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.

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