The Meaning of Osteopathy

Yes, that is a very pretentious title.

It occurred to me over a recent chat with someone.

She insisted that the ‘right’ practitioner was able to do work on a level of depth psychology. I think Germans use the term ‘depth psychology’, which to my knowledge has never occurred in English really, to denote something that is even deeper than psychology. I’m not exactly sure.

I’m not even sure what she meant.

My mind moves well in metaphors. I consider the nakedness and the touching of others a primal act or a primal something. it’s a very fundamental thing to touch somebody. Where and how that happens can trigger things for that person – good and bad (to use a very crude distinction). Think of victims of abuse for example. But also think of how a touch can be loving and kind without ever having to have that explained to you.

Touch is immensely powerful for these reasons alone.

What I said to her is that even though psychology is rudimentarily taught in osteopathic schools, it’s not discussed very much as part of the consultation and the space one inhabits with the patient. It is treated as a literal thing and its power is discussed literally.

I didn’t say that actually. I said that it depends on the practitioner what is being done with the patient and how. And I think it also depends on the patient. I think any treatment needs a willingness and openness from both sides. Not so open as to be permeable but open within the boundaries of the space. Something like that.

I hold to that. Depth requires a depth of inquiry and of reflection. We are resounding bodies and when we knock on each other we can sense the vibrations resonate through the other.

That’s a metaphor.

I don’t have an overarching theory of what osteopathy is in any real way. I’m trying to see it in a web that connects with psychology and philosphy, with metaphysics and mechanics. I like that it defies categorisation and that every time I say, ‘it’s a type of manual therapy’ I say facts and I don’t say nothing at all.

It’s a paradoxon šŸ™‚

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The Therapeutic Space

I would like to do more pictures here. I really would.

Let’s see if I can find a good picture of the ideal therapy room.

It should be private and clean and spacious but not huge. A medium-sized room.

This one is good, clean lines, unfussy. That sort of thing.

My idea is that it needs to feel safe and neutral and warm and cozy.

Now, when I discussed my reluctance to treat other students, the person I talked to, an experienced osteopath, said, oh, so you wouldn’t treat your family either? To which I tried to give some kind of measured answer.

I would, I have. But I want to be clear about their expectations. Also, I would like some kind of professional distance to be there. A clinic coat perhaps. A neutral room. Something that sets it apart.

Another student said, she had treated her mother but found it difficult because she *wanted* too much. To happen, I surmise.

I also want the protection of a neutral space.

So, experienced osteopath said, how do you feel about this clinic?

Ah, but you see, my grievances are manifold. (That’s not how I speak in real life. Maybe a little.)

The rooms are too large (we are currently using our classrooms because the treatment rooms aren’t ready). Try creating an intimate atmosphere in a classroom full of stuff, benches, chairs, huge windows to THE OUTSIDE WORLD.

The school has a majorly weird policy on bench covers. Majorly. The students are nowhere encouraged to even bring a bench cover to class for their own practice, never mind the school providing them. Paper is the one thing standing between the patient and a cold plastic bench. On our first day we were told that covering patients up during treatment is a matter we should approach cautiously. It would be too cumbersome to keep moving the cover around and most patients will be ok.

I have a feeling some of these concerns are about having to do laundry. The assumption seems to be that items have to be washed immediately after being touched by a patient. especially the ones that are ALSO COVERED WITH PAPER. This really baffles me. I have a very rudimentary understanding of hygiene but what prevents us from washing the towels even after WE have touched them ourselves? Are the patients summarily contagious??!! Yes, by all means, if they have a raging cold and keep sneezing or similar, I would absolutely change items but not on a patient-by-patient basis. It’s weirdly excessive and sacrifices patient comfort. In my world, patient comfort is key.

So, I’m similarly baffled by the students being so thoughtless about offering pillows. Pillows randomly turn up, in no way on a regular basis. What is this about?

From December onwards they will be charging money for this clinic. I wonder what kind of people will turn up. I don’t know how much money it will be.

Students play with their phones during the consultation. Why be there if they can’t be arsed?

Please, can they not be there for my treatment? I would really like to have a little space with just me and the patient. I love that space and cherish it. I haven’t had it here and I’m not liking that at all.

