Key Point

• Encouraging the client to be part of the discovery process can help build the connection with the practitioner.

I received a call from a physical therapist who often refers his patients to my office, and he asked if I would take on a new client.

“I know how busy you are, but I think you should see her, as this is a complicated case,” he said. “She has struggled with sacral pain for about 18 months. I think the physical pain is something we can deal with. The bigger challenge might be her frustration with her condition and the care she has received.”

I was appreciative of his perspective, and when I met the client, it was clear she was indeed frustrated and highly skeptical about the potential of this work being helpful. As she entered my treatment room, she seemed restless, eyes moving around the room to scan her surroundings. It was clear she was both physically and emotionally uncomfortable. I could tell she was assessing the situation carefully. 

Validating the Experience

What I have learned over the years is that an overly exaggerated attempt at assurance is often counterproductive. There’s a delicate balance between professionalism and the desire to connect with clients on a personal level. In her case, the skepticism and frustration were well-earned and perfectly understandable, made evident by a lengthy description of her struggle with this condition.

She described how this pain emerged over time, with no perceivable incident or trauma as its genesis. Over time, her pain began to limit her activities and then became pervasive. During the day, she couldn’t sit comfortably, and at night it interrupted her sleep. Eventually, the location of the pain seemed to widen, going from her legs to her feet. As with all pain, it isn’t just what you feel, it’s also what you think it might mean. In her case, having no clear reason for her pain invoked fear that some disease process was a real possibility. 

To rule out some of these concerns, she had seen many health-care providers. Each of them ruled out conditions she did not have, which on some level was helpful, but none of them could reasonably explain why she hurt. She even said she had an MRI read by five physicians, all with differing opinions. A couple of providers offered suggestions as to the source of her pain, and, quite insightfully, she said it was hard for her to trust a diagnosis from practitioners who never physically examined her. Again, skepticism well earned. 

“I can’t imagine how frustrating this experience has been for you,” I said. “Without a clear sense of the problem, it’s impossible for you to know how to respond.”

“Exactly,” she answered, making full eye contact with me for the first time in our meeting. That moment of validation changed our connection completely. “Do you have any ideas what might be causing my pain?” she asked in a much softer tone of voice. 

“I can think of at least four possible musculoskeletal reasons based on your description,” I replied. I outlined each possibility and what we would find upon examination. 

“Do you think an answer will surface by the end of the session?” she asked. 

“Highly unlikely,” I replied. “When everything is stirred up, the lines get blurred, making clarity difficult. As things settle down, the primary source should become more evident. I’ll probably pursue two to three of these possibilities until it becomes clear which is most involved. That is likely to take 3–4 sessions.” 

In our session, I did a thorough and careful examination/palpation of tissue I suspected might be involved. Soliciting her feedback over each area, she reported if the area I was addressing felt relevant to her pain and what the qualities of sensation were. In this way, she was fully involved in the discovery process, not a passive recipient. By the end of the session, her attitude was completely different—changing from skeptical to cautiously optimistic. That is in line with what I hope for with clients—not assurance and false hope, but the knowledge that this is a highly organized process of problem-solving that requires a partnership to be successful.  

Affirming Communication

My experience with her exemplifies the structure of a successful therapeutic encounter. To enhance connection, validate the client’s experience. Then convey, in an understandable way, what might explain their symptoms, including how you could confirm or, more importantly, disconfirm your concept. Lastly, outline the process of your approach and a probable timeline.

At the time of publication, she was doing well and had become a champion for the work and the lessons learned during her pain journey. Many people will benefit from these lessons as well, as she is able to educate future health-care providers about what constitutes good patient care and the potential role of soft-tissue in the experience of musculoskeletal pain.