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Old 15-01-2007, 03:43 AM   #1
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Default Manual Magic

Manual Magic


Any sufficiently advanced technology is indistinguishable from magic.

Arthur C. Clarke

I sit alone quietly for a few moments after every workshop and ask myself the same question: What do therapists want? I learned long ago not to expect my words and demonstrations to have any significant impact upon those who just spent a day watching the changes emerge from them and the people within reach. I explain all of it and I know it’s quite impressive – but I know it makes no impression. Nothing that lasts anyway.

I listened to a podcast from Science & the City this week featuring an interview with James Kakalios, a physics professor at The University of Minnesota. He teaches a course about “the physics of superheroes” that has had me thinking about it since. Kakalios says, “The super powers themselves are impossible, but we grant each character a one time miracle exemption from the laws of nature. In other words, ‘If you could (insert super power here) then what consequences would be consistent with physics?’”

The enduring popularity of comic book heroes is probably due to this combination of the unbelievable and the merely unlikely. Somewhere in there a bit of esoteric knowledge derived from careful study would reduce the mystery, but, in my experience, many aren’t especially interested in doing the study. Some are happy just letting others know. Others prefer the mystery.

This week I’ve also watched the movie The Illusionist starring Edward Norton as a stage magician in Vienna circa 1900. Though his popularity as a performer has everything to do with his showmanship, the method behind his illusions is entirely dependent upon his skill as a craftsman. He’s the son of a cabinet maker and throughout the movie short scenes make this skill with various materials obvious. The word “craft” itself holds a certain fascination for me, and, as you’ll see, it’s loaded. In Old English “craeft” meant strength and courage, expertness and skill. Eventually, craft connoted trickery or deceitfulness. A true craftsman might possess all of this and choose which qualities he’d like to combine or emphasize.

Manual care, especially the gentler sort, can appear mysterious. The therapist seems to “do” very little and certainly doesn’t introduce enough force to alter connective tissue in any enduring way. Still, dramatic changes in sensation and range of motion may rapidly follow the application of a hand upon the skin’s surface. That such things happen isn’t in dispute; how it happens is the primary purpose of neuroscience research as it relates to touch, sensation, stimulation, perception and efferent flow. Rational explanations have grown exponentially within this realm. It takes a little reading and thinking to gather it all in, I admit.

Let’s return to the super hero for a moment. The suspension of natural law necessary to actually possess a super power is one thing, but Professor Kakalios’ lecture makes it clear that beyond the application of the power itself there are physical consequences that can be predicted and measured. Super powers are fine for a comic book, or, perhaps, a session of “energetic” therapy, but, in the clinic, the method shouldn’t require any deferment of physics as it’s been understood for several centuries. Because of this, it’s not appropriate to equate gentle manual care with super powers, unless of course you feel you can get away with it. Obviously some therapists have done this.

What do therapists want? I think they want magic. But by this I mean magic in the way that a true craftsman might present it. Though subtleties in the method may be virtually invisible to anyone witnessing gently applied touch, these alterations in pressure have a purpose and a theory with construct validity. They can be explained and defended, and, in my opinion, they should be.

More about this in Part II of Manual Magic.
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Old 16-01-2007, 03:35 AM   #2
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Default Manual MagicPart II

I read once that "magicians aren’t trying to fool others, but to fascinate them." But having been a member of the International Brotherhood of Magicians for a while in the 80s, it seems clear to me that most magicians haven’t gotten this memo. In fact, I came to understand that the membership card I carried in my wallet was little more than a license to lie. Magicians call these lies ‘professional secrets” and they are certainly entitled to them. I noticed long ago that every one of them was available for purchase. I own a stack of books full of these professional secrets – not that that makes me a magician.

Though a magician might hold forth with an entertaining patter, the nature of the method he uses to fool or fascinate others is withheld. If he speaks of it at all he is probably lying. His words and movement are designed to confuse, hide from view, and distract the audience. Not exactly the sort of thing that creates trust.

As this thread progresses I’d like to return to different aspects of The Illusionist from time to time because the movie is emblematic of the essence of magic, including its dance with deception; the same dance many who practice manually do so often.

Often a director makes the hands of the protagonist prominent the first time we see them and this is one of those movies. Specifically, Norton’s character, Eisenheim the Illusionist, is seated on a simple chair in the center of a stage, his hands fully spread across each knee and almost glowing against the dark cloth in the stark stage lighting. Large and seemingly strong, these hands play an integral part in the slights he does effortlessly at various times in the movie. By contrast, Eisenheim’s nemesis, the dastardly crown prince, is traveling in disguise later in the movie when the camera focuses on his hands lying limply in his lap. Anxious about his appearance he asks his companion how he looks. ”Ordinary,” is the answer.

Whether they are used to actually perform the trick, simply to gesture toward the effect or distract the audience, a magician’s hands are always busy. If you perform manual care what qualities should your hands possess?
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Old 16-01-2007, 02:50 PM   #3
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If you perform manual care what qualities should your hands possess?
The exact opposite qualities to those of a magician: Still, slow, soft, warm, perceptive, receptive, kind, honest, non-threatening, boundaried.

It's ok if they are used to "take advantage" of opportunities that appear (e.g., taking up slack that appears for the first time in decades), but not suddenly, and they should communicate large amounts of thoughtfulness backing up any small amount of firmness. Fast moves are to be avoided entirely if you want the nervous system in your hands to actually learn anything new, or extinguish any former learning. The patient should be able to practically "feel" their own changing, amplified through such hands.
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Old 16-01-2007, 05:37 PM   #4
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Diane,

Actually, I would asign these qualities to a magician's hands as well. Of course, I've spent hours practicing slights (more properly, "sleights," though it seems the two words have come to mean the same thing within the proper context), learning to soften, slow down and sensitize the manipulation. I don't suppose someone who hasn't put the time in would realize this. In fact, the speed with which something is done deceptively isn't nearly as important as the angle of the observer's vision. Lying as they do, magician's would have us believe otherwise.

The obvious difference between a magician's handling and ours lies not in the skill we've acquired, but in the nature of the thing we handle - animated in our case, inanimate in the magician's. It would follow that they have a different if not more difficult job in one sense because they must make things happen via their own carefully disguised force and we don't need that; the patient already has the force necessary for movement within them.

