
and 1972 there was no place in the
course to study the e€ects of placebo
and persuasion. Mental, social and
emotional factors of any sort were
also hard to discuss. And yet many
of the senior lecturers were without
doubt extremely capable human
‘horse whisperers’.
Among these were three men in
their seventies who had all trained
with John Martin Littlejohn,
founder of the BSO, who had
himself helped to set up osteopathy
in Kirksville USA in the 1890s
Therapy or therapist?
In order to begin making sense of all
this we can start by drawing a useful
basic distinction.
. Placebo responsiveness, we can
make solely an attribute of the
patient.
. Persuasiveness, then, is a
conscious and/or unconscious
element in the practitioner’s
clinical repertoire.
Latey
curiously riveting bird-like manner
as he carried out his treatments.
Clem Middleton had the
misfortune to have had severe and
lasting Bell’s palsy. Behind this
slight grimace he was highly
intelligent, a great raconteur, and
adept at turning any question into
another question with great
modesty: illuminating and shifting
the area of inquiry. He seemed
wonderfully enigmatic at times.
Shilton Webster-Jones (Webber),
who had been principal of the BSO
since the 1940s, was an absolute
master of in-close engagement with
all sorts of dicult patients. When
we students had ground to a halt, or
didn’t know how to manage
‘nutters’, stubborn, surly or neurotic
people, we would call for Webber.
He would ask them a few extra
questions while deftly maneuvering
himself into their body space;
appearing kind and respectful, but a
firm and familiar figure to them.
Within two or three minutes they
were eating out of his hand. He
would smile up at us from his
bodywork as if to say ‘look —
what’s the problem — it’s easy when
you know how; but you’ve got to get
them on side first’.
All three of these had a wonderful
economy of flow and movement.
The choreography of their body
handling and use of space in the
treatment room was so graceful and
captivating that their love of their
work and care for people could not
be doubted.
These older men were very
personable, with a definiteness of
enveloping and reassuring touch,
tone of voice, and a respectful but
somehow ‘knowing’ acceptance of
the person. They also had a sort of
disrespectful way of handling the
body; as if this could be any old
specimen of humanity — without
gender, status, class of any
significance at all, at any age and in
whatever state we find them; but
treated still with some fondness and
JOURNAL OF BO
familiarity. There could be no doubt
about the persuasiveness of this
second generation of osteopaths.
In the next generation of BSO
teachers, then aged thirty to
fortyish, Audrey Smith, Bill Naidoo
and Laurie Hartman were
outstanding. Audrey had great
depth of exploration, very patient
discrimination, and understatement
in her approach. Her sessions always
felt secure and sensible; always ‘in
her element’ with bodies and clinical
work with people. Bill had a
combination of impeccable style and
manners with an unerring touch for
locating and releasing restriction in
the body; and he never seemed to
stop smiling altogether. Laurie has
always had a very solid feeling of
physical presence about him. This
comes across in his posture and
hands as an extreme but unobtrusive
sense of confidence: non-
confrontational, but definitely
all-pervasive.
Hard question
Given the obvious attributes of these
second and third generation
osteopaths, is it odd that they were
unable to decide which clinical
results were due to persuasion? At
the time they seemed unable even
to discuss the topic without
some evasion or dismissal.
Unfortunately, this aversion also
made psychosomatic studies
unapproachable.
The really hard question here is to
decide how much of our real or
apparent clinical e€ect is due to
placebo and persuasion. How much
is due to the real and lasting actual
bodily change produced by the
specific elements of the manual
therapy? To complicate this issue,
we would also need to distinguish
the e€ects of the patients
following helpful advice, and the
various changes that they themselves
make.
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DYWORK AND MOVEMENT THERAPIE
Additional di€erences between
suggestion and clinical rapport will
be brought out later in the paper.
Unfortunately, the usual statistical
type of clinical trial is not much help
in this kind of qualitative study. We
cannot ethically or practically use
‘dummy’ treatments that are entirely
impersonal; and our patients are
usually strongly self-selecting. So we
could never regard them as any sort
of ‘random sample’.
Patient responsiveness
A great deal of responsiveness may
be predicted from the way the
patient comes to their initial
consultation. In the very short term
these may contribute to our success
rates with uncomplicated problems
(Box 1).
In the first place our personal
reputation contributes a lot to these
preconditions. If the patient has
actually heard of our success and
skills from two or more people, or
even a whole social group who we
Box1 Positives
Favourable preconditions
. Reputation
. Expectations
. Precise problem
. Self-motivation
. Hurdles
. Self payment
. Timeliness
S APRIL 2000
contacts. We may also seem
considerably less important when
someone else is footing the bill for
them.
Success also seems much harder
when they have been bullied and
coerced into comingto see us — and
would not have done so under their
own steam. Success is sometimes
impossible when there is any legal,
occupational, social or medical
advantage from staying ill, from
staying symptomatic or maintaining
some disability. Unfortunately, this
e€ect can be operable even when the
patient is consciously entirely honest
and honorable. The secondary gain
from the illness may defeat us.
Placebo: a study of persuasion and rapport
have been looking after, this is
strongly favorable. Helpful also are
a set of expectations that fit with our
capacities; their problem is relatively
clearly identifiable, they are likely to
have been referred by someone with
a similar complaint. They are
prepared to undergo an appropriate
course of treatment, and to
participate in their own
rehabilitation.
This ‘self motivation’ factor is
often crucial to anything longer than
the very briefest interaction. And, in
the case of the more stress-related
conditions, a preparedness for some
dicult self-examination is also very
helpful. Where there is chronic pain,
compliance issues may be crucial to
the outcome (Liebenson 1999).
It helps also if the patient has had
to surmount some diculties in
order to get to see us.
. A bit of a wait for an
appointment at a time that is
not easy for them.
. Some directions to follow if we
are slightly o€ the map of their
usual movements.
. The e€ort of organising their
account of the problem.
. Preparing to be questioned,
examined and probably treated in
the first session.
These are all quite important
hurdles to get over.
The fact that they are prepared to
pay for themselves, however small a
contribution that is, makes a
considerable di€erence in private
practice. Except in some longer-term
work where budgeting is dicult,
people naturally expect to pay more
for the best, and do not count the
cost too greatly when their health is
at stake.
