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Old 08-06-2010, 03:36 PM   #1
proud
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Default Being decietful

I read this comment and thought it was a question to pose here:

"Maximising the efficacy of the clinical interaction is a great idea, the burning question is, is it OK to do this if we know we are being deceitful?"

Knowing that patient expectation can play a large role in eliciting a placebo response, often the "best" intial response one can get is when you provide a treatment that fits with the patients known constructs about the human body.

Is it wrong to initially elicit that pain modulating effect via known false constructs( acupuncture, manipulation, modalities like IFC, ultrasound etc) so long as this is used as a platform to then "deconstruct" and approriatly educate? In other words garner the patients confidence first...then move in for the kill so to speak...

In other words...is it appropriate to be deceitful intially so long as it fits a long term purpose and goal to provide information and guidance consistent with science?

Strange question I know...but I would like to hear others opinions.

Last edited by proud; 08-06-2010 at 03:52 PM.
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Old 08-06-2010, 03:42 PM   #2
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This isn't a strange question, it's a great question.
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Old 08-06-2010, 05:04 PM   #3
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I think the problem with deceit fundamentally lies here:
Quote:
O, what a tangled web we weave when first we practise to deceive! --Walter Scott
I think we should attempt to use accurate language to describe what we're doing and why, or it invariably backfires.

However, we have to meet the patient where they are and respect their values and expectations to the extent that doing so won't run contrary to ethical and appropriate care.

It helps to know what the hell your talking about.

Clear as mud, right?
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Old 08-06-2010, 05:43 PM   #4
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proud, I think that approach is commonly used by quite a few practitioners.
I disagree with it.

I think we should be confident enough in our knowledge base that we can face a patient's expectations (and possible protests) with clear and concise education. If they remain firm in their assumptions and expectations and they run counter to what we know - then we part ways, after they have paid me for my time.
So far, never with any anymosity.
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Old 08-06-2010, 05:48 PM   #5
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My student says that she thinks if the pt has had previous experience with something that they enjoyed, and they are specifically requesting it, and it fits with the POC, it's OK to start with something like manipulation or IFC (TENS units for instance) or whatever is available that they have requested.

We do agree that it is not appropriate to educate the pt on the false constructs in an effort to feed into their misunderstandings, regardless the placebo effects that we think we are seeking, however, using a technique that is beneficial is OK, as long as the education that goes along with it is science based/evidence based.

What I tend to do is utilize the POC beyond the modality or intervention to help the pt progress. I educate through constant assessment (assess sx, apply intervention, assess response) to use as a tool to get the pt to see for themselves changes with other interventions (added one at a time for greatest ability to individually get a clear assessement of changes). No matter what, I don't use non-scientific explaination for benefit, but I have avoided changing beliefs (explaination) for a time, and especially if I sense a resistance. I'm not gonna bang how wrong they are over their heads in some misguided effort to ensure that my understandings are drilled into their heads. I can wait, if the pt needs me to. I won't directly disagree, but I won't agree either. I ask questions, I assess willingness to hear/understand/learn and present accordingly (as best I can). Takes a lot of patience and watchfulness, but it's worth it....in the end, per the science and evidence on pain education, and to forward science/evidence-based practice.

So no, direct deceit is not OK, but allowing misunderstanding to continue is OK for a time, if efficiency is the goal, and the case is appropriate. I love to tell a pt about pain in addition to giving them a modality or intervention they think is "fixing" their problem, and have them then ask, "well, then, how does this work?" as it doesn't fit their construct. That's an opportunity knocking. Perfect!

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Old 08-06-2010, 06:31 PM   #6
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Quote:
Originally Posted by proud View Post
I read this comment and thought it was a question to pose here:

"Maximising the efficacy of the clinical interaction is a great idea, the burning question is, is it OK to do this if we know we are being deceitful?"
Proud's source: Neil O'C June 8, 2010 at 6:10 pm, I think...
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Old 08-06-2010, 06:32 PM   #7
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Steph, I do not quite agree with consciously allowing any misunderstanding to continue.
That is just my mode of operating - I am so focused on helping the patient understand the issues at hand, that leaving any misconceptions or false assumptions makes that impossible.
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Old 08-06-2010, 07:04 PM   #8
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Ya, I think I know how it sounds Bas........I'm thinking of cases where the pt is in pain, here for their first visit, just want a TENS or some Anodyne, etc, and I am trying to emphasize their options for other more science based approaches, but they still want their "prescribed" treatment (per a physician referral), and they still choose their intervention, despite my education, etc. I treat them, despite knowing they think it's helping based on some non-scientific rational, or something they heard. I try, when they are ready to accept info other than the beliefs in their head to feed them gently, but I will not feed into their beliefs to get at the placebo effect. I will simply not push them to see it science's way, at first....I can usually get at their readiness to learn pretty quickly.

