Attitude or Intention?

[Barrett Dorko]

Toward the end of the first hour’s lecture I approach someone in the class as I continue to speak, remark that they appear normal enough and evidently alive, rest my hands lightly upon their head somewhere and wait. Movement emerges. It is accompanied by warmth and softening. The person moving reports that what they’re doing is effortless and surprising. This happens without fail.

I let go and say, “The course is over.” Sometimes this gets a laugh – not always.

I often hear from therapists while speaking of their method that they think a certain intention accompanies their actual touching. When I question them closely about this they’ll often reveal a belief that their thoughts somehow exit their bodies and enter the patient’s body in ways that they can’t begin to measure or detect but believe exist nonetheless. How this intention travels without violating physical law is not usually something they’ve ever consider. The fact that I think about such things might be a little disconcerting, I know.

Recently I looked at the definition of intention and found this: “An act or instance of determining mentally upon some action or result; the end or object intended; purpose.

This does not describe my thinking or manual approach, and if it does describe others who handle patients perhaps this explains why ideomotion emerges so commonly in my presence and not theirs.

I prefer the word attitude when describing what I bring to handling. Consider the definition: “Manner, disposition, feeling, especially of the mind.” I know that the patient is self-corrective and in a way that can’t be coerced. I have no expectation with regards to the direction, speed or size of movement that will emerge. After all, that would be akin to mind reading, which isn’t possible. In effect, the patient begins to read their own mind which is simply introspection and interoception ( http://www.thefreedictionary.com/interoception). If I understand the current literature about painful sensation, these attitudes on the patient’s part would be useful and therapeutic.

So, I have an attitude when approaching another and this attitude is a consequence of what I’ve learned about the thing in my hands. If it were my intention to act with purpose and distinct expectation of movement correction would not have the freedom it needs to visibly surface in a culture that prefers repetitive, effortful and carefully planned exercise – none of which describes ideomotion.

So, attitude or intention? Which best describes your approach to manual care?

[Jason Silvernail]

I had a perfect patient for this today.

She had a 2 day history of L sided thoracic pain, starting after some kind of aggressive stretching routine. The pain was worse with deep inspiration and with thoracic rotation. She could change her pain with position and use, and no constitutional symptoms. I was pretty sure she had a case of mechanical thoracic pain.

I have found the following pretty typical of these cases:
-pain with deep inspiration
-pain with rotation to one or both sides
-tenderness on their manual therapy rib angle ( where the erector attachment is, about 5 cm from the costovertebral joint)

Most of these folks, in my anecdotal experience, do very well with prone or supine manipulation. The few that don't immediately improve, have difficulty overall in therapy.

Anyway, this young soldier had all the findings I listed above.
I approached her with the intention of "correcting" her alignment problem. She had about 5/10 pain, and was having difficulty tolerating positioning. She was down to a 4/10 pain after the supine "opening" manipulation, but still in obvious discomfort. As I watched, she started to spontaneously move her Tx spine - while seated she was flexing, extending and rotating in a kind of random order. I asked her if she was OK, and she started to slow down. "Don't stop!" I said, and I sat behind her on the table and gently placed my hands on her shoulders. More movement began to emerge, I verbally encouraged it, and I could actually feel her relax (parasympathetic shift). After about 5-10 minutes of this, she reported her pain at 1/10, and left with a smile. I reinforced her self correction. I doubt she'll ever come back.

So I started with intention, but changed to attitude. And my patient did much better.

J

[Barrett Dorko]

Great story Jason.

As Eden Philpotts once said: The universe is full of magical things, patiently waiting for our wits to grow sharper.

Just wondering: Which of our tissues do you suppose is compromised first when we stretch either actively or passively?

[vajranata]

I think this works on the macro scale also. If you're forcing something, you won't be able to sense the natural motion. ;-)

[Jason Silvernail]

Barrett- why, the nervous tissue of course.

The patient's story of over-stretching is rare for this particular problem, in my experience. Typically there is an insidious onset of the pain.
The failure of the natural self-corrective process is why people end up in my office, more often than not.

[Synergy]

Great insight Barrett and good story Jason!

Barrett,

I believe it's the nervous tissue as well. Shouldn't it be? I view it as a vast network of tethered bungee cords that when movement occurs, you get a mass uncoiling/longitudinal excursion...no matter what force brought it about...passive or active.

[vajranata]

Just wondering: Which of our tissues do you suppose is compromised first when we stretch either actively or passively?
Do you mean over-extended?
the nervous tissue of course
I disagree. The philosopher Osho once said (paraphrasing) that a tree will sacrifice its leaves before it sacrifices its roots. The point being that the nervous system would represent the most fundamental level of the healthy complex system and should be the last system to be compromised. Other systems should take the hit first.

