The Toolbox Revisited

[Barrett Dorko]

There's a thread in the archives of "Barrett's Bullypit" begun by Jon Newman that I think merits reviving. I think much of it goes to the heart of everyday practice, and this certainly includes the continuing education we choose to attend.

Go to http://www.somasimple.com/forums/showthread.php?t=1330

"The Toolbox" addressed many of the issues that, I think, retard our progress as clinicians. Contrary to popular belief, the more your therapeutic "toolbox" is filled with what the osteopaths have called their "therapeutic amamentarium" the less likely you are to choose the correct tool for the task at hand. To me, a full toolbox also implies a way of ignoring theory whenever convenient, and you know what I think of that.

I'd like to again discuss the issue and this time add what we've learned about the nature of "hoarding" as those who study obsessive compulsive disorders have come to understand it.

I've got a quote from Homer Simpson in mind but will save that for later in the thread.

[EricM]

There's a bumper sticker that goes "He who dies with the most toys wins." I think this applies equally well to the collection of techniques in physiotherapy. It is a competitive endeavour and gives the collector an illusion of greater power.

eric

[nari]

The expression has its origins in the pressure for CE attendance that assails most PTs. The thought of another tool has the promise that our skills will be enhanced.
To me, it discourages deep model thinking and enhances compartmental thought; just like the car mechanic when faced with an engine that doesn't work properly. Sure, the mechanic can fix it up and the car can run smoothly.

Trouble is, we're not cars.

Nari

[Barrett Dorko]

I keep a Homer Simpson bookmark on the table in front of class amongst my books. It shows our hero standing with a petulant look on his face, his arms folded in frustration. He’s saying, “Every time I learn something new, it pushes some of the old stuff out of my brain!”

To me, this is good news. Memetics has revealed that there’s a tremendous advantage given to those who are capable of emptying their brain of old ideas. Of course, the age of an idea or even its utility does not indicate whether or not it should come or go – it is our estimation of its factual nature. In other words we should always be asking, “Does this new tool now replace others I used to own and respect?”

I think Homer has less control over this process than others, but let’s not forget – he’s Homer Simpson, not Lisa Simpson.

[Jon Newman]

One Art
by Elizabeth Bishop

The art of losing isn't hard to master;
so many things seem filled with the intent
to be lost that their loss is no disaster.

Lose something everyday. Accept the fluster
of lost door keys, the hour badly spent.
The art of losing isn't hard to master.

Then practice losing farther, losing faster:
places, and names, and where it was you meant
to travel. None of these things will bring disaster.

I lost my mother's watch. And look! my last, or
next-to-last, of three loved houses went.
The art of losing isn't hard to master.

I lost two cities, lovely ones. And, vaster,
some realms I owned, two rivers, a continent.
I miss them, but it wasn't a disaster.

-Even losing you (the joking voice, a gesture
I love) I shan't have lied. It's evident
the art of losing's not too hard to master
though it may look like (Write it!) like disaster.

[EricM]

Why do people have such trouble letting go (http://www.slea.com/safehaven/poem01.html)?

Eric

sorry about the musak

[Jon Newman]

In an effort to stick with material I actually understand, this summary of hoarding (thanks Barrett) from Oprah should help.

What is compulsive hoarding? (http://www.oprah.com/tows/pastshows/200411/tows_past_20041118_b.jhtml)

[nari]

Fred's Law: (I don't know who Fred is, but he is related to Murphy)

As soon as one discards hoarded items, there will be a need for them.

Nari

[Barrett Dorko]

Years ago I wrote something about "sacred objects." I'd read somewhere that an object became sacred to us when we felt that its loss would parallel the loss of something within us that we wanted and would find difficult if not impossible to acquire again.

Looking at it this way it's possible to see that an object might be sacred today but perhaps not some time in the future. Movement in the opposite direction can occur as well. In other words, it isn't the object that changes - it's us.

I consider knowledge similarly, and there are bits and pieces of information that I'm perfectly happy to let go of because I recognize the changes that have occured in me. I sense very clearly that I don't need certain things any longer and that their loss will create no concurrent loss of what I want on the inside of my head. Conversely, I can hang on to other bits of information for years before I ever actually use them. I suppose they are sacred to me on an unconscious level. By the way, my ability to do this requires no effort. If it did I'd be proud of it. As it is, many have found it rather irritating.

Whatever else Oprah might have to say about it, I feel that hoarding has something to do with the inability to distinguish between knowledge that resonates with your personal experience and your understanding of a sensible deep model and knowledge that doesn't. You hang onto everything because you don't know how its loss will affect you.

Put simply - you don't know yourself. I cannot help but feel that therapists who spend years filling toolboxes without ever discarding anything suffer from this more than anything else.