On the other hand, while the magician merely needs to account for precision, friction and gravity, we have to constantly adjust the use of our pressure in response to the patient's movement. Bobath did this amazingly - and she appeared quite "magical."
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Old 16-01-2007, 09:30 PM   #5
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OK, I accept that.. I was meaning, opposite of "distracting" or "gesturing."
I was meaning, focused and responsible. Both require a considerable amount of self-learning in the hard drive of one's own sensing and outputting brain.

I described it to a patient I saw this morning, who is a visual artist, as similar to contact improv dance, two nervous systems learning from and suggesting to one another.
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Old 16-01-2007, 09:46 PM   #6
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I think this is relevant when we talk about touching someone:

Last night I watched a program about an autistic woman in her 60s who has become something of a hero in the USA with her understanding of the fear of cattle going into the abattoirs. As a result of her endeavours, the practice of shuffling cattle for slaughter any old way has been radically changed, resulting in happier animals easier to manage on the way to slaughter.
She also noticed that cattle in a press which totally constrained them, for example vaccination, relaxed with the high pressure on their bodies. As she has many fears and anxieties due to her condition, she put herself into a cattle press for 20 minutes and noticed her fears resolving.
Light touch is a real aversion to her; so she has managed her condition by building her own press, where she totally constrains herself for 20-30 minutes a week.
What this means I am not sure, but I thought it was interesting. Many people do not like light touch (I am one of them) and I wonder if part of the magic of touch is recognising those folk who respond to heavy pressure, and those who do not.....?

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Old 17-01-2007, 12:13 AM   #7
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Nari,

On page 154 of Shallow Dive you'll find Temple's Gift, an essay I wrote about this woman in the early 90s.
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Old 17-01-2007, 12:37 AM   #8
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Thanks, Barrett..it was one of the few I hadn't read yet.

I thought she was quite remarkable, having battled through endless psychotherapy and other, as it turned out, unhelpful measures. She noticed the cattle were disturbed by some leaf rubbish on the paved path to the slaughter room, and that reminds me of my horse who startled at the merest change in the environment - a small branch on his gravel path, sometimes even just a leaf.

I too think there is a lot to be learned about contact and connecting. Maybe we 'connect' only if the context is right; regardless of what we do or enable in the external and internal environment. Temple concerned herself with animals and the environment; but she probably will never connect with people and the environment. It doesn't matter, she succeeded anyway.....


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Old 18-01-2007, 02:44 PM   #9
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Yesterday I dusted off a book by Eugene Burger titled The Performance of Close-Up Magic. As it happens, he’s being interviewed on this week’s Point of Inquiry podcast. Coincidence? I think not!

Burger’s reputation as a master of sleights and performance is unsurpassed. And when he writes about his life’s work he doesn’t stick to the usual “here’s how the trick is done” format. I’d like to paraphrase what he says in this book’s introduction, altering the terms at times to connect more closely to manual care as I have come to know it and to teaching it as well.

Burger begins by separating the “technical” from the “theatrical” but emphasizes that these two aspects of the work should not oppose each other in any way. When they blend seamlessly what you finally see is a wonderful performance. Similarly, I have always emphasized that technique (read technical) should flow from theory (read theatrical). In this way when asked to defend what they’re actually doing therapists can explain their practice by appealing to its validity and biologic plausibility. Or, at least, that’s the plan.

If either the technique or theory is lacking this will show, especially when the therapist’s method and practice are questioned. Something that I think should happen frequently. Remember Joel Achenbach’s admonition regarding the nature of science: In science if you don’t work hard enough to prove yourself wrong your friends will gleefully take up the slack.

Magicians frequently watch and critique each other, and Burger is careful to point out how this should result in subsequent performances that are unique and original rather than merely mimicked. Such “slavish imitation” he says will seriously stunt the growth of any profession committed to theory – something that’s supposed to change – and certainly the method that should flow from that.

More about this in Part III of Manual Magic – The Fidelity of the Meme
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Old 19-01-2007, 02:45 PM   #10
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Default Manual Magic Part III - The Fidelity of the Meme

Like any magician teaching his colleagues, I try to get my theory and method across to the therapists who watch me during those few hours we are together. I think I manage this for the most part, but, ideally, they would then take all of this and pass it along intact to our colleagues. At this I fail miserably, mostly.

Thing is, I get paid the same, much as would if I failed to help a patient feel better. Not that that’s ever happened or anything.

What I’m trying to do has a name and a growing tradition in modern evolutionary psychology; it is the creation of a meme that is replicated with fidelity. Richard Dawkins speaks of this in his original work on the subject of memes here. I especially like this brief and clear description: “a noun that conveys the idea of a unit of cultural transmission, or a unit of imitation.”

Briefly, my ideas, my memes (admittedly, very few of them actually original) are transmitted via my voice, writing and behavior to the therapists gathered around me. They take that and use what they can to imitate what I’ve done. In theory, this behavior will result in the same thing I got a few moments earlier: a warmer, softer and more comfortable person in my hands. And, in class, it does. But if memes travel from brain to brain (and they do), mine poop out after that first jump. Okay, “poop out” isn’t what Dawkins would call it. He’d call it “a lack of endurance.” I like my description better for some reason.

The fidelity of a meme refers to its tendency to remain true to its original form from one transmission to the next. A truly successful meme will appear much the same even after numerous transmissions. Classic magic tricks containing a great deal of fidelity are pretty well known despite the fact that the method has been transmitted in a variety of ways many times and the presentation of the effect ends up very different from the original. I mean, how many ways have you seen a woman sawed in half? However it might have appeared the result is always the same. Now, that’s a meme with fidelity.

So, what’s the matter with my meme?

Consider this from Dawkins: If the meme is a scientific idea, its spread will depend on how acceptable it is to the population of individual scientists; a rough measure of its survival value could be obtained by counting the number of times it is referred to in successive years in scientific journals.

More in Part IV - The Fecundity of the Meme
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Old 21-01-2007, 03:04 PM   #11
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Default Manual Magic Part IV - The Fecundity of the Meme

“Not a single student showed up for his second lecture, and throughout almost every lecture for the next seventeen years Newton talked to an empty room, listening merely to his own voice bouncing back at him.”

From The Last Sorcerer by Michael White

When I think of the many things I’ve chosen not to learn in my life, I can’t come up with a single strategy for ignorance more powerful than indifference. I employ this daily, and thus I don’t know all kinds of things that perhaps I should. The consequences of this cluelessness sometimes surprises me and sometimes not. Sometimes I pay dearly for it, and at other times I’m grateful not to have known. All of this is something that takes some careful introspection, and I’m pretty sure anybody reading this could say pretty much the same thing.

