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Barrett's Forums This discussion is devoted to the latest advances in neuroscience and the clinical phenomena it explains.

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Old 19-11-2007, 01:19 AM   #1
Barrett Dorko
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Default 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.
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Old 19-11-2007, 02:32 PM   #2
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Default 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.
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Old 19-11-2007, 05:06 PM   #3
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Source: Funny Times
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Old 19-11-2007, 06:04 PM   #4
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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.
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Old 19-11-2007, 06:24 PM   #5
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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.
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Old 19-11-2007, 07:43 PM   #6
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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.

Quote:
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.
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Old 19-11-2007, 08:51 PM   #7
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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.


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Old 19-11-2007, 11:33 PM   #8
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Despite my inclination to think that we are fully caused, I agree entirely with the comments in your first post Barrett.

Quote:
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.”
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Old 20-11-2007, 12:53 AM   #9
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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.
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Old 20-11-2007, 01:04 AM   #10
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Quote:
Soon Jon you'll understand why you have remained so deluded for so long.
I look forward to it actually.
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Old 20-11-2007, 02:00 PM   #11
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Default 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.
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Old 21-11-2007, 04:26 AM   #12
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Default 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.
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Old 21-11-2007, 04:37 PM   #13
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I think that many PTs estimate that a problem is simple and may be resumed as this simple picture.
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Old 21-11-2007, 04:39 PM   #14
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But I'm now convinced that I'm looking at a partial piece of a bigger picture.
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If you can't explain it simply, you don't understand it well enough. Albert Einstein
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Old 22-11-2007, 03:05 AM   #15
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Default 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.
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Old 22-11-2007, 05:36 AM   #16
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It isn't really likely to change until a shift is made out of the boundary-ridden medical model into the much less predictable world of de-causation (sic). But that alone is a threat to the adherence to EBP, as well as the threat to power and control over a patient's CNS.

Very tricky. But you are not a dead man yet, Barrett.

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Old 22-11-2007, 06:10 AM   #17
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Might be better to avoid dualism whenever possible - just a 'thought'..
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Old 22-11-2007, 06:59 AM   #18
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I'm noticing that there is a similarity between this and the need for symetrical beauty that is a tendency within us all.

It seems we often use our clinical interaction to meet our own needs, even if unknowingly.

Is our job as a therapist, or a manner of growth as a therapist, realizing these needs and learning to overcome them? If that is the case, do we create stressful environments for ourselves because we are living someone else's life?

Or do we just need to be aware of the over-riding need of the patient and meet our own needs by helping them?
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Old 22-11-2007, 03:27 PM   #19
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Default Joyce's comforting thought

Yes Cory, the patient needs to tell their story, but are we obligated to believe it? Are we supposed to make it important?

No Nari, not dead just yet, but one day for sure. In fact, as Tony Soprano used to say of his mother and Uncle Junior, “They’re dead to me.” Of course, both these people tried to have him whacked (killed). This is what I imagine certain therapists say of me, often soon after hearing that I don’t actually think much of causation as an important aspect of management. I’ve questioned something they cling to for reasons that are primal and enduring. Gee, I wonder why they object?

It’s a mistake, but I am comforted by a quote from James Joyce in post #2 of the Altering the Ideal thread that Cory has alluded to:

A man’s errors are his portals of discovery.

Pinker has some wonderful things to say about this desire to order our universe with the illusion of reality generated by a belief in cause and effect and I’ll get to them, but first a word about the word “illusion.” I checked it out on this site and found that it refers to "a mocking, jesting, irony" which explains a lot about our distaste for it.

I imagine people thinking, “So this guy’s telling me that half of my assessment reveals nothing more than an illusion? I wonder if my cousin Vinny still knows that guy...”
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Old 22-11-2007, 07:44 PM   #20
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Hi Barrett,

Sorry. I'm not being clear, as usual.

I'm trying to say that, as in looking for symmetry, when we look for a cause we are trying to satisfy a need for ourself. Meeting this need does not necessarily meet the needs of the patient. We therefore need to be aware of this tendency, recognize when it is occurring, and attempt to overcome it.

