Editor’s note: Til Luchau and Whitney Lowe recently spoke with manual therapist, physiotherapist, and researcher Mark Bishop about his fascinating research into how clients’ expectations influence treatment results. His research shows that clients who think treatment will help often benefit far more than those who don’t expect much relief. Key excerpts from their longer conversation (which took place on Whitney and Til’s The Thinking Practitioner podcast) have been edited here for clarity and context.

In our last column, we spoke with researcher Mark Bishop, PhD, about how client expectation triggers neurophysiological (that is, physical) reactions in the brain, how pre-treatment expectation predisposes clients to get more (or less) benefit from their work with you, and the jaw-dropping finding that client expectation (before treatment) is an even bigger predictor of benefit than the modality or technique used. (If you missed the first article, see “How Client Expectations Shape Results,” in the January/February 2021 issue of Massage & Bodywork, page 88). So, as practitioners, how can we use this information?

In this article, we go deeper into the implications of Bishop’s research, and we think about ways to apply what we are learning about client expectation—specifically, how it shapes results in massage and manual therapy.

Letting Clients Choose

Til Luchau: If I’m remembering right from the San Diego Pain Conference, you had some thoughts about matching clients or patients with a therapeutic modality based on their expectations. You were saying there is a good research rationale for giving the client a choice of modalities—a menu of options that work—and letting them vote on which modality or method you’re going to use. Am I remembering correctly?

Mark Bishop: You are. For me personally, if there is no difference between me doing mobilization for your neck or manipulation for your neck or muscle energy technique for your neck—if I think the outcomes will probably be similar—then it’s no harm for you to say, “You know what? As the patient, what I want is this one.”

TL: Then, why don’t we just ask our clients what they want, and just do that? Is there any downside to that approach?

MB: If in my opinion there is a best way to treat you, then part of the [patient] education would be to say, “OK, the people who get this treatment program seem to recover the fastest and have the best outcomes. So, this is what I recommend we do today.”

But then, what if the patient doesn’t want to do anything suggested? They might say, “Well you know what, the only thing that I expect to help this is . . . a hot pack and some ultrasound, because [the] last time my neck was sore, what I got was a hot pack and ultrasound, and my neck got much better.”

So, include that with the other package, and say, “You know what, that sounds like a great idea. I’m very happy to finish with those. Once we get through a couple of things up front, then we’ll make sure we finish with the hot pack and the ultrasound.”

TL: What if the client wants something that I don’t particularly believe in as a practitioner, don’t enjoy doing, or don’t think helps? Is there still a benefit in me doing it, just because they want it or believe in it?

MB: Well, even a provider who thinks they’re a great actor will convey that they don’t believe very strongly in what they’re doing. I haven’t done any of those studies, but I’ve read a couple where clients and patients are able to pick out which providers are giving the real treatment versus a placebo treatment just because of the body language and interacting and stuff like that. So, [even] if you don’t believe in it, [your client may] still get benefit from their belief. They just won’t get the added bonus of your belief, positivity, confidence, and those type of things.

Listening

Whitney Lowe: Til and I are both educators. Are there specific things we could focus on in educational programs to enhance the benefits of expectation? I know certainly it’s a soft skill, and much more difficult to put in granular terms, but what kinds of things might we be able to focus on to improve those outcomes? There’s a much greater emphasis needed in some of our training programs on these factors, which I think are significantly underemphasized in terms of their contribution to the outcomes.

MB: I would agree. I think the metaphor that works for me is that I have never given a treatment in a blacked-out room, dressed all in black, with a mask on, and the client unconscious. If the mechanical effects of treatment were all that mattered, then doing treatment that way would work just as well as what we’re talking about.

I apologize I didn’t research any of the training for other professionals. But say for example, therapeutic communication, which used to be a standard class in every PT program everywhere, got removed as people wanted more physiology and pharmacology and radiology. “What are we going to get rid of? It’s just communication. We’ll eliminate that.”

I think learning how to communicate well is of imperative performance. I’d also suggest things like making sure people are asking open-ended questions and actually caring.

Recently I ran into someone I’d seen as a patient 20 years ago. We were catching up, and she was complaining about her shoulder—how she was doing all this exercise and doing all this manual therapy, but it just wasn’t getting any better. I listened to her, and then said, “You know what, I have to go. I need you to just do a couple of these catch-the-rain exercises, feel it back there. Just work on that for a week and we can talk later.”

Then, a week later I called her. She said, “I feel great. I have never felt so good. My shoulder is better.” When I asked her, she said I was the first person who actually let her tell me about her frustrations with what was going on and suggested a change.

So, I’m not saying that I’m awesome because of that, but I think just an episode of listening to her and saying, “OK, I hear you’re really frustrated. There’s lots of different ways to do this. How about we just try this alternative?” That was enough for her.

TL: That’s a great example. And Whitney, your question is great too, because it has a lot of implications for entry-level training for sure. Even at the continuing education or post-grad level, those of us who have been out there in the field working for a while can tend to think, “Yeah I got that. I know about that relationship stuff, I’m a natural, I’ve been doing this for X many decades.” There’s a lot of room for us all to get better in terms of understanding the alliance and the contextual possibilities and the power of expectations as well.