I'm not thinking of the general referral for pain without a specific request for a specific intervention w/a specific (incorrect) reason for why they think it will work. In fact, I jump at the opportunity to tell all about why what I do works, scientifically. Even if it flys in the face of what they may have heard before. I love to enlighten people on the neuroscience...but it's like our colleagues, you can't win them all....and when you are up against some ingrained belief....well, all you can do is try.


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Old 22-07-2010, 05:47 PM   #9
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I'm bumping this thread because I wanted more input to the question I posed. The more I think about it the more I'm certain it's an extremely important question.

I mean really....is it "right" to elicit a placebo response via false constructs( upslipped SI joints being maobilized back into place, acupuncture needles doing....anything at all, finding stiff segmental joints and "mobilizing" them back to "normal"...etc)

Given that these sorts of meme's fit so well with patients perceptions essentially maximizing the placebo effect( response). Especially when the treating clinician sells the construct so well( with confidence, charisma etc).

I know this sort of stuff happens and to my astonishment, I think many PT's actually still believe they can move joints back into place or mobilize a structure to free it up. Therefore...I think these clueless clinicians are even more powerful placebo dispensors due to their very own ignorance! If you believe what you are selling, it's that much easier I figure( I think Frderic hit on this).

But for those in the know....how do you compete with that? Patients WANT this sort of woo woo...they improve with the woo woo( placebo response). They think you are an idiot because you did not supply the woo woo. They tell others you are an idiot because you never figured out the actual cause of their pain( anteriorly rotated SI joint or something outlandish like that for example)

Would it not be fair to be deceitful at first...maximize the placebo response....then actually deconstruct and educate?

Is that not better than discharging a patient to the world with false notions about why they might have improved?
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Old 22-07-2010, 06:49 PM   #10
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Proud,

Your question is very interesting.

It still is hard for me to truly decide wich side I'm on on this one. For sure I will never tell again a patient that his rib, vertebra or whatever bone is out of place. For sure I will never tell a patient again he has a complex biomechanical problem that needs fixing for the pain to go aways.

But, If every thing in the patient's experience with his problem screams mesodermal issues (the orthopedists tells him so, his MRI and the radiologist report tells him so, his osteopath tells him so and he has confidence is all of them) and the patient's truly believes he has a mesodermal issue then I might provide a treatment that is coherant with these beliefs anyways. I will not teach him the mesodermal rationnal or add to it by finding biomechanical issues we need to work on but I will use treatment modalities that somehow fit with the patient belief while I try to downplay them.

For instance, I might use some motor control exercices that are tought to improve the mouvement of the scapula in an diagnosed shoulder impingement. But at the same time I will teach them that pain is not only related to issues with tissues and body parts position and mechanics. Sure I would prefer skipping the motor control part but if I altogether skip this part and the patients expects me to address it I think it hinders my chances of success.

If a patient thinks a manip will help him, I might use it in the treatment but give the proper education that goes along.

I treated a physiotherapist last winter. She was an experienced therapist with a manual therapy approach. I wanted her to get better. I did not go into all the deconstructing thing with her. We talked about some of it while I managed to avoid more delicate issues. I did not re-inforce the meme she believes in, I just downplayed it slightly and let my hands do the treath reduction.

I think you can teach about pain without being too deconstructive. Moseley was carefull not to bash on treatment construct in his books. I try to teach pain neurophysiology and I expose scientific facts but I try to avoid a clash of treatment constructs with patients when necessary.
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Old 22-07-2010, 07:16 PM   #11
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You know, come to think of it, I think the EIM clan has found a clever way to navigate this one.

Manipulation has known neuro-modulatory effects( is it a treatment effect or a placebo response?).

Regardless, despite using the Ctr-Alt-Del anaolgy to describe to patients the effects of manipulation, you cannot disconnect the ritualistic aspect of manipulating someone.

From what I gather...the EIM clan utilize manipulation but disconnect themselves from the "affecting mesoderm" notions we all grew up with.

But I'm not so sure they understand that you cannot remove patient expectation/ritual from the manipulation. So is it the manipulation that is resulting in these so called improved outcomes....or something else?

I'd bet something else.

I suppose this is sort of a way to limit how decietful we have to be overall:

"....I'm manipulating your spine because it's been shown to improve outcomes. The reasons are not well known however..."

Is better than:

"...I have found that your L5/S1 on rotated and side bent to the left resulting in hyperfacilitation of the nerve roots, as such, I will adjust that vertebrea back into place which should remedy this problem of yours..."

I'd LOVE to be in the clinic with one of these guys to see just how strongly they educate patients about the known "non" effects of manipulation?

I think they are still tied to the placebo response but just either don't know it....or know it but have found a way to make it "evidence based"....

Edit: Excellent response Frederic. I really enjoyed your take on it.