Fecund means “producing or capable of producing offspring; fertile; very productive or creative intellectually.” Along with fidelity and endurance it completes the triad of qualities that any successful meme is known to require. Dawkins calls it fecundity and aside from the obvious importance of a meme’s ability to generate new but deeply related ideas and behaviors, we know that the speed with which we this can happen is essential for its success as well. Think of the survival of animals in the same way and you’ll see what I mean.

The quote above from a biography of Isaac Newton describes what this man went through early in his career. More about him and his relation to therapy practice can be found here. Briefly, White describes the initial reaction to Newton’s first lecture on optics. Employing his unique knowledge and skill Isaac had personally handcrafted a new telescope that was ¼ the size of those in use yet was ten times more powerful. This is what got him the appointment to the Lucasian Chair at Oxford, the same one occupied by Steven Hawking today.

In short, people loved the device built as the end result of Newton’s knowledge, but when it came to understanding how he had come to build it as he did they were indifferent to the point of willful ignorance. Thus, this meme represented by a reflecting telescope (previously there only been refracting ones) took a while to get off the ground.

What if the therapy community were to learn of a method of care that immediately altered in the desired direction the signs and symptoms of chronic discomfort it saw in the clinic each day? Wouldn’t you expect this discovery to result in the adoption of this method – this meme?

Before you answer, I want you to think of the consequences of fecundity. If the offspring of an idea are desirable to the surrounding community then fecundity is to its advantage. If not, well, what chance is there of its survival?

Let me put it another way: If the “magical” effect of another’s hands fascinates us and compels us to investigate the deep model of its underlying reality then such a method might eventually become established along with a defendable theory.

If it scares us then something else will occur.

Do you see where I’m going with this?
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Old 21-01-2007, 07:32 PM   #12
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Wouldn’t you expect this discovery to result in the adoption of this method – this meme?

Before you answer, I want you to think of the consequences of fecundity. If the offspring of an idea are desirable to the surrounding community then fecundity is to its advantage. If not, well, what chance is there of its survival?
At first I was confused by the question. I thought that such a method would be desirable as it allows success in a patient population where success has been difficult in the past.

Then I realized how treating in such a way would differ from current strategies and typical clinic operation. It might be scary for the business owner who runs a clinic in this "we are paid not for the quality of our treatments, but rather the amount of treatment given" state of healthcare we are in. At least in the US.

There is an article posted on EIM from the New York Times, I believe, that is all about this topic and how a Virginia Mason hospital in Seattle is battling it. It stated that when the hospital changed its practice by focusing on quality, which did increase, it went from making $200 per patient to losing $100. Pretty scary. They found that having the LBP pt. seen by a PT first was the highest quality way to deliver their care. Turned out to be scary to some of the docs in the hospital's pain center who subsequently left.

Barrett,
Maybe you could market your course as "scary therapy for a scary profession."
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Old 21-01-2007, 08:03 PM   #13
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It was in the Wall Street Journal, not the new york times, and is titled "A Novel Plan Helps Hospital Wean Itself Off Pricey Tests."

Again, it is available through EIM site for free right now.
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Old 21-01-2007, 10:32 PM   #14
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Cory,

A perfect example.

True story:

Many years ago I learned of a card trick called “The Invisible Deck.” And it went like this: I hand someone and “invisible” deck of cards and ask that they go through the business of shuffling them thoroughly. Having done so, they choose a single card, memorize it, and then place it back in the deck face down while all the other cards are face up. Remember, this is all pantomimed because they are holding an “invisible deck.”

I then ask this person to tell us what card they reversed, pull a deck from my pocket and fan it out, face up. Only one card is reversed and it turns out to be theirs.

A pretty good trick, but after a while I learned to add this: I’d have the person pretend to tear a corner from the chosen card, and when I fanned the deck a few moments later they’d find that not only was this the only one face down, it was the only one torn as well.

I remember telling the magic store owner I knew that I’d begun presenting it in this way and he shook his head. “Too strong,” he said. And by then I knew that he was right.
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Old 22-01-2007, 12:01 AM   #15
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A link to that article discussed by BB.
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Old 22-01-2007, 04:27 AM   #16
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There are some lines and images from The Illusionist that struck me as appropriate to mention here.

In the movie’s prologue there’s a scene depicting Eisenheim as a young boy attempting to hide from some hostile men. He soon finds that he simply can’t do this with mere force of will and never tries to do this again. In fact, he later admits that he has spent much of his life “looking for a real mystery,” but he’s never found one. To me, this sounds like something a number of therapists have done over the years. Of course, a few stopped looking once they imagined that a real mystery had been found and they stayed there. This includes everybody doing “energetic” work.

The narrator also speaks of what he calls “the forces of the universe – life and death, space and time, fate and chance.” Of course, none of these are universal forces at all, they just sound like they are. Using language in this way makes the magician seem very wise, especially when the general public doesn’t know what the 4 forces actually are. As is said of Eisenheim when he is a young boy; “People began to believe that he had some kind of special power, or that he was, at least, a bit different.” Funny thing, John Barnes writes autobiographically of his own life in this way though I was simply described as “a well-adjusted child.”

Eisenheim is described as someone who’s “broken free” and whose illusions “approach the realm of art.”

Now, to me, that’s magic. Can we make manual care appear this way without pretending that it’s a super power?
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Old 22-01-2007, 08:25 AM   #17
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Barrett,

Do you do magic in the classes you teach? You should. It would leave a lasting impression about how our senses can fool us and many of the other themes that your class revolves around.
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Old 22-01-2007, 12:56 PM   #18
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Randy,

I agree that it would, but I found long ago that the performance of the simplest effect had a very negative effect upon me personally. Though I thought I eventually would, I was never able to overcome the profound fear and "flop sweat" magical performance would produce and I simply had to abandon it. I presume that this has its origins in a sort of deception I am uncomfortable with (I prefer other kinds) and the possibility of failure. Funny thing, juggling and playing the harminica don't have this effect and I've been known to do these when I feel it will help.

You bring up a good point though, and it's addressed in the movie. Eisenheim's rival is the crown prince, an intelligent but profoundly arrogant man who thinks he cannot be fooled. Having been humiliated by Eisenheim's use of a hidden magnet (something the magicians exploited until the general public learned about them), the prince is chastized by his fiance. He responds, "He tries to trick you - I try to enlighten you - Which is the more noble pursuit?"

I'm with the prince on this one. Too bad he's a sadistic control freak.