The timeliness of their
consultation is also crucial. It helps
when it is clear to them that the
problem is not going to clear up
without help, and they have reached
a point where it has got to be sorted
out. They have also abandoned
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previous attempts at treatment and
management; with enough time for
it to be obvious that these have
failed.
If all of these positive factors are
in place, the actual details of our
clinical work might not be crucial
provided we fit reasonably well with
their set of expectations. In fact it is
not uncommon for the symptoms to
vanish quite suddenly just before the
first consultation! We have only then
to examine them and advise about
recurrence and about any
preventative measures.
Reputation
On the cautionary side of things we
must be a bit careful about how we
assess our own reputation. A patient
comes in who we saw five years ago.
‘I came in here in terrible pain and
all bent over. After the first session I
walked out straight and completely
pain free — you’re wonderful; I’m
sure you can do that again’. But we
look at the old case records and find
that we struggled for 6 weeks to get
them out of trouble: and weren’t
really sure of the result at the end of
treatment. Somebody’s memory has
been severely edited!
Self cure
What we are seeing here, and calling
‘placebo’ is definitely a form of self
cure when it is successful. In part
this could be regarded as a form of
auto-suggestion. In this sort of case
the author would guess that at least
80% of the curative e€ect occurs
spontaneously as part of some
natural process in the patient. Our
contribution may have been neutral
or have added or taken away 20%.
Beyond the clues we can gather from
the bodily responses that we
monitor, we just don’t know how to
assess our ecacy in cases where
results have come quickly.
Assuming that we do no cutting
or poisoning it is actually possible to
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DYWORK AND MOVEMENT THERAPIE
ascribe all of our apparent successes
to placebo e€ects. We could call this
patient-produced sort of placebo
responsiveness a favourable
momentum towards spontaneous or
assisted self cure.
Lack of momentum (Box 2)
There are an opposing set of
unfavorable preconditions that can
make any self-cure increasingly
unlikely. If the person has just
drifted in from the street on the o€-
chance that they can be seen, or has
picked us out of the yellow pages we
are not someone of particular
importance to them or to their social
Box 2 Negatives
Unfavorable preconditions
. Unaware of therapist’s reputation
. No hurdles
. Not self-initiated
. Not paying for self
. Any current or anticipated
compensation claim
. Unreasonable expectations
. Unhelpful diagnostic labels
. Multiple failures to date
. Multiple current therapists
. No beneficial or adverse e€ects
reported
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but self-obsessed and socially
indolent. We may be just indulging a
rather pointless hobby and leisure
activity!
This cautionary flag is amply
confirmed when they make no
reference at all to our initial
attempts at treatment. ‘How are you
doing?’ elicits the same word-for-
word vague description of unclear
symptoms; as if they were a spur to
urge the practitioner into increased
e€orts, or to emphasise our
ine€ectual impotence. Did they at
the outset really convince us that
they were determined to get better?
These are broad generalizations
Persuasion
So there are patient-determined
factors that are active from the
outset. Persuasion, on the other
hand, is something that the
practitioner does to the patient. This
is to some extent a completely
normal part of manual and
movement therapies, and begins as
soon as the patient starts to hand
over direction of the session. What
use we make of the phenomenon of
persuasion may be crucial to the
outcome; especially in very brief
prognoses. Persuasion may also be
very complex:
Latey
It is not helpful when they have
unreasonable expectations as to
what might be achieved. Nor if they
have arrived with unhelpful
diagnostic labels. There is a subtle
di€erence between the person who
asks if we can help cure the label
(they have grown rather attached to
it) and the person who asks ‘please
can you help me?’ The di€erence in
body language, eye contact and
eagerness to meet us is usually very
marked. We often notice in
retrospect that the initial case
history was in fact very blurred, with
factors missing, and had no clear
descriptions and dynamics to the
particular symptoms.
The way the illness is labeled can
make a huge di€erence and is
subject to all sorts of vagaries in
medical fashion (Shorter 1992). The
intermeshing of labels like chronic
fatigue syndrome, post-viral myalgic
encephalitis, and fibromyalgia
syndrome, is always hard for us to
unravel. Leon Chaitow points to a
picture of ‘allostasis’, following
Hans Selye, where homeostatic
processes are so poorly formed that
any slightest perturbation is
automatically responded to as
noxious: making therapy virtually
impossible (Chaitow 2000).
We often erect a ‘cautionary flag’
if they have seen a chain of other
therapist — some of them of good
repute and skills — and don’t even
mention a temporary or slight
improvement, or recount e€orts
they have made themselves on good
advice. This is often much worsened
if they are involving multiple current
therapists. The ancient Egyptians
employed special doctors for every
function — including Irij who cared
exclusively for Pharaoh’s anus. This
would be far more a question of
vanity, status and faddist belief; but
‘therapy hopping’, therapy
collecting and ‘name dropping’
are on the increase. Often these
people are actually in very
sound and unstressed health;
JOURNAL OF B
only, and must not be allowed to
colour our decisions in the
individual case. There is a danger
that they might become synergistic
self-fulfilling prophecies if they
underminethe practitioner’s
confidence and optimism.
Of course any person su€ering
from long-term chronic pain and
disability is likely to be depressed,
broke, dependent, despondent, and
half-hearted in their grasping at
many straws. It is actually the most
splendid challenge to us when we
choose those very dicult and
hopeless-seeming jobs; and have
been able to help them function
better and manage their problems
with less diculty.
Fig.1 Domination.
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ODYWORK AND MOVEMENT THERAPIE
‘Another important set of
technique variables belongs to the
dynamics of the physical work
itself and are intersubjective. They
require a conscious and/or
unconscious contribution from
both parties in order to work.
Under favorable conditions some
patients can allow the practitioner
almost total influence over their
pain sense, proprieceptive sense,
pressure sense, location in space,
body image, sensations of
temperature, and sense of the
passage of time itself. We often
find ourselves using variants of
simple hypnotic technique, as in
distraction techniques —
occupying the patients’ attention
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In order to look at the persuasive
ordinary part of most manual
and movement therapies.