Of course, given the interpenetrated nature of all systems, the question is loaded.

[Barrett Dorko]

Chris,

That's an interesting perspective. Perhaps I should have asked, "Which tissue complains first?" The contractile and connective elements (mesoderm) are positioned to protect the nerves but don't always manage this, as we know. Their health may contribute to the prevention of neural strain if they are strong and pliable, but correction once a compromise is present is inherent to life. It requires no learning, just attention and permission - both of which a knowledgable therapeutic presence can provide.

Often my students think I'm trying to get them to feel something very subtle and thus abandon the use of Simple Contact when they can't feel it. In fact, I'm simply trying to get them to notice and understand something; something typically visible and easily palpated. I'll say, "If I'm sure there's a small pill in my pocket I will search for it quite differently than if I don't know it's there."

"Finding" ideomotion is similar. The reason it emerges each and every time in my presence is because I understand its nature, not because I'm especially sensitive.

[Jon Newman]

At this point I'm of the opinion (referring to the original post in this thread) that it our attitude but our patients' intentions that have importance to the movement and subsequent outcomes we witness and record for a living.

On the topic of learning: Correction doesn't require learning but is strongly influenced by it. Maybe one day "not thinking" will end up being understood as being very important.

[Barrett Dorko]

Jon,

Our patient's intentions are mainly conscious in nature, but what they fundamentally want and need are driven by an unconscious that is infinitely more powerful and insidious to boot. That's the part I speak to, listen to and, hopefully, get the patient to hear and express as well. No doubt, some patients can subvert this process if they put a great deal of energy into being something they aren't. Given the culture we live in, this is a familiar task.

If I model a certain personal authenticity it probably helps them to mirror that in their own way.

Isn't this whole "not thinking" thing pretty much what Zen is all about? Simple Contact adds "not doing" to manual care. See this (http://www.barrettdorko.com/articles/do_nothing.htm) for more on that.

[Chancellor Mobley]

Perhaps the greatest attitude we are affecting is the patients/client's. Are we not affecting their attitude towards their pain through movement, touch and education?

Chance

[Barrett Dorko]

Chance,

No doubt.

Yesterday I saw a woman with chronic LB, hip and leg pain who had been seen repeatedly by a therapist working at a local facility devoted to training. She'd been told that strengthening would solve the problem and directed to hold herself in ways that undoubtedly irritate the nervous system. My focus during the first ten minutes was upon her ability to make alternate but reasonable choices.

I see people as the solution, not the problem, and that attitude is infectious. More specifically, I demonstrate an appreciation for the genius of their unconscious and the ways it wishes to express who they actually are. The facility that originally treated this patient has precisely the opposite attitude.

[nari]

I'm glad to second the motion that training facilities, or return-to-work programs, are more of a dissuasion to recovery than a facilitation.
As long as they promote the myth of strengthening/endurance/resistance in the hope that chronic pain will simply go away and lie down, they must fail in the long term, for many. But their existence is so entrenched in society...

People are the solution, not therapists. I think the facility you mentioned is simply one of many which cost a lot of money for uncertain and unsatisfactory results. But I could be wrong.....maybe there are some which actually allow the clients to express themselves.

Nari

[Sarah]

Hi everyone,
I witnessed a unique (for me) reaction to simple contact yesterday and wondered if any of you could offer thoughts. I was working with a middle-aged woman in extreme discomfort from her neck to her tailbone. She admittedly has a large amount of anxiety about losing her job (Ford Motor Company) and also presents with cutaneous allodynia of the inter-scapular region.
While I was gently contacting her arm, she began corrective movements and then started shivering quite noticeably. I assumed it was a sympathetic reaction, and assured her that she was alright. She denied feeling cold at all. We continued for a little while longer and I moved my hand to her interscapular area and the shivering stopped. I encouraged her to continue deep breathing and explore movement at home. The next day, she stated her symptoms had remained reduced until during the night, and she reported bilateral forearm tingling that persisted. Gentle skin stretching techniques around the thorcic and scapular areas abolished the tingling.
This is a very interesting patient, who was actually transferred to me from another clinic by my supervisor because she didn't respond well to the other PT (the patient became very anxious during the evaluation because her physician had told her that her facet joint was "locked" in her neck and her pelvis was "upslipped"). I have done a lot of pain education and listening, which seems to be the most beneficial. I think I've learned just as much from this patient as she has from me....especially about the words we chose to use with patients and how detrimental those can be.
Any thoughts??
Sarah

[Diane]

Sarah,
:teeth: :thumbs_up :thumbs_up :thumbs_up :thumbs_up :thumbs_up
Those are my thoughts.

