Repackaging Simple Contact

[Barrett Dorko]

“There are so many ways we can touch the person with chronic pain to reduce their discomfort.”

Joseph Kleinkort, PT, MA, PhD President, Pain Management Special Interest Group – American Physical Therapy Association

I read the quote above yesterday, August 31, 2006, in the latest issue of Orthopaedic Physical Therapy Practice – The Magazine of the Orthopaedic Section, APTA. Over the years I’ve found that the very thing that’s been floating around at the front of my brain is attached to something I’m just about to read. Clearly, I am psychic.

Dr. Kleinkort’s remark showed up after I’d spent some time thinking about how the care I provide might be more effectively taught and explained. Perhaps I should begin by saying that I strongly disagree with him for several reasons. Touching in and of itself is unlikely to have a significant effect on another with chronic pain aside from its well-know psychological effect. This effect isn’t insignificant by any means but I fail to see how it could possibly endure once actual contact is lost. Any subsequent prolonged relief would be a function of the person’s brain. In any case, we are now dealing with phenomena that would require the expertise of the trained counselor in addition to the physical therapist.

Still, saying that we can touch another and “reduce their discomfort” is a remarkably seductive message. I’ve met thousands of therapists who long for this skill. In Jay Conrad Levinson’s Gurrellia Creativity – Make Your Message Irresistible With The Power Of Memes ( http://www.amazon.com/Guerrilla-Creativity-Message-Irresistible-Power/dp/0618104682/sr=1-1/qid=1157109299/ref=sr_1_1/104-7213658-3536738?ie=UTF8&s=books) he notes that “(People make purchases) because some sort of emotion lies beneath them. It is difficult to sell anything to anybody unless you tap into an emotion they’re already experiencing.” When I see how much my students want to learn some secret way of handling that will mark them as sensitive, insightful, astoundingly skillful, “healing,” even "magical" I know how easy it would be to sell something promising all of that. Anybody who thinks that educated therapists don’t want this should follow me around for a while.

Despite the profession’s longing to provide a sort of manual care that resembles faith healing (and I think Kleinkort’s quote reflects that), it remains clear that the majority of the patients we can help with painful problems will find the origin of their pain to be some sort of mechanical deformation. It follows that only movement will help, not touch. And if that movement is to be truly analgesic and enduring it must be corrective in nature. So, if a movement therapy of some sort is required for enduring relief, what does manual therapy have to offer?

For many years I’ve drawn people to my workshops with the promise that they will be instructed in Simple Contact, defined as “A technique of communication, either verbal or manual, designed to make another aware of their already ongoing processes and encourage their expression. Simple Contact does not move others. When used manually, it just deforms the skin.” At every course someone will walk up to me and say, “Okay, when you do this Simple Touch…” I correct them and then they say, “Whatever,” as if their desire to touch others magically were more important than my explanation of my manual method’s effect, i.e. to make another aware of the movement they might do therapeutically. This is ideomotion, of course.

I feel today that my lack of concern for the emotion that underlies our profession’s longing for skillful handling has short-circuited my message. I have, in fact, violated several rules of marketing that Levinson makes clear in his book.

I need to address this and subsequent posts in this thread are already in my head, so stay tuned.

Any thoughts?

[gary s]

Barrett,
I think that most P.T.'s have a hidden inner wizard. Some how, you need to appeal to that. If I recall correctly, during the earlier "cranial concept" days, you gave fleeting references to NLP and Milton Ericson's works. I assumed that it was because these works paralelled yours--a small input that stimulated a self corrective process. I haven't seen those references lately. I think that you need to expound more on Animal Health. We are no different from animals, but culture/civilization has blurred our instictive self corrective responses. With Simple Contact (the wizard's wand) you will enable your patients to access their long lost instinctive self via ideomotion. Voila!
Great advice or loose vowels?
BTW, wasn't Kleinkort a big advocator of cold laser therapy? Funny that he should be writing about touch.

[Diane]

if a movement therapy of some sort is required for enduring relief, what does manual therapy have to offer? It would depend what kind of manual therapy, how slowly it is introduced, what sort of interactivity is allowed to take place. I'm reading about "manipulons" just now, in the Rywerant book, Teaching by Handling.

I want to stick up for hands-on.

[Barrett Dorko]

Gary,

As you may know I advocate Cindy Engel’s research and additional commentary in Wild Health (http://www.amazon.com/Wild-Health-Animals-Themselves-Learn/dp/0618071784/sr=1-2/qid=1157130251/ref=pd_bbs_2/104-7213658-3536738?ie=UTF8&s=books) and emphasize the presence of self-correction – ideomotion - within our instinct. I try to make a case for our culture’s rejection of instinctive movement in favor of appearance and control. I also point out that our profession has made up a story (several stories actually) that justify our colluding with a culture that mainly wants to control and sell us stuff. This happened, I say, because somewhere along the line we abandoned the scientific method. Well, pretty much anyway.

What’s not to love about that approach? Apparently, a lot.

This is where my thoughts about repackaging come in. I’m thinking of emphasizing the touching part as an impetus to change, not as the change itself. The manual care part, which I feel is essential for the patient’s initial awareness, must be sold as something that fulfills the therapist’s emotional need, to say nothing of the patient’s. Ironically, I’ve come close to this for years but continue to bump up against barriers that have grown in our clinics for years.

More on that later.

[nari]

I've pondered this aspect of touch/movement for a while.

