Manual Magic

[Barrett Dorko]

Diane,

I agree entirely and now introduce my students to the concept of allostasis when I speak of adaptive potential. I point them toward the thread you began some time ago. Has anybody followed up?

With your post we've come full circle to the Repackaging Simple Contact thread begun here just over a year ago.

Maybe we need to repackage the profession, not the newest information and available method within it.

[christophb]

Barrett,

I agree about changing the packaging of the profession. But I seriously doubt it's going to happen any time soon. The "biomechanical approach" is too engrained in the minds of PT's and its shoved down the throats of the new grads. I do not see any PT that I work with questioning the theory about why they do what they do. Perhaps it's because they feel that they do not have to and they have found a way of working that is adequate and gets the job done. The learning that is taken up is to reinforce the current theory, learn new and better techniques, find more problems to work on... I find it kind of boring, but whatever. It's common to find people asking how, but rare to meet someone in our profession trying to find out why. I just got around to reading Ramachandran’s Phantoms in the Brain and I can't stop thinking about the chapter on neglect "the sound of one hand clapping". Perhaps that is what our profession is suffering from. We have learned what is comfortable or what has kind of worked and have made peace with it (to fit in, get paid, etc).

Ramachandran states

At any given moment of our waking lives, our brains are flooded with a bewildering array of sensory inputs, all of which must be incorporated in to a coherent perspective that's based on what stored memories already tell us is true about ourselves and our world. In order to generate coherent actions, the brain must have some way of sifting through this superabundance of detail and ordering it into a stable and internally consistent "belief system" - a story that makes sense of available evidence. Each time a new item of information come in we fold it seamlessly into our preexisting worldview. I suggest that this is mainly done by the left hemisphere.

He goes on to suggest that when something comes along that does not fit into the story you either re-write the script, fit it in to the preexisting plot or ignore it.

It doesn't take much work to actually do simple contact... to re-write the script is another story.


Chris

[Barrett Dorko]

Chris,

I'm right there with you. I wonder how much I'm going to aggravate your coworkers when I'm in Seattle in two weeks? As always, I'll do my best.

You can't go wrong quoting Ramanchandran, and the "neglect" he refers to might also describe how our profession has treated neuroscience when it comes to understanding pain.

As often happens, a post here will remind me of something I'd previously written. This showed up in One Hand Clapping - Physical Therapy in the 21st Century written several years ago. Here I quote the poet David Whyte, another person you can't go wrong with.

Think of Whyte’s original contention that individuality begins at the point of engagement, at that moment when we meet another to whom we can relate and create something together. He speaks of his experience as a guide in the Galapagos Islands years ago, of how the animals seemed not to have read any of the books about their behavior that he had, and how it took months of quiet observation on his part before the islands revealed themselves to him “on their own terms.”

I imagine that any clinician would relate to this. At least, I do. As I think back over my long career, it seems obvious now that my patients often behaved in ways that I never anticipated, having only read about what they were supposed to do. And I’ve spent a lot of time quietly waiting for them to reveal ways of understanding their problems. I found that this happens in its own time, and that my attention and presence is all that is required. No less than that, though.

This brings me to my last point-that if our practice does not commonly include our actual presence; it will resemble the “one hand clapping”, in fact, the feeling of exile and frustration that the image evokes.

This cuts both ways. The patient arriving for care who can find nothing other than a machine to grasp (or a piece of paper with an exercise protocol), according to Whyte, will not become the individual they seek to be. This only happens when something with which we can truly relate meets us. In the case of therapy, that would ideally include actually being touched. This is something that happens less frequently in our profession every day.

I understand that your colleagues are both present and manually involved with their patient's care so maybe they're ready to hear what I have to say and see what I can show them. Maybe they're ready for the ectodermal (magical) perspective.

Maybe not.

[EricM]

On a whim I googled 'unlearning' after reading the word in Diane's last post; as usual Google did not disappoint. I found a good essay which highlights many of the concepts made here and in other past threads called Unlearning Ineffective or Obsolete Technologies.

Some of the highlights:

"Often, before they can learn something new, people have to unlearn what they think they already know. That is, they may have to discover that they should no longer rely on their current beliefs and methods."