Students turning up late for the consultation. Inacceptable. No no no no no no. I had a case of myself turning up in one consultation room for a practitioner who swapped at the last minute and so ran off to see the other patient with the other practitioner in the other room. I chastise myself for a lot of stuff and this was definitely not fine. So I apologised and it wasn’t a big deal. But it seems endemic to the kind of attitude there is.

I feel old writing this.

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Being baited

In addition to last week’s post on patients (everything sort of revolves around patients, but nevermind). I thought a little back on my encounters with patients. Or second-hand encounters at any rate.

Another student treated a patient. She said she had made smalltalk. She had asked what he’d done over the weekend. She knew he had children and asked whether he’d spent any time with them.

The patient said, amongst other things, that he hadn’t. That it wasn’t his choice. And he said he didn’t want to talk about it.

I remember thinking, he is baiting. I don’t like being baited. Make up your mind, you wanna discuss this or not but don’t leave me hanging. I don’t like this sort of behaviour at all.

I said as much to her. I also told her I was convinced there was something about the relationship, a very young woman and a much older male patient, that made this sort of behaviour easy for him. I figured that he thought she wouldn’t challenge it. I also had the impression that he’d done this at least twice during concultation, baited her.

So I suggested she call him out to see what would happen. Make it clear, if he wants to discuss an impending seperation, it’s fine, but no baiting.

She was adamant she wouldn’t, other people were adamant this amounted to madness and that this was ok. It made me think of practitioner culture as well.

That’s it, really, except I still remember this and when I was baited similarly by my patient last week, I wondered what to do, ad hoc. I didn’t get the ‘I don’t want to discuss it’ line. I got a very provocative line and then nothing at all.

I tried to direct the conversation on to the abuse whilst doing some manual therapy on the side (yes! that’s what people come to us for!) but trying to be safe at the same time. Safe for the patient and safe for me. I’m not trained in the arts of psychological therapy, I consider it a tightrope act. The patient hadn’t come to me for that kind of trauma but she kept bringing it up.

I try to be proactive in these situations. She wasn’t being nasty, I was trying to remain neutral. But what is neutrality. Anyway, I don’t know how exciting it is to read a back-and-forth of these things. I asked my patient about when the abuse stopped. I asked her whether she’d received any therapeutical input.

I was trying to touch the trauma without putting pressure on it. The complication is of course that the person is another student and I will continue seinge her. as a student and potentially as a patient. This is a violation of … I’m not sure what.

I have often been told I’m very rule-bound. I consider some things absolutes. In a therapeutic setting there are absolutes such as the space and how to deal with seeing people outside of the space, can one still speak to them, interact with them etc. Is this ok?

I’m very aware of these things but also, I gather, pretty rigid. And my course isn’t designed to help me understand these dimension of dealing with patients. I agreed with my tutor then that I would like to point her towards other types of therapy to help her process the experience. And that the school would not be the most suitable space for this. And that it is also not something I would necessarily like to take on. All of which I will still have to wrap into appropriately sensitive words.

And so to bring this around a today a little, I managed to have an instructive conversation with a tutor today about the therapeutic space we provide. More on that later.

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Self-flagellation

Another day in clinic.

The weather hs turned properly autumnal after all the sunshine we’ve been having. There is now drizzle and wind.

I was scheduled to have two new patients. The first turned out to be a patient whose history my tutor had taken. No pressure then. He explained to me stomach pains that radiated to the back. I must have looked puzzled. He said this was a normal presentation (??!!) of tension in the stomach area. Ok, I said. He said he had done some visceral treatment and found sore spots in the lower thoracic spine, the logic of which I agreed with.

I generally have problems taking on someone else’s patient. I DO NOT like it. There is no doubt that I don’t always ‘understand’ my patients’ stories as fully as I would like but I strive to do that – understand what it is they have come in for. I feel the best chance for that I have is to take their history. It is the most time I’m allowed to hear them describe the problem and the most time I’m also allowed to discuss it in a student clinic obviously. This bit of discussion seems essential. I learn a lot just discussing a case.

Now I hadĀ  patient whose presentation wasn’t something I had seen taking over from someone much more experienced. I DID NOT like it.