With my clientele, most have completely lost their awareness of instinctive movement; almost every move they want to make is painful, so to them, movement = pain at all times. On top of that, rest = pain.
I cannot elicit anything with them without touch; words do not work as they have been drowned in words and orders from health professionals for years.
So, for them the right touch is crucial. They have had a lot of touch from previous PTs that inevitably ended up with a one hour "feel good" and then it is back to pain. Often it is worse pain.

So, for me, the balance between education and manual therapy is like sleeping on a cliff - make a wrong move (or say a wrong word) and correction/connection is lost.
I'm still working on that 'connection' bit.

In the words of our very cluey registrar: I'm not sure I want to be an anaesthetist..this working with complex pain patients is absolutely exhausting. They are definitely not meeting his emotional needs.

Nari

[EricM]

Barrett, in order to help answer this question I'm trying to think of what it is about SC that met my emotional needs. I don't know what that was yet, but I'll let you know if I get any closer.
The biggest barrier for me in implementing SC in my practice is Time. There just isn't enough of it. Along with discovering what emotional needs need to be met perhaps you also need to show people how they can create more Time in their practices. A tall order.

eric

[BB]

Hi Eric,
I think you already summed it up in the"why I work alone (http://www.somasimple.com/forums/showthread.php?t=2768)" thread an answer to that problem;) . I think that conclusion (the alternatives allowing ample time) may be another problem for popularity of the concept.

[EricM]

I suppose franchising private practices might work Cory. Imagine a therapist with their own practice on every corner, like Starbucks, complete with a kit to show you how to get up and running. I'm being facetious of course.

More please Barrett.

eric

[nari]

This is a naive question, but do those of you who are not in a cash practice have a minimum number of patients to see per day? Apart from the fact, of course, that minimum number may be one financially necessarily set by you - or by insurance or both?
If that minimum is >15-20 then that is a problem for a heck of a lot of PTs.

Nari

[BB]

Nari,
The minimum at the clinic I work in is is nothing mandatory. It is more a demand vs. supply issue. Lots of patients needing access, few therapists to provide the care. The fact that it is from high demand make it tolerable, people needing help, vs. some arbitrary threshold set by a bean counter. I see 15-20/day usually, less if I have a lot of new evaluations. It feels like a lot sometimes, although I know there are many seeing a lot more.

[Barrett Dorko]

As I’ve said here a number of times, the therapists attending my courses are just as likely to suffer from chronic pain as not. This 50% rate of chronic pain among us is the great shadow of physical therapy and rarely if ever is it made mention of. Let me be clear: I don’t think they hurt because they’re therapists. I think they hurt because they don’t know what’s wrong and/or how to treat themselves. It’s embarrassing. I mean, if you attended a meeting of physicians who specialized in obesity and half were seriously obese, wouldn’t it make you wonder?

The Levinson book previously cited provided me with much of the following.

Thomas Jefferson said, “The art of life is the art of avoiding pain: and he is the best pilot who steers clearest of the rocks and shoals with which it is beset.” When selling, Levinson says, “Hear the prospect’s words, but listen for their pain.”

Among the “Fifty Reasons People Buy” I found:

• To become more comfortable
• To attract praise
• To make their work easier
• To speed up their work
• To become more efficient
• To avoid effort
• To escape or avoid pain
• To save time
• To give to others

Now, to me, all of this is available in the product I’m selling but obviously it isn’t often perceived as such. I'm working on that. These “fifty reasons” aren’t listed in any specific order but surely some must be more powerful than others. These reasons are also listed:

• To be trendy
• To be popular
• To be informed
• To be in style
• To avoid trouble
• To be an individual

One way or another my workshops don’t satisfy these needs as I’ve seen them expressed in countless students. One way of putting it is this: PTs want to be trendy, stylish, popular people who avoid trouble. Being informed and individual (unique) is a very low priority in most clinics, especially when group-think and productivity are highly valued. In short, the second list is more powerful than the first.

Back to that comment about listening for the pain. I know that many, many of my students want to become uniquely informed and generous, efficient practitioners. Today’s norms of practice are arrayed against that. Wanting one thing and being forced to accept another has got to hurt.

Maybe I need to figure out how to relieve that pain.

[Diane]

Maybe you should focus on how to help wean PTs off insurance and into their own cash practices.

It truly is a weaning process for most, myself included. I wasn't an adult until.. sometime around 40. I already had been a PT for 20 years by then, half my life. (PT was easier to jump into right out of highschool and the program was just 2.5 years.)

Unless there's a spark in them that comes from all of the first list (except maybe point 4) and the third and sixth bullet on the second list, it's a no go - they'll end up in admin, look forward to that pension from their hospital, or else they'll be a wage slave in a clinic forever working for insurance, or else they'll turn to a different career.

Part of the ball and chain in the US is that everyone wants to have an employer, rather than be their own employer, because of your expensive health insurance - it becomes part of the ball and chain if it's picked up by the employer. Insurance is that from which walls around PT minds are made.

[Barrett Dorko]

Diane,

I can't disagree, but the audience I have is the audience I have. They don't often resemble the moderators on this site who, coincidentally, have never been a hard sell.

It would be nice to see a few comments from the academics in the profession. I've invited a few personally. So far, zip.

What I feel I have to do at this point is to present the concept of Simple Contact for the abnormal neurodynamic as a form of manual care essential for the specific movement therapy that will solve the problem.

Now I need a slogan.

