Sunday, November 08, 2015

Dangling in the chasm

I should be finishing up my manual and sending it in to be published, but the project got derailed at the end of July, and I just have not got back to it. It's 85% done, too, which is even more maddening - it would only take about a week of concentrated effort to get that thing done
But I procrastinate. I have procrastinated for years, and lately for months. 

I think it's because I still don't "like" it enough. It's still not the manual therapy book I would buy in a flash and read cover to cover and refer to endlessly. Not in its current state.
The problem is the introductory chapter.
So far it's about 16 pages, with about 40 references, and it's still not right. I still don't have that satisfying sense of accomplishment about how it's structured. It needs yet more work.

The rest is just images and explanations of how to do the "moves." That was the easy part, even though it took years of fiddling around learning how to do photoshop to meet the need for it to be visually appealing.

What is lacking is the right mental frame. I've got the content down, but I don't have the right shaped container. Not quite. Not quite yet


I have an anecdote that might make some people gag,  others laugh maybe, but I'll share it anyway. 
Even as I was still going through school, I could feel that there was a massive chunk missing completely. I wasn't being taught what I really needed to know. I was not being taught any people skills. 
I flailed around a lot after graduating, all through my twenties (during the 1970's), trying to make my "marriage" to my profession work; leaving it for a time, going back to it after awhile, trying on other lines of work to see if I could love them more, but always returning to PT, and eventually settling down with it as my "life." 
One of the extra"marital" alternate-profession "affairs" I had, was, I went into real estate for awhile. 
I lasted about 6 months. RE sucked, and so did I. I actually sold a property, even, but I wound up hating RE even more than I hated PT the way it was, and the way I was..

I did learn various sets of people skills.
These were crude and cartoonish by today's standards, and I still loath that they were established ways of getting to "yes", getting people to part with their money, buy a house they maybe didn't even need, but at least they were something. I appreciated that they were in place and taught didactically, even though I hated being in "sales" and went back to PT right after. 

Meanwhile something that happened over the past few decades is that PT has turned itself into "sales." 
Maybe I should have just stayed in real estate! Kidding.. kidding.. I could never have been happy doing that for a lifetime. 


This morning I learned about "Ethics of proximity," something that Scandinavian PTs are onto lately.. 
I've got to say, I love the basics (from a non-related open access source (1) ): 
1. When interacting with another, we have an ethical obligation to help the other.
2. What constitutes “helping” can be defined through discourse but must always respect the other’s self-determination.
3. To interact authentically with the other is to risk ourselves and give up some of our control over where the dialogue between us takes us.
4. Do what works in the particular situation, taking from any other ethical field (especially discourse ethics, but also virtue, utility, or duty) but always respecting the other as the primary virtue.
5. In bringing preconceptions and prejudgments to our interaction with the other, we dismiss his needs.
6. When in a position of power over another, we are obliged to act in his best interest, not our own.
7. A relationship of caring has as its goal that of helping the other to gain his autonomy

I think these are gold. 
I am so disappointed that my profession stopped being a profession and turned itself into an "industry."
I so very much hope it can turn itself around before it hits the iceberg.
I so want my humble manual to include these values and be truthful.


Todd Hargrove wrote a good blogpost recently about treatment models, and three reasons why it matters what we think and say about what it is we think we're doing when we treat, explanations we offer up. 

1. If you get on the right track you can improve. >>>"...if my target was breaking up fascia or muscle knots then indeed I wouldn’t care how they felt. And I wouldn’t do as good of a job." [.. or getting some presumed stuck joint to move.. or jabbing needles into "trigger points" as if those were actually things]

2. False beliefs have unintended consequences. >>>"...false beliefs, no matter how small, are like viruses - they multiply, get passed to others, mutate to form super bugs, and can eventually cause disease. Don’t spread them people!" [Look how pervasive the mirage of perceptible joint movement is in our profession! Look how the profession turned itself into a mechanics shop!]

3. Truth matters. >>>"Every step away from misinformation and confusion is a step in the direction of the truth." [Egggggggzactly.]