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Old 22-07-2010, 08:07 PM   #12
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New Body in Mind blogpost - might be pertinent to this thread. Hands-up who thinks a patient’s expectations influence how well they do in treatment?
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Old 22-07-2010, 08:18 PM   #13
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In Symptoms of Unknown Origin, Dr. Meador recounts an episode where his mentoring physician, Dr. Doherty, "healed" a man who had been afflicted with a voodoo curse by having him "regurgitate" a lizard through the effects of an emetic and careful sleight of hand with a real lizard.

One could argue that Dr. Doherty, although saving this one man's life, helped to perpetuate a dangerous myth about the power of voodoo curses. You could even say that he elevated the power of voodoo's mythology with his elaborate charade while diminishing the scientific foundation upon which the practice of medicine is supposed to be based.

Fortunately, we therapists don't deal with life and death situations directly. But, when you think about all the patients who end up getting maimed by unnecessary surgeries- and the costs these present to society- I think as professionals we need to keep in mind the broader ramifications of our actions.
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Old 22-07-2010, 11:23 PM   #14
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I konw what you mean John,

On the other hand, when and if a patient decides to have a surgery shouldn't we at least try to maximize the outcome of it?

It is also known that conflicting information given to a patient about his condition can have a negative effect on outcome. So, even if we are damn right, do we want to be the one insisting everybody else the patient has seen so far were plain wrong?

I generaly am disclosing as much info as I can to the pt about pain, neurophysiology, sx and placebo, expectation and all. But there are patients with whom I feel it's best I refrain from confronting too much their preconceived ideas.

If they get better then great, at least I know why. If they don't, then I will alter the course. It won't be too late cause when they brought up their conviction about mesodermal notions, I did not confirm it, I might have just politely nodded and changed subject, putting emphasis on something else.

When someone really believes his rib or vertebra can pop out of place. Maybe a thorough biomechanical assessment orchestrated in a way to not find much of anything wrong can help treath reduction. «Well, everything is in place, no need to worry M'am» «By the way, look at all these ligaments and muscles, vertebras are really hard to dislocate.»

It would be way more simple if we were not deadmen walking around.

Anyways, any intentionnaly deceptive approach should be kept to a minimum.

I think there is a difference when we are being deceptive with totally inert treatments as opposed to effective treatment but with wrong rationnal. In the latter, if the emphasis is not put on the rationnal of the technic there is less deception.
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Old 22-07-2010, 11:40 PM   #15
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I am still of the same opinion as before in this thread.
Not even " minimum" levels. I will NOT participate in it.
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Old 22-07-2010, 11:52 PM   #16
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Recently in our local paper there was an article on lying. A child learns to lie about a behaviour or event at about age two, and becomes more adept as time passes.

There was an interesting comparison between people with Asperger's (who can be deadly honest) and others who have become so entrenched by avoiding the actual truth, become offended and huffy.

I think there is a middle road with patients; if their beliefs are firmly mesodermal, one might offer not an alternative explanation per se, but a sort of complementary one. Manips are a good example.
If we say: 'Yes, your shoulder pain could be due to weak muscles, but it's also likely it's caused by irritated nerves and we can try to settle them'.... plus pain ed, in this way the patient may think: 'ah, so it's not just due to weakness, but something else as well.....'

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Old 22-07-2010, 11:59 PM   #17
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Quote:
Originally Posted by nari View Post
If we say: 'Yes, your shoulder pain could be due to weak muscles, but it's also likely it's caused by irritated nerves and we can try to settle them'.... plus pain ed, in this way the patient may think: 'ah, so it's not just due to weakness, but something else as well.....'

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Old 23-07-2010, 12:23 AM   #18
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Quote:
Originally Posted by Bas Asselbergs View Post
I am still of the same opinion as before in this thread.
Not even " minimum" levels. I will NOT participate in it.
Bas, I can agree with this 100%, but will admit I have been an offender of the opposite. I respect the therapist that can hold their ground and part ways with the patient that isn't ready to hear the truth..or as David Butler talks about understanding it "in the marrow of their bones."

A while back I had a lady come in wanting ultrasound because that would "fix" her back. She had to have it. She had it before and that is what "fixed" her. She was deeply worried that this back injury would affect her life significantly if she did not get it. She was recently for the first time in many years actually able to get a job, which allowed her to actually get an apartment. She had been homeless for the previous few years while she did not have a job. I started to try and explain pain and that ultrasound has very poor research showing any affect. But you could hear and feel the fear and anxiety in her words and body motions. I realized that I was only adding to this and choose to do the ultrasound - to her entire back from neck to tailbone because that is how she got it before. Funny side note, as I pulled the machine into the room I unplugged it and decided it really didn't matter if I plugged it in or not and wanted to do a little placebo expirement. Upon completion of the 10 minute ultrasound, she got off the table with relief because her pain was gone. She was so thankful because she knew would be able to work her job and keep her apartment now. We went through some simple movement activities and she was on her way. She came back 3 days later with no pain and extremely happy that she was not going to be homeless again and did not see the need to continue.

