Stepping Back Part III

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If you are still with us and are more confused now than before, this is good. Keep in mind, it gets harder before it gets easier. Now that we have discussed some of the limitations with our root beliefs and began the discussion of shifting into a contextualistic worldview, it’s time to see what that really looks like in the clinic. Keep in mind, shifting into the worldview of contextualism isn’t introducing new philosophies, it’s simply showing the ability to adapt your philosophical perspective based on the context associated with the individual you are seeing in the here and now.

To shift into a contextualistic worldview, we must first be willing to accept and embrace uncertainty. Although this seems extremely daunting and uncomfortable, throughout this next blog post I will discuss ways you can improve your confidence by instilling a thing we like to call ‘confident ambiguity.’ It means having the confidence that you know certain directions or paths to head down while still being open to the idea that there are literally thousands more options available. To develop confident ambiguity, it is pertinent that we utilize a process-based framework.

Process-based theory has been discussed heavily by prior experts such as Steven Hayes and Stefan Hofmann. Most of their work can be found in the writings associated with Acceptance and Commitment Therapy, Cognitive Behavioral Therapy, and Relational Frame Theory. Expanding upon their work, Dynamic Principles took it upon themselves to utilize their successes and explore ways it can be applied in physical rehabilitation and pain. Without getting too much into the weeds of how this is accomplished, you can read extensively on how this was performed through many of our prior blog posts as well as our soon to be released whitepapers describing the Human Rehabilitation Framework.

With over a trillion different synapses and millions of different biophysiological mechanisms occurring daily mixed in and interacting with various psychosocial influences, there is no single model that can adequately categorize someone’s pain experience. Nearly all existing frameworks utilize a protocol-based approach that helps identify and categorize an individual into a subset of interventions, but as mentioned above, that almost seems impossible. People don’t fit in boxes and since we are all unique, we don’t do well categorized in a group.

That is why we need a process-based approach. The word “process-based” appears to be sort of a buzz word for many clinicians currently, yet there are very few frameworks that exist that are actually process-based, none of which are in the physical therapy world. Many frameworks such as Mechanical Diagnosis and Therapy (MDT, AKA McKenzie), FAAOMPT frameworks, Applied Functional Science, Certified Movement Links Specialist, Movement System Impairment Syndromes, and many more may claim they utilize a process-based approach, but in actuality are just larger protocol based decision makers. Also, it may be important to note that all these frameworks were built in a mechanistic worldview and despite their willingness to move towards a more BPS model, their theories become too incoherent because they have yet to address where their root beliefs remain. For MDT, it started in the discs, for others, it’s all about the muscles/fascia, and for some it’s all about these dysfunctional movement patterns (whatever that means).

To be truly process-based, we must first move away from reductionism and acknowledge that with every intervention we employ, we are constantly interacting with multiple processes involved in one’s network. There are now over 70,000 different ICD-10 codes and we use these specific diagnostic labels to categorize people and group them into a set of interventions. People don’t fit in boxes, they are all too unique to be reduced down to one or a few specific labels. What happens if someone has more than one specific diagnostic label? If someone is dealing with neck and low back pain, should we reduce the neck down into a tissue dysfunction and the low back into a stability impairment? Many may believe that’s what process-based means, but instead you are merely using two different sets of protocols and adding them together.

With nearly 20% of people experiencing chronic and complex pain, we have to do more. Most of them are feeling broken and have had a thousand different rules created from so many providers. Don’t bend over too much, no twisting, be careful with walking too far, your hips are weak, your upper shoulders are too tense, you have dysfunctional patterns all over you. Algorithms, flow charts, and categorization are just not going to cut it.

In our Human Rehabilitation Framework, we describe processes as the following:

“Processes of therapeutic change are the dynamic functional collection of overlapping and interconnecting mechanisms operating at multiple levels and dimensions that are changeable and interact in an orderly manner accounting for history, time, and the diverse contextual factors involved in a meaningful outcome.”

We have identified nine different processes that are flexible and can allow us to continuously adapt based on the CONTEXT involved with every encounter. This allows us to address multiple body parts, specific individual needs, and create endless opportunities to engage with our clients. Put simply, it’s up to us to learn about each unique experience to figure out what sort of processes they may be stuck with and provide strategies that can potentially get them unstuck. This may very well entail some of the many criticized interventions such as core stabilization or manual therapy, but we aren’t performing them to “stabilize the core” or the “rub out the issue.” We may be performing them to engage with attentional and social relational processes that ties in with the education we are providing that ultimately helps our client build ownership in managing their conditions.