This distinction will be
discussed later.
Domestic animals and livestock
are quite easily hypnotised. An
excellent method is described in
‘dog’s hypnosis’ (Wilson 1996). The
owner or trainer can use these
techniques to enhance
responsiveness, remedy bad
habits, and for more advanced
training.
First a special mat or piece of
carpet is produced that is only used
for the hypnosis sessions, and is put
away out of sight and access
Placebo: a study of persuasion and rapport
elsewhere while doing otherwise
painful work, or when we need an
instant’s relaxation. But this is not
an adequate explanation. We do
not know how the patient is
Fig. 2 Animal magnetism.
induced into the acceptance that
our technique is lighter or more
painless or less deep or quicker or
slower than it really is. There is
some sort of useful non-verbal
collusion available to us that is
unique to physical contact’.
(Latey 1984)
Animal magnetism was the ‘force’
or influence that Anton Mesmer
thought he was using back in the
1760s (Wilson 1996). The illusion
that some magical fluids and esoteric
energies are responsible for cure is
still with us in spite of all evidence to
the contrary. There has been so
much study of the e€ects of
persuasion and suggestion (Bowers
1976) that we should by now be able
to say how this contributes to
mainstream therapies. But, apart
from those who make deliberate and
stated use of hypnosis and
JOURNAL OF BO
hypnotherapy, few are willing to
question the type of influence that
may be at work in their own
practice.
elements in our sessions we might
look first at the hypnosis of animals,
since this is largely non-verbal. The
manipulation of language to
produce delusion and illusions
through suggestion is not an
Fig. 3 Good-dog mat.
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DYWORK AND MOVEMENT THERAPIE
afterwards. The dog is allowed to
play with the mat for a while till the
enthusiasm wanes, then called onto
the mat and made to sit or stand.
With much reassurance and
soothing voice the dog is told to
respond to familiar commands in a
relaxed way until tuned in to the
trainer.
New material, for example to
reduce fears or aggression, is
introduced calmly and gradually,
with return to reassurance and
routine whenever the dog seems
confused or agitated. The session is
ended with a couple of familiar
movements, an alerting tone of
voice, rewards if it has gone well,
and putting away the mat.
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Within this sequence we can see
several features that are common to
most clinical work. The time and
place are defined as clinical and
therapeutic, with the treatment table
or exercise mat ready to confine the
movements and attention of the
patient. Special clothing or states of
undress further define the
interaction.
Wilson also makes use of special
smells to mark the hypnotic session
Latey
for the dog. We all of us know the
smell of the hospital; but many other
therapy rooms have a highly
distinctive odour.
With cooperation from the
patient the practitioner takes over
their movements, with directions to
stand and move in particular ways.
The movements themselves tend to
be rhythmical and repetitious; the
teacher/practitioner using steady
non-alerting voice tones for their
instructions.
The end of the session is often
marked by encouragement,
conveying a sense of achievement,
and the return to a more matter-of-
fact voice tone reminding the patient
of helpful advice, homework, and
the fixing of a next session (Box 3).
The setting
There are many lesser details that
can make a di€erence to the type
and intensity of persuasion that we
use. We might have a very formal
authoritarian type of setting, with
white coats, therapist at a desk,
Box 3 Animal Hypnosis
. Territory and place
. Restriction of movement
. Direction of movement
. Voice tone
. Repetitions
. Reassurance
. Rewards
JOURNAL OF B
anatomy wall charts and impressive
appearing bit and pieces. An
egalitarian emphasis with informal
clothing, free from medical
paraphernalia, and with equal chairs
to sit on may suit the more secure
practitioner and those patients who
approach life with a healthy
skepticism.
The gender and age of the
therapist might also make a
di€erence. But this is o€set by many
good therapists seeming to be
somewhat ageless, and having quite
an overlap of traditional gender
qualities. Some are also able to
combine a chameleon-like
responsiveness with a very definite
sense of self.
Limiting persuasion
When the patient hands the
direction of the session over to us
they are submitting some aspects of
themselves to our ministrations. As
their responsibility for themselves
lessens, so our responsibility must
necessarily increase.
We actually do best if we make a
great e€ort to minimize persuasion,
so as not to produce artificially
distorted results. We need to be
careful not to exceed the limits that
the patient would normally feel
comfortable with — both ethically
and aesthetically. Even though we
are inevitably in charge we must
diminish their sense of vulnerability
and our tendency to dominate;
overwhelming no aspect of them at
all — however, much it might seem
that they want this. No aggression,
no violence, no bullying.
Initiating rapport
To a certain extent we have to
capture and engage attention, limit
movement, and usually pitch some
of our directions without alerting
critical examination and second
thoughts. But for useful sustainable
work it is much better that the
128
ODYWORK AND MOVEMENT THERAPIE
patient stays as alert as possible;
with the minimum of passivity.
When we are aiming for change
across important linked aspects of
the person it is best if they have all
their wits about them. They can then
synthesize and integrate much of
what we are doing as we go along in
the session. They will also remember
and reflect on interesting parts of it
later with a clearer mind.
About two minutes into the case
history we can often sense patients
hurrying us to get on with the
bodywork. We cannot collude with
this. Some firm minimum conditions
must always be met before we can
safely start treatment. On the table
some want to switch o€ altogether
and become putty in our hands, and
to wake up cured after we’ve done
whatever we have to do! It is often a
great challenge to keep them
thinking about their tenseness, and
where the tensions are coming from
and going to. Putty is very dull stu€.
We can keep them from doing this
by keeping some tactful questioning
and leisurely discussion going. In
this way most components of their
personality stay intact and active;
and we become gradually more real
tothem as they get to know us.
We also come to appreciate them
more as they are out in the real
world and find them much more
interesting as they gather the
confidence to express themselves
with us.
As so much of our work is
definitely ‘psychosomatic’ we can
keep the physical body central to
our clinical work; with the emotions,
minds, and psycho-social being
attended to lightly and tactfully in
the periphery. Recognition of this
figure-ground relationship is crucial.
From time to time the gestalt
reverses, the body becoming
peripheral to other pressing needs:
often just to stay clothed and talk.