I admit and confess I was deceitful and probably added to her misconceptions. But I also felt some joy inside thinking I was in some strange way helping her as well.

That's why I would agree with John, when I decide what to do..."probably as clear as mud?"
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Old 23-07-2010, 12:28 AM   #19
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For what it's worth, I approach this the same way as Frederic.
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Old 23-07-2010, 12:41 AM   #20
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Kory, i must admit that when I have a patient such as yours, who "must have" what "worked" before, I send them to another clinic where she could get that - after having explained to her why I wouldn't do it and why "it worked".
Some leave, some end up staying anyway.

I wil not tell them they are full of cr*p with their notions, but tell them WHY the whatever-it-was-that "worked" actually did work. If they are not ready or willing to absorb that or at least try to consider my take on things, they get the above solution.
I am very comfortable with that.
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Old 23-07-2010, 12:50 AM   #21
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I think that this is a question with very interesting ramifications. I'm with Bas. I don't ever want to intentionally decieve. I may not always view it as my job to attempt to un-decieve people, but I think there is a big difference there.

That said, it also matters what you mean by decieve. Do you mean tell somebody something you know to be untrue? Or do you mean to tell somebody something that is untrue even if you don't realize it?

The first is pretty black and white, the second is tougher.
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Old 23-07-2010, 12:59 AM   #22
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I'm with Bas and Cory about not intentionally deceiving a patient.

In my mind one important service I can offer is "Here you will get no nonsense, but real, valuable information about your problem."

That said, the "bone out of place" idea is very strong and hard to compete with.
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Old 23-07-2010, 04:30 AM   #23
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After I got rid of the ultrasound machine (and the laser and the tens) I no longer had to wrestle with myself about any of this. It was a non issue. They got what I had to offer and paid from pocket or they moved along.
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Old 23-07-2010, 05:46 AM   #24
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Proud,

You may be interested in some of the papers, links and discussion in this thread.
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Old 23-07-2010, 06:02 AM   #25
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Quote:
Originally Posted by proud View Post
I read this comment and thought it was a question to pose here:

"Maximising the efficacy of the clinical interaction is a great idea, the burning question is, is it OK to do this if we know we are being deceitful?"

Knowing that patient expectation can play a large role in eliciting a placebo response, often the "best" intial response one can get is when you provide a treatment that fits with the patients known constructs about the human body.

Is it wrong to initially elicit that pain modulating effect via known false constructs( acupuncture, manipulation, modalities like IFC, ultrasound etc) so long as this is used as a platform to then "deconstruct" and approriatly educate? In other words garner the patients confidence first...then move in for the kill so to speak...

In other words...is it appropriate to be deceitful intially so long as it fits a long term purpose and goal to provide information and guidance consistent with science?

Strange question I know...but I would like to hear others opinions.
This issue of deceit to maximize the placebo response is interesting and is known in medicine as the "virtuous deception", "benign deception", etc.

I believe the AMA recently called it unethical, against the wishes of the majority of it's delegates. Recent studies of British and American MD's say 40% to maybe 60% use deception for placebo purposes. Some academics and medical ethicist's say any deception in the doctor-patient relationship is unethical. There is however a Kantian solution which allows one to only say true statements while at the same time hiding the issue at hand. It's a type of evasion or misdirection that some would say follows the "letter of the law" but not the "spirit of the law."

Michael Sandel's Justice series has this entry called "A Lesson In Lying"

[Fixed link]

http://academicearth.org/lectures/lying-and-principles

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Old 23-07-2010, 06:11 AM   #26
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Grrr. The link wouldn't work mszlazak. I was able to find it by going directly to the website and searching for "lying and principles", however.
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Old 23-07-2010, 06:19 AM   #27
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Quote:
Originally Posted by proud View Post
I read this comment and thought it was a question to pose here:

"Maximising the efficacy of the clinical interaction is a great idea, the burning question is, is it OK to do this if we know we are being deceitful?"

Knowing that patient expectation can play a large role in eliciting a placebo response, often the "best" intial response one can get is when you provide a treatment that fits with the patients known constructs about the human body.

Is it wrong to initially elicit that pain modulating effect via known false constructs( acupuncture, manipulation, modalities like IFC, ultrasound etc) so long as this is used as a platform to then "deconstruct" and approriatly educate? In other words garner the patients confidence first...then move in for the kill so to speak...

In other words...is it appropriate to be deceitful intially so long as it fits a long term purpose and goal to provide information and guidance consistent with science?