Optical illusions are common knowledge except when it comes to the visual inspection most therapists do though they exist on the patient's surface as well. There's also the issue of the usefullness of this information even if it is reliable. I tell my students that with one exception (hip posture) they'd be better off not looking.
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Old 23-01-2007, 04:36 PM   #19
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So, if therapists want to appear magical, and I think they do, the question becomes this: What do we need to understand about the magician’s knowledge and skill that will make us appear magical?

1) Magicians don’t mistake their skills for super powers. What they claim is up to them and this is where ethical concerns play a role. Many would say that their entire disclaimer regarding special powers is contained in the words “magic SHOW.”

2) Though they typically remain silent regarding the science that forms the foundation of their effects, they are capable of explaining all of this at an appropriate time.

3) How they go about presenting their knowledge and skill is an individual thing and will vary depending upon the context of the situation. Seen from a therapist's perspective this includes, of course, the nature of the patient.

Finally, there is the moment of revealing. By this I mean the orchestration of the trick’s unfolding; its completion. Customarily this is enhanced with elements of surprise and further mystery.

This is where I think the practice of magic and that of Simple Contact differ profoundly and fundamentally. I touch others and they soon begin to move in ways they find effortless and surprising, warming and relaxing. I know that this appears magical, and I know as well that this result and this moment are the end result of study and experience on my part. I know where the movement comes from and what it represents. I know that my attitude is reflected in my hands’ activity at the outermost layer of the patient.

Here’s where I break from the magical community. I do this by explaining everything I can immediately. Random and unexpected movement may be present and observable in the patient, but there is no mystery, and I never encourage another to treat the phenomenon of self-correction as if it were.
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Old 23-01-2007, 08:01 PM   #20
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I just learned of this article and thought I'd post it here.

Great thread Barrett.
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Old 23-01-2007, 08:27 PM   #21
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My favorite bit of Jon's article:
Quote:
Reality is the most potent check on runaway magical thoughts, and in the vast majority of people it prevents the beliefs from becoming anything more than comforting — and disposable — private rituals. When something important is at stake, a test or a performance or a relationship, people don’t simply perform their private rituals: they prepare. And if their rituals start getting in the way, they adapt quickly.
My bold.
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Old 24-01-2007, 01:46 AM   #22
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A patient commented to me during the middle of a session that they felt as though lots of little demons were being exorcised from his body. I had explained what was happening and why a few days earlier of course, and the comment was offered in a joking manner, but it made me think of this thread and how at that moment I had the option of playing up the whole exorcism angle and if I had, whether the outcome would be any different? If therapists want the magic and the mystery, do patients too?

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Old 24-01-2007, 02:03 AM   #23
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I don't think so. I think when patients talk that way, they are describing their own interoception in their own way, that's all. I think we can nod along, taking it for the metaphor it is, and let them express it as part of their own "narrative therapy".. but when they ask a question they should get a straight answer. The therapist needs to be the stand-in "parent" in a therapeutic relationship - I think that entails a responsibility to not confuse patients with more fantasy, perceptual or otherwise. They need information, not a "pandering".. remember their brain chemistry is changing along with their motor output. Someone has to stay sober to "drive home".. - points of info in this case. If they want fantasy they can go to the Reiki person, right?
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Old 24-01-2007, 03:35 AM   #24
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Great additions to the thread here.

I can’t think of the name of the thread I began some time ago but it contained a passage from one of Michael Shermer’s books. An anthropologist in the South Pacific found that when fishermen journeyed far from shore their rituals and superstitions grew in relation to the distance from land. As they returned to shore their rituals and irrational beliefs diminished. In short, it’s the uncertainty that generates magical thinking, not its effectiveness. Shermer points out how you see this in baseball in the form of players heading toward the field or the batter’s box.

In my experience therapists begin to act a little strangely and tend to accept irrational explanations when dealing with neurologic problems but not when they can make the case for mesodermal dysfunction. Neurologic problems are, in effect, far from shore. And, the fact is, movement solutions for neurologic problems look a bit like “magic” and the therapist in their presence like a magician. This puts the ortho people in a bit of a bind when they try to stay with the biomechanical rational they hold so dear.

To me, that last paragraph explains a lot about the quandary many trying to treat an abnormal dynamic find themselves in. No wonder they are drawn to the “magical” sorts of care sold out there. I don’t think they’ve quite thought this through.
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Old 24-01-2007, 04:23 AM   #25
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Thanks to Jon here is the link to the previous thread I mentioned.
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Old 25-01-2007, 03:28 AM   #26
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Let’s go back to the issue of fecundity. Cory’s link to the newspaper article was perfectly appropriate because it demonstrates a problem with any successful meme any therapist might propose – financial disaster for those who have come to depend upon our prolonged and (possibly) incompetent care to generate all kinds of money related specifically to repeated visits for chronic pain.

This is not rocket science, and I defy anybody to explain to me why any manager would welcome a real reduction in visits simply because it helps patients get better and stay better more rapidly.

In the case of my method for the abnormal neurodynamic there’s also this: a distinct reduction in time spent doing all sorts of testing. I’ve written about this in The End of Evaluation? and discussed in depth in the Five Questions thread.

If I'm right, my meme spawns decreased attendance to therapy and an elimination of many dearly held notions of evaluation, thus it is very unlikely to endure or be passed along with any real fidelity.

Therapists want magic but when you give it to them they can’t use it.

Ironic, huh?
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Old 25-01-2007, 04:24 AM   #27
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Neurological problems are definitely far from shore in comparison with mesodermal issues. This is why there is a plethora of orthopaedic-mesodermally inclined PTs.
It doesn't seem to matter much whether we think about the free system or private; but I dare to say that in the free public system the drive is to keep seeing patients for as short a time as possible. Not so much in the private...

Of course, no-one has managers who are keeping an eye on pursestrings; what an individual therapist chooses to do with a patient and how long they choose to do it for is entirely up to him/her. Privately, the patient can call it quits if they can't afford any more sessions; the PT calls it quits if no changes are occuring. Or they should do so.
A meme that means patients get better faster and stay better much longer is probably everyone's theoretical mission. Unfortunately the means to this outcome lies away from the mainstream mesodermal focus. And that is dangerous territory for some.....or so it seems.
Therapists want magic - but they are scared of being labelled offshoreists. (A neologism, but I like it)

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Old 25-01-2007, 01:46 PM   #28
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I like this "off shore" analogy more and more as we write of it. The solid ground of the island most therapists would prefer to remain upon is akin to the “concrete” nature of mesodermal thinking and dysfunction. It is a place where predictable reactions to time, position and metabolic economy are seen and where imaging has a reliable and valid place. On that island patients hurt where and when they’re supposed to.