But that does not require us to call
ourselves counselors or
psychotherapists. If we are careful to
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‘brainwashing’, as a widespread
social phenomenon (Latey 1998).
We could say that the tendency to
trust, sometimes against our own
better reflective judgment, is
hardwired into the behaviour of the
group or herd; and part of the glue
that tends to bind us together.
In the presence of group pressure
and strong suggestion we are being
coerced into agreeing to agree; and
never allowed space to question
what we are being required to agree
with.
We naturally suspend our
disbelief to engage with a piece of
good storytelling, theatre, cinema, a
novel, and even newspapers — that
recreate reflections of some aspects
those willing to exploit their
gullibility.
A 50-year-old patient had been
working with the osteopath for
some months to ease and improve
her severely arthritic hip. On
impulse she went to a ‘faith healer’
of grandiose repute. He used
strong suggestion to convince her
that her hip was pain-free and
could move fully. She abandoned
her stick and walked all the way
home in a state of euphoria and
religious ecstasy. Next morning
she was unable to move from bed.
In extreme pain she was taken to
hospital and, due to bony collapse,
had to have a complete arthrodesis:
permanently fusing the joint.
Placebo: a study of persuasion and rapport
acknowledge limitations and
gradually expand our capacities, the
‘mind’ that emerges from our bodily
understanding may be very di€erent
from previous models (Latey 1996,
1997).
In longer term work, then, the
good manual and movement
therapist often becomes someone
with whom discussions are very
useful when supported by a robust
and unhurried rapport: without
psychobabble or sermonising. This
would not be possible if we had been
using more than the minimum of
persuasion.
Suggestibility
Adding to the two original
categories of placebo and
persuasion, we can draw two more
distinctions that are useful, and
distinguish between suggestion and
rapport. As an extension of
persuasion, suggestions are specific
attempts to over-ride and alter the
perceptions and underlying
assumptions that the patient brings
to their inner and outer milieu.
Persuasion, on the other hand can
be viewed as just temporarily
allowing themselves to do as they
are told: much simpler.
Suggestibility is extremely
variable between people (Bowers
1976). It is a measure of the extent to
which people make themselves
available to external authority to
govern their lives and thoughts, and
to govern how they feel their own
feelings. It is essentially passive and
uncritical — and may have nothing
to do with common sense at all.
Looking again at how Steve
Wilson trains his dogs (Box 3) we
can see that these conditions cover a
far wider range of phenomena than
just the one-to-one relationship.
From the crowds in the sports
stadium to the religious
congregation, military parade and
Nuremberg rallies we can see
conditioning by suggestion, or mass
JOURNAL OF BO
of living. It is a triumph of the
human imagination that wishful
thinking and make-believe can
almost become truth and fact to us
— at least temporarily.
But suggestible people’s
perceptions are so easily influenced
and overwhelmed that they can only
see evidence for the convictions that
they have been sold. They lose touch
with common sense and healthy
questioning far too readily. These
are the cannon fodder in the battle
for people’s hearts and minds;
inflating the wallets and egos of
Fig. 4 Abject submission.
129
DYWORK AND MOVEMENT THERAPIE
(Case report from UK colleague)
Results due to the application of
strong suggestion to suggestible
people are often dramatic and
extreme. Rapid responses producing
high levels of pain relief, altered
perceptions and other strong bodily
e€ects are not at all unusual. The
pain threshold is the human
subjective variable that is most
particularly labile. Hypnotherapists
use numbering of parts of the body
as part of some common
‘inductions’ (Calof 1997).
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or depressed. Their condition may
be worse.
We have every good reason, then
to be wary of the more charismatic
quick fix ‘healer’, whatever versions
of therapeutic practice, religious or
social philosophy they espouse.
Many practices and reputations
have been built on their success with
problems that are spontaneously
remitting and episodic.
It is also likely that some
practitioners themselves become
addicted to the quick fix, to the
patient. The real degree of diculty,
if we take on the patient, is
represented by the length of the
prognosis; the complexity of
technique; and whether its aims are
actually met.
Problems that are going to take
many weeks, months or even years
to get right (Box 4) will depend less
on the e€ects of persuasion and
suggestion, and more on the skill of
the practitioner and the ability of
both them and the patient to sustain
the momentum through dicult
ti
y
.
f
ha
ed
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ai
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Latey
End results
Longer term e€ects of strong
suggestion are much more variable.
Patients of the author who have
responded to acupuncture analgesia
(administered elsewhere) usually
report pain relief that lasts between
two hours and a week or so.
Unfortunately for patient and
practitioner these responses are
highly fatigueable, and su€er from
the law of diminishing returns. By
about the third session the e€ects of
suggestion on the suggestible are
exhausted; which is why the snake-
oil salesman and apocalyptic
preacher have to move on so
quickly. The end is not nigh; we are
not saved; the symptoms return.
Some of these initial e€ects may
be recoverable after a month or so;
but never to the strength of the
original. This may be part of the
appeal of regular treatments that are
repeated at wider intervals; and
really achieving very little. This also
helps to explain the army of patients
migrating from modality to
modality, and from fad to fad.
Suggestion and belief
General belief systems are often
more durable. But when they have
been instilled by the usual
combination of suggestion,
repetition and auto-suggestion they
may have to be renewed by frequent
reminders. This ‘compulsion to
repeat’ staves o€ the pangs of
disillusionment and the intrusion of
common sense realisations. We none
of us wish to appear naı¨ve and
stupid, especially to ourselves. Some
attrition of treasured illusions,
unfortunately, is part of growing up.
The massively over-responsive
person in unlikely to tell the
practitioner that the results of their
treatment were transient or illusory.
Once their besotted and blinkered
state begins to evaporate they may
feel foolish, abused and remorseful
JOURNAL OF B
appearance of dramatic cure and to
instant results. Excessive zeal and
fervent belief render them blind to
people’s real needs and the
possibilities for longer-term success.
Their indecent haste and
inappropriate intensity usually make
this clear.
Nevertheless more sober and
modest practitioners are used to
estimating the severity, complexity
and chronicity of problems that will
take time to sort out. They sense the
momentum of the patient carefully.