[EricM]

I don't know where else to put this article.

Clinical reasoning and movement: it is not only what therapists see but how they see it

The application of clinical reasoning to practice presented in this paper may be a step in the right direction towards solving the toolbox enigma. Each time I read something by Mark Jones I can't help but feel he is getting closer and closer to describing in his own way what Barrett has written about for years.

Eric

[nari]

Eric

I think your post sits very well in a toolbox deconstruction thread...

Mark Jones is quite a strong figure in Aust. physiotherapy; and his references provide a good resource for those wanting to know more about his themes. I think the 'toolbox' meme encourages physios to think mechanically, and have the concept of 'normality' as a baseline; it is rather like trying to push an inflated balloon into a slightly bigger bag....using the bag as a 'norm'.
I agree that Mark's line of thinking is very similar to Barrett's; the language is different, but that is about all.

Do you agree, Barrett?

It is another reason why neurorehab is valuable - it brings the brain to the forefront, and, as important, the constant contact with friends and family who know the patient. Neurorehab work humanises patients in a way that "musculoskeletal" physiotherapy does not.

Nari

[EricM]

If therapists subscribe mainly to the Instrumental model of movement learning I can see how they would value a greater number of intsruments in their toolbox. The Communicative model described in the paper could encompass the manual and verbal communciation that is Simple Contact. Unfortunately, the examples in the paper of this sort of reasoning don't quite go far enough.
I keep wondering whether these people have actually ever read any of the material on Simple Contact? Jones and co. seemed primed to take on this theory and incorporate it into their models of clinical reasoning. But as you say Nari, the normality meme must be so strong with them that the communcative model is still only an adjunct to the Instrumental one.

Eric

[nari]

I would dare to suggest that they have read material on SC and ideomotion but have not made that leap of unfaith away from the hardwired memes.

Maybe I'm wrong here, but for someone involved in teaching students, it would be a scary jump to make without inciting nociceptive comments! It's always safer to wander around outside the perimeter than to set off and leave the enclosure altogether facing possible ridicule.

Nari

[Barrett Dorko]

Nari,

No kidding.

Eric,

I'm struggling to get through Chicago at the moment and cannot read this article with the care it requires. I will while traveling this week however and appreciate your posting it here. Sounds like these therapists should be made aware that we are talking about them. I don't know why they wouldn't want to contribute a thought or two.

Now I have to step over a few bodies on my way to the gate.

[nari]

Barrett

No kidding?

I know I state the obvious a lot, but I do think it needs to be stated frequently or else those memes will never get established in the brains of PTs in general.

Perhaps Mark Jones could be invited to visit this board????


Nari

[EricM]

The invitation has been extended. Mark, are you there?

Eric

[nari]

Eric,

I think we would have to extend it a little further...he may not be aware we exist. I can see if he has a email address......

Nari

PS After a google Australia, zero results. Will have to think a bit more about contacting him.

[EricM]

Nari, I did send him an email. It's mid-semester down under right? He should be in the office.

Eric

[nari]

OK, Eric, that's good. I might also send an email to Ian Edwards as Mark is the Director of the School of Health Sciences and pretty busy, I'd think.....

Nari

Addit: The email address for Ian Edwards did not work...for me, anyway.

[Jon Newman]

I've been contemplating our fascination with passive interventions. Why are these typically the first chosen and studied? Are the few minutes someone might spend doing these things the most potent aspect of therapy and thus worthy of all our attention? Of all the minutes that make up a week, are those minutes spent doing something TO somebody what make all the difference? What about the research indicating that passive care approaches are more likely to cause problems than help?

[nari]

Don't contemplate for too long about passive interventions, jon..it gets quite depressing when one thinks of the huge $$$$s spent on gadgets and things that go 'ping' plus jumping on joints..even if the placebo factor is a significant one. :)
I guess we don't know enough yet about their true physiological effects; but nevertheless, it all seems a bit of a waste when we could do better by active interventions directed at self-efficacy.

Nari

[Barrett Dorko]

A simple thing but it finally just occurred to me - we should be looking into the patient's toolbox more often than our own. This week as I teach it again becomes obvious that you can never know what another might do given the opportunity, and you certainly don't know how much help/encouragement/information/acceptance they will need from you in order to continue moving as you suggest - especially when the movement isn't choreographed by the therapist.

I'm not a big fan of the Harry Potter books but appreciate the way they have welcomed so many young readers into the world of literature. I came across an excerpt recently that I feel fits here; it concerns a bit of advice Harry is given by an older man:

Harry is given a map that reveals where everyone is on the Hogwarts campus at any given time and he is excited about how he will use the map, until he recalls Mr. Weasley's advice. 'Harry, don't trust anything that thinks for itself if you can't see where it keeps its brain.'