COHERENCE (PART 4 OF 4): BRINGING WORLDVIEWS INTO PRACTICE

Part 1 is available [here],part 2 [here], and part 3 [here].

By now a good chunk of you are wondering, where does this fit in the movement and pain science realm? I will attempt to explain the importance of the above groundwork by drawing a comparison of a mechanistic viewpoint of psychology for mental health presented by Russ Harris in ACT Made Simple, to that of rehabilitation professionals utilizing a mechanistic viewpoint for physical health. Mind you, I’ve taken some liberty in how I recreated his text and this is not word for word from the book:

Psychology mechanistic models for ‘mental’  health

Many clients approach psychological therapy with mechanistic ideas. They believe they are faulty, damaged, or flawed and therefore need to be “fixed” – how many times have you heard a patient/client use the term “I am damaged goods”?

They believe they have “faulty parts” – negative thoughts, anxiety, or painful memories that need to removed.

Many psychology MECHANISTIC models readily reinforce the notions through two processes:

    1. Often terms such as “dysfunctional”, “maladaptive”, “irrational”, etc. which imply we have faulty or damaged components to our minds
    2. A variety of tools/techniques used to directly reduce, replace, or remove unwanted thoughts and feelings are provided with the assumption this is essential to stepping forward in improving quality of life

Rehabilitation mechanistic models for ‘physical’  health

Many clients approach rehabilitation with mechanistic ideas. They believe they are faulty, damaged, or flawed and therefore need to be “fixed” – how many times have you heard a patient/client use the term “I am damaged goods”?

They believe they have “faulty parts” – bad parts, tight muscles, trigger points, maligned/stuck joints, or painful areas that need to removed.

Many rehabilitation MECHANISTIC models readily reinforce the notions through two processes:

    1. Often terms such as “dysfunctional”, “maladaptive”, “irrational”, etc. which imply we have faulty or damaged components to our bodies.
    2. A variety of tools/techniques used to directly reduce, replace, or remove unwanted ‘physical’ symptoms are provided with the assumption this is essential to stepping forward in improving quality of life

 

This comparison was drawn because what I commonly see are cobbling together of concepts from pain science, biopsychosocial principles, and movement principles with all sorts of ecclectic tools but sometimes the underlying viewpoint from which a “tool” is drawn from does not match the root viewpoint of the other “tool” they are paired with. Take for example, if you wished to combine classic “Directional preference” (MDT) with ACT principles you would be attempting to pair a mechanistic viewpoint (MDT) with a contextualistic viewpoint (ACT). At face value, this seems unimportant, but when the mechanistic basis of symptom modifying from MDT is combined with the contextual acceptance/expansion fundamental basis of ACT, there will be inconsistencies which may arise for the client over time through their experience of the combination, such as why is there such an emphasis on symptom modification in MDT but a greater emphasis on not modifying symptoms in ACT? Likewise, the clinician may struggle with deciding on a clinical direction between symptom modifying and function oriented objectives. Similarly, if you combine classic Cognitive Behavior Therapy (CBT) with a contextual movement exploration exercise, you are again inevitably going to run into coherence issues in practical application with clients over time due to some of the mechanistic cognitive reframing aspects of CBT working in opposite of the contextual flexibility processes introduced in contextual movement exploration. Examples of organicism worldviews as the foundation of their development include NDT and DNS with their emphasis on developmental phases. Dry needling, trigger points, myofascial, craniosacral, specific postural/breathing methods, and much of our professional trends are examples of work rooted in mechanistic viewpoints. Both organicism and mechanistic rooted “tools” are often paired with contextual dialog when attempting to “educate” patients about their pain and the role of biopsychosocial factors. This is not to say that these approaches are not useful interventions, but rather that the interventions may need to be reconceptualized from the ground up before they are deployed in clinical practice to reduce coherence problems for the client and the clinician. The biopsychosocial model could be seen as being developed from organicism viewpoint if looked at simply as an interaction of multiple systems in a scientific descriptive manner but I would argue clinical application is nearly impossible for the BPS model without viewing it from a contextualist viewpoint.