[bernard]

Simple Contact, Better Motion

[Diane]

B.M.Bodied Better
Motion is Lotion (Butler picked that one up from me in 1998)

We have a number of national memes here in Canada..
1. Physiotherapy - it'll move you
2. Physiotherapists - the movement specialists
3. Physiotherapy - Get moving

This book (http://www.amazon.com/gp/product//1557869405/ref=cm_aya_asin.title/002-6993260-4536013?ie=UTF8) might contain a few clues as to where PTs in general are at in terms of their receptivity. On the other hand, it might be just another repetitive but disguised chakra book.

[EricM]

Work smarter, not harder.

[Jon Newman]

Touch: Motivation par excellence.

or

Touch: Destroyer of antagonistic representations.

[nari]

Moving instinctively;
Instinctive movement therapy;
Natural movement therapy;
Touching the movement;
Bypassing the will;

I think I'll end it before this gets really corny..

Nari

[Diane]

Move the brain and the body will follow.

[EricM]

Do certain aspects of PT need to be publicly deconstructed, exposed, essentially destroyed, in order for it to be properly built back up again?

Eric

[Diane]

What do you think Eric?

[Barrett Dorko]

Eric,

I think it does, and I do that. It is the most popular thing I do. It is also the least popular.

Here's my contribution to the slogan list:

Simple Contact for Pain - Resistance is Futile

[nari]

Eric,

What certain aspects of PT need deconstructing the most, in your mind?

Nari

[EricM]

Of course I realize that 'deconstructing' is what goes on here all the time. I was thinking on a grander scale I think, more public, with potentially more humiliating outcomes.
Nari I want to be careful not to include all aspects of PT in my critique as I am unfamiliar with their practices. For instance, the folks who work in ICU's, developmental paediatrics, and pulmonary rehabilitation. Maybe they are doing fine in those areas, I don't know.

eric

[Cheryl Conard Haight]

Slogan--Finishing the pitch; transforming tension into movement. (The first part is mine--think baseball, the second Gil's.)
Diane, Eric, Barrett, etc...
What do you think is more effective for finding some open-mindedness to allow new ideas to filter in?--Totally demolishing traditional and strongly held beliefs such as stretching, posture, symmetry, the one and only "right way" to be physically, detailed evaluation; or, finding some bit of truth in the way most PTs treat and adding, "And what about this..." and talking about the neurophysiology of Simple Contact?
The first is certainly more satisfying and one way of dealing with the frustration of not being heard or understood, but (as I know Barrett has experienced) the resistance factor is huge when you tell people most of what they've been doing is at best unscientific and at worst useless and possibly counterproductive.
In other words, how does totally blowing most conventional physical therapy out of the water serve to satisfy the emotional needs of the people we're trying to educate? Not many buyers.
What, if any, universal truths do the various philosophies of care, including Simple Contact, share?

[EricM]

Thanks for your thoughts Cheryl. You have nicely encapsulated what I was trying to express. You are quite right, it is probably out of frustration that one would want to blow conventional physical therapy (for painful conditions) out of the water. However, in the unlikely event that this ever came to fruition, I suspect the emotional landscape might change a bit. From the shattered remains one could reconstruct a more logical model of care that would people would accept, theyd have no other choice.

There must by now, thanks to Barretts efforts, several thousands of therapists who can no longer claim to be ignorant of contemporary pain science and its implications for providing manual care to people in pain. Yet little if any change in behaviour has resulted, with most opting for sophistry until they completely forget everything they've learned. One reason for this might be that there are no consequences for practicing ineffeciently. (I don't even know if inefficient is the right word??) All of the many stakeholders involved in any one person's care (the GP's, specialists, insurers, legislating bodies, governement officials etc.) are all working from essentially the same conceptual platform. They take it for granted that PT is providing optimal care. The point I keep trying to make, in this and another thread, is every possible stakeholders also needs to be educated with this information. Somewhere in there we will find our Maven.

Just gently dropping ideas into the ears of other therapists doesn't work, I've tried it daily for 3 years now. This meme just doesn't seem to be fit enough to survive that method of transmission.

eric

[nari]

I realised what you meant, Eric; and any active deconstructors here would need to stick to what they deal with primarily - ie the socalled outpatient musculoskeletal aspect. Thoughts and understanding from deconstruction of this group of patients' conditions could flow onto other areas.

As for ICU, there have been considerable changes over the last several years.
Once considered as the area where PTs saved lives, it is now seen as relatively downregulated; staffing is much reduced and part of this is due to superior medications and a growing tendency of nurses upgrading skills.
The major role is preventative in terms of limb positioning and education for the neurologically compromised. Pulmonary rehab has proved itself beyond doubt, but this is not necessarily a strictly PT territory either...

Cheryl, I think your words are wise. Which is why we attempt to bring about changes slowly, so PTs have time to rethink and reconstruct. I agree that a PT who has traditionally carried out protocols and regimes for particular conditions is not going to drop them lightly. Any threat to pre-determined certainty can be very real, and likely to be shelved.

I have thought about common ground and universal truths - although I would consider there is no such thing as a universal truth, but I digress...
Common grounds:
Motivation to improve a patient's wellbeing.
Motivation to keep learning.
Focus on the most effective intervention.
Develop a working relationship and understanding with the patient.
Knowing when we can do no more to assist.
Recognising the patient as an individual, with unique values.


Nari

[Jon Newman]

Great points Cheryl,

I like your slogan best so far. Looking at my own I think I'd better hire someone to help me with marketing.

