Reconceptualizing the therapeutic alliance in osteopathic practice: Integrating insights from phenomenology, psychology and enactive inference

This narrative review presents key concepts from neurophysiology, phenomenology, psychology, and narrative medicine which underpin a developing enactive-ecological framework for osteopathic practice. This framework aims to provide a coherent theoretical basis for understanding healthcare processes and outcomes, based on the neuroscience principles of active inference and enactivism. It offers insights into factors that influence patients' pain perception and behaviour and foster or inhibit the development of effective therapeutic relationships. Although this approach offers promising opportunities to increase the scope of care by harnessing potential in the unique embodied ecological niches created between patients and osteopaths, it raises challenges to traditional treatment agendas. Healthcare which frames the patient-as-a person, and acknowledges the multidimensional nature of the self, requires practitioners to be collaborative and self-aware, and be able to elicit patients' lived experiences and body stories. Phenomenological and psychological studies into enactivism emphasise the complex, dynamic nature of therapeutic relationships and the need to understand each person's unique lifeworld context. The new framework represents an important step forward, but further research is now needed to explore ways of integrating active and enactive inference into practice, of developing psychological or mindful self- and body-awareness, and narrative communication skills for shared sense-making.