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  • Cause's Confusion

    This thread is about something at which I fail regularly. Maybe that will change as we investigate the subject, but at the moment I have my doubts.

    The subject is causation; specifically its relation to complaints of pain. I find that most therapists have an attitude toward it that I feel needs changing. In fact, I feel we must change that attitude or we’ll continue to struggle with the patients that need us the most.

    As I said, I haven’t managed to convince many that they need to change, so let’s try this.

    As when I teach, I’ll begin with the definition of cause: “A thing that exists in such a way that some specific thing happens as a result.” I say, “Almost without exception therapists interviewing a patient in pain begin to try and figure out how this patient came to be the way that they are. They work to create a story that explains this, and then search for evidence. This is called looking for cause, and I think it’s a tremendous waste of time. It’s a great black hole, and I suggest you stop doing this as soon as you possibly can.”

    Thus, my failure begins. Soon I’ll go on from here.

    One more thing. One of my primary references for this thread will be a specific chapter from Steven Pinker’s newest book The Stuff of Thought: Language as a Window into Human Nature which I’d highly recommend. In any case, when I refer to Pinker’s book in future posts this is what I’m talking about.
    Barrett L. Dorko

  • #2
    Control leads to confabulation

    People assume that the world has a causal texture – that its events can be explained by the world’s very nature, rather than being just one damn thing after another.

    Steven Pinker

    I’ve currently concluded that therapists work very hard to gain control. In fact, I think that they self-select themselves for the profession of physical therapy with this in mind. Eventually this motivation translates to a plethora of techniques that feature forceful and/or coercive handling and choreography and there are plenty of threads here about the problems inherent to these methods. What I want to emphasize in this thread is how this tendency to control typically begins long before management begins – it begins in the initial questioning of every patient. It begins with the question, “What happened?”

    In response the patient has two choices. They can say, “I don’t know” in the case of a truly insidious onset of pain, or, they can tell their story. There are numerous problems introduced with that, not the least of which is everyone’s strong tendency to confabulate whether they mean to or not. Consider this or this. Bottom line – we’re all lying about the past most of the time and there’s plenty of evidence that this is unlikely to change as long as we remain human.

    When we ask our patients “What happened?” we are inviting them to lie. In an effort to determine a cause for the current situation we fall into a trap that leads to an unsolvable maze.

    As I said, “I suggest you stop.”

    More soon.
    Barrett L. Dorko

    Comment


    • #3


      Source: Funny Times
      Last edited by Jon Newman; 23-11-2007, 01:37 AM.
      "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

      Comment


      • #4
        Barrett,

        Very true- depending on the perspective one takes, the causes are potentially infinite.

        Therapists aren't the only ones that search for a cause though. I find that many patients are also anxious to discover a cause. And often when they think they have, it has similar effects as a diagnosis does for someone with an illness that doctors have struggled to pin down - a sense of relief and a readiness to move forward. Although knowing the/a cause does not provide recovery, it does seem to help some people create a satisfying narrative (even if it is unreal), which can be an important part of their recovery.

        We certainly don't need to play a part in creating such a narrative, but we may need to help in creating an alternative one if the chosen narrative is detrimental.
        Last edited by Luke Rickards; 19-11-2007, 10:15 PM.
        Luke Rickards
        Osteopath

        Comment


        • #5
          Deric Bownds might as well join SomaSimple - he's always posting something that fits right in with whatever we happen to be talking about. Distinguishing true versus illusory memories with brain imaging. He links to this paper: Trusting Our Memories: Dissociating the Neural Correlates of Confidence in Veridical versus Illusory Memories.

          In that we can't know what's going on in peoples' heads for sure while we are interviewing them, or know if what they are saying is fact or fiction or a combination, I see the exercise as a combination of relationship building (the patient will use my reaction to their story to verify it or not in their own mind, decide if they can trust me or not).

          It's important to listen, but to see 'through' it too, to what's more important. And the story should be allowed room to change if it needs to. The story is just a story - its use is in that it helps to move the plot along to a successful treatment conclusion. Thinking about a way that something might have come about is "movement" of a sort, regardless of what part of the brain is most active in the telling. One should never get sucked into a patient's "movie". Here's a whole piece about it.