Your approach certainly makes sense and, believe it or not, I do my best to pursue this in the clinic. I haven't quite determined whether it is the right approach regardless of venue however. It will give me something to process tonight.

[Cheryl Conard Haight]

Eric,
You're absolutely right, "gently dropping ideas" doesn't work, with therapists, with MDs, insurance companies, etc. But what does work? I think that's what we all struggle with. And the expectation of "optimal care"...the ignorance of what that might actually be is staggering.
I think Barrett is onto something with the emotional hook idea. What is it that hooked all of us and how do we spread that? And how do we make it safe for them to get hooked?

[Diane]

The second way, for sure, Cheryl.
Here is a thought I just found, here (http://www.somatic.com/real_illus2.html):
Learning takes place in different forms, from slowly filling in details about things we already know to the instantaneous "ah ha!" of a level shift, which shows us the world in a whole new light. Growth involves experiencing each form of learning in turn, in never ending movement toward fuller understanding. The world itself is a "training aid," where all this can take place.

Growth is not always comfortable, and many people work hard to avoid it. The reasons include infatuation with where they are now, fear of the unknown, and simply not wanting to take responsibility for themselves and their actions. You can delay growth, perhaps for lifetimes, but it is as inevitable as water running downhill. There are no quick solutions, no keys to sudden enlightenment. Others can provide insights and assistance, but you are your own best teacher and guide. In the final analysis, your growth is your own responsibility. You cannot delegate that responsibility to anyone else.

It is speaking about personal growth of course, not professional growth. The part about growth being uncomfortable and about people wanting to avoid it sounds about right. This is about changing memes in a profession. But, in order to get the memes to change, people in the profession, one by one, have to be willing to take them on and let them sink in, so it boils down to either personal growth of some sort, slow but sure, or topdown dictating, which no one likes and creates resistance.

[Jon Newman]

The hook that got me was the nonconscious. I'm unsure if it was an emotional or intellectual hook. For sure an emotional hook for me was the lament over the loss of expressive touch in favor of procedural touch.

[Diane]

Jon, now you've got me all hooked into your post. Exactly.

[Luke Rickards]

I don't think I'll be much help. It was the intellectual hook that got me all emotional about Simple Contact. To quote Barrett from MORE THOUGHTS ON SIMPLE CONTACT (http://www.barrettdorko.com/articles/thoughts.htm) - "For me, Simple Contact made more sense than any other manual technique.":teeth:

How about Simple Contact - Reflective manual care and movement therapy for pain. ?

[Randy Dixon]

I have to wonder if the questioning about repackaging Simple Contact isn't primarily rhetorical, a means to start a conversation.

I think Cheryl made a good point about the best way to approach people to change their mind. I've watched on RE as ginger, with no evidence to back him up, has created a good deal of curiousity and even acceptance of his ideas about referred pain. I also watched Diane get a practitioner of CST to question the basis of what she is doing. I think we need to look at why those approaches created good will and an openness to new ideas, while many of the "debates" here lead to antagonism and rejection of new thoughts.

I also think that Barrett is asking the wrong crowd. It's like a preacher asking the choir, who are yelling "Hallelujah!", what is wrong with my sermon? The people who have that answer are the ones walking out the door or in this case who have attended the course, and haven't accepted what was taught or don't use it. People like Raulan, who attended the course, but still question it. These people need to be listened to, not judged, dismissed or lectured to. I assume there is a formal feedback form at the course, does it ask, what could I do to make it clearer, more understandable, more practical, better? What are the answers?

Good sellers, and I define good sellers as those which are not always the most successful but which do often make the sale and can be proud of what they do, do one thing more than anything else. Listen. They try to understand the customer's wants and needs and then they figure out a way to meet those needs. They don't assume the wants and needs and try to sell them on those. Personally, I can't think of a quicker way for a person to lose my business than to try to sell me on things they think I want rather than what I do want. Ok, insulting me or implying that I'm stupid for considering buying a competitive product might be worse.

[Barrett Dorko]

I take issue with a number of assertions and assumptions in Randy’s post.

“New ideas” have not been “rejected” here. A few people have offered their theory and then during the course of its examination it was found sorely lacking in construct validity. This isn’t “rejection.” It’s the fundamental experience of scientific debate. Those who don’t recognize that or don’t understand that those who seek to destroy your theories (fairly) are being your friends shouldn’t be representing themselves as trained professionals in healthcare provision. Without exception, the moderators here are skeptics. This insures both open mindedness and careful scrutiny. For many these combined qualities are too difficult to maintain and require too much courage to express. We do it anyway.

I get your point about asking the unhappy students what they’d prefer in the way of an educational experience and if I were much younger I’d take such advice to heart. But I discovered long ago that what most therapists want –protocols of care, specific sequences of handling and coercion, completely predictable responses to various pressures, an absence of ambiguity and complexity with testing and consequent diagnosis, magical powers – don’t have anything to do with the clinical reality of most painful problems. I simply won’t teach them things I know to be untrue. Others are glad to do that, and I know the students love them for it and report that their educational goals have been met. Too bad their patients don’t need or often want what they’ve learned to do.

In short, my presumption is that the patient’s “wants and needs” trumps the therapist’s. This certainly explains a lot. It’s been my experience that selling my ideas and methods to the patient is easy.

Ginger’s effect on RE is a consequence of his persistence, not the reasonable nature of his argument. This tells me more about his audience than it does his, uh, theory. Diane uses accepted and logical inferences from research to make her case. Again, when people reject those because their current worldview cannot tolerate change I know more about them than I do Diane’s ideas.