(Boxes 1 and2), and use only
enough persuasion to enable the
patients to participate voluntarily in
the work.
Having studied the problems
presented to us we consider first a
very thorough di€erential diagnosis,
and whether to refer them elsewhere.
We develop our ideas of aetiology,
and discuss the prognosis and
treatment agreement with the
Box 4 Typical long-termcase
At the initial consultation a potential pa
irritable bowel and spastic colon of many
of hip rotator and sacroiliac dysfunction
stressed and unhappy at work, and feel a
to routine general questions it emerges t
their mid-teens, their parents are divorc
foods, used to have severe migraines, ha
very poorly. Without adding further det
would not be particularly uncommon. W
prognosis would we be contemplating; a
be reached?
130
ODYWORK AND MOVEMENT THERAPIE
phases. There will always be a need
for changes in tack, strain on the
rapport, and much rethinking in
review sessions to make an honest
measure of progress.
Useful suggestion
The patient allows themselves to be
persuaded in a limited way — so
that we can work with them. In
addition to this a small amount of
carefully metered suggestion is often
useful in the short term. In acute
pain and in the initial stages of work
reassurance and supportiveness are
often vital. Specific suggestions can
be a great help to the patient here.
Reassurance alone is often enough
to solve many problems if major
anxieties are relieved.
‘Imagine this sudden nasty back
pain you have had is just like a
joint strain. We’ve positioned it on
ent has symptoms that might suggest
ears’ duration, combined with some sort
Unprompted they mention being very
ailure at relationships. In their response
t they had a serious fall from a horse in
and both ill, they are avoiding many
e mild urogenital symptoms and sleep
l, this rather generalized presentation
at sort of minimum and maximum
uming a sound treatment agreement can
S APRIL 2000
Placebo: a study of persuasion and rapport
your side here to relieve pressure
on it as you breathe and relax.
That’s it, that’s better. Let the
breathing go slower and relax. It’s
like a strained ankle, when it hurts
really badly at first and you cant
put much weight on it at all for a
while. Most of what you feel here
is muscle spasm from the strain,
and I’m just using very slow
stretching and easing to relieve
some of the muscular spasm
around the strain. No sudden
movements. And that leaning to
the side you feel is just you spine’s
way of limping to keep your weight
away from the strained part. It will
be very sore again when you stand
up, but I’m really confident that it
will be clearing up — (tentative
prognosis and management plan)’.
More complex suggestive work
(e.g. Haley 1973) can also be a great
help in manual therapy when
addressing specific fears, impulses,
anxieties and phobias that so often
emerge. Combinations of suggestion
with behavioural modification,
guided imagery, dramatic
enactment, narrative development,
and thought experiment are quite
natural extensions from our
ordinary conversations and
bodywork. But these may require
considerable further training, and
will usually need the fully informed
consent and cooperation of the
patient. Ordinary good humour may
be most helpful (Latey 1997).
From persuasion to rapport
When working with long-term
complex problems the author has
found that there is a very familiar
repeating pattern that occurs in
many of them. If the complex
patient has, say five predominant
symptoms and aspects to their
complaint, they might start with a
quite dramatic improvement in as
many as four of them during the
opening phase. The fifth remains
JOURNAL OF B
stubborn and recalcitrant
throughout these early sessions.
In the next phase very little seems
to happen to symptoms while the
patient and therapist adjust to each
other and find ways of relating.
Gradually the symptoms return,
perhaps during a brief trial of ‘no
treatment’.
In the third phase each symptom
or area of complaint will tend to
move into prominence as the bodily
regions, functions and subject
matter in discussion start to come to
a focus. As we expect all aspects of
the person to be interdependent it is
quite usual for one or two of the
symptoms to be forgotten about and
resolve out of sight in this phase; but
it is also likely that transient extra
symptoms emerge as the pattern
starts to shift.
Our irritable bowel patient
(Box 4) may have become much
more comfortable round the hip and
groin, with less bowel spasm and less
food sensitivity. But a persistent
sacral ache has failed to respond,
and dominates the symptom picture
for quite a while. As they begin to
discuss their dented adolescent
optimism round the time of their fall
from their horse, the hip pain
comes back and they remember that
their parents were divorcing at that
time. Food avoidance and gut
spasms increase also in this third
phase, and they recall a school camp
when they had diahorroea and the
food was awful. The change in
appetite that accompanies the
teenage growth spurt also gave them
much trouble.
All of this comes from the
leisurely conversation that
surrounds the body work. We also
discover they have been having sore
eyes for a week or so, with increased
urinary discomfort and some foot
pain (possibly transient Reiter’s
syndrome). They su€er one isolated
migraine, but have been sleeping
very much better ever since their
early sessions.
131
ODYWORK AND MOVEMENT THERAPIE
This third phase is very satisfying
when the symptoms, bodily work
and other findings begin to make
sense. But the main symptoms do
not disappear altogether. There
usually follow at least two periods of
relapse and reworking — as if the
body refuses to let go of its position
till the third time around. This
fourth stage is by far the longest: a
severe challenge to the practitioner.
They have to be very patient
themselves, and surmount their own
frustration and boredom to look for
missing elements, avoid repetition,
and invent fresh ways of covering
the same ground.
In the fifth phase there is a
combination of quiescence and
complacency alongside a sort of
searching around for more work to
do. As sessions are spaced further
apart the symptom-free periods
lengthen to the point where they are
hardly mentioned; but recur in a
minor form just before each session.
This is a clear sign that the
therapeutic process is coming to an
end. The patient and practitioner are
nearly ready to disengage.
In the sixth and final phase, the
ending of the work, there is often a
brief return to the need for
reassurance. We will nearly always
feel it helpful to o€er continuing
support if it is needed from time to
time, say that we will miss the
patient we have got to know so well,
and set the scene for follow-up.
Something quite similar to this
sequence often happens during a
single session. The way we
choreograph our work, and expect
changes to happen can take
advantage of this, making an easier
flow to the rhythm of our sessions
and of our longer prognoses. This
sequence is also mirrored in many
other forms and human interaction.
