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BB
14-08-2006, 07:34 AM
After some of our recent discussions on the thread "Oh my God, I finally got it!" (http://www.somasimple.com/forums/showthread.php?t=2529) I have been doing some thinking about expectations.

I was thinking about need states and expectations.

In the book, A Brief Tour of Human Consciousness by Ramachandran he talks about face blindness. It is a condition in which a person will, when they see their mother for example, they recognize that the person in front of them looks exactly like, sounds exactly like, dresses exactly like their mother, however will say that it must be an imposter. It is a condition in which a person loses the ability use emotion to mark context (I don't feel like I do when I see my mother).

The reason I bring up this example, is to make the point we must have explanations. In absence of normal function, an explanation will still be formed. "This must be an imposter, because they look and sound exactly like my mother, yet they are not." And, as is evident by the face blind, is not always reliable. I know this is a point that Barrett makes occasionally.

There is another example in Joseph Ledoux's book, The Emotional Brain regarding split brain patients.

In the other thread, I brought up the possibility of what I think may be 2 different need states (http://www.somasimple.com/forums/showthread.php?t=1394) that we see in the clinic that can be blurred in our evolutionary need for social grooming. My suggestion is that we may be seeing a need state for pain, as well as a need state for social grooming. Satisfying one does not necesarily satisfy the other.

I quote Randy:
The distinctions between psychological, emotional and physiological needs aren't neatly compartmentalized as we might like them to be.

I take this to mean that regardless of what need states are present, people come in with expectations, period.

Since our brains seem to require explanations (as evident in the face blindness example), I'm wondering if expectations are an output of need states, placing them in a context that is accessible to our consciousness, in the same way that explanations fill this role. We don't have conscious awareness of the implicit workings of need states, but we do have awareness of thier consequences. I wonder if expectations are the consequence of need states. Think about how if you are hungry (a need state) you would expect to be satisfied if you ate.

Since we don't have conscious access to the inner, implicit workings of need states, all of our expectations are the explicit result of all our various need states, but we don't have the ability to know which expectation goes with which need state all of the time.

And if this process is occurring in the same way that we form explanations, it is unreliable (as in the face blindness example). So, our expectation is not a reliable guide to satisfying our need states. So, if someone expects that burying a rubber chicken in the backyard will cure their baldness, that doesn't mean that it will.

Finally my point:
We may not be able to distinguish what expectations coordinate with which need states, and our patients don't come in neatly compartmentalized. They present as a big ball of expectations, and that is all we have access to.

What makes it tricky for us Human Primate Social Groomers who are attempting to satisfy need states, is that we must also still satisfy those pesky expectations, even if they are unreliable.

So can we meet unreliable, unrealistic expectations and still fulfill the need state of pain?

Is our best bet to, instead of attempting to meet their expectations, attempt to elicit new ones, then meet those?

Or, is that being manipulative?

Sorry, way long post!

nari
14-08-2006, 08:54 AM
Cory,

Your three questions are the essence of clinical practice.
To meet a patient's need states, they have to be identified first. I think it would be easy to confuse pain need state with a nurturing need state, as the second may be the cause for the first; ie, a chronic pain state, not acute.

Just today, I assessed 2 young women, both in pain and have been for 6-9 years; both with totally un-nurtured childhoods with neglect, abandonment, heroin use, and unlovedness.
If that need for reliability, support, and assurance can be met in some way, the Pain team agreed the pain would be greatly reduced or resolved; which doesn't mean the pain goes away, but suffering and the experience would resolve.

Knowing all need states is helpful..but complicated.

I don't think it is manipulative to elicit new expectations, provided they are acceptable/realistic to the patient. And we have to know why we are changing expectations - to suit our needs or the patient's?

Nari

Randy Dixon
14-08-2006, 11:03 AM
I wonder if expectations are the consequence of need states. Think about how if you are hungry (a need state) you would expect to be satisfied if you ate.-Cory

I like this example because I think it clarifies the idea in my own mind, if I am hungry, I want to eat, if someone could give me a small pill that would satisfy all my physiological needs that eating provides, I don't think I would be very happy with that. There are times, of course, that I would love to not have to eat, there are many more times that I wish that I could eat without the nutrition (calories) that food provides. Applying this to PT treatments, I think that the distinction between the two needs to be made clear to the patient to prevent the expectation of a fine meal when they may be getting a pill. I think it might be helpful to refer them to a place where they can go to get their desire to eat met as well.

Your going to have a hard time convincing some people that they can give up food if they wanted to also.