The disparity between my view of a therapist’s role in cases involving an abnormal neurodynamic and the view of those who show up at my courses seems to grow larger as the years pass. If you were to follow me around you’d find that for the most part I deal with therapists overwhelmed by their jobs, and, I notice, by their lives. They are hiding, blowviating about their imagined successful outcomes, bitching ineffectively about a wide variety of work issues and hanging on by a thread. These things I cannot fix. But I am absolutely convinced that a commitment to self-learning, formal and informal instruction and, above all, communication with others in a place like this would help. All of that is primary and it’s a big part of what I sell. Too bad that they want something else; as I’ve said, they want an easily employed manual pressure that relieves pain. To my knowledge, the human body doesn't work that way, no matter how much therapists wish it did.

While teaching, I say more than once something that thrills some and disheartens others: “Your patients will never be helped by your skills nearly so much as they will be by the depth of your knowledge.” In response I get both nods and frightened stares. Above all, I get complete silence.

No one refutes this, but for many it is not what they want to hear – or buy.

[Jon Newman]

Randy suggests, "I also think that Barrett is asking the wrong crowd."

This is available to the world. Just because others don't participate doesn't mean they aren't being asked.

[Jon Newman]

This is something that might help with repackaging. Honestly, I think it's already in there (like Ragu) but perhaps it could be emphasized.

The more they understand, the less they need to memorize (http://headrush.typepad.com/creating_passionate_users/2006/09/how_to_get_user.html)

[Cheryl Conard Haight]

To be clear-- I am not saying I know the best way to change people's minds. I have been only mildly successful with a few colleagues, and these only the ones I work closely with who have a chance to ask me "why?" questions a lot.

As far as feedback forms in Barrett's courses...I've been to his course a couple of times and there IS a feedback form. I'd bet the vast majority who disagree, or just don't get it, do not take the time, and more importantly, do not want to work that hard, to fill it out in any thoughtful way.

"Your patients will never be helped by your skills nearly so much as they will by the depth of your knowledge." This implies the need to increase our knowlege--read, think, question. How many of us were taught this in PT school? I remember being asked to memorize a great deal, but very rarely to reason things out or question. We were passive learners. Tell me the "answer," show me the "right" technique and I'll work hard to be able to reproduce it and "fix" my patients.
I think it's ironic that Simple Contact is so much less work physically and mentally in one way, and yet requires a much greater depth of knowledge and critical thinking. Not to mention awareness and trust. And it's not airy/fairy magical or reductionistically mechanical; it makes sense (that was my "hook" also.)
Overwhelmed by their jobs and their lives and still looking for that magical one right answer to fix everything. Not the way our bodies work and not the way life works.
Here's a W.H. Auden quote from Joko Beck's NOTHING SPECIAL:
We would rather be ruined than changed,
We would rather die in our dread
Than climb the cross of the moment
And let our illusions die.
She goes on to ask, "What pushes us to abandon this melodrama, to sit through the confusion? At bottom, it comes down to the unease we have with the way we are living our lives." I would add-- the unease with our profession and the way it is practiced.
Still no answer to how to best "spread the word."

[EricM]

If most of us here were attracted by the emotional and/or intellectual hooks suggested by Jon and Luke, and I think that we are, is it also safe to say that those hooks were baited in such a way as to attract a unique type of fish? A whole fishing metaphor is coming to me now...use your imagination.
Barrett's assertion that the "emotion that underlies our profession’s longing for skillful handling has short-circuited (the) message," like fish who simply pass up a certain sort of bait. He goes on to say "the manual care part, which I feel is essential for the patient’s initial awareness, must be sold as something that fulfills the therapist’s emotional need, to say nothing of the patient’s." "Ironically, I’ve come close to this for years but continue to bump up against barriers that have grown in our clinics for years."

It seems to me there is a balance between intrinsic and extrinsic factors at play here. A fisherman can only appeal to a fishes intrinsic needs, he has no control over the extrinsic factors such as weather, and water temperature.
If this hook is going to attract more fish, it will have to be baited with something different than what brought each of us here, thus the original purpose of this thread. As far as I can tell we are all unique fish. Unlike a fisherman, with a great deal of effort, I think we can exert some effect over the extrinsic factors as well. We are not only going to have to find the correct bait, but create the correct conditions for a feeding frenzy to occur.

Eric

[Diane]

I was thinking about this as I woke up this morning, and knew I'd likely end up back on here with the ideas that arose.

1. Human primates don't do well when they feel shamed, as a group or as individuals. Shame is often an unconscious projection, doesn't belong, shouldn't even be there, but the more unconscious it is the more pernicious it can be. It's the hardest part of the shadow to own and integrate. People really don't like being reminded they have things to feel ashamed of.

Human primates do much better when they feel reassured and encouraged, as a group or as individuals. Reassurance and encouragement is not flattery. It is an appeal to the best that others harbour within themselves. Patients or students.

Everyone has things to feel ashamed of and everyone has things that are their best things. The "shame" things immobilize minds, and the "best" things mobilize minds. It behooves a teacher of anything to speak to the bit that will motivate/move/mobilize the "best" bits and not stimulate the shame bits, whether inadvertantly or by design. Sometimes it's hard to know where to place the authenticity line in this, to reassure and encourage but not flatter, and not denounce or shame unduly when we see the mess we'd like to set right.