My real question is, do we pay a price for this?
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Old 23-11-2007, 04:52 PM   #21
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Hi,
Barrett, correct me if I'm off on this...Are you saying that, although it's important for the patient to be able to tell his/her story, to be listened to, the therapist shouldn't buy into the narrative, as there might be 100 causes or no cause at all, and it doesn't matter anyway? (Which I agree with.)
One compelling distinction for me, between Simple Contact and other methods of treatment, is that SC is about returning power to the patient. I, as the therapist, don't need to know all the "whys" of what brought them to my office. What I need to do is first listen, be interested, then, through the experience of Simple Contact, allowing ideomotion, help them to realize they can trust themselves, their bodies, their instincts. They become their own expert and so the power is shifted from professional to patient, where it should have been all along.
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Old 23-11-2007, 05:26 PM   #22
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Default Working toward blame

Cheryl,

You're entirely correct. Perhaps the reason so many don't "get" this will be found in the following.

Cory,

In my opinion, one of your enduring qualities is clarity. That’s why we allow you to post here (ha,ha). I see what you’re saying but may not have made my answer relevant to the question.

In any case, Pinker’s basic premise is that the way we use words drives our thinking and understanding – not the other way around. At least, that’s part of what he says. His is a long book, about 500 pages, and its contents may very well extend my capacity to apply it to this subject. I think. I’m pretty sure.

It seems to me that the unconscious motivation of many therapists, which, of course, is unknown to them unless they become somewhat obsessively introspective, is important here.

We know that stories are unreliable, often misleading and irrelevant to care. We know that eyewitness testimony in legal circles is distrusted for the same reasons. Still, most therapists insist on emphasizing their importance in an effort to discover cause. Throughout history great thinkers have warned against this linear relationship between what we think we know and imagine we see. I know, it’s spooky.

But Pinker says this quite clearly: Our concept of causation is indispensable to our attribution of credit and blame in everyday life.

Is it possible that a therapist’s desperate desire to blame something or somebody (unconsciously there for the most part) for the current complaint is what drives us to search for cause?

I think you know my answer. What’s yours?
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Old 23-11-2007, 06:27 PM   #23
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Hi Cheryl,
Quote:
although it's important for the patient to be able to tell his/her story, to be listened to, the therapist shouldn't buy into the narrative, as there might be 100 causes or no cause at all, and it doesn't matter anyway? (Which I agree with.)
One compelling distinction for me, between Simple Contact and other methods of treatment, is that SC is about returning power to the patient. I, as the therapist, don't need to know all the "whys" of what brought them to my office. What I need to do is first listen, be interested, then, through the experience of Simple Contact, allowing ideomotion, help them to realize they can trust themselves, their bodies, their instincts. They become their own expert and so the power is shifted from professional to patient, where it should have been all along.
I think more like where it always has been, except that the patient lost track of it (came to feel dis-membered) and needed a bit of help with re-membering, and (as you point out) regain their intra-power/inter-power dynamics, about which PTs (mostly) remain completely ignorant.

I think on another level, it's the same thing as the patient's "locus of control" that psychologists constantly remind themselves they must not violate. Physical therapy (the way it's taught and practiced by most) violates this all the time in its attempt to be "medically" acceptable AND simultaneously blames the patient if they don't get better, or fall into some unacceptable "category", or if they don't automatically align with some "clinical prediction rule". Hard for a patient whose nervous system can't feel any sense of control within the therapeutic relationship to regain inner locus of control.
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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

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Old 23-11-2007, 07:39 PM   #24
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Diane,
Nicely said. I believe the initial listening, truly listening and believing that what they are saying is their story, regardless of and putting no importance on the details of that story, (which are likely inaccurate. As Barrett pointed out--who can pass that test?) is key to establishing a therapeutic relationship, improving the likelihood that the patient's perception of the story as defining them or their experience, will change, empowering them to have a therapeutic relationship with themselves.
Barrett,
Doesn't casting blame, finding a cause for something, give us the belief that we can control that something, therefore IT CAN'T HAPPEN TO US.
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Old 23-11-2007, 07:54 PM   #25
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Cheryl,

Exactly. I thought at the beginning of this thread that perhaps I could uncover two things deeply embedded in therapy, both to our detriment and both unlikely to ever disappear or ever be understood by those who teach us, direct our departments or articulate our future as a profession - blame and control. Not optimistic, not hopeful, not complimentary, of course, but real nonetheless.