But most of this world is water, and if we refuse to learn how to navigate it we will never venture far into it without undue fear and superstition. Figuring out the way of the ocean reliably took some time but it was well done centuries ago by people who had little to go on but their own observational skills, experience and intuition. Those with special knowledge often kept it to themselves in order to maintain their position of power and I’m certain that this advanced technology appeared “magical” to an ordinary seaman. (see the Arthur C. Clarke quote at the top of this thread)

I’m reminded of an essay I wrote a few years ago after seeing the movie Cast Away. To me, this is the story of a man in physical pain who finds himself out to sea and alone. He rescues himself with creative acts, and there’s a good deal of magical behavior involved.

Years ago I wrote this in a journal I keep in a corner of my office: The moment I want to nurture lies between the question and the creation. The question is: What do you want to do? And the patient’s response is a creative act.

I meet the patient at sea and make no effort to tow them toward shore. Instead, I float along with them as their strategy for a return toward dry land emerges. I think that this is a job for their intuition and instinct, and wonderful literature supports that theory.

Unfortunately, no one reads the literature. No wonder this meme remains so unsuccessful and appears so mysterious.

Today, I'm not certain how to overcome this.
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Old 26-01-2007, 04:02 PM   #29
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This morning I thought a bit more about the nature of my work and teaching as it has evolved over the past 35 years. I want to use the “stress ball” analogy I’ve mentioned in the past, most recently here.

Aside from its useless nature, a stress ball is most commonly an impulse buy. The marketers stack them by the checkout counter, shape them pleasingly, color them brightly and price them cheaply. They give the buyer free access to play with them and experience in a tactile and visual way their seemingly magical ability to both lose and regain their original shape. This isn’t some sort of moldable and passive clay in your hand; it seems to have a life of its own. We buy it for all of these reasons, take it home and then never play with it again. It wouldn’t be uncommon for many to hide this impulse buy from others once we realize how wasteful it was.

For the vast majority of therapists my lectures and method have all the same qualities or seem to gain them rapidly once they are placed beside the realities of modern practice, institutionalized documentation and financial expediency.

At least, as far as I can tell.
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Old 26-01-2007, 05:54 PM   #30
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I've been thinking about this thread, even though I haven't been adding to it. Learning something new, even if it's "easy", adds to allostatic load on the students. Perhaps especially if there's a suggestion that everything they've been doing is wrong or muddled. (I'm not saying it's not, I'm just saying that it may add to the overall allostatic load if that is pointed out directly.) There will be unlearning to do as well, a lot probably.
Do you think therefore that part of a solution to the overall problem might be an issue of framing the information differently?
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Old 26-01-2007, 06:55 PM   #31
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Diane,

I agree entirely and now introduce my students to the concept of allostasis when I speak of adaptive potential. I point them toward the thread you began some time ago. Has anybody followed up?

With your post we've come full circle to the Repackaging Simple Contact thread begun here just over a year ago.

Maybe we need to repackage the profession, not the newest information and available method within it.
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Old 26-01-2007, 08:15 PM   #32
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Barrett,

I agree about changing the packaging of the profession. But I seriously doubt it's going to happen any time soon. The "biomechanical approach" is too engrained in the minds of PT's and its shoved down the throats of the new grads. I do not see any PT that I work with questioning the theory about why they do what they do. Perhaps it's because they feel that they do not have to and they have found a way of working that is adequate and gets the job done. The learning that is taken up is to reinforce the current theory, learn new and better techniques, find more problems to work on... I find it kind of boring, but whatever. It's common to find people asking how, but rare to meet someone in our profession trying to find out why. I just got around to reading Ramachandran’s Phantoms in the Brain and I can't stop thinking about the chapter on neglect "the sound of one hand clapping". Perhaps that is what our profession is suffering from. We have learned what is comfortable or what has kind of worked and have made peace with it (to fit in, get paid, etc).

Ramachandran states
Quote:
At any given moment of our waking lives, our brains are flooded with a bewildering array of sensory inputs, all of which must be incorporated in to a coherent perspective that's based on what stored memories already tell us is true about ourselves and our world. In order to generate coherent actions, the brain must have some way of sifting through this superabundance of detail and ordering it into a stable and internally consistent "belief system" - a story that makes sense of available evidence. Each time a new item of information come in we fold it seamlessly into our preexisting worldview. I suggest that this is mainly done by the left hemisphere.
He goes on to suggest that when something comes along that does not fit into the story you either re-write the script, fit it in to the preexisting plot or ignore it.

It doesn't take much work to actually do simple contact... to re-write the script is another story.


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Old 26-01-2007, 09:00 PM   #33
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Chris,

I'm right there with you. I wonder how much I'm going to aggravate your coworkers when I'm in Seattle in two weeks? As always, I'll do my best.

You can't go wrong quoting Ramanchandran, and the "neglect" he refers to might also describe how our profession has treated neuroscience when it comes to understanding pain.

As often happens, a post here will remind me of something I'd previously written. This showed up in One Hand Clapping - Physical Therapy in the 21st Century written several years ago. Here I quote the poet David Whyte, another person you can't go wrong with.

Think of Whyte’s original contention that individuality begins at the point of engagement, at that moment when we meet another to whom we can relate and create something together. He speaks of his experience as a guide in the Galapagos Islands years ago, of how the animals seemed not to have read any of the books about their behavior that he had, and how it took months of quiet observation on his part before the islands revealed themselves to him “on their own terms.”

I imagine that any clinician would relate to this. At least, I do. As I think back over my long career, it seems obvious now that my patients often behaved in ways that I never anticipated, having only read about what they were supposed to do. And I’ve spent a lot of time quietly waiting for them to reveal ways of understanding their problems. I found that this happens in its own time, and that my attention and presence is all that is required. No less than that, though.

This brings me to my last point-that if our practice does not commonly include our actual presence; it will resemble the “one hand clapping”, in fact, the feeling of exile and frustration that the image evokes.

This cuts both ways. The patient arriving for care who can find nothing other than a machine to grasp (or a piece of paper with an exercise protocol), according to Whyte, will not become the individual they seek to be. This only happens when something with which we can truly relate meets us. In the case of therapy, that would ideally include actually being touched. This is something that happens less frequently in our profession every day.