2. Human primates of any age do very well, better than expected even, when a series of steps are provided to get them from where they are at /from where an instructor perceives they are at, to where they ought to be /to where the instructor thinks they ought to be.

3. It's the instructor's job to offer just the first step. Explain it, "sell" it, I suppose, answer questions about it, explain it again, encourage curiosity to be expressed about it.. explain it again.. Randy's definition of soft sell. Act like there is all the time in the world to just hang out and talk. Meanwhile this marvelous invisible thing called "rapport" is building bridges between minds. It is thin but tough, like spider silk.

4. The "thing" that is being sold is not a car, fridge or stove. The "product" here is an intellectually derived set of thoughts/thinking/behaviors. Because it's invisible, not a concrete item, it will defintely NOT be as obvious to the students/"buyers" as would be a physical car.

5. As intellectually derived products go, the ones without the built-in warm fuzzies are a harder sell than the ones with, i.e., "science-based" ideas are a tougher sell than "spiritual" ideas.

6. There is no way to make up for the fact that we are selling a fuzziless product without concete reality other than;

to be accessible,
reassure people that they a) definitely have the capacity to do this, b) that they are smart enough to learn to think for themselves, learn to revamp their professional minds,
provide them with a series of steps that trail off into the future, but highly elaborate the first step so they can grok it fully (which includes emotionally).


7. All social changes start with a frustrated instigator who believes all is lost and that he or she is getting nowhere. It is usually true (for themselves) in their own lifetime, but growth of an idea is achieved over several lifetimes and through many lives. So.. it becomes a gift in the end, even though the giving is hard and thankless.

[Cheryl Conard Haight]

Diane,
Thanks and WOW! Your post reminds me to treat the people I'm trying to sell to in much the same way, and with the same respect, as I treat my patients.
Cheryl

[Barrett Dorko]

Diane’s said quite well what I’ve come to understand over the years, though this isn’t a situation I’ve handled perfectly. That’s obvious.

Early in the day I ask these questions:

Is there a correlation between pain and strength?

Is there a correlation between pain and posture?

Is there a correlation between strength and posture?

Is there a correlation between appearance and pain?

According to me and the literature I carry with me, the answer to each question is “no,” though each may take some explaining. By the time this is done, I can usually sense a shift in a few present. Some have had their suspicions confirmed while others see their basic philosophy/theory of care undermined, to say the least.

For that second group a choice must be made; defend, attack, learn or shut down. If they choose to feel guilt for their lack of reading or interest in neuroscience I suppose that’s understandable. Shame, however, is typically defined as the sense that there is something fundamentally wrong with the person feeling it, whereas guilt is the sense that we’ve done something wrong.

As well as I am able, I make it clear that the skill necessary to do what I do (and what I demonstrate is pretty much all that needs to be done) is something every member of the class already possesses. Seeing that, shame, as defined above, would surely dissipate. Guilt will disappear with study. At least, that’s my message.

[nari]

I came into the picture because I had an intrinsic interest in the brain and its tributaries, ever since graduating. I was also dissatisfied with a) the system and b) the sort of thinking involved in being a diverse, but muscle/joint based PT. I figured it was me, a square peg in the round hole of physiotherapy. It probably was, to a certain extent.
So I was looking for a change, to both the system and the focus on mesoderm. A fish inclined to take any bait, with the proviso that my sense of professionalism prevented my taking juicy baits, offering extraordinary claims to success, such as CST, et al.

Perhaps the second group that Barrett identified in his latest post are happy with the system and with themselves as providers of care. Or, if they are not, they don't know it; it can be an insidious discontent. Perhaps, like tourists on a bus tour of the Europe of physical therapy, they simply need to "tick off" yet another CE requirement - yes, this is an interesting city but others felt more like home, vaguely familiar and therefore safe. Not all travellers read up intently before going to a completely different place - or follow up on its differences for months afterwards. They simply are not interested enough in deepening their experience.

Nari

[Diane]

Still on the topic of shame and guilt, I think it's likely that most of your students are either too young or too busy thinking about external stuff to have given much thought to them"selves".. likely they haven't yet learned to distinguish the two terms, own what is theirs and lay to rest that which isn't. So, when dealing with unsophisticated thinkers, I still think one must not tread too heavily or expect too much too soon. They could easily go spinning off into feeling immobilized rather than charged.

And, as Nari has pointed out there may be illusions of either grandeur or self-complacency to dismantle (carefully), which it sounds like you already do.

I just have to add this, from Ian. It's about perceptions and human foibles, and traps therein, so clearly and cogently written that I think it could add to the discussion.
Mind Stuff (http://dericbownds.net/MindStuff.html).

[Randy Dixon]

I take issue with a number of assertions and assumptions in Randy’s post.

“New ideas” have not been “rejected” here. A few people have offered their theory and then during the course of its examination it was found sorely lacking in construct validity. This isn’t “rejection.” It’s the fundamental experience of scientific debate. -Barrett

You don't think your ideas are new to many people you present them to? Or you don't think those ideas are rejected? WhY assume that I meant this only occured one way? As to the rest, I understand your points but they aren't really relevant to the question you posed: how should I repackage my course so it will be better understood and accepted? This is why I questioned whether the question was rhetorical or if you really wanted other's opinions. If you have already decided what therapists want, and that you won't or can't give it to them, why bother asking the question?

"Randy suggests, "I also think that Barrett is asking the wrong crowd."

