Tuesday, September 11, 2012

Deep versus shallow models of treatment

Last week I posted "Deep versus shallow models of manual therapy", but, as we all know, "therapy" isn't necessarily "manual." In fact, most therapy isn't manual at all. So, I'm going to expand the idea of deep versus shallow a bit more, to include therapy in general. This will encompass all the other kinds of treatment out there that has nothing to do with manual or physical contact. 

Joe Brence, in his Open Question to PTs... asks, "In your opinion, what is the one thing you would change about PT and why?" This effort is an answer to that question, I suppose...

But permit me to digress.

This past weekend I spent two days immersed in the small, 7-person think tank known as the executive of the Pain Science Division of CPA, in the beautiful and comfortable home of Dave Walton, current chair, who led the meeting. Almost all have been involved in research of some kind, spanning the range from me, with one paltry case series, to Tim Wideman, our chair elect. Out of 7 people, 4 have PhDs. We turned ourselves into a team. Out of our meeting emerged 1-year, 3-year, and 5-year plans. We intend to be unstoppable. 

General Effects
At that meeting I learned of the work of Maxi Miciak, a colleague of Geoff Bostick from U. Alberta, who is our division research representative. She has written a paper called: 

A review of the psychotherapeutic 'common factors' model and its application in physical therapy: the need to consider general effects in physical therapy practice.

In it she examines the idea that "general effects" count for far more than any sort of skilled technical expertise when outcomes of treatment are examined and put through a detergent cycle of statistical scrutiny. She mentions work done by someone named Jerome Frank*:   

[Jerome Frank's] "..conceptual framework includes four common features: (i) an emotionally charged confiding relationship with a helper, (ii) a healing setting where there is belief the therapist can help and is acting in the client’s best interests, (iii) a rationale, conceptual scheme or myth that plausibly explains the symptoms and prescribes a procedure for resolving the symptoms, (iv) a ritual or procedure that requires active participation of both patient and therapist and is believed by both to be the means of restoring health."   
* Frank JD, Frank JB. Persuasion and Healing: A Comparative Study of Psycho- therapy, 3rd edn. 1991, The Johns Hopkins University Press, Baltimore.

Don't you think, realistically, that manual therapy is mostly "ritual" procedure? It seems to me, after a lifetime of being a therapist, and for most of that time, being a manual therapist, that it's a way to fill up time while the patient's brain changes itself. Hey, you gotta kill time doing something. Hopefully something useful. Hopefully something that will make sense to both of the two people in the treatment dyad, therapist and patient person experiencing pain. 

In other systems, e.g., Peter Levine's Somatic Experiencing (which I attended in 1992), time is killed by just sitting there calmly. Peter Levine referred to this as paw-licking, something cats do a lot when they are just sitting, thinking, cogitating (or whatever cats do in those feline brains they have..), basically just passing time. The point is, you don't want to interrupt while your patient or client or consultee is busy doing what they have paid you good money to facilitate. The other thing to remember is, their brains will do their own changing, automatically. You don't have to "do" anything at all, if you don't want to. You can just sit there and watch. All the facilitation is purely social. Your job as therapist is to stay out of the way, for the most part. Just like siphoning - get the water to come up against gravity by sucking on the hose a bit, recruit normal air pressure to assist, then you can sit back and watch it flow uphill. It will work fine as long as the output end of the hose is a bit lower than the intake end. (In the brain, this has something to do with its finding more efficient metabolism, I think.)
The skill set is to know when to intervene slightly, and when to back off. Like steering while driving. You do not have to devote much hard drive to steering after awhile. The skill set of keeping a car on the highway, between the lines, while avoiding other moving vehicles, becomes completely automatic, implicit knowledge. 

(The challenge as far as I'm concerned, as a manual therapist, is how to keep the process alive and dynamic and fresh with each patient, how to stay tuned in so it doesn't get stale and turn into automaticity.) 

Putting the SOCIAL into biopsychosocial (finally!)
Serendipitously, this little gem turned up: PAINWeek 2012 Conference Keynote Address: The Realities of Pain as a Public Health and Social Issue. In it, 
"Daniel B. Carr, MD, of Tufts University School of Medicine delivered a keynote address titled “Have We Been Backwards, Upside Down, or Both?” at the opening session for PAINWeek 2012."
It's great! He can see how all this time we've all been looking at pain through a telescope backwards! If we start at the social end of biopsychosocial, instead of always at the bio end, we could do better

The social end is where all manual therapy starts. It's interactive, not operational, no matter HOW resistant manual therapists might be to that idea. We are not treating stretchy corpses, we are not treating tissues, we are treating people who have pain. We are treating brains in pain. We are treating nervous systems in pain, nervous systems that span the entire distance, both physically and conceptually, between skin cell and sense of self. 

So, Joe, in answer to your question, I'd say, let's be less physical, more therapist. 


Miciak MGross DPJoyce AA review of the psychotherapeutic 'common factors' model and its application in physical therapy: the need to consider general effects in physical therapy practice. Scand J Caring Sci. 2012 Jun;26(2):394-403


Maxi said...


Thank you for a great post! (and not just because you happened to mention my work:) I believe ritual is embedded in what 'we do' as therapists. I think the idea of ritual implies, on some level, that what we do has meaning within biological, psychological, and social spheres. And, it could be that 'meaning' is the glue that holds together what we know and what we do with our patients and clients. Meaning is not separate from biology - some authors (Moerman, Wampold, Kaptchuk, Miller) are trying to shift the understanding of the placebo response (the psychological and neurobiological response to the context) to a meaning-based conceptualization, which sheds the negativity that the language 'placebo' evokes toward any influence the context has on the client. What we know and what we do as therapists does go well beyond a reduction to the biological. I think that it was Abraham Verghese that said something along the lines of 'rituals are about transformation' - that about sums it up, I think.


Diane Jacobs said...

You're welcome! Thanks for your comment Maxi. And here is the link you mentioned elsewhere:


Anonymous said...

great articles and excellent post Diane.Carrs comments really hit the mark and made me think of Daniel Siegal and his interpersonal neurobiology theory.
I'm just listening to mindsight for a second time on audible.
The type of brains that have ruled the roost in our teaching institutions( at least as far as medicine goes)for at least the last century dont do very well when it comes to any sort of knowledge you cant see or cut up.and the idea that reversing the direction of the gaze might be relevant is off the page so it is very refreshing to see maxi's piece- unfortunatly it doesnt roll off the tongue in the other direction