Although we can blame Diane for the gastronomic bent of our metaphors lately I think that it is quite appropriate in this case. The secret for losing weight is "Eat less energy than you use", that's it, all you really need to know. Explaining calories and nutritional content of foods, etc. could probably be written in two or three pages. Yet go to your local bookstore and look at the diet section, whole rows of books about dieting and weight loss. Books, which when distilled down to their core, have very little to do with nutrition and a great deal to do with psychology.

Barrett Dorko
14-08-2006, 01:55 PM
Seeking emotional fulfillment through food is a pretty well known problem. I see the road signs advertising a national chain of restaurants say in large letters, "Comfort. Food." I carry with me to the courses a table top ad for a rich chocolate dessert that says, "Resistance is Futile." Both of these marketing devices have identified and then preyed upon a need state not necessarily inherent to our physiologic needs but certainly our human ones.

Are there therapists that do something similar when they regularly shift into "counselor mode" despite a lack of education and training? I know therapists who are satisfied with their work as long as their patients "love them" and thus become adept at finding out what will elicit that response. Makes you wonder whose needs are being met, doesn't it? For me personally to be understood is a very strong need, and, believe me, being loved is way down the list. I contend that understanding is a greater goal, especially when you're teaching continuing ed.

Cory, A great topic. I would add: What are each individual therapist's expectations and how do those drive the way in which they practice?

Diane
14-08-2006, 05:06 PM
Hi Cory,
In the other thread, I brought up the possibility of what I think may be 2 different need states that we see in the clinic that can be blurred in our evolutionary need for social grooming. My suggestion is that we may be seeing a need state for pain, as well as a need state for social grooming. Satisfying one does not necesarily satisfy the other.

The only way I can think to overcome the potential dilemma is:
1. Pain education
2. Clarifying objectives, making a little treatment plan/contract/seal together with the patient
3. Sticking with it, staying boundaried. Letting them go to someone else for their "backrub"...
4. Don't try to treat (really treat) pain issues in friends or relatives. It just won't work. At least in my experience. And don't make friends out of your patients. Which is why I have no friends, because I don't really know anyone I haven't treated at one time or other. OK, just kidding. I have a few therapist friends left that haven't abandoned me. Yet. Which makes me feel hungry.. uh-oh..

BB
15-08-2006, 08:15 AM
Diane,
I think you are right on. Shocker. As I was treating a patient today and explaining pain to him, I realized that he was forming expectations based on my explanations.

This might be why this issue is a surprise to you. You are so good at setting boundaries and providing explanations, that you have been fostering realistic and positive expectations all along.

Here is how I figure it. We build explanations based on our history and our memory. (The Feeling of What Happens, by Damasio is excellent in its description of "autobiographical self." I highly recommend it) I think that expectations must go into developing explanations as well.

1) have expectation
2) have action (treatment)
3) did action meet expectation
4) compare against present explanations to develop new explanation of why or why not.

Education will give the patient explanations. It is a way to attempt to base their explanations on what we know from science, before going through the above sequence. Otherwise, they will come up with their own explanations, which as we have discussed are unreliable.

Barrett,
I would say that my expectations have been that I expect to be able to treat in an environment that gives the patient the best chance for success. As this is unrealistic, my expectation is often not met, resulting in my sympathetic state.

Now that I'm aware of it, I'll hopefully be more responsive than reactive!

nari
15-08-2006, 09:46 AM
In reply to Barrett's question:

What are each individual therapist's expectations and how do those drive the way in which they practice?

The way I see it, the patients come with their own expectations that follow a certain pattern - at least amongst the clientele I see. I want to be rid of the pain; I hope you can get rid of the pain; I hope you can show me ways to make the pain less.
The third expectation is something we can deal with; the other two mean a heap of education that may or may not alter their expectations.
I can usually meet a patient halfway; he/she can state their hopes, and I can state mine; if the two are in agreement, well and good. If not, there is a compromise. Most are happy with that. The compromise is I will do what I can to assist the process of self-efficacy.
But if a therapist believes they know better than the patient and just follows a routine, such as graded exercise, relaxation, etc, it is unlikely to work well. No one routine works for everyone, but it will work for some. If patients establish their own plan it is much more likely to result in satisfactory outcomes for both patient and therapist. Guiding and not leading, once education has been covered to meet patients' needs.

Nari

Luke Rickards
16-08-2006, 05:22 PM
I just remembered posting this thread at NOI (http://www.noigroup.com/cgi-bin/ubbcgi/ultimatebb.cgi?ubb=get_topic;f=5;t=000290#000002).

There are some interesting responses here.

Luke