The importance of understanding your viewpoint can also be seen in your attempts to create behavior change via education.  When you try and provide therapeutic neuroscience education from the lens of classic CBT to “change beliefs”, or “conceptual change”, as defined by NOI for Explain Pain. These approaches were originally built on mechanistic perspectives, and a limitation of this viewpoint is that it cannot account for why “Successful” education is nullified when the client leaves the clinic, next time they arrive, they may be even more rigid in their thinking than the first time! However, looking at behavior change implications from an educational perspective through Relational Frame Theory (contextualism), accounts for these complications, and while nothing can guarantee change, at least provides a working understanding of why this occurs and how to work with the darkside of human language opens up opportunity for meaningful action with a functional understanding.

By drawing these comparisons I hope to start to clarify the importance of clinicians learning to look at viewpoints more critically and in doing so,  “develop the adequacy of one’s own position, to analyze other positions from within, or simply to illuminate the nature of the philosophical disagreement.”(Hayes, et al. 1988) 

Furthermore, in consideration of the complexity of pain and movement, consider exploring a viewpoint of contextualism as the foundation of developing practical frameworks for clinical practice, a task which we will attempt to undertake on future posts.

COHERENCE (Part 3 of 4): DRAWING LINES IN THE SAND

Part 1 is available [here] and part 2 [here].

…Disclaimer: The depth and scale of Stephen Peppers work is in many ways an understanding of philosophy that is beyond my pay-grade and will likely take some time for me to fully appreciate. In what little I have been able to process, he has provided some significant insight into the coherence issues we are seeing in healthcare related to the topics of pain and movement in particular. For a more educated review, please see Hayes, Hayes, and Reeses book review of Pepper’s World Hypothesis work to explore this topic prior to my butchering and overly simplifying these worldviews [here].

Steven Peppers proposed the idea that the philosophical worldviews (Pepper describes these are world hypothesis) each of us hold can be looked upon like objects in our world. That these viewpoints can be described and compared to each other, and that through viewing them critically it is even possible to determine “relatively adequacy” in their scope and precision. A “Relatively adequate Hypothesis” is built on a root metaphor, which serves as a conceptualization which balances common sense with “refined knowledge”. An adequate world perspective should be “..unlimited (in) scope and is so precise that it permits one and only one interpretation of every event” (Hayes, et al. 1988), but as reviewed by Peppers, rarely do these viewpoints completely succeed and therefore, the “best” can only be considered “relatively adequate”. 

Peppers discusses several principles at the core of his world hypothesis and I could easily get distracted by describing all of them. However, his “Maxim number 3”, states that “eclecticism is confusing”, and this once again rang true for me in my own “yearning for coherence”. In this principle, Pepper states an adequate root metaphor (therefore world view) is autonomous, which means they are mutually exclusive, and to attempt to mix them with other viewpoints can only become confusing. Now, with that stated, Steven Hayes describes a powerful implementation of contextualism to incorporate other viewpoints but avoids the costs of conceptual confusion which we will discuss later.

Here is a A VERY Brief Summary of the ”Relatively Adequate” World Views

Formism

Commonly Called: Realism

Root Metaphor: Similarity

Formists like to organize and categorize things, they label the quality of things and relationships between things. Fruits are often sweet and can be organized relative to the type of fruit and trees or plants they come from. Principles of operation, such gravity/force, etc, are not important, only how things relate to each other in form matters.

Mechanism

Commonly Called: Naturalism, Materialism, and sometimes also Realism

Root Metaphor: The machine

Mechanists look at the entire universe as a machine. Parts and pieces have distinct roles which are systematically related in the machine and alter its function. Mechanism is similar to formism but discreet relationships between parts do allow operations to produce predictable outcomes. Emphasis on outcomes is a key component of this worldview as mechanism is essentially the root philosophical viewpoint of the biomedical model.