Our search for cause perpetuates this situation and, I think, the dynamic keeps my students from hearing me when I try repeatedly to teach the origins of pain as an alternative emphasis. That's the failure I mentioned in post #1.

It appears that we've arrived, and I appreciate your expressing this so well.
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Old 23-11-2007, 08:07 PM   #26
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The search for a cause in order to blame someone or something else isn't just confined to therapists. This shift seems to have become inherent in today's society.

I think the locus of control is an interesting comparison between psychs and PTs' behaviour. How did it happen that people go to psychs knowing all they will do is offer suggestions, listen closely and provide empowerment to the patient; but people who go to PTs expect to be told a cause or a diagnosis, and a prescribed treatment plan, plus compliance and obedience to this plan...

Damn dualism dodo.

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Old 23-11-2007, 09:56 PM   #27
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Nari,

PTs encourage the situation you describe even more than patients do. This is why I wrote Body Counseling a few years ago.

In a thread as complex as this I often find it useful to sum things up from time to time.

1) Even though therapists generally understand that the patient’s story is unreliable and often irrelevant to the care consequently needed, they continue to honor and emphasize the patient’s story and treat the details of history offered as if they were true.

2) The resultant “discovery of cause” provides comfort for both therapist and patient, despite its lack of veracity.

3) Acting upon the cause derived from the patient’s history and the therapist’s bias, treatment proceeds toward its logical conclusion in a manner that might or might not alleviate pain.

4) In any case, this sequence of discovery and management satisfies the therapist’s unconsciously generated need to find blame and exert control. It may even provide an illusion of self-protection.

5) Thus, searching for cause, even if not helpful, serves a purpose more important to our unconscious motivations than our conscious and reasonable ones, and it makes learning about the origins of pain difficult, dissatisfying, and, in some instances, nearly impossible.

Have I got all this bad news about right?
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Old 23-11-2007, 11:36 PM   #28
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Sorry, Barrett, I often have hidden agendas which aren't explicitly expressed. When I said patients expect to be told and directed, it is because doctors and PTs want it that way, and transmit that attitude.

I think you got all 5 points quite right, and it is bad news. But some of us have known the bad news for a while, in a broad sense. Good to see it 'pointed' out.

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Old 24-11-2007, 08:11 PM   #29
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Pinker speaks late in his chapter about causation from the perspective of a television show. I know, perfect for me. Specifically he cites the wildly popular series Law & Order.

…any fan knows that the legal system really does turn up agonizing scenarios that hinge on whether an act may be causing to die, enabling to die, or allowing to die…Given the endless enigmas flowing from our concept of causation with its model of directness, it’s no wonder that episodes of Law & Order seem to fill every channel on the cable, morning, noon and night.

Pinker also says: Our concept of causation is indispensable (but) in the full drama of human experience, it will sometimes collide with circumstances that don’t meet its standard checklist.

It seems that though we want desperately to assign blame and exert control we also find the inability to do this easily quite intriguing - thus the appearance of Law & Order marathons. We want them and we watch them unless thoughtfulness is for us boring and scary.

Some do, and they watch Desperate Housewives.
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Old 29-11-2007, 12:40 PM   #30
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Jon Newman found this and posted it elsewhere. I think it fits perfectly here.

Those who make causality one of the original uralt (age-old) elements in the universe or one of the fundamental categories of thought - of whom you will find that I am not one - have one very awkward fact to explain away. It is that men's conceptions of a cause are in different stages of scientific culture entirely different and inconsistent. The great principle of causation which, we are told, it is absolutely impossible not to believe, has been one proposition at one period in history and an entirely disparate one at another is still a third one for the modern physicist. The only thing about it which has stood... is the name of it.

Charles Sanders Peirce, Reasoning and the Logic of Things

He said this in 1898.
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Old 07-12-2007, 12:44 AM   #31
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Ready, set...