"..the essential requirement for unlearning is doubt, any event or message that engenders doubt about current beliefs and methods can become a stimulus for unlearning."

"Dissatisfaction is probably the most common reason for doubting current beliefs and methods. But dissatisfaction can take a very long time produce results."

"People who see themselves as experimenting are willing to deviate temporarily from practices they consider optimal in order to test their assumptions. When they deviate, they create opportunities to surprise themselves."

"Events that violate expectations, both unpleasant disruptions and pleasant surprises, can become opportunities for unlearning."

"Beliefs held by qualified observers nearly always have foundations in some sort of truth. The most common problem is not to prove that one set of beliefs is wrong but to reconcile apparent contradictions by showing that they are not contradictions at all. These efforts can lead everyone to new conceptualizations. They can also produce some strange inversions."

"It is usually easier to respect the views of collaborators than those of strangers. Unfamiliar with current methods and unacquainted with recent efforts, strangers are likely to make suggestions that seem naïve or ignorant or foolish. Yet, new people often introduce new perspectives. Although the newcomers may be less expert than their predecessors, they are also free of some expectations that their predecessors took for granted. Thus, strangers may be able to see peculiarities that the indoctrinated cannot see or they may be able to offer breakthrough suggestions. Indeed, "reengineering" seems to be designed to exploit this principle."

[nari]

I think the last paragraph of your post, Eric, is most enlightening.
Perhaps people just cannot 'connect' with a stranger whose thoughts and pedagogy are 'outside' the norm paradigm despite evidence that those thoughts are logical and science-based.
It is the onshore/offshore analogy. It is probably why programmed pitstopped bus tours with everything done for you, are more popular than a trip where you have to work out what needs to be done or observed.....


Nari

[Diane]

This was my favorite line of the whole excerpt provided by Eric:

The most common problem is not to prove that one set of beliefs is wrong but to reconcile apparent contradictions by showing that they are not contradictions at all. These efforts can lead everyone to new conceptualizations. They can also produce some strange inversions.

I wonder how we could do that?

[EricM]

The sentence that catches my eye was "Events that violate expectations, both unpleasant disruptions and pleasant surprises, can become opportunities for unlearning." I think that there are many examples of unpleasant disruptions in most of our practices, for instance, a particular method which fails to produce a desired effect in a predictable way. At least this should be an unpleasant disruption to most. I wonder if many perceive this occurrence to be just par for the course and have become somewhat numb to failure.

eric

[bernard]

for instance, a particular method which fails to produce a desired effect in a predictable way.

Eric,

I think that most of us will blame the patient himself. It is a very common and "safe" behaviour.

[Barrett Dorko]

Eric,

Your "numb to failure" line went right through me. I think that this is mainly what I see. When I interrogate reality during the first ten minutes of my workshop by mentioning that half of the class has chronic discomfort a number will nod their heads in agreement, slightly amazed that I would have the gall to mention this and others remain perfectly still and placid. It's not unusual to find many people in pain in the latter group. They've been found out, and their culturally induced "poker face" has been employed in an effort to hide.

My mind often returns to a seasoned therapist in Dallas who began a conversation by asking me if this kind of handling would help her patients. When I asked her what she thought was going on inside the people she saw and what she thought she was doing when she did what she did it became clear that she couldn't speak about her patients in any meaningful way whatsoever and that the effect of her care was a complete mystery to her.

She grew angry and forcefully told me that the doctors loved to send her patients because she was so good at helping them. Evidently she was very popular and successful according to others but it was obvious she didn't feel that way when looking in the mirror.

In the face of such cognitive dissonance growing numb is a common strategy.

I showed her how to perform "magic" but made no promises about its effect on her clinical life because that is something I never do. I know she remained very unhappy about this.

If promises of success from me is what's required I'm in a fix because I won't do that. At least very soon I'll have published research by Luke and Jason to point to.

I doubt that this will make the impact it's supposed to. It appears from what I've seen this past couple of years that a study justifying a "clinical prediction rule" might work. Anybody want to do one?