The patient, it turned out, was lovely. She was better already. Great, I thought, I have no idea how this was achieved. I asked the tutor (who had also taken her history) what to do with her. He advised to treat diaphragm and abdomen. I panicked in not the smallest way. When he checked on us a few minutes later I confessed the diaphragm seemed hard and not very much in the mood to be treated. I got very stuck with this. I had articulated her thoracic spine and now felt lost. He showed me how he had treated her abdomen and when my hands were on the patient’s belly, she directed them, which was unusual but much more helpful. She kept directing them to where she wanted me to push in and how much pressure she wanted and she was so happy!

I told her that for me it was difficult because all I had agaisnt my hands was the abdominal pulse and it made enough noise and vibration to drown anything else.

Not a great treatment.

Not because it didn’t do what it was supposed to accomplish, more because I felt so little in charge of it.

The tutor then told me he expected a treatment plan from me. A treatment plan.

A) I haven’t done much visceral treatment (read: none). I haven’t even got much liking for it which is silly, I know. I have a lot of issues with a lot of things and I need some help with them. I appreciate being thrown into the water to learn swimming but I need some input in terms of presentations I have no experience with.

B) She was my tutor’s patient. He didn’t seem to take this very serious but I did.

He thought I should reflect on my lack of treatment planning. All I could think was how much I got stuck with the scary visceral idea that I didn’t fully understand. And maybe none of these people do.

The one suggestion he also made is to speak to my class mates to learn how they would have assessed the stomach. When I did this today, I was told visceral is a bit of a sore subject.

And we have a winner.

I have met the visceral teacher they had. I have heard the stories.

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Do patients have a culture?

Well, here I am. I’m writing a post.

I have recently embarked on reviving my career in osteopathy. This is a good thing for several reasons, most of all because i really missed seeing patients. Really.

The upshot is that I am now with the OSD (Osteopathieschule Deutschland) in Berlin and an advantage (if you can call it that) of me being there is that I get to experience patients who aren’t, well, British.

I have only seen a few people in Berlin and I find it all very interesting so I thought I’d share a few of my observations.

Osteopathic students on either side of the channel always strike me as the most difficult patients. Not because they are horrible or non-compliant or whatever, they uniformly seem to suffer from virtually unrecognisable disorders that change every time you see them. There will be dysfunction but nothing that points you to anything really tangible and either way it’ll disappear ere long. It can be very dissatisfying.

The German patients I have seen so far are very generous with information. They will tell you almost anything. I feel the form the students use is designed to make them ask the same things over and over. Patients are asked about trauma and previous operations and illnesses. I try to be rigorous with how much information I’ll allow into my case history because especially in the beginning it can be confusing.

The students here seem to meander and fill out their form still. They will discuss the injury in detail and then ask AGAIN for previous trauma and again for musculo-skeletal complaints. I think this is because patients will indeed come in with complaints that aren’t musculo-skeletal in nature. I find this quite scary. Or perhaps unsettling.

My first patient today fairly provocatively and openly mentioned childhood abuse. Another patient discussed her sex life (sort of) without prompting.

They will come and expect treatment but for what. I’m not in a position to treat their psychic trauma as much as I would like to… well, to tell the truth, I don’t want to do this much. Knowing myself, I would take things very personal and burden myself with someone else’s problems.

Either way, British patients have rarely ‘burdened’ me with this kind of revelation. I don’t recall EVER discussing sex life with a patient – prompted or unprompted. I had a patient I discussed his marriage with. I didn’t feel particularly comfortable with this either (I’m not married) but I felt that it was good he opened up to me in this way and it needed honouring.

I’m interested in how much detail our German patients provide, how much they seem soul-searching when answering. Like, it is important I’m not being lied to. The British often seemed perpetually embarrassed about even wanting to be there. I feel the few patients now are much more confident.

I wonder if a more specific ‘person’ will emerge over time or whether patients will just be patients and they will form a category like that.

