I undertook the review of this book blind, because I had the privilege of hearing Annie Mitchell speak on the therapeutic relationship last summer at Exeter University, when she mentioned the book's impending publication. So I received my copy with pleasurable anticipation, having already been a party to some of the very interesting ideas expressed in it.
Mitchell and Cormack have written a book which I will read and re-read, a book which I will designate as an essential text for Practitioner Development modules on oriental medicine courses, and a book which I will use as a reference regularly in lectures.
Maggie Cormack, in her introduction to the book, says of herself and Annie Mitchell that they combined her own 'analytic approach and attention to minutiae' with Annie's 'imagination and creative ideas', and thus worked together on 'the essential tension in our profession between the scientist-practitioner and the humanistic, interpersonally-oriented therapist'. This is exactly the feel which is created by this book: the ideas are vibrant, stimulating and powerful but not at the expense of objectivity or scholarliness. There is very little here to alienate the man of science, and plenty to feed the soul of the artist-practitioner.
Therapeutic Relationship in Complementary Health Care is a book which will fascinate most complementary medicine practitioners but which is equally relevant to other disciplines, such as physiotherapists, psychotherapists, doctors, nurses and, in fact, anyone who works with patients, as well as patients themselves. Mitchell and Cormack have explored the therapeutic encounter from a wide variety of angles, looking at published research and established theories to support their discussion. The referencing is varied, broad and eclectic, taking from the fields of biomedicine as well as complementary disciplines.
The book comes at a particularly timely moment in the history of complementary health care in this country. David Reilly, Lead Consultant Physician, Glasgow Homoeopathic Hospital, in his introduction to the book says: 'Perhaps the greatest single contribution from complementary medicine so far has been the re-awakening of the importance of good healing encounters within orthodox care, yet, paradoxically, there are now signs that practitioners of complementary medicine are not championing this aspect of their work. In fact they are in danger of undervaluing it, drawn by the human tendencies to invest in the potency of their chosen intervention at the expense of their consultation - be that intervention an acupuncture needle or a psychological approach. The climate of demands from increasing professionalisation will likely intensify this tendency in the years ahead; the demands of survival and success, and of scientific and culture evaluation.'
It is interesting, in the light of these comments, to compare Mitchell and Cormack's book with Patient Centred Medicine (Stewart, M., et al,1995) who present a view of patient-centred medicine from the more orthodox side of the fence, yet reaching startling similar conclusions. On page 94, under the heading of 'Erosion of Medical Authority' it is interesting to see Mitchell and Cormack presenting an analysis of the arguments for and against statutory regulation. If we wish to take part in the current debate within our profession many of us could do worse than read these pages and follow up the references to help us to stand back and gain an overview.
As a practitioner and a teacher of acupuncture, I found their view of the centrality of the therapeutic relationship to any healing encounter well presented and utterly convincing. Mitchell and Cormack argue persuasively, precisely by being so ready to take a broad perspective and to maintain an objective and reasoned stance.
I found the format eminently readable, as well as being useful: some very nebulous issues are dealt with in a very grounded way, drawing on the wisdom and suggestions of other writers. To take an example, chapter 8, which is entitled 'The Process of Treatment' explores several models of the process of treatment, citing different ideas on how the relationship between patient and practitioner may develop. Mitchell and Cormack go on to look at the issues within the process of treatment and to propose a model which they then divide into five phases: mutuality, trust, care, challenge and return to mutuality. Each phase of these difficult concepts is described clearly with references to support the ideas expressed. The following section is allocated to questions for practitioners to provoke reflection on the nature and value of the therapeutic encounter. Nothing here to disturb the more scientific amongst us: the questions are simple, straightforward and thought-provoking. Applying them to my own practice straight away gives me pause for constructive and creative thought.
One chapter which I found particularly arresting is chapter 6, entitled 'What makes change happen in treatment?' Mitchell and Cormack review the evidence of the effectiveness of non-technical factors in healing, looking at studies done on the placebo effect, on the psychotherapeutic outcome and observations of 'spontaneous remission'. The book is often by its nature an overview and this topic is always particularly fascinating. I found myself wishing they had devoted more space to it: I wanted to hear more. On the placebo effect they say: 'At first sight, acknowledgement of the placebo effect can lead to therapeutic nihilism: if change occurs irrespective of technical intervention, practitioners may ask, Why bother with technique at all?' Just so. Is this not the exact response many of us had when first considering the placebo effect?
Occasionally, there was a paucity of references: for instance, the discussion of transference and countertransference, surely a very important concept when looking at the instruments of change in therapeutic relationship, was sadly less than a page long, with the only reference being Strupp (1989). With such a wealth of literature available in the field I found this disappointing.
Mitchell and Cormack write well and clearly, moving with fluency and objectivity through an argument. They represent an overview of existing and current theories and often move a step further by proposing a conclusion of their own which fits their basic premise of the centrality of the therapeutic relationship to the healing process.
When I initially discussed this book with colleagues, I presented it in what was perhaps a rather woolly light, and was challenged by one to give one good reason why the book would be of value to him. The answer which immediately came to my mind stands: although I felt I had considered the therapeutic relationship quite a lot in the past, nevertheless, within one week of practice after first reading the book, ideas I had read and mulled over directly affected the progress of treatment in several cases and I believe prevented at least one patient leaving altogether. Surely this book is well worth the time spent in reading and reflection.
In conclusion, I offer the following as reported by David Livingstone and quoted in The Greatest Benefit to Mankind (Porter, R., 1995) This, for me, seems to address the central issue in Mitchell and Cormack's book:
MEDICAL DOCTOR: 'Hail friend. How very many medicines you have about you this morning! Why you have every medicine in the country here.'
RAIN DOCTOR: 'Very true my friend; and I ought, for the whole country needs the rain which I am making.'
MD: 'So you really believe that you can command the clouds? I think that can be done by God alone.'
RD: 'We both believe the very same thing. It is God that makes the rain, but I pray to him by means of these medicines, and, the rain coming, of course it is then mine.'
Susanna Dowie Susanna Dowie has been in practice since 1982 and is widely experienced in many aspects of the complementary medicine field, including homoeopathy and massage. She is now studying for an MA in Complementary Health Studies and since 1995 has been Principal of London College of Traditional Acupuncture. She currently holds a seat on the British Acupuncture Accreditation Board.