I understand that your colleagues are both present and manually involved with their patient's care so maybe they're ready to hear what I have to say and see what I can show them. Maybe they're ready for the ectodermal (magical) perspective.

Maybe not.
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Old 27-01-2007, 02:52 AM   #34
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On a whim I googled 'unlearning' after reading the word in Diane's last post; as usual Google did not disappoint. I found a good essay which highlights many of the concepts made here and in other past threads called Unlearning Ineffective or Obsolete Technologies.

Some of the highlights:

Quote:
"Often, before they can learn something new, people have to unlearn what they think they already know. That is, they may have to discover that they should no longer rely on their current beliefs and methods."

"..the essential requirement for unlearning is doubt, any event or message that engenders doubt about current beliefs and methods can become a stimulus for unlearning."

"Dissatisfaction is probably the most common reason for doubting current beliefs and methods. But dissatisfaction can take a very long time produce results."

"People who see themselves as experimenting are willing to deviate temporarily from practices they consider optimal in order to test their assumptions. When they deviate, they create opportunities to surprise themselves."

"Events that violate expectations, both unpleasant disruptions and pleasant surprises, can become opportunities for unlearning."

"Beliefs held by qualified observers nearly always have foundations in some sort of truth. The most common problem is not to prove that one set of beliefs is wrong but to reconcile apparent contradictions by showing that they are not contradictions at all. These efforts can lead everyone to new conceptualizations. They can also produce some strange inversions."

"It is usually easier to respect the views of collaborators than those of strangers. Unfamiliar with current methods and unacquainted with recent efforts, strangers are likely to make suggestions that seem naïve or ignorant or foolish. Yet, new people often introduce new perspectives. Although the newcomers may be less expert than their predecessors, they are also free of some expectations that their predecessors took for granted. Thus, strangers may be able to see peculiarities that the indoctrinated cannot see or they may be able to offer breakthrough suggestions. Indeed, "reengineering" seems to be designed to exploit this principle."
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Old 27-01-2007, 03:30 AM   #35
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I think the last paragraph of your post, Eric, is most enlightening.
Perhaps people just cannot 'connect' with a stranger whose thoughts and pedagogy are 'outside' the norm paradigm despite evidence that those thoughts are logical and science-based.
It is the onshore/offshore analogy. It is probably why programmed pitstopped bus tours with everything done for you, are more popular than a trip where you have to work out what needs to be done or observed.....


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Old 27-01-2007, 03:45 AM   #36
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This was my favorite line of the whole excerpt provided by Eric:
Quote:
The most common problem is not to prove that one set of beliefs is wrong but to reconcile apparent contradictions by showing that they are not contradictions at all. These efforts can lead everyone to new conceptualizations. They can also produce some strange inversions.
I wonder how we could do that?
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Old 27-01-2007, 04:42 AM   #37
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The sentence that catches my eye was "Events that violate expectations, both unpleasant disruptions and pleasant surprises, can become opportunities for unlearning." I think that there are many examples of unpleasant disruptions in most of our practices, for instance, a particular method which fails to produce a desired effect in a predictable way. At least this should be an unpleasant disruption to most. I wonder if many perceive this occurrence to be just par for the course and have become somewhat numb to failure.

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Old 27-01-2007, 07:08 AM   #38
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Quote:
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for instance, a particular method which fails to produce a desired effect in a predictable way.
Eric,

I think that most of us will blame the patient himself. It is a very common and "safe" behaviour.
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Old 27-01-2007, 01:52 PM   #39
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Eric,

Your "numb to failure" line went right through me. I think that this is mainly what I see. When I interrogate reality during the first ten minutes of my workshop by mentioning that half of the class has chronic discomfort a number will nod their heads in agreement, slightly amazed that I would have the gall to mention this and others remain perfectly still and placid. It's not unusual to find many people in pain in the latter group. They've been found out, and their culturally induced "poker face" has been employed in an effort to hide.

My mind often returns to a seasoned therapist in Dallas who began a conversation by asking me if this kind of handling would help her patients. When I asked her what she thought was going on inside the people she saw and what she thought she was doing when she did what she did it became clear that she couldn't speak about her patients in any meaningful way whatsoever and that the effect of her care was a complete mystery to her.

She grew angry and forcefully told me that the doctors loved to send her patients because she was so good at helping them. Evidently she was very popular and successful according to others but it was obvious she didn't feel that way when looking in the mirror.

In the face of such cognitive dissonance growing numb is a common strategy.

I showed her how to perform "magic" but made no promises about its effect on her clinical life because that is something I never do. I know she remained very unhappy about this.

If promises of success from me is what's required I'm in a fix because I won't do that. At least very soon I'll have published research by Luke and Jason to point to.

I doubt that this will make the impact it's supposed to. It appears from what I've seen this past couple of years that a study justifying a "clinical prediction rule" might work. Anybody want to do one?
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Old 27-01-2007, 04:36 PM   #40
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Barrett, find a research partner to steer the project, and do one yourself. Of course, you'll have to find a place to treat patients if you're shutting down your clinic..

I really like the essay. The example of the Swedish navy being absolutely convinced the Soviets were invading them with submarines and divers (which turned out to be minks and seals, animals who are at home in deep water), whereupon they blasted the water with everything they could, is a metaphor for our mesodermal friends perhaps, who blast every pain as if some contrary piece of mesoderm deep inside simply refuses to "heal" or bend or move the right way.

The Swedes remained vigilant, certain the Soviets were lying when they said they did not send submarines into Swedish waters. Finally they unlearned their vigilance after the Soviet regime changed completely, and realized they'd been fighting marine mammals. Hilarious.

Here is more that pertains to us, my bolds:

Quote:
Surprisingly perhaps, technical experts may be among the most resistant to new ideas and to evidence that contradicts their current beliefs and methods. Their resistance has several bases. Experts must specialize and their specialized niches can become evolutionary dead-ends (Beyer, 1981). Because experts' niches confer high incomes and social statuses, they have much to lose from social and technical changes. Expertise creates perceptual filters that keep experts from noticing social and technical changes (Armstrong, 1985). Even while experts are gaining perception within their domains, they may be overlooking relevant events just outside their domains.