Strange question I know...but I would like to hear others opinions.
It seems no one wants to intentionally deceive a patient/client, but what about if we?re simply wrong in our approach to therapy. Point being we all, to one degree or another, have an ?ectodermic perspective? that?s not (yet) considered scientific law. What if we are all wrong and the results we elicit are unintentionally deceiving a patient/client.

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Old 23-07-2010, 06:25 AM   #28
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OMG! How young were those folks giving those answers?

I'm suddenly hopeful.
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Old 23-07-2010, 08:18 AM   #29
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Coming from a patients perspective I would choose to have a PT like Bas or BB. I went through many treatments for my LBP, each practitioner having their own justifications for their treatment plans, some more woo-y than others. One thing I came to realize was that my mesodermal expectations often didn't match up with outcomes. Perhaps I'm just a bad placebo responder, but judging by how often people return for treatment I'd think I'm not alone. Thanks to the information on this board I can look back at what actually worked, and why it did despite my lack of expectation. ( I was convinced gentle handling wouldn't have much affect, but it did, despite the therapist not knowing why).

Therapists with the knowledge that you guys have can do a lot of good connecting dots for patients who wander around the medical landscape bouncing around various mesodermalist explanations. I think the term "placebo" is a well enough known for many patients to understand and would go a long way in helping them grasp why it seems random therapies work.

I also find it strange that many more people in this thread don't oppose the idea simply based on the fact that it seems like you would be perpetuating the need for passive treatment.

As long as you can establish a good rapport with the client, communicate well, and invite what questions they may have, I see little reason you couldn't make a good run at convincing them that their and/or their previous doctors/therapists beliefs were incomplete, inadequate, or even worse, inept. I could possibly see a newer patient not buying it, and thinking their other doctors knows better. They might leave, but give them more time in the system and I wouldn't be surprised if they eventually come back wanting to hear what you had to say again. Not too mention, it would have saved me a lot more money knowing what I know now, instead of gambling my savings on the mesodermal crap-shoot. And for those patients who are 100% convinced they need a certain treatment like ultrasound, I'd refer out. Granted pushing out paying clients isn't exactly a great business practice, especially if you need the income. But that's a different discussion.
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Old 23-07-2010, 02:01 PM   #30
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Todd, "unintentionally decieving" is an impossibility. "Deceive" and "deception" imply awareness of the action and intent by the perpetrator....
In your example all of us would be uninformed and/or wrong, and unintentionally misinforming the patient.

I do not think all practitioners who practice Reiki or CST or MFR or other woo are "deceitful". They are woefully misinformed, and gullible, and pass that on to their patients in good faith.
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Old 23-07-2010, 03:36 PM   #31
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Quote:
Therapists with the knowledge that you guys have can do a lot of good connecting dots for patients who wander around the medical landscape bouncing around various mesodermalist explanations. I think the term "placebo" is a well enough known for many patients to understand and would go a long way in helping them grasp why it seems random therapies work.
I think JayCola has summed up the issue pretty well, and I personally feel validated when I hear a non-clinician make such an important observation.

For the life of me, I can't see how deceiving a consenting, rational-or at least capable of being rational- adult just because you think it might help their individual circumstance can be justified. Not within the scope of what we do. I not only think we have to assume that our patients are capable of understanding how placebo works, but that they deserve to know it. And as professionals we have a duty to help them understand this.
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Old 23-07-2010, 06:03 PM   #32
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I think there is a difference between decieving and simply witholding some facts.
There is no lying involved, no inert treatment dispensed. Simply an avoidance of a full out confrontation between what I know to be right/necessary and what the patients thinks he knows to be right/necessary.

I have had a very unpleasant experience with a patient in the past that resulted in a complaint from that patient to my Order. Of course I was cleared with some bogus recommandations, but I intend to avoid this in the future, thus my way of working.

I like the way Nari presented it.

I prefer to meet the patient half-way then having him go to a full mesodermal clinic where he will definitively be feed B.S. and his meme will get re-inforced. I propose new ideas to him, downplay his memes but still try to provide him something congruent with his beliefs.

This is not something I will do with every patient. In fact only a small percentage will get this type of approach depending on a number of reasons that have to do with experience and well... hunches.

As for US, IFC and their likes, no chances anyone gets these treatment in my clinic, I don't own any of them!
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Old 23-07-2010, 06:41 PM   #33
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Quote:
Originally Posted by Bas Asselbergs View Post
Todd, "unintentionally decieving" is an impossibility. "Deceive" and "deception" imply awareness of the action and intent by the perpetrator....
In your example all of us would be uninformed and/or wrong, and unintentionally misinforming the patient.

I do not think all practitioners who practice Reiki or CST or MFR or other woo are "deceitful". They are woefully misinformed, and gullible, and pass that on to their patients in good faith.
Hi Bas,

I'm not sure you're correct in your definition. For example, appearances can be deceiving without any intent. Self-deceit isn't intentional, right?