To dive into each of these processes is not within the scope of this blog piece as we have several pieces of coursework that do that. However, my original intent of this series remains the same, which is to help you recognize that most of our current theories are extremely flawed and until we step back to explore what worldview we are living in, we are not going to move forward. Philosophies such as enactivism and dispositionalism sound promising, but if we apply them in a mechanistic worldview, we are only going to make the same mistakes we did for the BPS model where it becomes lost in translation. Having the ability to zoom in and zoom out in a unified and coherent manner while being able to understand the functional context involved with each situation is the path we need to move forward towards, and engaging in process-based therapy helps us do exactly that.

I understand this material can be dense and difficult to comprehend, because it takes a long time to actually shift your beliefs especially when society expects us to live in a mechanistic world. But by being a little more curious and challenging where your root beliefs stand, you may find that through time, it gets a little easier to deal with all this uncertainty. You may even recognize that you are finally developing some confident ambiguity.

 

If this series left you with more questions than answers, good, because there is a lot more to come, so stay tuned…

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Stepping Back Part II

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In Part I of this series, I discussed the limitations that exist with our current beliefs and theories we hold when it comes to dealing with pain. For most of us, this involves having theories rooted in a mechanistic worldview believing that our bodies are like a machine and can be fixed with certain interventions. To understand some of the content in this next part, it’s important you read the first part to process through some of the complex nuances discussed.

Throughout this post, my intent isn’t to give you a new philosophy you need to learn, and it isn’t to suggest which interventions are the best; it’s simply to challenge some of your root beliefs and provide a new worldview that is able to adequately explain with enough scope, depth, and precision why certain interventions work for some people in the right context. By doing so, my hope is that we can move our profession forward through a new worldview that isn’t often discussed or taught in the medical field.

When investigating research surrounding pain, many of the interventions we use have demonstrated some effectiveness, but not necessarily for the same reasons we are led to believe. It wasn’t until the early to mid-2000s when researchers began to challenge some interventions that we idolized with sham-placebo controls. This began to unravel questions as participants seemed to improve equally as well with the intervention compared to the control. Why did people do so well with an intervention that was fake? Surely, if our theory was encapsulated in a mechanistic worldview, it would make no sense; the participant didn’t get the thing that changed the mechanics of the issue, yet they still got better?! This must mean there has to be more to the story. Besides the several thousand differing physiological interactions and processes occurring, there has to be some CONTEXT involved that interacted with the human receiving the intervention.

To work with pain more efficiently, we don’t necessarily need to add any more tools to our toolbox, we just need a better framework that is rooted in a philosophical worldview that can adequately explain with enough scope and precision all the complexity that is involved. Having a mechanistic worldview to explain pain might have been what was needed when Descartes first discussed his theory of mind-body dualism, but now that we are in the 21st century, it’s time to move on to a better worldview that accepts and helps us understand the importance of context involved with every unique situation. This worldview is known as Contextualism, and by embracing the scientific philosophy of pragmatism, the framework we want to implement is called a process-based framework.

Shifting from a mechanistic worldview to contextualism acknowledges the importance of context in every situation. For people with pain, this includes all the unique individual biologic, psychologic, and sociological factors influencing one’s experience. Even though the Biopsychosocial Model (BPS) was proposed in the late 1960s, we still have not had a chance to fully understand its scope because we have forced it into a mechanistic box. However, when you start to view the BPS Model within the worldview of contextualism then the idea of application becomes a little clearer. We can’t just use the model to help explain all the mechanisms involved within each realm. Instead, we must show enough flexibility and willingness to shift our philosophical perspective based on the context that is involved with each realm. This entails having the ability to quickly and efficiently shift between different perspectives based on the CONTEXT involved in one’s unique case.

To help explain this practically, let us think about someone with low back pain. When you take on a contextualistic worldview, your thinking becomes more dispersive allowing you the opportunity think about the back pain mechanistically to rule out any serious red flags, and then can easily transition into a different perspective recognizing all the different dynamic and interacting processes that are involved. Without that ability to zoom in and out in an efficient manner, you either miss the boat completely on red flag issues and risk the ability to help someone receive a necessary life-saving intervention, or you become stuck trying to find a single cause for something that has many different synthetic processes constantly interacting and interconnecting to formulate one’s pain experience.

Failure to become aware of all the differing, complex networks involved often results in a loss of coherence for both the clinician and the patient. This happens often as their beliefs suggest one thing, your words say another, and the intervention you describe doesn’t align with either of them. They may be hearing that their pain is multifactorial, yet you both are in search of the one single cause. (To learn more about coherence within a clinical setting, be sure to read our prior blogs here, here, here, and here.)