The e€ects of the patients’ initial
momentum, the persuasiveness of
the therapist and the setting, with
any initial suggestions that have
been used are usually exhausted by
S APRIL 2000
lots of requests aimed at expansion
of each others’ viewpoint in
particularly interesting areas.
While the good therapeutic
rapport is not part of normal
everyday life, it needs to have a close
relationship to it. As close, perhaps
as a work of art, novel, movie, poem
or song in it’s evocative qualities.
This means that we have been able
to reach an accord and resonance
with the patient where they really
can feel that we ‘take it to heart’,
uggestion (minimal in complex cases).of symptoms. Gains lost.
sures fail.
ce in e€ectiveness: focused e€ort is
eas recycle for second and third time.
-
’;
Latey
the end of the second phase. From
the third phase onwards it is the
clinical framework and setting, the
rapport and the joint e€orts of
practitioner and patient that does
the work. Only in the ending might
we have to return to a more stylised
and formal way of working (Box 5).
Building rapport
Box 5 Overall patterns in long-termwork
1. Opening
Patient momentum. Auto-suggestion.
Practitioner persuasion and specific s
2. Refractory
Patient unresponsive. Gradual return
Practitioner frustrated. Quick fix mea
3. Rapport
Good working relationship. Confiden
worthwhile.
4. Recurrence
Confidence is strained as the same ar
5. Quiescence
Calming down, increasingly symptom
work.
6. Discharge and follow-up
Patient unsure if ready to disengage.
Practitioner retreat to more ‘distance
Modern clinical skills able to tackle
dicult problems depend a lot more
on the quality of the interpersonal
rapport than used to be thought.
There is much evidence that good
results from therapy depend far
more on the rapport than the
supposed theories and schools of
though of the practitioner (Roth &
Fonagy 1996). There are also areas
where the ‘untrained’ may do best of
all (Spinelli 1999).
What matters most is that we and
the patient find some gradual way of
tuning in to each other as people. If
this is working all sorts of good
humour, imagination and invention
can be brought into play gently; and
can bring the whole process to life.
When we are able to separate the
e€ects of persuasion and suggestion
JOURNAL OF BO
from lasting results that have been
hard to achieve in the long term, the
importance of rapport becomes very
clear. But clinical rapport is
extremely dicult to teach (Box 6).
In interactions where there is no
need for a durable rapport there is
always an imbalance between
activity and passivity, dominance
and submissiveness, giving and
free for longer. Casting around for new
slight reassurance and suggestion.
receiving; and so forth. But in phase
three of the therapeutic pattern
(Box 5) both participants are present
in a more equal form. Control and
direction of the interaction is passed
back and forth. Questions, ideas,
topics, pauses, wry comments and
tentative answers flow freely — with
Box 6
The artist’s dilemma is of a peculiar sort.
the craft components of his job. But to p
It makes him, on the one hand, more abl
on the other hand, by the phenomenon o
ware of how he does it.
If his attempt is to communicate about th
performance, then it follows that he is on
about whose position he is trying to com
function of his e€orts to communicate (B
132
DYWORK AND MOVEMENT THERAPIE
whatever emerges. Experienced
practitioners will not take on a
longer-term case unless they feel that
this sort of rapport will be likely to
emerge.
The main parts of the work in
phases three and four are like
musical figures: with statements of
theme, subject and counter subjects,
developments, restful and energetic
passages. Our job is partly to keep
steady progress, with the ability to
introduce refreshing di€erences; and
partly to maintain an exquisite
sensitivity to ‘flinch’.
In conversation with them we can
be watching for sings of recoil.
. Have they suddenly gone very
silent for a moment?
. Did they suddenly withdraw for a
second, and freeze their smile?
. Do we know when we have
overstepped the mark in some
way, and must change tack and
o€er prompt apology?
He must practice in order to perform
ractice always has a double e€ect.
e to do what he is attempting; and,
f habit formation, it makes him less
e unconscious components of his
a sort of moving stairway (or escalator)
municate but whose movement is itself a
ateson 1972).
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Placebo: a study of persuasion and rapport
Physical rapport
In physical work we are used to
monitoring the responses of tissue
tone and muscles.
. Are they able to relax with what
we are doing without
disconnecting?
. Do their muscles contract back
against us?
. Do we notice a slight catch in
their breathing?
. Are their hands or feet curling?
. Is there a slight flicker or grimace
at the side of their face?
. Are we checking how sore they
feel in areas we are working on?
This ‘flinch’ boundary, where we
are carefully monitoring the
impressions we are making, and the
responses evoked, is a very precise
line of demarcation in the sustaining
of rapport. It is equally critical in the
work of physical contact. When
physical work is part of the process
there is a very rich mixture within
which the two parties can attune
themselves to each other at many
levels simultaneously.
Towards the end of the 1880s
Andrew T. Still was bringing
osteopathy together from his work
as a bonesetter and magnetic healer.
At the same time Sigmund Freud
was himself using hypnosis, massage
and head pressure while he discussed
with the patient what memories and
images came to mind. There was
much interest in therapeutic
suggestion at that time (Bernheim
1888). Sadly, just as psychoanalysis
retreated from physical rapport, so
did osteopathy retreat from
psychological awareness; to the
great loss of both professions.
Physical work with their bodies can
often help produce marked
psychological, emotional and social
improvements for people.
When we are in close physical
engagement with the patient’s body
we are moved by their inner
movement. They are moved by ours.
JOURNAL OF BO
This attunement reaches deeper than
just to their proprieceptive and
locomotor senses and muscularity
(our sixth sensory system?). Here lie
an additional three systems; the
emotional, visceral and ‘mental’
patterns of muscle sensation,
movement and embodiment that
express to us the essential subjective
person in all of it’s complex layering
(Layer 1979, 1996). To the author it
seems clear that we connect with
these seventh, eighth and ninth
senses when we engage with the
other in a process of change,
transformation and evolution.
From the bodywork we can often
tell far more about them than the
person themselves may be aware of.
To what extent are covert emotional
strictures, torment and painful or
numb paralyses keeping them from
progressing? The impacts, longings
and bending to group pressures that
we feel give us strong evidence of
most useful areas to explore in our
tactful conversation with them. Very
simple tactics are often all that is
needed to broach new areas of
inquiry as we progress (Latey 1992).