Regardless, my question still stands. Is it any better to be wrong and misinforming to a client/patient than to actively deceive them?

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Old 23-07-2010, 07:28 PM   #34
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I think it's worst to be wrong and misinformed than to be informed and trying to dispense a treatment congruent with both science and the pt's belief.

Leading a pt to believe something you know is wrong is deception.

When the patient is already firmly believing something and we are not leading them to believe in it per se, there is less deception involved I think. I think we are simply willfully avoiding delicate issues that could impede positive expectation. Since there is a science base for boosting expectation I think it's ok.
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Old 23-07-2010, 11:03 PM   #35
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At the risk of showing my hand as a fully-fledged pragmatist:

If the patient improves quickly then it matters (to them) very little whether they were told the truth about their condition, treatment. With acute problems the injury isn't a big part of the patients life and will frequently resolve rapidly- so most times the patient doesn't want too much information and education other than basic management advice.

If a patient doesn't improve ie problem is chronic and/or recurrent then i believe it's very important that they are given accurate information about it. It's with the chronic stuff where the false meme's do their damage.
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Old 23-07-2010, 11:26 PM   #36
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Quote:
f the patient improves quickly then it matters (to them) very little whether they were told the truth about their condition, treatment. With acute problems the injury isn't a big part of the patients life and will frequently resolve rapidly- so most times the patient doesn't want too much information and education other than basic management advice.

If a patient doesn't improve ie problem is chronic and/or recurrent then i believe it's very important that they are given accurate information about it. It's with the chronic stuff where the false meme's do their damage.
Yes. It is professional negligence, or should be, to withhold information which could significantly improve or resolve a chronic condition.

Nari

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Old 23-07-2010, 11:33 PM   #37
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In this context I would consider "deceiving" a willful wrong. That "appearances may/can be deceiving" is an expression that indicates a disconnect between perception and actuality.
We are talking about deception and deceiving. Two action verbs indicating intent. Appearances are not cognitive beings. "Self-deception" means intentional behaviour; if you want to typify behaviour that is unintentional, you will need another word..."unknowingly", "unwittingly", even "uninformed".

Still, as long as we are judging behaviours in therapists: I tend to think that being a uneducated twit is somewhat more forgivable than a willful act of deception. But only a bit better.
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Old 23-07-2010, 11:43 PM   #38
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I'm with John and Bas completely.

What I see all the time is this: The therapist is saying a lot of stuff that is absolute rubbish and they personally haven't a clue that this is the case. The patient certainly doesn't know this, and shouldn't be expected to.

In this case, the therapist is self-deceiving, especially if they imagine themselves competent, up-to-date, science-minded or anything like an actual "patient advocate".

Approaching the therapist in this situation is thought extremely impolite, and I don't think that's ever going to change.
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Old 24-07-2010, 04:22 AM   #39
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I entirely agree that in a chronic conditions of long lasting pain it is of outmost importance to give the most accurate info. Anyways, maybe if it's really a chronic condition the little expectation boost that could provide some deceptive behavior might not really make a big difference.
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Old 24-07-2010, 04:41 AM   #40
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It would be interesting to put forward more specifically examples of what we consider deception.

For instance, I consider that saying «your rib is superiorly fixated and I will unfixate it with a ribs manip thus your pain will stop» is really a deception. I would not do that.

On the other hand,

«You have some stiffness in your lower back probably because of a reflexive reaction to pain. You fit a scientific criteria that predicts you might do fine with a lumbar manip. I will do the manip and it should help you.»

Is this being deceptive?

Or better yet :

A post op patient comes in with a stiff shoulder post acromioplasty but little pain.

«Physical therapy, mobilisation and supervised exercices will help you gain your mobility back» is that OK ?

Because we could also say :

«There are very little studies really demonstrating you will get better, quicker with physical therapy as compared to a simple exercice program I can give you right now. We could simply check on your improvement in a few weeks»

My point with this is that theoricaly it is better to never deceive. But in reality, we work in a pretty grey zone where I often wonder myself how much what I do is really worth. If I was to be fully open with that with my patient, I would do very little to a very small number of patients and would probably hinder positive expectations. So, to certain degree, my overt optimism with patients is deceptive.

So, I do agree philosophically with John, Bas and Barrett. Practically I struggle in applying strickly this philosophy.
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Old 24-07-2010, 05:14 AM   #41
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Some examples of what I would consider unintended deception:

'So you have had this ongoing pain in your shoulder for three months - I'm certain I can fix you up in a few weeks with my (mesodermal) programs.'

Intended deception:

'So you've had this pain for three months and you have had a lot of treatments. I have this new machine, just on the market and it will fix you up in a few days.'

Deception through ignorance:
'.........the shoulder muscles are still weak so I'll try this intense strengthening program. You may need to take some more painkillers for a few days, then after that, all should be well.'