This is available to the world. Just because others don't participate doesn't mean they aren't being asked."-Jon

Do you really think posting on this forum, which consists almost exclusively of those who share similar thinking on the views of therapy, is really the same as asking those you know to have differing viewpoints? That it is the same as asking the wider therapy world?

I agree with Eric and I like Diane's analysis. A funny thing is that I find myself agreeing more with Diane after she once admitted that on the matter of ectoderm/mesoderm and related issues that she has a bias a mile wide. I make allowances for that now and can better see the thoughtful approach that sometimes that bias masks.

[Jon Newman]

Do you really think posting on this forum, which consists almost exclusively of those who share similar thinking on the views of therapy, is really the same as asking those you know to have differing viewpoints? That it is the same as asking the wider therapy world?

This is available to anyone willing to look at it and Barrett apparently introduces the website to his students. And yes, I think plenty of people with opposing viewpoints read these pages without responding or even registering. They don't participate but they could.

[Barrett Dorko]

Randy,

Bias is a consequence of knowledge, and Diane’s bias toward some explanations rather than others is rooted in her reading the research and listening to her patients. I’ve always appreciated the way scientific investigation makes things I don’t initially understand understandable, but even more, I like the way it proves that some entrenched ideas are wrong. To the great consternation of many therapists the neurobiologic revolution has demonstrated that many of the things they have assumed to be true simply aren’t. If they won’t or can’t change their clinical approach in response then one day we’ll have a profession full of bad ideas and irrelevant clinical procedures.

Wait. I think that’s already happened.

Careful reading should result in “similar thinking.” If someone’s thinking is markedly dissimilar to mine then one of us is wrong. Being wrong about one’s philosophy of life or about what constitutes a pleasing aesthetic isn’t uncommon and really isn’t that big a deal because in those disciplines there’s room for different or opposing views. This is not the same in neuroscience, physiology or functional anatomy, all of which follow certain laws they cannot break. I find that when I am in disagreement with another therapist who favors heavy coercion or “energetic” theory that their deep model differs from what is known and/or their theory of effect violates basic laws of physics. In such a case I have to assume that they’re wrong. My own ideas, of course, must be defendable. As you know, I focus upon that whenever I present them. The quote at the top of the thread reflects thinking that is undisciplined, postmodern and, of course, quite popular. Not surprisingly, Dr. Kleinkort has declined comment about his practice in similar forums.

No doubt I think that many of my colleagues are asking for something unreasonable and this thread has again revealed the fundamental flaw in the profession – it is not rooted in basic science to the degree that it should be. There is also the undue influence of a therapeutic culture that does not reward and, in fact, punishes anyone who suggests changes that may prove detrimental to billing.

Again we return to this: Progression in the profession will not result from what we sell or how we package it. It will result from a fundamental change in the way therapists see their role in relation to painful human dysfunction. Given reliable information free of basic inaccuracies, what they see will lead to a certain bias that should be free of the effects of belief or faith or personal philosophy or emotional needs that have nothing to do with nature , which contains none of this.

Today I'm convinced that this isn't going to happen.

[Diane]

Barrett, I agree with the gist of your latest post above, so I went back up and found the quote. Here it is.
“There are so many ways we can touch the person with chronic pain to reduce their discomfort.”
I disagree with it too, that "there are many ways." Yes, a lot of ways to touch patients in chronic pain are carried out, but most of them aren't going to reduce chronic pain, especially if there's a mesoderm target at the end of the touch, which is the way most therapists are touching most of the patients out there, blindly trying to restore some sort of mesodermal function to some moving part, overriding nocioceptive signalling in the process. Pain is a wiley foe, especially if truly chronic and not just persistent. They don't have reduction of discomfort in mind when they touch. Later, if there's a reduction, it's more by fluke than by design, but the therapist takes credit and uses the outcome to bolster their mesodermal treatment approach. Anyone who doesn't improve from these 'therapeutic' efforts, or whose pain worsens, is labelled crazy.

[Nick]

Randy,

I think the point in asking the people here is that most of us have lived through a transition in our thinking. Many of us have been assisted by Barrett whose no-holds-barred style of logical discourse forced us to rethink our premises.


Barrett,

I recall our earliest arguments and the gradual change in my understanding. I had been mentally juggling the mesodermal mobilipulation approach held up as the gold standard of care by our profession with a more satsifying (for me anyway) gentle contact that I first learned under the not-so-deep model of craniosacral therapy. I'm not sure how the manipulative therapists have ascended to the top, except by their dissociation from actually addressing the patient's symptom. As long as that twisted/subluxed/hypomobile joint is moving again, they have been successful (in their own minds anyway). Why bother with that messy pain stuff. I've even heard some say that pain doesn't exist while insisting what we treat is biomechanical dysfunction. The gentle approach of craniosacral suited me because it seemed more humane. It allowed me to spend time with the client. It allowed me to begin sensing what was happening beneath my hands (even though the mental constructs that accompanied that sensory info. at the time were woefully inadequate). I was never very comfortable with the airy-fairy theory though, especially on the Level 2 course when they started discussing channeling:embarasse . I struggled with the disparity between the empirical results and the ideas proposed. Enter Barrett Dorko...

I can't remember where I first encountered your writing, but I could not understand how you could disagree so strongly with things like CST and MFR and yet practice in a way that seemed very similar. I wish I still had that first e-mail correspondence where you took my thinking to task. I recall being very annoyed. At first. But then, I slowly began to get it. Finally, I had an acceptable explanation for the phenomena that I experienced. Even more so once I met you and experienced what you had been talking about.

