Crossing the Chasm - Meso to Ecto

[Barrett Dorko]

The worst policy of all is to besiege walled cities. The rule is, not to besiege walled cities if it can possibly be avoided.

From Sun Tzu’s The Art of War

As the days pass and the silence grows deeper I have the sense that an opportunity will have been lost unless something more is said. Yesterday while wandering through a book store I came across the quote above. It was actually used by Woody Hayes within the context of Ohio State football but I think I should save that part of the story for another time.

I really like the image of being “walled off” however, and often feel that many therapists choose this strategy when confronted with dissonance. Perhaps without even knowing it they move directly from the open spaces a workshop provides back to the insular nature of their life, clinical and otherwise. It seems that this can be accomplished by the time they reach the car to drive home. Others drift back a little more slowly as we’ve seen here – but they make it back there nonetheless.

The Internet has provided an openness regarding conflict that some of us enjoy and others find, well, inconvenient. Perhaps the paradox of the situation is this: the very thing that could provide a vehicle over the bridge also exposes the inertia of those on one side of the chasm.

I know a lot of wonderful hard-working therapists who hate the vehicle, dismiss it, distrust it and/or virtually deny its existence.

They effectively wall themselves off in this way and, as Sun Tzu says, we’re stuck with the worst possible strategy when trying to reach them.

[amacs]

Light in the Tunnel

An illuminating and stimulating thread. Thank you Jason for the succint precis of the respective positions. Having struggled (nay struggling) to get my head around this stuff I think I might be able to detect some light at the end of the tunnel (but then again there are tunnels and tunnels and likewise lights and lights)

ANdy

(small of brain and slow of wit)

[Mary C]

(small of brain and slow of wit)

Not at all, Andy. You're just like the rest of us. I've been at it for a year and it's really starting to pay off with some of my most difficult cases.

By the way--have you checked out the threads on tunnel syndromes?

Mary

[amacs]

slow of wit

indeed so slow I began looking for the threads ...

doh!

not helped by the hour of the night I am sure!

ANdy

(small of brain slow of wit)

[Barrett Dorko]

I was interested to hear Ginger Campbell say on the Point of Inquiry interview this week that “The most important book I read last year was Burton’s On Being Certain. You can read Soma Simple’s take on this book in the thread Reducing Certainty, which I thought pointed out several things of importance but didn’t gain the sort of traction I anticipated – rather like this thread.

I continue to contemplate the silence from our colleagues and, as often happens, the books in my briefcase provide answers. I’ve cobbled together the following thoughts from things read from both Rivers and Midgely referenced recently.

When therapists speak of the body they are generally thinking in terms of shapes. Whether it’s internal anatomy or not, they seem driven to suppose that the external manifestation of posture and movement should be symmetrical and controlled. Many forms of examination begin with a visual inspection that notes anything out of the ideal position and connotes it negatively.

But the human body isn’t remotely symmetrical in an actual sense, and soon I’ll explain exactly how. This, I think, will explain in another way how it is that the ectodermal perspective generates what I’ve come to see as a “shocked silence” from those who had not previously considered it.

[EricM]

I just read an op ed piece by Atul Gawande in The New Yorker (probably deserves a thread of it's own). In it he raises the concept of path-dependence. He wrote:

With path-dependent processes, the outcome is unpredictable at the start. Small, often random events early in the process are “remembered,” continuing to have influence later. And, as you go along, the range of future possibilities gets narrower. It becomes more and more unlikely that you can simply shift from one path to another, even if you are locked in on a path that has a lower payoff than an alternate one.

Path-dependence is discussed often on the web in relation to economics and social issues, and I can't help but think it has some explanatory power in what we witness happening in our profession.

More on path-dependence (for the motivated)

[oljoha]

What this change DOESN'T involve is a large change in "your toolbox". In fact, just about every treatment technique itself could be ectodermal or mesodermal, depending on:
# the rationale for its use
# the way it is used
# the explanatory model used for both the patient and other stakeholders (other colleagues, payors, etc)

In The Chasm, I tried to provide a brief blueprint for how to move a traditional OMPT-based impairment model of treatment toward ectodermal reasoning. I'll reproduce it here for ease of reading. It's Post #81 in The Chasm.

Whoa, long post Jason. A tad too long for me, but your post from The Chasm described exactly what I have come to be doing during the course of the last year except the ideomotion thingy.