Itisa grey zone we work with, due to the variance in patients' responses. If honesty is the way to go, then one has to find a path between BS and doing the best approach available.

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Old 24-07-2010, 05:32 AM   #42
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Let make this a bit more interesting. Correct me if I'm wrong but wouldn't a consequentialist or rule utilitarian's view be expressed by a sentiment similar to this one:

A patient says that they would be interested in a doing what's best for them in terms of their health and would go to the clinician that gives them the best therapy (in this case a placebo). They want a clinician that interested in them and not one that is self-interested in upholding a moral philosophy at the expense of their health.

If correct then by consequentialism or rule utilitarianism wouldn't it be unethical to tell the truth? Truth here does not mean a Kantian evasion.

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Old 24-07-2010, 05:36 AM   #43
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Quote:
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In this context I would consider "deceiving" a willful wrong. That "appearances may/can be deceiving" is an expression that indicates a disconnect between perception and actuality.
We are talking about deception and deceiving. Two action verbs indicating intent. Appearances are not cognitive beings. "Self-deception" means intentional behaviour; if you want to typify behaviour that is unintentional, you will need another word..."unknowingly", "unwittingly", even "uninformed".

Still, as long as we are judging behaviours in therapists: I tend to think that being a uneducated twit is somewhat more forgivable than a willful act of deception. But only a bit better.
Hi Bas,

I appreciate your perspective.

My posts didn't compare the uneducated vs. the deceptive. I asked if it was better to be educated and misinforming to a client/patient than to actively deceive them. My point being that we, the small faction that make up SomaSimple, could all be wrong and unintentionally misleading patients/clients. I don't believe we are, but find it imprudent to completely dismiss the possibility. At which point the difference between us and the uneducated/deceptive isn't as striking as many wish to believe.

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Old 24-07-2010, 06:39 AM   #44
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They want a clinician that interested in them and not one that is self-interested in upholding a moral philosophy at the expense of their health.
I don't agree with the premise that intentionally upholding a moral tenet is done in self-interest. In fact, isn't intentional, preemptive ethical behavior what distinguishes a professional?

Imminently, we should find ourselves confronted with the dilemma of whether to provide the patient in front of us with more accurate information- or not. Certainly within the current context we find ourselves practicing therapy, these situations are plentiful. I honestly don't think our colleagues are unintelligent; rather, I think they've chosen ignorance out of fear. Where else can such a choice come from? What they're afraid of varies, but that doesn't matter, the result is the same: a blissful walk through a dark alley whistling a happy tune.

It's just not a savory proposition to walk into a room where someone is expecting you to make them feel better, and the question on your mind is, "What myth am I going to have to dispel for this poor sap today?"

I might even add that such a thought is "suicidal".
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Old 24-07-2010, 07:38 AM   #45
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It's just not a savory proposition to walk into a room where someone is expecting you to make them feel better, and the question on your mind is, "What myth am I going to have to dispel for this poor sap today?"
No its not. In fact, I somehow pride on being knowledgable enough to be able to dispel some myths but I don't like it. I wish this did not have to be a part of my job. I wish things could be simpler. But hey! perhaps that would take all the intellectual challenge away would it?

Regnalt,

I always envision I could be wrong, on anything. But I weight the probability of my chances to be wrong and so far, it seems to me «our little faction» is the lightest.
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Old 24-07-2010, 02:52 PM   #46
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Todd, I completely agree that we could be wrong. Which is an essential part of what makes this group different.
The fact that we even consider that makes us more like scientists and generally more informed already than many who are 100% positive of their "being right". A willingness to be proven "wrong" is absent in many - and that is a slippery slope towards possible willful deception.

However, simply being wrong has not much to do with deception in my opinion. Continuous self-evaluation and searching for the sources that falsify our theories, shows that one is doing everything possible NOT to steer the patient wrong. A continuous attempt to be MORE educated.
That sets it apart from deceit.

I think we are probably 100% on the same page - however, as always the subtleties and tone of language can suffer in written conversations.
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Old 24-07-2010, 05:54 PM   #47
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Originally Posted by John W View Post
I don't agree with the premise that intentionally upholding a moral tenet is done in self-interest. In fact, isn't intentional, preemptive ethical behavior what distinguishes a professional?

Imminently, we should find ourselves confronted with the dilemma of whether to provide the patient in front of us with more accurate information- or not. Certainly within the current context we find ourselves practicing therapy, these situations are plentiful. I honestly don't think our colleagues are unintelligent; rather, I think they've chosen ignorance out of fear. Where else can such a choice come from? What they're afraid of varies, but that doesn't matter, the result is the same: a blissful walk through a dark alley whistling a happy tune.

It's just not a savory proposition to walk into a room where someone is expecting you to make them feel better, and the question on your mind is, "What myth am I going to have to dispel for this poor sap today?"