          Jon, that cartoon is hilarious.
          Last edited by Diane; 20-11-2007, 03:57 AM.
          Diane
          www.dermoneuromodulation.com
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          "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

          “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

          “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

          "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

          "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

          Comment


          • #6
            I happen to be one of those people who think the world has a causal texture but as Luke notes, it's sort of complicated. Closely related to causation is mechanism. In a special issue of Cognition and Emotion John Cacioppo and Gary Bernston wrote an article titled Affective distinctiveness: Illusory or real?. In their conclusion they made some interesting comments.

            Reverse engineering observable behaviors using the notation of cognitive science has led to a rapid expansion of theories and methods in the behavioral sciences, and the contributions of this special issue underscore the power an importance of cognitive theories and methods for understanding affect and emotion....However, the ability to reverse engineer a feat does not necessarily mean that the underlying mechanism has been duplicated. This uncertainty is inherent in scientific inquiry and the reason theories are just that. Scientific theories represent intellectual structures that provide adequate predictions of what is observed, and useful frameworks for answering questions and solving problems in a given domain. It is parsimony that favors the interpretation that the ability to reverse engineer a feat also implies the underlying mechanism has been duplicated. The hazards of letting parsimony off its leash are important to recognise, as well, for parsimony can promote the status quo at the expense of imaginative theorising and hypothesis testing.
            "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

            Comment


            • #7
              That cartoon is sooo accurate. Most of today's 'truths' are based on untruths spread by Chinese whispers. As Barret said, we all lie.

              I too think there is a cause for everything; it is just we can't determine our reasoning too well. Patients often expect a simple cause for their pain - be it posture or sleeping or typing - because, like many health professionals, it is so much easier to accept.


              Nari

              Comment


              • #8
                Despite my inclination to think that we are fully caused, I agree entirely with the comments in your first post Barrett.

                This thread is about something at which I fail regularly. Maybe that will change as we investigate the subject, but at the moment I have my doubts.

                The subject is causation; specifically its relation to complaints of pain. I find that most therapists have an attitude toward it that I feel needs changing. In fact, I feel we must change that attitude or we’ll continue to struggle with the patients that need us the most.

                “Almost without exception therapists interviewing a patient in pain begin to try and figure out how this patient came to be the way that they are. They work to create a story that explains this, and then search for evidence. This is called looking for cause, and I think it’s a tremendous waste of time. It’s a great black hole, and I suggest you stop doing this as soon as you possibly can.”
                Last edited by Jon Newman; 19-11-2007, 11:36 PM.
                "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

                Comment


                • #9
                  Soon Jon you'll understand why you have remained so deluded for so long.

                  No need to thank me.

                  The regulars here seem to know exactly what I’m talking about, and the problems inherent to seeking causation are increasingly evident with every post. I’ll attempt to put a few more nails in the coffin before I go on to explain how and why this search will never die. I’m not kidding.

                  First, what I consider to be the major problem with traditional practice – the imaginary connection between strength and posture and posture and pain – was constructed from a heuristic that proved to be inaccurate. (A heuristic is a problem solving technique that leads to conclusions that are based on appearance rather than careful investigation) In a perfectly human attempt to figure out how people got to be the way they were (painful), an erroneous cause was chosen and remains today, much to our detriment. (See this for more)

                  The absence of evidence pales in comparison to the comfort a cause will create, and this is exactly why we should consider cause with a certain amount of suspicion.

                  There’s also this. It appears that one of the primary reasons people come to believe that they’ve been kidnapped by aliens from outer space is that they want desperately to find an explanation for their bizarre and persistent sensations of estrangement and isolation. If the cause for this shows up within the proper context some people will adopt this story and never, never let it go - all because they needed a cause. (More about that here)

                  So be careful.
                  Barrett L. Dorko

                  Comment


                  • #10
                    Soon Jon you'll understand why you have remained so deluded for so long.
                    I look forward to it actually.
                    "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

                    Comment


                    • #11
                      Why we fabricate causes

                      Semantics is about the relation of words to thoughts.