Do Credentials Enhance Results?

WL: I’m curious to hear your opinion on this. I didn’t see this picked up at all in any of your other research.

In the massage therapy profession, massage might be administered by a physiotherapist with a great deal of academic education and high level of credentials, or it could also be administered by an individual with just a very basic level of massage training who has very little formal academic training. Might you see expectations from the client or patient change when they see you don’t have a lot of significant training? Could that change the outcomes of the client’s perception of effectiveness of your treatment?

MB: It may indirectly. One of the things you’re talking about is within the therapeutic alliance. One of the elements people have identified as building therapeutic alliance is the trust in the provider and the perceived, as you said, skill level of the provider. So potentially, yes. If you walk into a place, and the person has their academic training, their clinical certifications, and the pictures of the happy people on the wall who’ve signed with the “Thank you for a great job!” and all that type of stuff, that helps build the kind of confidence that our client has in you as a provider.

I don’t know enough about it to give you an answer about the degree qualification. I think that whether you’re someone from the physical therapy background or massage therapy or osteopathy, for example, it’s potentially the same environment setup, and that would be the healing context, the therapeutic environment around this.

One of the things is the first person with whom the client interacts is [the] expectation ambassador. Whoever interacts [with the client] the first time has great potential to help set this context in motion. Like, “Whitney, yes, we’ve got an appointment at the time that works. You are going to see Til. You’ll love Til. He is such a funny guy. He does great work. Everyone loves seeing him.” Even just those sorts of comments can begin the person on the other end of the phone saying, “Good, good. I got to see Til. He’s the best in the clinic. This is going to be great.” Same with [other] people giving the good reports; these all help build that pre-contact expectation. Then, once you get there, that therapeutic context has been shown to really influence alliance, client confidence, and that type of thing—the trust and confidence that the patient and client [have] in the provider.

Author’s note: What the client hears about you early on sets the tone of the therapeutic encounter. This applies whether you have someone else as an official “expectation ambassador” or you do your own client orientation and scheduling. Clients can see evidence that others received benefit and are appreciative of your work through client comments on your website or scheduler, positive reviews on your social profile, or information in your “client welcome” materials. Though we can be shy about blowing our own horn, we could also argue that if we don’t help the client understand that others have benefited from working with us, their perception of their treatment results they get from their investment (fees) may be less.

COVID Expectations?

TL: What about COVID? How might that influence the contextual factors or the client expectations?

MB: I would think that being very reassuring . . . and saying, “Do you have any concerns about coming to see us? Anything about COVID? Let me tell you about the protocol.” Just interacting with people before they get there [is helpful] . . . setting the stage . . . so people’s expectations of what [treatment] is going to look like matches what they experience when they get there.

Closing Thoughts

WL: Mark, thank you so much for sharing your research and your perspective on this with us here.

TL: Absolutely. Is there anything you want to leave us with? Any key thoughts or key points that you think we should be keeping in mind?

MB: Well, if I were to summarize, I’d say I think it’s important to think about what the person is expecting—[to] find out if they have specific expectations about a treatment or types of treatment. Then, if you are able, and it does not interfere with your treatment plan, consider including elements that patients expect to help.

There are some patients who don’t want to be involved, and just want you to tell [them what to do]. But unless you ask you may not know what the expectations are. So, I think asking people about what they expect is useful to help you plan the right approach.

TL: And that could be as simple as [asking], “Is there anything you want to make sure we cover today? Anything you want to make sure that I do?”

MB: Yes sir. Absolutely.

About Mark Bishop, PT, PhD, FAPTA

Mark Bishop is a physiotherapist with more than 30 years of clinical and research experience in the area of rehabilitation of musculoskeletal pain disorders, and is a faculty member in the Department of Physical Therapy, with affiliations in the Center for Pain Research and Behavioral Health and the Pain Research and Intervention Center of Excellence, at the University of Florida. His work has focused predominantly on the mechanisms underpinning the effectiveness of conservative interventions for pain—especially manual therapy and exercise.

Learn more about Bishop and his work at https://pt.phhp.ufl.edu/profile/bishop-mark/.

Client expectations have been shown to have an enormous impact on the effectiveness of our work—maybe more impact, the research suggests, than your modality or technique. This article mentioned a few of the many ways you can shape helpful client expectations. How often do you use these ideas now? Take our Massage & Bodywork survey at www.surveymonkey.com/r/MLHS8TW.

Learn More

• Listen to Til Luchau and Whitney Lowe’s entire conversation with Mark Bishop in Episode 23 of the Thinking Practitioner Podcast, sponsored by ABMP, at a-t.tv/ttp.

• Watch Til’s video comments on this article and read his past
articles in the Massage & Bodywork digital edition, available at
massageandbodyworkdigital.com, abmp.com, and on the Advanced-Trainings.com YouTube channel. Watch Til’s ABMP video playlist on YouTube, where all his videos have been compiled.