[Barrett Dorko]

According to Midgely, humans quite naturally have “a strangely selective way of attending to things.” Basically, we look for that which we assume is simple and proceed to act upon those things in a logical progression that typically includes coercion and certain prediction. But the ectodermal perspective has little relation to absolute certainty of response and there is nothing simple about the shape of its primary anatomical component, the nervous tissue itself.

For a long time those who tried to describe the heavens and their movement were flummoxed by the fact that the observable orbits of the planets wouldn’t conform to mathematical calculations that included circles. They accepted the asymmetrical ellipse as a path only when forced to do so after the simplest explanation proved inadequate.

As far as I know, we’re working today with essentially the same brain we had in Copernicus’ time. We seek that which is simple and deny as long as possible the eccentric, the complex, and the unpredictable. If control is our mantra, though not explicitly stated as such, mesodermalism will dominate our vision, training will dominate our education and coercion will dominate our touch.

Is it any wonder that we’ve made such slow motion toward neuroscience; quite possibly the least coercive medical discipline?

[Diane]

As far as I know, we’re working today with essentially the same brain we had in Copernicus’ time. We seek that which is simple and deny as long as possible the eccentric, the complex, and the unpredictable. If control is our mantra, though not explicitly stated as such, mesodermalism will dominate our vision, training will dominate our education and coercion will dominate our touch.

Is it any wonder that we’ve made such slow motion toward neuroscience; quite possibly the least coercive medical discipline?

This is it - this paragraph should be in the foreword of your next book Barrett.

[oljoha]

If control is our mantra, though not explicitly stated as such, mesodermalism will dominate our vision, training will dominate our education and coercion will dominate our touch.

That's what I thought I'd have after physio school. But I found none. Then I thought I'd get it after a masters in manual therapy. But nope. I found kind of found Zen here at SomaSimple. I have let go. My success now depends on the nervous system of the patient being receptive to my interventions.

[nari]

Oljoha,

Exactly.

The need to control the patient's actions and movements is out of date, but it is still expected by patients due to this pervasive meme.

Nari

[John W]

Dead Man or Zombie?

Yesterday morning, I spent two hours laboring like an automaton over my unfinished patient charts from Friday. Realizing that my clinic days are increasingly spent with the mindless drudgery and starkly unimaginative counting of treatment minutes and the assigning of appropriate intervention categories to the proper diagnostic code, I reflected on the "chasm" and Barrett's post about imagination.

I think that mesodermalism has created this gray and dreary clinic world: where the electronic patient note regurgitates the appropriate chunk of mesodermal mush all tidy and packaged up like tripe from the butcher shop. Then, it's tossed up on the scale where its weight determines its value. Chunk after chunk is tossed up onto the scale to be weighed and valued: the more chunks you toss onto the scale, the more you get paid, so just keep tossing the chunks.

In the mesodermal realm, patients are hunks of chunks to be processed by your neighborhood physical therapist : mobe that L4-5 [chunk], stretch that medial hamstring [chunk], strengthen those lower traps [chunk], release that trigger point [chunk].:vomit:

I suppose a good question for the mesodermalists then would be: Why do you check your imagination at the door when you get to work?

[nari]

John, that's hilarious. I love it.
Chunk-tossing could be defined as a new sport within physical therapy rooms.

Nari

[Diane]

John's post facilitated an intrusive deja vu flashback (suggesting to me that I still harbour dregs of post traumatic stress disorder) brought on by years of complying with insurance requirements that I document joints treated, in order to get paid. It was a monumental effort to remain free from seeing only the "meat." I had to pretend to myself that I cared nothing about getting paid in order to stay receptive and therapeutic. Like a butcher shop, the system saw the body as a cartoon, sectioned off by dotted lines, where one "joint zone" started and ended. I hated it. :vomit:
No reimbursement for "therapy," rather a conflation of "therapy" into that all important descriptor, "physio-"... I felt I was being treated like a gob of meat, expected to treat others as though they were gobs of meat.

When I started to consider that what I was really treating was the nervous system, I counted up and charged for all the (meso) "joints" crossed by/innervated by a given (ecto) nerve, and prepared to defend myself if necessary. I never had to, but I would have. Eventually I was able to operate my practice as an insurance free, joint irrelevant zone. Now "PT" is considered, and reimbursed as, a single, whole payment category or service by insurers, at least here in BC. Thank goodness.

[Jon Newman]

John,

Based on your emoticon it seems you felt your situation as much as reflected on it. As such I don't think you could be a zombie. Dead man working sounds right.