                      Steven Pinker

                      Pinker begins by pointing out that while we are capable of imagining all kinds of things, we cannot visualize something that doesn’t take up space or occur at a certain time. Time and space are hardwired and simply cannot be eliminated from any scenario we concoct. Likewise, we live in a universe that obeys causal laws, or, at least, causes that are detectable by our sense organs, and our senses are imperfect, to say the least.

                      The basic problem is this: The way we see space, time and causality are riddled with paradoxes and inconsistencies. This is a function of our limited view. In other words, our intuition (from the Latin meaning “to look upon”) leads us toward conclusions that are just plain wrong. We see something other than reality but are unlikely to sense that and carry on as if we were right all along. After all, there’s nothing more comforting than being right, and for many it’s what gets them through the day.

                      Pinker puts it this way: It can be easily argued that we live in infinite space and time, but it’s not possible to imagine that so we place limits on such things as we visualize them. Similarly, what he calls “the causal grid,” – that thing that connects all events – is a human fabrication, rather like finite space. It doesn’t exist in reality and on some level we understand that, but we are bound to construct it in order to lend order to our daily lives and the lives of others. This is an order that doesn’t actually exist, but imagining that it does will make everybody feel better.

                      So we come up with a story, a cause for the patient’s complaint. An American poet named Robert Cuver said this in 1910: We need myth to get by – we need story. Without that, the tremendous randomness of life would overwhelm us. Story is what penetrates.

                      I recite this to every class, and Pinker has now made the significance of these words even greater in my estimation.

                      More soon.
                      Last edited by Barrett Dorko; 20-11-2007, 02:02 PM.
                      Barrett L. Dorko

                      Comment


                      • #12
                        A mind such as ours

                        Brilliant as he obviously is, Pinker makes it clear that he didn’t come up with these ideas about causality on his own. He’s simply following the thinking of both Immanuel Kant and David Hume, which raises the intellectual level of this thread quite a bit, I think.

                        Hume wrote that we have no justification for our belief that one event must follow another (which makes me feel a little better about having said the same thing a few times myself) and that all we have is an expectation of this.

                        With “a mind such as ours” (Pinker’s phrase), though our experience isn’t organized we are forced to imagine that it is. This allows us to do what we call “grasp reality,” and, as it turns out, reality is an illusion.

                        More about that problem in the next post.
                        Barrett L. Dorko

                        Comment


                        • #13
                          I think that many PTs estimate that a problem is simple and may be resumed as this simple picture.
                          Attached Files
                          Simplicity is the ultimate sophistication. L VINCI
                          We are to admit no more causes of natural things than such as are both true and sufficient to explain their appearances. I NEWTON

                          Everything should be made as simple as possible, but not a bit simpler.
                          If you can't explain it simply, you don't understand it well enough. Albert Einstein
                          bernard

                          Comment


                          • #14
                            But I'm now convinced that I'm looking at a partial piece of a bigger picture.
                            Attached Files
                            Simplicity is the ultimate sophistication. L VINCI
                            We are to admit no more causes of natural things than such as are both true and sufficient to explain their appearances. I NEWTON

                            Everything should be made as simple as possible, but not a bit simpler.
                            If you can't explain it simply, you don't understand it well enough. Albert Einstein
                            bernard

                            Comment


                            • #15
                              Nietzsche's insight

                              Bernard,

                              You're right.

                              Without Pinker’s help a few years ago I wrote a few things about our desire to seek a cause in The End of Evaluation?. There Frederick Nietzsche reminds us of this:

                              “To trace something unknown back to something known is alleviating, soothing, gratifying and moreover a feeling of power. Danger, disquiet, anxiety attend the unknown-the first instinct is to eliminate these distressing states. First principle: any explanation is better than none…The cause-creating drive is thus conditioned and excited by the feeling of fear…"

                              It appears that the mystery bound to accompany the de-emphasis of cause is something we literally fear. What I’m asking therapists to do reasonable or not, scares them and makes them feel less powerful.

                              I have no hope.
                              Barrett L. Dorko

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