I might even add that such a thought is "suicidal".
Oh I know that holding up moral tenant's are intentionally done in self-interest in health care and other places. Do you actually think that bio-ethicist's take mostly neutral positions? They are philosophers and adopt a philosophical stance. Researchers and academics have their agenda and moral stance as well. However, these may not always translate into the realities of practice.

The issue here is whether you are choosing to do what's best for your patient over what's in line with a particular moral philosophy. It's pretty clear what the patient wants and that's both the best help they can get and the truth. The dilemma is that these are in conflict when placebo is the best therapy because deception is part of it's application.

Here two virtues can change relative importance in the practice (not the research) of health care and truth, or at least the explanation given to the patient when they ask for it, takes a lesser position in the case of placebo.

The best explanation then becomes interesting because it's based on the expectations and beliefs of the patient as mentioned previously. But what are the consequences of these explanations? I know what the consequence is to drug and medical device companies if mega-placebo is really happening. However, some say that magical thinking will become dominant but I don't "buy" that at all. Explanations can be crafted in ways to avoid this by making them sound "scientific" and the public accepts that "scientific explanations" go through processes of change with time which is their other virtue. Now ask yourself if this "scientific sounding" approach hasn't been intentionally happening in many fields of health care already for a long time.

My other question is whether this is in line with Kantian, Utilitarian, Rawlian (or other) theories of justice. I know that ethical relativism can be easily dismissed but what came out of those debates is ethical pluralism which I believe is becoming the dominant view.

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Old 24-07-2010, 07:35 PM   #48
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The dilemma is that these are in conflict when placebo is the best therapy because deception is part of it's application.
I'm certain that this is a common misconception about placebo. If your mode is through dispensation and not evocation, then I suspect there is an element of deception. We shouldn't dispense placebo willy-nilly. In fact, we shouldn't dispense it at all for the very reason that it requires deception to provide it's beneficial effects towards resolution. On the other hand, the interactive quality of evoking placebo requires careful thought and consideration directed towards the authentic nature of the patient's problem.

This is an aside, but it fits well within this discussion. In a fit of satire, as was his custom, Mark Twain responded to a frustrated editorial writer who had been told by the higher ups to refrain from writing about important moral and ethical issues because people were canceling their subscriptions. His advice:

Quote:
But you are proceeding upon the superstition that Moral Courage and a Hankering to Learn the Truth are ingredients in the human being's makeup. Your premises being wild and foolish, you naturally and properly get wild and foolish results. If you will now reform, and in future proceed upon the sane and unchallengeable hypothesis that those two ingredients are on vacation in our race, and have been from the start, you will be able to account for some things which seem to puzzle you now.
One of the original Missouri dead men.

I don't find the distinctions we're making here requiring too sharp an edge or too deep a philosophical rendering. Isn't the catastrophe in plain view?
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Old 25-07-2010, 12:18 AM   #49
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It's just not a savory proposition to walk into a room where someone is expecting you to make them feel better, and the question on your mind is, "What myth am I going to have to dispel for this poor sap today?"
It's exausting. I do it daily. In my past life it was just so easy to come up with some wacky explanation( though part of me knew was wacky).

I don't mind hard work...in fact it is part of what makes me happy...to know I'm providing patients with as factual information as I can.

But this is what makes it especially challenging:

Down the street, or perhaps across the plinth, there may be another PT who is not well informed. Who continues to string together false rationals about pelvic rotations, stuck ribs, etc etc.

These clinicians can often have astonishing results. As we know, they are primarily due to effectively matching patient expectation and the ritual of it all. Regardless....the patient leaves highly satisfied. Yet mis-informed.

And guess what? In larger facilities, those that provide that sort of care often recieve letters of gratitude. Patients EXTREMELY satisfied with their care. Afterall, they were the first person to finally be smart enough to figure out their SI joint was stuck...

A colleague of mine ( who get's it) simply says that the ultimate goal was to get the patient moving and so long as the end result is a mobile/painfree patient...it really doesn't matter how you achieve that goal. This is where the question is coming from.

Meanwhile, those that provide care consistent with known facts( like Frederic's example of how to handle a post op AC joint patient)....if you went this way....you are MORE likley to get a complaint because you didn't provide care!( this has happened where I work by the way).

I don't like the position this places me in overall.

Last edited by proud; 25-07-2010 at 12:24 AM.
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Old 25-07-2010, 04:12 AM   #50
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You know Proud, the way our profession is regulated makes it hard to entirely turn your back on some mesodermal issues without a higher risk of complaints. And I talk with experience on this part. I've had a pretty loud and unpleasant discussion with the Syndic back then.

I mean, when even the colleges regulating us publicises PT through fully mesodermal tx constructs we really are swaying against the breeze, well... the wind - a pretty gusty one.
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