[Diane]

Barrett, find a research partner to steer the project, and do one yourself. Of course, you'll have to find a place to treat patients if you're shutting down your clinic..

I really like the essay. The example of the Swedish navy being absolutely convinced the Soviets were invading them with submarines and divers (which turned out to be minks and seals, animals who are at home in deep water), whereupon they blasted the water with everything they could, is a metaphor for our mesodermal friends perhaps, who blast every pain as if some contrary piece of mesoderm deep inside simply refuses to "heal" or bend or move the right way.

The Swedes remained vigilant, certain the Soviets were lying when they said they did not send submarines into Swedish waters. Finally they unlearned their vigilance after the Soviet regime changed completely, and realized they'd been fighting marine mammals. Hilarious.

Here is more that pertains to us, my bolds:

Surprisingly perhaps, technical experts may be among the most resistant to new ideas and to evidence that contradicts their current beliefs and methods. Their resistance has several bases. Experts must specialize and their specialized niches can become evolutionary dead-ends (Beyer, 1981). Because experts' niches confer high incomes and social statuses, they have much to lose from social and technical changes. Expertise creates perceptual filters that keep experts from noticing social and technical changes (Armstrong, 1985). Even while experts are gaining perception within their domains, they may be overlooking relevant events just outside their domains.

Second, organizations make it more difficult to learn without first unlearning. People in organizations find it hard to ignore their current beliefs and methods because they create explicit justifications for policies and actions. Also, they integrate their beliefs and methods into coherent, rational structures in which elements support each other. These coherent structures have rigidity that arises from their complex interdependence. As a result, people in organizations find it very difficult to deal effectively with information that conflicts with their current beliefs and methods. They do not know how to accommodate dissonant information and they find it difficult to change a few elements of their interdependent beliefs and methods. The Swedish sailors who conducted the searches had been trained to interpret certain sounds as a submarine and rising bubbles as a diver; they had not been prepared for the sounds and bubbles made by animals. A Swedish navy that had just spent three weeks dropping depth charges and antisubmarine grenades in the belief that it had trapped an intruder was not ready for the idea that it had been deceived by playful young seals.

Tushman, Newman, and Romanelli (1986) characterized organizations' development as long periods of convergent, incremental change that are interrupted by brief periods of "frame-breaking change."

Kuhn said the same about science.

They said "frame-breaking change occurs in response to or, better yet, in anticipation of major environmental changes." However, even if abrupt changes do sometimes "break" people's old perceptual frameworks, the more common and logical causal sequence seems to be the opposite one. That is, people undertake abrupt changes because they have unlearned their old perceptual frameworks.

Third, unlearning by people in organizations may depend on political changes. Belief structures link with political structures as specific people espouse beliefs and methods and advocate policies (Hedberg, 1981).

Hello, is this not the case in PT, wherein a mesodermal agenda has completely overridden any neuro one we might have once had?

Since people resist information that threatens their reputations and careers, it may be necessary to change who is processing information before this information can be processed effectively. Thus, a change in control of the Swedish government may have been essential before the Defense Ministry could concede the possibility of errors in the conduct of antisubmarine hunts. A change in control of the Soviet Union may have been essential before the Swedes could allow the possibility of Russian vulnerability or truthfulness.

Top managers' perceptual errors and self-deceptions are especially potent because senior managers can block actions proposed by their subordinates. Yet, senior managers are also especially prone to perceive events erroneously and to overlook bad news. Although their high statuses often persuade them that they have more expertise than other people, their expertise tends to be out-of-date. They have strong vested interests, and they know they will catch the blame if current policies and actions prove wrong (Starbuck, 1989).

[EricM]

Another interesting essay on the same topic, Lifelong Unlearning by Trevor Pateman. I particularly like the opening statement

"people who live in acquisitive societies will tend to write books about how to acquire things, not how to get rid of them..."

[Diane]

I love this bit:

people know their Imperial measurements so well that they will not and cannot forget them. They are both proud of what they know, and able to use it fairly effortlessly. As a result, Eurocomputation is a lot farther off than the Euro. It will have to wait for the long run, when we are all dead. Had our school system been less good at instilling our crazy measurement system, we would have been able to forget it the more readily, and move on to deploy something more useful. As it is, we live in a society full of people proud of knowing how many furlongs there are in a mile, and totally unwilling to forget it. It's a terrible state to be in.