At the second course I attended in New Brunswick I remember being completely shocked by the resistance people had to these ideas. It was overwhelming for many. It was infuriating for others. There was a big CST contingent from that area who I thought would be very happy to hear a sensible explanation for what they did every day. One of them left the course early. As for course evaluations, half of the participants really liked the course (though I wonder if it ever changed their practice) and half hated you and thought you should never be allowed back in the province. Interesting how your dispassionate presentation can become so personal.

It is interesting to speculate how meme-building is changing. I think people need serious inoculation from the ideas that clamour for their attention. A scientific foundation is definitely required. Our profession, however, being so anxious to prove that what we do works, wants to jump over the foundational work and embrace outcome studies alone. Big mistake. In the process, the academics open the door for eroding professional standards and claims made by a PT in favor of anything that "works."

Since you are the Forrest Gump of physical therapy, how about some thought on how the professions memes were constructed and propagated. Perhaps there is a lesson there. On the other hand, we now live in a Brave New World of knowledge propagation. I learn more here daily than I could from hundreds of CEUs.

Nick

[Jason Silvernail]

Well, in the interest of repackaging the premise and use of SC, I'd like to begin at the beginning (or what Barrett says is early in the course) and I think that might help.

Barrett said that he talks about the fact that strength, posture, appearance, and pain are not related. While I agree, I'd like to suggest an alternate approach.

Instead of starting with telling people that what they think they know is wrong, I think we should start by telling some things they'd like to know, or understand.

Instead of starting with strength and pain are not related, we can start with questions.

"Would you like to understand where pain comes from? Do you want to understand what is required to relieve pain in your patients? Do you want to understand the common reason why many widely differing approaches in therapy today can sometimes be successful for some patients? Would you like to know why adding more "tools to your toolbox" might not be such a good idea? Do you want to know why your patients might complain of such things as: pain increase in the early morning hours, stiffness and pain in the morning that improves with movement, pain which seems unrelated and that tends to occur in different places on the same limb or body area? Above all, would you like to understand the scientific background for these answers, and be able to explain them to your patients and colleagues?

This knowledge will lead you toward a new concept in manual therapy and a gentle approach rooted in science, movement, and patient empowerment. Learn to use Simple Contact."

I think this satisfies many of the need states and pain/fears that our colleagues have. I find I get the most interest from other therapists about these ideas when I let them know that a common complaint of their patient in pain, while mysterious to them, makes perfect sense to me.
I will admit that I enjoy this more than I should.

Thoughts?

J

[Diane]

Jason, that would be about perfect.

[EricM]

Nick and Jason, great posts, thanks. Now we're repackaging!

eric

[Barrett Dorko]

Nick,

I remember walking to the front of that Canadian class for the first time and, instead of greeting them and saying my name, I said, "Two weeks ago I sold my father's house. I sold the house I grew up in..." I always end my courses with this story now. I think it still works for about half the class, but at least for them it works well.

What I'd like to do is take Jason's questions, print them on a separate sheet and put them in the course manual before class. This would begin on Wednesday this week.

Okay with you Jason?

[Bas]

Jason, excellent thoughts! That intro covers the concepts with a selling technique that is familiar AND not (yet) threatening to what some participants will know as their PT-foundation. You slide it in like a scalpel...

[Jason Silvernail]

Barrett-

I'd be honored, go to it.

I think if we approach it like the old honey/vinegar saying, and focus on dangling all this cool neuroscience knowledge in front of people, we'll do better.

Instead of telling them all the things they don't know, and why what they do is wrong (i'm not suggesting Barrett actually does this, as i've never been to his course), I think we should focus on making Paracelsus's quote come to life:

(please forgive the paraphrase, i know we all remember this one) We become physicians only when we see and understand what is invisible and yet, has it's effect.

There's an element of wizardry involved in understanding things that others don't, and though it's cheesy, I think we'd be fools not to realize it and use it to help educate people.

J

[Barrett Dorko]

Jason,

I actually have a collection of wizards that I've come across over the years. Long ago I figured out why, and you made that point again today.

The sheet with your post and name will be inserted tomorrow in Harrisburg, in Allentown on Thursday and Philadelphia on Friday.

I'll let you know how it goes.

Are you now in Germany? Please tell us what you're in charge of there. Nice photo of you in the latest PT Magazine, by the way.

[Randy Dixon]

Jason,

I think your questions were precisely the approach I was advocating. The irony for me, of course, is you presented it to the forum using the same approach, while I was unable to.

Practice what you preach, right?

[Jason Silvernail]

Barrett-

Yes, I'm in Germany, writing from my laptop at the guesthouse, waiting to move in to our new place next week. It should take a week or so from then to get the internet up and running at home. In the meantime, I'll hope to post when I can. One of the side effects of moving is that all my mail hasn't arrived, which means I haven't seen my mug in the PT magazine yet. Mom and dad should love that.
I am the chief of a clinic with 3 FTEs of physical therapists, and the regional supervision of 3 or 4 other one person PT clinics. Keep in mind, the Vegan thing hasn't even come up yet, never mind that I don't play golf, vote republican or play well with others. I'm not sure where in the order of things I should bring up the modern concepts of neuroscience. :)

Randy-
Precisely. I think your posts and your point of view are very valuable, and I definitely took a page from your book with my suggestion. It was rather off the cuff, so somebody please feel free to make some additional suggestions..

J