Attachment and separation from the
practitioner may also be a key factor
here.
Practitioners’ feeling
Less predictable are the experiences
and reactions of the manual
therapist with the transforming
patient. This is a much neglected
and under-reported area. The
author can sometimes feel deeply
moved — as if swirled slowly in a
massive tidal undercurrent in the
sea, or as if caught in the field of
powerful interweaving magnetic
fields. In discussion with colleagues
feelings of melting, fluidity and drift
are most common. Having poor
di€erentiation of these muscular
senses, and even less language for
them, these experiences tend to be
‘synaesthetic’. They induce strong
echoes in senses that are otherwise
133
DYWORK AND MOVEMENT THERAPIE
disengaged. So we may experience
colours, vibrations and resonant
shapes that are not there, or more
rarely sounds, music, tastes and
smells.
In the author’s opinion this goes a
long way towards explaining why
people have needed to invent
esoteric energies, magical auras,
chacras and so on. A better
understanding of the mutual
rhythmicity of our therapeutic
‘dance’ with the patient should also
reduce the confusions surrounding
involuntary movement patterns,putting their clinical usefulness into
better perspective (Latey 1979, 1985).
This type of experience may not
necessarily be associated with
specific emotions for us, but it is
usually well clear to us and the
patient that a major shift has taken
place. We may afterwards feel
shaken and weak, or very much in
tune with ourselves and the world.
Sometimes we may feel exhilarated,
sometimes extremely peaceful, or
near to tears of happiness.
Musicians might report the same
range of feelings after an exceptional
performance.
While relatively rare in ordinary
daily practice, these very moving
experiences make our more routine
work much easier. They deepen and
broaden our body awareness. And
like an experienced deep sea diver,
any brief plunge under the surface of
life holds no further fears for us. We
can also learn to skim under large
waves that would otherwise seem
quite threatening.
We also understand better how
patients may feel disorientated and
di€erent after a ‘moving’ session. A
fruitful phase of integration and
revision will usually follow for them
quite naturally.
Structural coupling
Chilean biological philosophers
Francisco Varela and Humberto
Maturana make an extremely useful
S APRIL 2000
Latey
set of distinctions about interactions
between cells and organisms. These
concepts fit well with the author’s
understanding of clinical rapport in
bodywork.
Instructive interaction, where an
organism can be expected to
respond to some perturbation in an
exact and predictable way cannot
happen. Each organism can only
respond in a way that is
predetermined by it’s own history
of idiosyncratic self-structuring.
They call this self-structuring
‘autopoiesis’ (Maturana Varela
1980).
Structural coupling, on the other
hand, happens when two organisms
in close contact begin a process of
mutual recursive change. Here they
undergo a sharing of each other’s
restructuring processes achieved by
tuning in to each other. Multi-
cellular organisms could not have
evolved without some such process.
Maturana and Varela call this
‘second order autopoiesis’. This is
not the mechanical joint coupling
that we study in spinal movements.
It is closer to the ideas of
‘entrainment’ that come from
physics and complexity or chaos
theory (Davies 1989).
In ‘social’ organisms structural
coupling would seem to be either
more intermittent or less intense. In
any case there are obvious parallels
in bodywork, where we are faced
with the di€erence between trying to
make things happen, and tuning in
to engage in such a way as to allow
changes to happen. This is a highly
significant distinction for us, when
we recognise that structural
coupling cannot possibly be
unidirectional. Our own personal
plasticity and mutability are an
essential element in clinical
structural coupling.
Sexual parallels
The slow upheaval or lurch that we
could call ‘clinical structural
JOURNAL OF BO
coupling’ does not fit well with our
previous more linear views of
persuasion, suggestion and placebo
responsiveness. Something di€erent
is happening here; and is happening
to both parties; though they will
perceive it di€erently. These
phenomena (previously called
‘inter-transference’, Latey 1979)
seem completely beyond the scope
of the non-touching
psychotherapist’s models. They fear
regression, fragmentation and
sexual abuse. Whereas we will
commonly perceive a subtle
integration and emergence of the
renewed person: with boundaries
intact; softer and more resilient
when they were brittle; healing
where they were broken or ill-
formed; firmer where they were
blurred.
There are very close parallels here
to sexual coupling. Two people
alone in a warm room, with
undressing, fleshy contact and
handling of parts make this
undeniable. Using sex as a very close
analogy for physical therapy we
could say that the hypnotherapist is
metaphorically seducing
compliance, or that the faith healer
(above) sexually overpowered the
woman and in doing so mutilated
the integrity of her pelvic structure.
A meeting of the minds is more like
a ‘mating’ when fruitful new ideas
are generated. When any of this
works well we could say that
there is therapeutic conception
and gestation: new life has been
gained.
A close relationship is necessary
for clinical structural coupling. In
fact it is unlikely to work or even
happen at all unless it is a
metaphorically interpenetrative
relationship; at least in the intimate
interaction of motile muscular
sensation. The ‘sensory systems that
sense the senses’ (Latey 1997) may
be uncoupling and rebalancing
here — perhaps flowing upwards
towards higher functions from the
134
DYWORK AND MOVEMENT THERAPIE
reticular activating systems and
cerebellum.
Imagine a widow and a widower.
They have known each other for
years, but are not a couple. They
dance together at a reunion party,
finding they can jive and quickstep
passably well with each other. In the
last slow waltz at the end of the
evening you observe them very
close, leaning in to each other. Their
swaying movement is no longer in
time to the music: it slowly wanders
chaotically around a small area.
Looking at them you sense a deep
warmth of a€ection, sadness,
happiness and compassion. A few
minutes later they have parted,
feeling fuller and more contented.
They leave for their separate homes
hoping they might meet again next
year; feeling perhaps some healthy
tiredness and a little heartache.
Something has unfrozen for them;
they can breathe more easily — even
if it is just a sigh.
Clearly there is a mature intimacy
of ordinary life here: without sex.