Second, organizations make it more difficult to learn without first unlearning. People in organizations find it hard to ignore their current beliefs and methods because they create explicit justifications for policies and actions. Also, they integrate their beliefs and methods into coherent, rational structures in which elements support each other. These coherent structures have rigidity that arises from their complex interdependence. As a result, people in organizations find it very difficult to deal effectively with information that conflicts with their current beliefs and methods. They do not know how to accommodate dissonant information and they find it difficult to change a few elements of their interdependent beliefs and methods. The Swedish sailors who conducted the searches had been trained to interpret certain sounds as a submarine and rising bubbles as a diver; they had not been prepared for the sounds and bubbles made by animals. A Swedish navy that had just spent three weeks dropping depth charges and antisubmarine grenades in the belief that it had trapped an intruder was not ready for the idea that it had been deceived by playful young seals.

Tushman, Newman, and Romanelli (1986) characterized organizations' development as long periods of convergent, incremental change that are interrupted by brief periods of "frame-breaking change."
Kuhn said the same about science.
Quote:
They said "frame-breaking change occurs in response to or, better yet, in anticipation of major environmental changes." However, even if abrupt changes do sometimes "break" people's old perceptual frameworks, the more common and logical causal sequence seems to be the opposite one. That is, people undertake abrupt changes because they have unlearned their old perceptual frameworks.

Third, unlearning by people in organizations may depend on political changes. Belief structures link with political structures as specific people espouse beliefs and methods and advocate policies (Hedberg, 1981).
Hello, is this not the case in PT, wherein a mesodermal agenda has completely overridden any neuro one we might have once had?
Quote:
Since people resist information that threatens their reputations and careers, it may be necessary to change who is processing information before this information can be processed effectively. Thus, a change in control of the Swedish government may have been essential before the Defense Ministry could concede the possibility of errors in the conduct of antisubmarine hunts. A change in control of the Soviet Union may have been essential before the Swedes could allow the possibility of Russian vulnerability or truthfulness.

Top managers' perceptual errors and self-deceptions are especially potent because senior managers can block actions proposed by their subordinates. Yet, senior managers are also especially prone to perceive events erroneously and to overlook bad news. Although their high statuses often persuade them that they have more expertise than other people, their expertise tends to be out-of-date. They have strong vested interests, and they know they will catch the blame if current policies and actions prove wrong (Starbuck, 1989).
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Old 27-01-2007, 05:31 PM   #41
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Another interesting essay on the same topic, Lifelong Unlearning by Trevor Pateman. I particularly like the opening statement

Quote:
"people who live in acquisitive societies will tend to write books about how to acquire things, not how to get rid of them..."

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Old 27-01-2007, 06:03 PM   #42
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I love this bit:
Quote:
people know their Imperial measurements so well that they will not and cannot forget them. They are both proud of what they know, and able to use it fairly effortlessly. As a result, Eurocomputation is a lot farther off than the Euro. It will have to wait for the long run, when we are all dead. Had our school system been less good at instilling our crazy measurement system, we would have been able to forget it the more readily, and move on to deploy something more useful. As it is, we live in a society full of people proud of knowing how many furlongs there are in a mile, and totally unwilling to forget it. It's a terrible state to be in.
And this one (I've been all the way through the nausea that this involves, an example dear to my heart therefore):
Quote:
If, for example, you get right-handed students to draw with their left, you deny them use of what they already know how to do in a more-or-less routinised way. Coming from a very different background, the cognitive scientist, David Marr, argued some years ago now (Marr 1982) that the serious work of visual artists involves them in unlearning the routines of habitualised seeing and regressing from 3-D to what he called two and a half D vision. That was what Cezanne was trying to achieve in the endless repainting of Mont St Victoire, learning in order to forget and forgetting in order to learn.
Hey Barrett, maybe you could do this in your class as an example of what "unlearning" means. Ask people to draw a simple dog shape with their dominant hand, then with their left hands, then with their eyes closed or while looking away from the paper the whole time, relying only on their memory and proprioception. This will make their proprioception cross over into their visual cortex memory bank. Tell them not to judge the results, but just to feel what it feels like as their minds are forced to go places they aren't used to going. Tell them this is good for them ultimately, even if it feels quite awful.. that this is what cognitive dissonance feels like. Tell them there is authenticity in each and every one of them, and that you are there to help them find it and experience it, that you are there to help them learn to help their patients find it too, that authenticity is therapeutic "magic".

It might perk them up enough that they'll be willing to let go of the stuff they need to unlearn.
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Old 27-01-2007, 07:45 PM   #43
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It seems to me that if anyone is going to take on anything new, they must be ready and willing to "unlearn" automaticity and a lot of their familiar instrumentalism.
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“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

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Old 29-01-2007, 04:12 AM   #44
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Default The Magus' Message

There’s a passage, a story within the story of John Fowles’ The Magus; it’s complex and I can’t repeat the whole thing here, but it begins on page 550 of the hardback edition, in case you happen to have a copy. “Magus” is another word for magician.

Without going into detail, a young prince is shown things that he had not previously believed to be true, only to find out from his father, the king, that these things had always existed but that the prince had been under the king’s spell and that the king is a magician. The prince insists that he must “learn the truth beyond magic” but the king tells him: “There is no truth beyond magic.” Ultimately, the prince sees the truth, and thus becomes a magician.

I’ve spent many years thinking about this story and find today that this thread may have given me some further insight. In another thread titled Truth and Consequences I quoted from the wonderful book Why Truth Matters: “The truth is important to us but so are our needs and desires and hopes and fears. Without them we wouldn’t recognize ourselves. We want the truth but we also want to care, and some of the things we care about are threatened by the truth. So we’re stuck – but we have to choose.”

Combine the book and Fowles’ story and you have this: Magic (as distinct from super powers) is the truth, and, as such, it works within the confines of physical law, of course. I say, choose the truth and you'll find the magic you want.

Shouldn’t therapy resemble this? Shouldn’t therapy resemble magic when it’s practiced truthfully? Again see Arthur C. Clarke’s quote at the top of this thread.

Is it possible that therapy based on scientific principles cannot be practiced simply because it appears magical? Has common practice strayed that far from reason?
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Old 29-01-2007, 12:25 PM   #45
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One of the difficulties in clinical practice is the lack of consistent follow-up to know whether our interventions, magic or not, have lasting effects.
I remember when Mckenzie was the rage (about 1986) that it was described as "magical" by a lot of PTs, echoing what was thought about Maitland in the late 1970s...but after the initial resolution of pain and stiffness, we never heard of the patient again, usually.
Perhaps magic is relative to history. Something entirely new, dealt out by a wellknown figure in an atmosphere where EBM did not exist, and questioning was not 'done', can be magical.
It's not like that anymore - new grads are challenging, asking, questioning. The sense of magic seems to have gone; things happen by design and hard work lined with the expectation of well, it should work anyway, according to the clinical experts .
I think, here anyway, that clinical reasoning is very much alive and thriving. But it is reasoning, or a truth of sorts, based on old premises. Like old comfy socks, the premises of 30 years ago are still holding sway, and until that changes, the clinical reasoning will be shaky.

