Why do I get anxious before I see a new patient? If my patient list includes new patients I get more anxious than other days. I arrive at the clinic early, open up my computer and settle down awaiting the appearance of the first patient. New encounters are loaded with a degree of anxiety and I assume patients experience similar feelings especially when in pain.
Therefore, it is important for the practitioner to keep unnecessary anxiety, such as unexpected events or surprises, to a minimum. Anxiety is reduced however, in a safe, therapeutic environment or put another way, when clear boundaries are set.
"Clear boundaries" is a term often used in the adult-child relationship where they are considered important for the child's development. Boundaries help the child know that the parent won't let behavior get out of hand, making the child feel safe, even if they frustrate and inhibit.
Boundaries in the therapeutic sense can be considered factors which define clearly the consultation as... a consultation.
The 3 most important boundaries are:
1) Space. The space is defined as the room in which the consultation takes place. At the risk of stating the obvious, it's a room, not a corridor, not a field nor a person's home. In the patient's mind (and in the practitioners's mind too), it is a room which is dedicated to the treatment. Anything inappropriate that permeates the "therapeutic membrane" increases anxiety. Examples might be people walking into the room without proper warning (receptionists, other practitioners, or students), or telephones ringing etc.
2) Time. It should should be made clear before the consultation the start and finish time of the session and how long the session will last. Changes in scheduling can increase a patient's anxiety. Even when the reason for rescheduling may be benign. Regular schedule changes made by the practitioner may elicit the patient's fantasies (other patient's are more important and take preference). Running late for a session also arouses feelings such as anger or jealousy. Similarly, giving patients more time than agreed. This is also considered breaking a boundary as it may arouse feelings of favoritism.
Which brings me on to my 3rd boundary.
3) Role. The role of a practitioner in the manual therapies has many sides to it. We are medical practitioners but we are given permission to touch. Patients offer emotional information about themselves but we are not strictly speaking "talking-therapists". With some patients we may become friendly but they pay us for our services. It is a constant struggle to stay in role. Sometimes we may find ourselves being pulled out of role. In one of the sessions in the series "What is the patient really telling me?" (The Osteopath, Nov 2006, Page 24), an osteopath told the group that she occasionally shopped for one of her elderly patients. This became increasingly tiring for the osteopath. The group was able to help the osteopath recognize that her behaviour related to the osteopath's feelings of guilt for not helping her own elderly parents who lived far away. The example reflects the way an osteopath can get pulled out of role.
One of the most fascinating aspects of keeping boundaries is the positive therapeutic affect on the patient. As a parent, as well as taking care of the child's physical needs, maintaining safe boundaries for the child is 90% of the work. Similarly I believe is true of the treatment consultation. As practitioners we need to attend to the patient's medical needs, but maintaining clear boundaries will affect to what extent the patient will internalize the treatment.