Tuesday, June 07, 2011

Therapeutic domain

Click to enlarge

I woke up yesterday morning with this picture in my head. So I got busy and made a slide before it faded away.

Tweaked with the helpful input of several friends since, here's what it depicts:

The top half is the patient, bringing some sort of pain experience, bothersome enough that they have chosen to include another person in their private world. The bottom half is the therapist. Together, they make a treatment dyad, separated by the x-axis. It could be any kind of person or caregiver or social contract, probably, but I decided it's a manual therapist and a patient seeking pain relief through manual therapy this time.

The left half of the image is the inner non-verbal physiological biologically processing interactor(3) world, of both.
The right half is the operator(3) world, the outer, shared, negotiated, verbal, conceptualized, noun-filled world, so pathetically symbolic, so vulnerable to misunderstanding and non-clarity, if we aren't careful. Luckily, in manual therapy, this area can be left quite spacious and airy, able to be used mostly for auditory feedback.

Before then, however, it is the area of sharing and agreeing to a therapeutic contract. It's the space in which each can come into attentional focus about the other. The patient can take some time in that shared space to reflect on how good a listener this therapist is, whether or not he or she can possibly help him or her. The therapist, likewise, can reflect on whether the sort of pain being described by the patient is something he or she can take on with his or her set of skills. They can each size up the other within their own private world, determine their readiness to develop a therapeutic relationship. This might take just a few minutes, or an hour, or take place in a continuous manner over the first 2 or 3 sessions. Or all of the above. As the contextual architect(1), the manual therapist must permit sufficient time for a signal from the patient that they are ready to begin the manual therapy 'ritual', the actual contact part of the visit.

As the therapist, it really helps if we can at least be clear on a set of concepts that can make intrinsic congruent sense to the patient: in trying to explain pain to the patient, one really must include the nervous system itself in the explanation. Explain Pain(2) is a good book for that, quite user-friendly. The nervous system includes the patient from skin cell to sense of self. It might be a tiny thing, at only 2% of the whole body, but it's what keeps us alive, and creates a pain for us to feel somewhere.

The pain is in the patient. No therapist can "feel" somebody else's pain directly. There are, however, correlates of pain, often: part of the pain experience will perhaps manifest as an area of secondary hyperalgesia, or "sore spot", or a tight spot, or something the patient can point to and the therapist can touch. If that's the case, then it's game on. No problem. Physical contact applied judiciously by an experienced clinician can assist that patient's nervous system by a little or a lot. Depending.

Depending on a great deal, much of which is still a biopsychosocial mystery, but most of which, if we're lucky, the patient's brain will decide to set aside in order to take advantage of the current possibility to "form a new opinion".

The y-axis is the treatment action or ritual itself. In my mind, I'm seeing careful handling, focused, non-nociceptive physical contact input, (forever and always indirect) input into the interior "self" construct of the patient, into his or her physicality, reported to/by his or her nervous system and processed, an effect to which the patient's brain mounts an affect, then provides a motor response, which moves back out through physiological change palpable by the therapist: it's a bi-directional dyad system, because the therapist's next shift of contact (ideally) takes this nervous system response into account, then builds upon it, to enhance it, assisted if necessary or if desired by verbal contact/communication as well. 

In this way, the treatment encounter is always a team effort. The resolution of pain will happen only when the patient's brain, on all its non-conscious as well as conscious interactive levels, forms a new opinion of its own state of function and state of its attached body.

1."Contextual architect" - coined by Cory Blickenstaff at Forward Motion 
2.  Review of Explain Pain by Mick Thacker  (2-page pdf)
3. Operator/Interactor

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