Lust, passion, desire, arousal,
foreplay, all can be entirely
unnecessary to episodes of very close
structural coupling. They may well
be antagonistic to it, temporarily
shelved, or totally irrelevant.
Although clinical structural
coupling has a di€erent history
and social setting, it has identical
qualities to the couple at the
reunion dance. Our secure ethics
of un-sexualised compassion
also make this a safe area of
practice for both patient and
practitioner.
It is likely that lesser degrees of
clinical structural coupling are an
ordinary everyday characteristic of
good manual therapy practice. In
which case this is a major aspect of
the empathy that we bring to our
daily work.
Conclusion
There are many e€ects of touch and
movement not mentioned in this
S APRIL 2000
Placebo: a study of persuasion and rapport
paper (Nathan 1999). Touch
restores some of people’s ‘felt’
identity. In opposition to the
unreality and instabilities of non-
touch methods, touch can defuse the
excesses of transference and counter
transference. But touch on it’s own
may be deeply addictive; it is so
sorely needed in our alienated
society. The degree of separation at
which we must live our lives is
sometimes painful and always
emotionally distressing.
Hopefully we can now begin to
see some di€erences between
persuasion, suggestion, the patient’s
momentum, and their suggestibility;
and look at some of the realities of
the treatment rapport in dicult
cases. Our very careful work of
trying to understand their problems
and to work out some treatment
agreement and prognosis with them
provides the only real and reliable
Fig. 5 Structural coupling.
JOURNAL OF B
measure of success. With better
understanding we can rethink those
processes that are foundering.
But, to some degree, all of our
successes could be ascribed to one
form or another of placebo. It is up
to us to decide which form; and to
confess with honesty that attention
to these areas is long overdue; and
only just at a tentative beginning for
most of us. We might begin by
distinguishing between rapid results
from brief procedures, and the
complex patterns and phases that we
meet in longer-term work.
The author’s ‘Muscular
Manifesto’ startedfrom the premise
that impressive and satisfying ‘cures’
can come from a palpable consensual
condensation between osteopath and
patient when the problem can be
viewed simply (Latey 1979). The
depth of understanding, compassion
and skill that will enable this to
135
ODYWORK AND MOVEMENT THERAPIE
work with complicated patients
dawns very slowly in today’s hurried
society. With most dicult patients,
and for most of the time, the author
is accustomed to waiting hopefully;
with considerable optimism about
our human capacities for self-
righting.
Further reading
For studies of synaesthesia in other
fields the author recommends
Baron-Cohen S, Harrison JE 1997
Synaesthesia. Oxford: Blackwell
Artwork: Maxwell John Phipps.
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making the same mistakes?
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i
mechanisms which he claims can,
in an unstructured, almost intuitive
manner. Lederman has evolved an
approach which he suggests lifts
proprioception, autonomic
powerful placebo influences, along
with whatever e€ects are resulting
on the physical level, in terms of
alterations in tissue tone and
cannot be purchased separately) is
Leon Chaitow
Senior Lecturer, Centre for
Community Care and Primary
r,
K
Latey
these basic approaches to a level
which ‘produce therapeutic e€ects
that are beyond the physical
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Journal of Bodywork and Movement Therapies (2000)
4(2),136
# 2000 Harcourt Publishers Ltd
JOURNAL OF BO
function, neurological modification
and fluid interchange.
136
DYWORK AND MOVEMENT THERAPIES
Health, University of Westminste
U
when applied appropriately, move
rhythmicity beyond purely
mechanical influences, allowing it to
achieve a harmonic interaction with
bodily tissues. Rocking and
pulsating, cyclical actions are
common basic massage methods,
and few manual therapists, whether
they work in massage therapy,
physiotherapy, osteopathy or
chiropractic do not already use some
form of rhythmic movement, albeit
functions, motor responses, as well
as emotion and behaviour. These are
large claims and Lederman attempts
to back them up with detailed
discussion of the concepts, as well as
by means of research evidence. One
explanation for the benefits of
harmonic technique relates to the
virtually hypnotic (and therefore
profoundly relaxing) e€ect of any
rhythmic movement. This may in
fact be enough to provide a
very instructive and competently
produced, and should allow the
application of these gentle,
economical (in energy terms) and
potentially e€ective measures.
Ruddy TJ 1962 Osteopathic rhythmic
resistive technic. Academy of Applied
Osteopathy Yearbook 1962, pp. 23–31
Chaitow L 1996 Muscle Energy Techniques.
Edinburgh: Churchill Livingstone,
pp 56–57
Roth A, Fonagy P 1996 What works for
whom: A critical review of psychotherapy
research. New York: Guilford
Book rev
Harmonic technique
Eyal Lederman
Churchill Livingstone,1999
ISBN 0-443-06162-9,
Price: »60
Eyal Lederman is a leading
osteopathic theoretician and
clinician who, in this text and video,
draws together and describes the
Spinelli E 1999 If there are so many
psychotherapies how come we keep
B O O K R E V I E W
ew
phenomenon.’ He maintains, and
o€ers evidence to support the
assertions, that during application
of harmonic technique the patient’s
own oscillatory frequencies can be
induced to influence local tissue,
neurological, as well as
psychophysiological organizations,
a€ecting repair processes, fluid
dynamics, pain reflexes,
Australia, Bankstown: BluePrint
A curious omission (which could
be rectified in a second edition)
involves a lack of mention of
osteopathic researcher T. J. Ruddy
DO, whose ‘rapid rhythmic resisted
duction’ method (commonly now
called ‘pulsed muscle energy
technique’) has distinct echoes in
Lederman’s work.1,2 The video
which accompanies the book (they
APRIL 2000
	Personal style
	Hard question
	Therapy or therapist?
	Patient responsiveness
	Reputation
	Self cure
	Lack of momentum (Box 2)
	Figure 1
	Persuasion
	Figure 2
	Figure 3
	The setting
	Limiting persuasion
	Initiating rapport
	Suggestibility
	Figure 4
	End results
	Suggestion and belief
	Useful suggestion
	From persuasion to rapport
	Building rapport
	Physical rapport
	Practitioners' feeling
	Structural coupling
	Sexual parallels
	Conclusion
	Figure 5
	Further reading
	REFERENCES