I really want my manual to be about how to handle people who hurt. How to touch their nervous systems by letting them express themselves, by touching/trying to help their nerves. Nothing else.
Yet I know that currently it looks like just another how-to recipe book of ideas for manual therapists to copy. It doesn't have a unifying theme yet. It's still lacking soul.


Also this: 
"We like to think our senses can give us unbiased, truthful information about the external world.... that's utter nonsense - we are not driving the bus. By the time we are aware of a sensation, that sensation has already been filtered and edited and combined with our expectations and our emotions and our personal history so in the end there is no sensation without emotion, there is no sensation without personal history without evolutionary history - it's all combined into a mush and that's what we have to deal with." 
This is David J. Linden, speaking in a podcast he did with Ian Sample at ScienceWeekly, back in March 2015.

This is important to grasp - i.e., as manual therapists we're dreaming if we think we are doing anything "specific" - everything we do, every sensation we provide, is subject to filters by a patient and their past, all bundled in their neuromatrix, churning endlessly, trying to predict its own future. We need to get over ourselves and stop trying to do things TO people, instead just be WITH them. Which circles back around to what the point is, of even bothering to put out yet another manual therapy manual, if it doesn't explicitly state all this somehow? How can I get across the point that manual therapy is a ritual that kills time while people spend time in your presence letting their brains figure out at subcortical levels how to get over themselves? While you busy yourself doing innocuous things, rather specifically? (Well, we hope "innocuous" things..) It's one of those chasms in which I am stuck simply not being able to cross at the moment. ................
One thing that gives me hope though: This past week I got some feedback from the "system" in which I do not participate, in fact stay out of for the most part, quite deliberately. Back to the "marriage" analogy, it's like my profession and I sleep not only in separate bedrooms, but in separate wings and floors of the house. We meet once a year when I renew my licence. Anyway, back to the point, I got two documents from a very-much-in-the-system facility in a far away city. The backstory here is, a woman called to see me who had been in a lot of back pain for a very long time and had been way overtreated and biomedicalized and pathologized, and finally they stopped, referred her out to another therapist who lived closer, because she lived a long way away and had to travel recumbent. The therapist they referred her to had not wanted to deal with such a sensitive nervous system and had mentioned my name. When the patient called, I said sure, come on in, we'll see what's what and if I can help you. Anyway, she did well, could even travel sitting upright in the vehicle after a few visits. She returned to the first clinic for closure. They were sort of surprised, I think, that she tested very well after all their own efforts hadn't worked. The discharge note was like, hurray, she's better thank goodness.. don't know what Diane did but whatever it was, yay.  In retrospect, I think they had inadvertently taught her to be more worried about her back than she had ever needed to be, and worry/stress was her main obstacle.

I really want my manual to explicitly contain values and people skills and convey how important it is to put the responsibility onto the patient and divest oneself of any responsibility other than positive encouragement, including by doing careful manual therapy of a most superficial kind, a set of tricks really, and how to give the patient full rein to get themselves better. I give people a little speech before I ever lay any hands on them, that puts them in charge of my touch/handling. I make it clear they can feel themselves better than I can, that I need their help to help them with their pain problem, that treatment shouldn't hurt at all, that hurting them is counter-productive when pain is being treated, that if they experience any discomfort of any kind they need to tell me right away so I can change what I'm doing right away - we want their nervous system to work, yes, but work normally, not in this hypersensitive way, and provoking it won't get us where we want to go.
This does a couple things - it makes them the boss over me - if they have locus of control they will feel less stress about being touched. It's built-in that the whole point is about coming off the table in less pain than when they went on the table. It also takes responsibility of being the "fixer" off me completely, and puts it on them. I'm just a helper. I'm just holding up a kinesthetic flashlight so their nervous system can see what it has to do to get over itself.
I call that person-centered treatment.
I want my manual to get across the idea that person-centered treatment is where it's at and anything else is a great big fail waiting to happen. 

Denna Hintze , Knut Are Romann-Aas , and Hanne Kristin Aas; Between You and Me:A Comparison of Proximity Ethics and Process Education. International Journal of Process Education (June 2015, Volume 7 Issue 1)