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Old 30-01-2007, 01:40 PM   #46
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Default Tagore's Insight

I’ve had a number of people tell me privately that they’ve enjoyed this thread, and, for me, it’s been one of those that has sent me pouring over stacks of paper in my office searching for relevant quotes and bits of articles I’ve read or written and then saved for just such an occasion as this writing.

After her passing my sisters went through my mother’s bureau drawers and found a short poem by Rabindranath Tagore that we had reproduced on a brass plate and placed in a memorial garden. I’d never heard of this Indian poet and associate of Gandhi’s before but his writing always draws me now. I found this:

“A teacher can never truly teach unless he is still learning himself. A lamp can never light another lamp unless it continues to burn its own flame…A teacher who has come to the end of his own subject can only load his student’s minds, he cannot quicken them.”

What I see here is the teacher/therapist as magician; full of knowledge that grows even as the teacher speaks. I know this happens to me, especially when I speak to patients. It doesn’t happen so commonly when I speak to my colleagues in therapy. I think that this has to do with the relative “aliveness” of the person listening. I find my patients alight with curiosity and not heavily burdened with the mesodermal memes that retard the learning therapists might do given the information I offer. Many therapists walking into my workshops are looking for a place to hide and rest. They openly admit that it’s the CEUs they seek and spend the day in perfect, personal silence. In such an environment the generation of magic can be difficult, but I manage.

I manage because I have become what Moore and Gillette describe in The Magician Within: “(A mature magician) contributes to healing through stewarding his knowledge. (He) keeps abreast of the latest developments in his area of specialty and in general human knowledge too.”

More about this and Hillman’s “shadow” magician in my next post.
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Old 31-01-2007, 01:57 AM   #47
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Default Hofstadter the Magician

Another writer with a magician’s archetype strongly expressed is Douglas Hofstadter. I took his thick book, Metamagical Themas off the shelf in my office and discovered that in 1985 I had underlined a bunch of passages regarding Dawkin’s memes (first described in ’76). I remember taking the book on vacation to Travers City Michigan back then but can’t remember marking it or remembering what a meme was. As far as I know, I first became aware of this concept in the late 90s. It appears that my unconscious was trying to get me to notice something carefully long before I understood its significance. I know it led my hand to use the red marker.

Anyway, there’s another portion of this book devoted to our fascination for magic and our simultaneous desire to make sense of things. Hofstadter puts it like this:

“Perhaps we all have a desire to dilute reality with fantasy, to make reality seem simpler and more aligned with what we wish it were. Perhaps for us all, the path of least resistance is to allow reality and fantasy to run together like watercolors, blurring our vision but making the world more pastel-like; in a word, softer.”

I agree. And it seems to me that this tendency is recognized and exploited by the ‘shadow” magicians out there. These are our colleagues full of information often acquired after hard work and careful study. In this way we’re the same, but often they’re also very nice people. Here’s the problem: they create a system of teaching that conveniently (for them) doles out information in dribs and drabs (each one is expensive) and keep people coming back with a promise of magic at the next level. They never give anything away, they only sell it. Maybe the tons of information I acquire and share freely is my primary distinction. In addition, I offer the magic immediately. This hasn’t made me wealthy, just satisfied with that part of my life.

But Hofstadter goes on: “Yet at the same time, perhaps all of us have the potential capacity to sift sense from nonsense, if only we were introduced to the distinction in a sufficiently vivid and compelling manner.”

Clearly, this is the teacher/magician’s task in a workshop like mine.

I’m working on it, really, I am.
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Old 31-01-2007, 07:35 AM   #48
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After learning what I have over the lasts few years, and putting it into to practice, what strikes me most is how much simpler my work is compared to my peers. I never seem to have charting to catch up on, I stay on schedule, I leave at the end of my shift, sure I have failures like anyone else but for the most part my patients seem fairly happy.

I entered the profession wanting to be able to perform magic, no doubt about that; I wanted to learn the tricks of the trade. I never learned this at school. What I learned was systems for dealing with uncertainty; systems that became more complex the greater the uncertainty. And to be honest, only a brief taste of the systems is ever offered to undergrads, you have to pay more and work more for the whole thing. Does this not seem really odd? We are graduating therapists, licensed to work with patients, who haven't even been taught the complete system(s)? Just how they heck are they supposed to cope? I hope we don't let surgeons practice autonomously after watching a few videos and being shown where the tools are.

If on the first day of class students were given the option of doing this (the degree) the hard way or the easy way, I wonder which most would choose?

‘House’ on tv tonight said something like “doing nothing ensures that nothing gets done.” This may have been true in the context in which it was said, unfortunately I’m afraid this meme steers most towards the hard way of doing things, at least in our profession. Call me a sucker, but I am equally impressed with the magic of a simple trick involving one coin as I am with extravagant Vegas style shows. It’s all magic, not better or worse, more or less. I think patients want magic too. When they don’t get it, they must console themselves in the fact that someone is working really hard on their behalf; someone who will try to do as much as they can for them, and put on a really good show to top it off. They must think that if this therapist is willing to work so hard, the least they can do is match their effort, and around they go on the more must be better spiral. When magic is all that’s needed, the magic of neuroscience, a really simple trick will do.

Who wouldn’t want to make their life simpler??
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Old 31-01-2007, 09:10 AM   #49
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Eric,

One would think that it is everyone's goal to make physiotherapy simpler.

But many complicated methods seem to indicate proficiency, cleverness and competence, viz: the body is complicated, therefore its remedies must also be, to keep out the charlatans. And patients are impressed by this hard work...
Eric, if you are a touch cynical now, watch out. Age tends to increase cynicism and scepticism.......

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Old 31-01-2007, 03:57 PM   #50
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Eric,

Sounds like my practice. I have a funny story though. I had my charts reviewed and of course they looked rather simple. When you tend to do one thing for a system vs 100 things for various structures, the notes look a little sparse. I was criticized for this of course. Seems insurance doesn't pay for understanding something, just doing something. The eval is great also. It is an extensive computerized list you have to check off, posture, biomechanical exams, etc. it's pretty detailed. I'm always relieved when I finish it and can finally ask, "does it alter with position or use?" and "are ya a little cold?" Then my work can begin.


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