The link to the book review by Patricia Churchland (see post #17) has garnered a response by Pinker. See John Wilkin's Evolving Thoughts blog for more.
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Old 15-12-2007, 05:02 AM   #32
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Here's a podcast/article about neuroscience and the law. I'll look for the content in the new season of Law & Order.
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Old 21-03-2008, 11:56 PM   #33
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Last Wednesday's episode (of Law and Order) was the first I remember the series using fMRI in the courtroom. I feel confident that it won't be the last time we see it.
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Old 27-04-2008, 05:31 PM   #34
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This Philosopher's Zone podcast could have found a place in any number of threads but this one is still interesting to me. Consider spending some of your time learning more about the time you're spending.
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Old 29-09-2008, 02:34 AM   #35
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[YT]62daicHQ9as[/YT]
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Old 29-09-2008, 01:28 PM   #36
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Jon,

Great tune and directly to the point of this wonderful thread; one of my favorites.

In case anyone's wondering, emphasizing origin as opposed to cause hasn't gotten any easier.
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Old 02-12-2008, 02:01 AM   #37
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From the folks at The Science Network: Neurolaw and Neuropolitics
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Old 02-12-2008, 08:45 PM   #38
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Reading through this thread I can't help but think that actually lots of the things that patients come to us for DO have causes!
And that even though no doubt the pain/injury is part of a large, global, holistic, multi-factorial neuromatrix system we can and should identify the causative parts of this that we are able to.

Identifying causative and provoking/allieviating factors helps to give the patient more insight and therefore more control of their health.
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Old 02-12-2008, 08:51 PM   #39
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Jono,

I always tell therapists that looking for the cause (as it has been defined here) is a perfectly human thing to do, but that the search will probably be both fruitless and unnecessarily time-consuming.

Please convince me otherwise with a specific example.
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Old 02-12-2008, 09:03 PM   #40
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Okay i'll take the bait!

Smoking causes lung disease/cancer. There are other factors involved such as genetics and environmental influences but if you have a patient with COPD it is important to ask them if they smoke. Then you should explain to them that this is a cause and help them to quit.

From a PT perspective lots of things are "causes" for pain. Some people use their bodies poorly (biomechanically, posturally), some people have bad workstation set-ups, some people are stressed, some people are overtraining.... my last patient ran 4kms wearing jandals and now has plantar fasciitis, my next patient just did a cycle race and now is complaining about tight suboccipital m/s.... i see causes everywhere!

I do understand the bias of our brains towards seeing patterns in randomness- but it doesn't logically follow that EVERYTHING is random and there aren't causes anywhere!
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Old 02-12-2008, 09:49 PM   #41
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Jono-
Well, this need to see causes is common, but unfortunately it is also counterproductive.
Let's see to your examples and find out why.

For COPD - does smoking cause this? Meaning, does smoking exist in such a way that COPD always follows? Well, of course not - and lucky for all the smokers out there. This is at least a contributing factor that we can establish through a plausible and basic science mechanism, and therefore might be worthy of approaching. But it's certainly not a "cause".

For your runner and cyclist examples - certainly there are people who have done those things and not had pain or "tightness" - what do we tell those people? Certainly there are people who have those same "problems" yet have not done the activity that supposedly "caused" these problems in your patients. What do you tell them?

In short, we have now spent some time and energy trying to determine a cause for these problems. This time has done no further work toward helping us address the origin of the patients complaint or assist the patient in any meaningful way. Other than that, its really a good idea. (just a joke there)

I think addressing contributing factors makes sense. For those with mechanical pain, prolonged postures and positions are a good example. But calling them a "cause" is probably leading us down a path that won't lead to any useful care.
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Old 02-12-2008, 10:01 PM   #42
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Jono,

I sense that you're talking about something to blame, not for the cause. Finding something, or, better yet, someone to blame is perfectly human, but it's not productive.

Forgive me, but I don't think you're getting the concept of origin (or cause) here.

One more thing. It's 2008. Do we really have to tell people that smoking isn't healthy? Isn't that kind of patronizing?
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Old 02-12-2008, 11:32 PM   #43
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Along with the smoking thing, what about carbohydrates 'causing' diabetes, red meat 'causing' bowel cancer, poor posture 'causing' spinal pain; all these things may contribute along with many other factors to ill health, but living is a risk factor anyway.

People look for a cause, certainly. It is logical that a bad car crash will cause some degree of injury. But if someone with no history of trauma presents with debilitating pain in one or two parts of the body and he has been cleared of morbid pathology, searching for a cause is not useful. Primarily because we don't treat anatomy, we treat processes.