[Barrett Dorko]

Sarah,

Great stuff. Mid-thoracic change is something that occasionally produces reactions of sweating, cooling, flushing and (in standing) nausea. I'm of the opinion that these people do well soon after and that it doesn't often happen more than once or twice.

The presence of the sympathetic trunk probably contributes greatly to this. What's happening beyond the obvious mechanical deforming I can't say. Not because I don't know but because it's time to eat dinner.

[Sarah]

Very enlightening Barrett. ;) Maybe when your stomach is full, you can continue your thoughts. I'd very much like to read them. I've got a crockpot full of beef stew (sorry Jason) that I need to attend to myself.

[nari]

Sarah,

As it is said in North America...way to go!!!:thumbs_up

It is very exciting when a patient responds so smoothly, effectively and fearlessly when the therapist does nothing.

And yes, re the mid thoracic; whether we are fiddling with mobilisations or some other technique or some other mesodermally-directed technique, nausea and temperature changes aren't uncommon. Usually the patient is so happy with the experience..that's what strikes me.

Nari

[Synergy]

Sarah,

If you don't mind my asking, did you educate the patient on what you were about to do? How did you position your hands for placement and how much pressure did you apply? The reason I'm asking this is simple...I'm not having a great deal of success with this technique. Perhaps it's the way I approach my patients or how I educate them re: ideomotion. I've a long way to go I suppose. ;)

P.S. Anyone besides Sarah please feel free to chime in.

[nari]

Chris,

I'll chime in briefly...

Re education: Minimal or none before the event. The patient finds it helpful after the expression has occurred.

Contact can be anywhere - no rules. Perhaps a rather bony area (shoulder?) is an advantage. It's brief, a few seconds, and is not a requirement for expression. PAtients seem to find contact useful when they are doing it at home.

No pressure. Just touching. One or two hands, doesn't matter.


Nari

[Sarah]

Chris,

Hmmm, difficult questions. I don't think I really knew what I was going to do with the patient initially, so no, I didn't describe the techniques or anything. I think I might have mentioned "massage", but could tell right away that her system wasn't responding to traditional soft-tissue techniques. So, I switched to what I call "light touch techniques", and my colleagues call "voodoo". The patient was initially prone, but I also had her lie supine at some point. She has very guarded posture in sitting, so we haven't worked in that position yet. While I was treating, she kept asking me if her reactions to treatment were normal, and I would always reassure her that she was, and that her body wouldn't do anything to hurt her, but it is trying to protect her. I taught her how to do deep diaphragmatic breathing and she practiced that while I worked. We discussed a lot of the subjects in the Explain Pain book, and talked about her job. My treatments are very intuitive. I don't know if that is different or similar to intent or attitude, but I tend to just know where to place my hands next. If I don't get a response, I move on. What do you all think about intuition in treatment??
Sarah

[Barrett Dorko]

Intuition isn’t just a “good guess” but rather a consequence of observation and decision making done on an unconscious level. Aside from the very popular book Blink (http://www.amazon.com/Blink-Power-Thinking-Without/dp/0316172324/sr=1-1/qid=1164849330/ref=pd_bbs_sr_1/104-7213658-3536738?ie=UTF8&s=books), there’s David G. Myers’ Intuition – Its Powers and Perils (http://www.amazon.com/Intuition-Powers-Perils-Yale-Nota/dp/0300103034/sr=1-8/qid=1164849461/ref=sr_1_8/104-7213658-3536738?ie=UTF8&s=books). The title of that last one says it all.

There’s a line in there from Herbert Simon I like: Intuition is nothing more and nothing less than recognition.

Remember, that recognition is almost entirely unconscious. The trick is to find it in some way and then act upon it. I usually see a picture in my head of the patient positioned in relation to me somehow and then I follow that script.

I’m not kidding.

[nari]

Intuition is often mistrusted by PTs because it is not accepted EBP and all that.

If we bypass that aspect, intuition enables us to see patients individually, as well, rather than a subcategory or a mechanical niche to be fitted into. It enables us to explain the language of pain for the patient in front of us. It sneaks up and gives a "Eureka" moment, often just when you need one...although it equally occurs after the patient has gone.

Backed up with adequate knowledge of (neuro)physiology and a dollop of anatomy, intuition is very useful. I suspect it comes from the patient's language and the story he/she tells...but I'm less observant than Barrett.