And this one (I've been all the way through the nausea that this involves, an example dear to my heart therefore):

If, for example, you get right-handed students to draw with their left, you deny them use of what they already know how to do in a more-or-less routinised way. Coming from a very different background, the cognitive scientist, David Marr, argued some years ago now (Marr 1982) that the serious work of visual artists involves them in unlearning the routines of habitualised seeing and regressing from 3-D to what he called two and a half D vision. That was what Cezanne was trying to achieve in the endless repainting of Mont St Victoire, learning in order to forget and forgetting in order to learn.

Hey Barrett, maybe you could do this in your class as an example of what "unlearning" means. Ask people to draw a simple dog shape with their dominant hand, then with their left hands, then with their eyes closed or while looking away from the paper the whole time, relying only on their memory and proprioception. This will make their proprioception cross over into their visual cortex memory bank. Tell them not to judge the results, but just to feel what it feels like as their minds are forced to go places they aren't used to going. Tell them this is good for them ultimately, even if it feels quite awful.. that this is what cognitive dissonance feels like. Tell them there is authenticity in each and every one of them, and that you are there to help them find it and experience it, that you are there to help them learn to help their patients find it too, that authenticity is therapeutic "magic".

It might perk them up enough that they'll be willing to let go of the stuff they need to unlearn.

[Diane]

It seems to me that if anyone is going to take on anything new, they must be ready and willing to "unlearn" automaticity and a lot of their familiar instrumentalism.

[Barrett Dorko]

The Magus' Message

There’s a passage, a story within the story of John Fowles’ The Magus; it’s complex and I can’t repeat the whole thing here, but it begins on page 550 of the hardback edition, in case you happen to have a copy. “Magus” is another word for magician.

Without going into detail, a young prince is shown things that he had not previously believed to be true, only to find out from his father, the king, that these things had always existed but that the prince had been under the king’s spell and that the king is a magician. The prince insists that he must “learn the truth beyond magic” but the king tells him: “There is no truth beyond magic.” Ultimately, the prince sees the truth, and thus becomes a magician.

I’ve spent many years thinking about this story and find today that this thread may have given me some further insight. In another thread titled Truth and Consequences I quoted from the wonderful book Why Truth Matters: “The truth is important to us but so are our needs and desires and hopes and fears. Without them we wouldn’t recognize ourselves. We want the truth but we also want to care, and some of the things we care about are threatened by the truth. So we’re stuck – but we have to choose.”

Combine the book and Fowles’ story and you have this: Magic (as distinct from super powers) is the truth, and, as such, it works within the confines of physical law, of course. I say, choose the truth and you'll find the magic you want.

Shouldn’t therapy resemble this? Shouldn’t therapy resemble magic when it’s practiced truthfully? Again see Arthur C. Clarke’s quote at the top of this thread.

Is it possible that therapy based on scientific principles cannot be practiced simply because it appears magical? Has common practice strayed that far from reason?

[nari]

One of the difficulties in clinical practice is the lack of consistent follow-up to know whether our interventions, magic or not, have lasting effects.
I remember when Mckenzie was the rage (about 1986) that it was described as "magical" by a lot of PTs, echoing what was thought about Maitland in the late 1970s...but after the initial resolution of pain and stiffness, we never heard of the patient again, usually.
Perhaps magic is relative to history. Something entirely new, dealt out by a wellknown figure in an atmosphere where EBM did not exist, and questioning was not 'done', can be magical.
It's not like that anymore - new grads are challenging, asking, questioning. The sense of magic seems to have gone; things happen by design and hard work lined with the expectation of well, it should work anyway, according to the clinical experts .
I think, here anyway, that clinical reasoning is very much alive and thriving. But it is reasoning, or a truth of sorts, based on old premises. Like old comfy socks, the premises of 30 years ago are still holding sway, and until that changes, the clinical reasoning will be shaky.

Nari