Jono, I can understand your stance; some years ago i would have argued that everything has a cause and it should be searched for.
But I've worked out, as Jason has stated, it is counter-productive. It doesn't change anything and the patient tends to become over-medicalised.

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Old 03-12-2008, 01:25 AM   #44
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Wow! I'm honestly kind of suprised by those responses!

I agree with Nari's point that it certainly isn't always possible to know the cause, and i agree that sometimes knowing a 'cause' doesn't actually change your management of the patient.

I know that health isn't a linear, cause/effect process and i do understand that simplistic "X causes Y" type formula's lead to frustration and aren't particularly helpful.
If you got 1000 people to run 5kms wearing jandals some would be injured and some would feel fantastic- there is a great deal of variability in any normal population.

I don't disagree with any of this!

BUT the guy i saw this morning didn't have any fasciitis until he ran wearing jandals and since then he has had fasciitis. If i didn't probe around to find out this cause- i might have done the best treatment in the world but he may have just kept on aggravating the problem and i wouldn't have been able to have help him. Seeing as i did ask him for a bit more detail I can suggest that he walks his dog in running shoes not jandals and hopefully he'll have a much better/quicker/cheaper outcome. Asking him about the circumstances around his injury gave me a possibe clue to helping him.

I would think of finding 'blame' as being a judgemental way of approaching things... looking for 'causes' is different in my opinion.

Barrett- Sorry if i came across as being patronizing re: the smoking thing. I was just using it as an example.
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Old 03-12-2008, 01:35 AM   #45
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The spectrum of "causes" becomes obviously non-functional when you look at something like chiropractic. First of all, "subluxations" cause all things that can ever go wrong with anyone (justifies treatment by manipulating the spine for "wellness" care).

On the other hand, chiropractors claim they never "cause" stroke in patients, because "cause" cannot be "proven" definitively (excuses treatment by manipulating the spine for "wellness" care).

Not even a well-oiled trombone could slide up and down the cause spectrum faster from one "cause" for everything, to "can't prove cause," faster than chiro.

Slick eh?
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Old 03-12-2008, 01:37 AM   #46
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Jono,

Good answer. I really think we're very close to complete agreement here and the jandals are certainly something to talk to this guy about.

Whatever they are.
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Old 03-12-2008, 02:03 AM   #47
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Old 03-12-2008, 02:24 AM   #48
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I think a major difference here is whether the pain is acute or chronic.

If the pain is acute,there is - atleast in most cases - a linear relation between pain and injury. If the pain is chronic,finding the cause will not help much. If it is chronic, even if we get rid of his sandals, the pain will most probabaly linger.
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Old 03-12-2008, 02:43 AM   #49
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and Jono, let's not forget that even the use of the thongs (our old word for jandals, but because of underwear design, now an archaic term) is only a 'likely contributor". A very likely one.
He may not have developed the plantar fasciitis, had he not run with the jandals on a slanted road, or on grass, in the rain, or on hot ashfalt, or with a full bladder, or while pulling his dog with his right arm....
You get my drift? The semantics are of importance in these things.

I will never forget the example of the 23 year old figure skating coach, standing on dress shoes (flat heeled) in the middle of the freshly flooded (smooth) ice surface to make suggestions to our national champ. She pivoted on the ice - in flat dress shoes - and fell down in agony. X-rays showed she had a spiral fracture of the tibia (and NO osteoporosis) . Shoes? Ice? What? They still have no idea why.....She had no previous injury or participation in sports preceding this injury - no falls, slips, mishaps.

The idea is, that obvious pathology can contribute to pain. Is it the "cause"? No. What the brain does with the input IS the "cause of pain" - it creates that output.

Sorry for this rambling post - I am going to send it anyway.
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Old 03-12-2008, 02:58 AM   #50
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We didn't discuss it in our book discussion of the Last Well Person by Nortin Hadler but he describes this cause seeking as proximate-cause epidemiology. He defines it as "the exercise that attempts to deduce which of the health hazards operating at the time of death is most likely to have been the cause. p18" He instead advocates for "life-course" epidemiology.

From Hadler: "proximate-cause epidemiology, which has enjoyed recognition and generous research support, provides the raison d'etre for much that is lucrative for the contemporary pharmaceutical industry. p217"
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