Nari

[Chancellor Mobley]

Hi All,

I've been pondering this thread topic since it began and I'm glad it has been kept alive. It struck a chord of resonance with me after reviewing Barrett's essay on the origins of pain. As I was reviewing the essay, a client of just a few sessions came to mind. This lady was in dire straits, having had coritisone shots, PT and expecting to go under the knife next. She came to me seeking relief from bilat. LB, hip, leg pain and numbness. Shortly into the first session I found that she had similiar simptoms in her neck and arms. She could walk in the front door and up the stairs to my office, so that was good. The severity of her symptoms came upon her after slipping and falling at work as a nurse. She was on leave from her nursing job but was still able to keep up her hours at her computer tech job. As she rapidly improved, I wondered what mechanical and chemical deformations were resolving.

To my surprise she came in for what I think was her fourth session with many of her symptoms flared up after having subsided so well. "Has something happened", I asked, thinking that something had happened to mechanically deform her tissues again after subsequently resolving. She responded that nothing had happened during the previous week and that she had no inkling as to why the symptoms had returned so vehemently. So....I rolled my sleeves up and got to work.

Well towards the end of the session, nearly on the way out the door she tells me that the hospital she had worked for, for nearly twenty years fired her because there was no position she could be moved to that would'nt necessite her bieng able to lift at least three pounds. The doctor they had sent her to dictated the lifting stipulations. She is greaving, upset and is now taking legal action. People are complicated and thankfully I do not take insurance.

I have since seen her once since finding out this added information and was able to tell her that something had happened to flare up her symptoms. All pain is in context.

Now back to the origins of pain. Could attitude not be added to one of the origins of pain. Or is attitude an emotional response that may be pain evoking?

Chance

[Sarah]

Chance,
I don't know how long you've been hanging out here, so this may be old hat to you, but to answer your question: yes, in chronic pain cases where central sensitization has begun, the patient's thoughts and beliefs can contribute to the problem. However, I believe Barrett was referring to the practitioner's attitute versus the patient's, even though that is an important factor in treatment as well.
Barrett, on the topic of intuition (recognition) in treatment. If this is the case, couldn't it be said that the practitioner who practices intuitively cannot help but impart some of his/her own motivations/attitudes toward the patient by acting in such a way as to create or reproduce the "picture" in his/her mind of where the patient should be moving? Can we ever truly act completely objectively in our hand placement, timing, touch, and sequence of treatment?

Sarah

[Barrett Dorko]

Sarah,

I know what you mean. But I think this is yet another example of how poorly I get my point about ideomotion across to my classes.

1) If I as the manual care provider can figure out, consciously or not, how to push people in a direction that is corrective (as characterized by warmth and softening) then I'm some sort of genius. Generally, I'm not.

2) The most important ideomotion the patient can pursue while recovering is the motion they choose to do in the absence of the therapist.

I'm convinced that most therapists, if they use this method at all, don't emphasize this because they can't figure out how to get the patient to do it. Personally, I just holler at the patient until they do.

[Diane]

This quote is from one of the reviews of the book mentioned above by Barrett:
the mind operates on two levels, "deliberate" and "automatic." The nondeliberate mode (aka the intuitive) can be an effective way of knowing and doing, helping us empathize with others, intuit social cues or perform rote tasks like driving cars. It can also lead us astray: illusory correlations, self-fulfilling prophecies, dramatic anomalies and other misleading heuristics may feel like direct perception, but are not.

I think that as long as we are using our perception as directly as we possibly can, in this case kinesthetic perception, we will be working with the right "attitude", and any intention involved can take a back seat or be very vague or general, e.g. "to do one's best with this patient before one." I think that will take one further in the direction of ojectivity than "tools from the toolbox" with all their attendent expectations ever can.

What surfaces in the mind while working on another's nervous system is largely a function of what one has put into it earlier. GIGO... but if you put in good stuff, like detailed anatomy and understanding of function and physiology, that sort of thing will likely surface instead.

[nari]

Sarah,

The points you raise are important; I think the greatest difficulty faced by therapists is the notion that they should do nothing. We're trained to within an inch of our lives to coerce, in some way or another.

I think we can be quite objective; I say very little and do nothing but a bit of random contact. I never make any suggestions during the initial meeting when patients are relating their story; if they mention how painful it is to bend/sit/lie down, I just agree with them. Once ideomotion has started, I simply take a step back. They tend to move towards the more painful side, and I say nothing. That is not my decision to make. Talking about what's behind ideomotion comes later, when they are still rather surprised.

I would certainly agree that if we are doing ergonomic education, certain exercises and all that, how we behave and talk must have a heavy influence on the patient with good or bad effects. No matter how benign we think we are.

Nari

[vajranata]

It seems there is no way to act with another organism where it is not a concert. Most of this is non-conscious.