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observations

now obviously, due to professional reasons we spend a lot of time looking at bodies and what they tell us. often this is becoming impaired as the people we look at are very aware of our gaze. we can ask them to relax but i doubt they will spontaneously forget us. i think even people who are looked at a lot for whatver reason, find it difficult. i guess because it involves an element of judgement – or they presume this anyway.

in reality of course, when i see a patient, i am aiming to puzzle them out in a manner of speaking, or to make some sense of them. in very young people i often find this hard, there are fewer signs of a life lived, fewer scars, fewer flabby bits – just a lot less obviousness.

another aspect of observation is asking a patient to walk. i have yet to do that. i surreptitiously watch them as they get up from their chair in the waiting room, i walk next to them as we get to the consulting room, i try to remember what my impression was. it’s interesting: if i have no impression, they are probably ok and maybe they are coming in with a shoulder problem anyway!

incidentally, i often find that my clinical judgment is based on these glimpses, did the patient get to the treatment room with relative ease? great, they are probably ok!

what i’m finding interesting is how much i get to look at people in the street, when people aren’t so aware i’m watching them. i love these small observations. i watch women in heels and how they tend to wriggle their ankle as they walk. i always wonder if all this instability is compensated in knee or hip. i watch people’s pelvic movements as they wander along. the other day i watched a very bow-legged man walk. i wonder what kind of pain these people might have, would they appreciate me asking? it’s intrusive, isn’t it? hey, you seem to be walking funny, are you ok? but i have done so in the past, not in the street tho.

i was working in a care home somewhere and one of the staff seemed to rotate around her hip or flex one knee more, i couldn’t decide what i was seeing (this is a very frequent complaint i make to myself, all you can say for definite is that it looks ‘funny’ but how and why??!!). so i asked her about it. she told me about knee problems and how she was receiving treatment. she was interested in what i did and so i ended up telling her about the knee and the strain she was likely to experience. not much else, it’s work, not a consultation.

so, i pick things up, definitely.

what i feel in clinic is that i’m so busy ‘having’ to see things, that i have no real space to appreciate what i’m actually seeing in front of me. so, i’m busy looking but there’s no seeing. i had a patient recently where a mechanical problem suggested itself and yet i couldn’t figure it out. it was very stressful and vexing, essentially i asked the tutor to do the work for me. and he did and when he pointed it out, i could see it. but it was hard to look at her and think, i’ve been doing this for 3 years now and yet i cannot see a thing.

in fact, for a long time in clinic, my impression was often, ‘i’m seeing a person in their underwear’ – as if my mind simply refused to work with me. things that stress do to you.

when i feel freer in my approach and i feel that i’m allowed to make mistakes, i am more relaxed and open to the -for lack of a better word- experience of a patient and their body. it’s an intimate thing and i try to let them feel that i appreciate this intimacy and that i’m respectful of their body. i often see other students stood observing their patients with a clipboard. i find that very weird and dehumanising, as if we are appraising cattle.

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in which i’m told i’m vague

so my first six weeks stint in 4th year clinic have passed… this means we swap tutors for the next halfterm and the tutors now give us feedback.

i was told that my patient interaction is fine, that my patients seem to get better and so on. but i’m vague when it comes to my diagnosis. this was only my first review, so i might have more things to add to this over the rest of the week.

i’m not sure why i am so vague on my diagnosis. i’m certainly not vague all of the time. i think it depends on individual patients and their circumstances. and it depends on the tutor i’m with.

i feel that i’m vague partly because i don’t have a lot of confidence in my diagnosing. i spend almost forever trying to figure out whether sometiĀ“hing counts as an actual diagnosis on the paper it needs to go on. and because this seems such a gamble in the first place, i’d rather leave it out completely. like i said, i don’t think this happens all the time. but it happens enough for me to think i’m uncomfortable with being pinned down. or maybe it’S something else i haven’t yet worked out.

part of me, i think, just isn’t particularly interested in the diagnosis as a thing. the diagnosis is part of what drives the treatment plan, i understand that, but i also want to have my hands respond to the patient in a way. this is not sanctioned. i spoke to a tutor two weeks or so ago and he said part of being examined is the performance. he said he was once told he looked supercilious. i wasn’t sure what this meant. he explained it means he looked like he didn’t care for the examiner’s opinion. i said, damn right you didn’t!

but when you’re examined you have to appear to care. this seems an impossible task.

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