Organicism

Commonly Called: Absolute Idealism

Root Metaphor: Process of organic development and organic systems

Organicists look at the “Whole” as being the basic foundation, the whole is not made of parts or a synthesis, rather, they are meaningless except for when they are part of the process of the whole. An acorn is going to become a tree, unless of course the acorn is eaten by pig and then becomes a part of the pig. 

Contextualism

Commonly Called: Pragmatism

Root Metaphor: Ongoing act in context

Contextualists essentially look at “truths” varying within the context of which they are made, including the historical context.  Hayes describes the most powerful application of contextualism is that it “allows the strategic use of categorical concepts from other worldviews subordinated to contextualistic criteria”. What this means is that other viewpoints such as mechanism can be use toward a specific end. The machine metaphor can then be used toward “successful working” of the contextualists agenda if the context is defined. Similar to Steven Hayes’s perspective that contextualism is the most important viewpoint for which to look at behaviorism, we at Dynamic Principles see contextualism as the most practical lens in which to look at movement and pain. After all, when it comes to movement and pain, context is king.

So what now? Read next week’s blog post conclusion: “Coherence: Bringing worldviews into practice.”

COHERENCE (Part 2 of 4): SOMETHING ISN’T RIGHT!

Part 1 is available [here].

Something deep in me (and many of you) has driven a pursuit of knowledge, yet with every new thing I learn, there is this underlying feeling, urge, that recognizes the available pieces do not fit together in a meaningful way and that simply pursuing more knowledge mindlessly is, to some extent, a dead-end road. Given enough time, anyone who has extensively explored movement and pain science would also start to feel the urge to look for new knowledge to serve as another patch and to provide another fix toward our insatiable addiction to gain more and more knowledge that might once again temporarily satisfy us. Unfortunately, this process can lead to endlessly spinning of cognitive wheels in new territories with little reward of fulfillment after spending enough time there. Some just give up and call it “good enough”, make do with their knowledge base and do what they can with it and feel their clients will either get what they’re giving them or not. Many others, particularly those early in their careers will continue to be unsatisfied. While working through an ACT Intensive course led the creator of Acceptance and Commitment Therapy (ACT), Steven Hayes, we were introduced to several “core yearnings” which form some of the functional basis of ACT. One of these yearnings I believe best describes the urge for things to make sense, and that is the “yearning for coherence”. In the course, this yearning was a introduction to Relational Frame Theory (RFT), which is a working model of language and behavior (we will discuss this further and it’s valuable role for working with movement behavior in subsequent posts), but for the purpose of this first series, we are stepping back further and looking at  “yearning for coherence” as our entry point addressing a bigger picture of our desire for things to make sense. This recognition of my own yearning for coherence required me to follow Hayes advice to look at Stephen Pepper’s work on “World Hypotheses”, or world viewpoints, as a place to begin to make steps toward a sense of coherence.  In this process, it is important to note that coherence in a literal sense is not achievable, but coherence in a functional sense is sustainable, workable, and “liveable”. To recognize, understand, and firmly place your feet in one world viewpoint is necessary to develop a sense of coherence, yet most of us have no idea where we stand. In observation of this in myself, past and current colleagues and clients, it has become very clear that most of us are not fully aware of our current world viewpoint, and if we believe we have one, it is likely an incomplete awareness at best. This makes our current working viewpoint unstable ground to begin with, and our efforts to create a new viewpoint out of two distinctly different world views, let alone inadequately developed viewpoints, is further broken when creating “something in the middle” of two perspectives. Creating yet another cobbled together viewpoint which will fail to withstand minimal scrutiny. We then keep throwing knowledge on top of this shaky ground hoping somehow things will fall into place and finally “make sense” , but instead we get further convolution, poor translation, and of course, arguments that are based more on the viewpoint, than on the  content of the argument. Content based on language, which as we will discuss later, lends to it’s own complications, but for now I best leave this post with the following:

“Hold language lightly even the things called facts because they are built only on one part of your interactions..” Stephen Hayes

 

How can we even define this for ourselves and our patients? Read next week’s blog post: “Coherence: Drawing Lines in the Sand.”