So how does viewing pain from a contextualistic worldview change what we are doing in the clinic? Many people have the belief that with a new framework comes a ton of new interventions. That isn’t necessarily the case for this. As mentioned in the very beginning of the first blog of this series, when we think about interventions for pain, it’s better we challenge the thought process behind them rather than the intervention itself.

Let’s take core stabilization for example. Many people have their patients with low back pain perform core stabilization interventions. This idea is often formed from the mechanistic belief and theory that the back is unstable and needs to be fixed or stabilized. The belief becomes stronger when patients who perform these interventions report improvements in their pain experience, which we know happens quite often. Since patients are improving, it must mean that their backs were unstable, right? This all sounds appropriate, however, when you investigate the research and find that people with low back pain are often more tense and guarded around their low back, why would stabilizing an already tense muscle make much of a difference? If people with low back pain show less mobility and coordination then other healthy controls, that doesn’t sound like the back is unstable to me. But why then do some people get better with core stabilization interventions?  There has to be context associated with their unique history, beliefs, expectations, etc, and by performing low graded movements mixed in with increased awareness into the low back is just what someone may need to gain the confidence that they were indeed going to improve over time. It’s hard to truly explain the exact reasons which is why it’s much easier to say it depends on the context and several other thousand interacting, dynamic processes concomitantly occurring for that individual!

Okay, so now that we may have a better rationale for explaining why someone with low back pain benefits with core stabilization, with thousands of interventions already existing, how do we know which one will be the best? This is the path we will take in Part III of this series where we dive deeper into the concepts related to process-based thinking and clinical-decision making.

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Stepping Back Part I

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When it comes to the science of pain, I would say that I remain agnostic about many of the interventions employed in rehab. Social media often displays a dichotomous view where people are either for or against certain interventions, however, when I post content, I only challenge the thought processes we have behind those interventions rather than the intervention itself.

Many researchers and publications have been saying for years that the context and complexity involved with what we call the human experience is far too ambiguous to be able to predict with high precision that we know the solution to one’s problem. This definitely creates uncertainty.

To become comfortable with uncertainty means embracing the fact that you will never be fully capable of comprehending the totality of evidence that has been compiling over the past millennia. This feat is so far outside of our current scope of knowledge that we can’t even begin to imagine the type of information we don’t know we don’t know.

In turn, there appears to be this pervasive nature of individuals opting for reductionist models and lines of thinking to help make sense of their thoughts. To find comfort with our reasoning, we then cling to others who share similar views seeking confirmation that our theories are most certainly true.

Problems exist in this mode of knowledge because when it comes to complexity, it’s hard to reconcile what is actually true. Circling back to the interventions we perform, one thing that seems to be ubiquitous is that most people get somewhat better or will regress back to their average over time. What is difficult to understand and is why some people are able to improve far more significantly than others despite similar courses of treatment.

Again, we can theorize all we want, but for there to be any validation to the theories we create, it must have adequate scope, depth, and precision remaining consistent over time. For example, if we use the theory that the body is like a machine, this is based on a mechanistic worldview. For this to be true, we will have to see a linear progression of tissue degeneration with more active people showing significantly more degeneration. However, that doesn’t appear to be the case. As our knowledge improves and we find that active people have better looking joints than their sedentary counterparts, it pokes holes in the original theory, and one cannot adequately explain why that may occur. This becomes an incoherent way of thinking as the theory says one thing, yet what is observed appears to be different.

Since medicine has been derived from a mechanistic worldview stemming from Descartes theories of dualism, most theories formulated today hold similar mechanistic perspectives. This draws us back to the belief that our bodies are like a machine creating the idiom commonly referred to as ‘wear and tear’. Mechanistically speaking, it makes no sense to describe our bodies like a machine that will only break down when there is solid evidence of one’s ability to adapt based on the context surrounding their unique history. Without context, it’s hard to understand whether someone’s tissues will degenerate to the point they become problematic.

As research continually evolves, pain science enthusiasts have recognized the many flaws in these theories, so they decided to create new ones. Although this sounds good in theory (pun intended), the new theories that are replacing the old theories are still viewed in a mechanistic worldview. Instead of thinking of our bodies like a machine, we moved into the neurocentric idealism that our brains are the machines that can be controlled. Replacing one reductionist model based on a mechanistic perspective with another reductionist model based on another mechanistic perspective is like the definition of insanity. We keep doing the same things repeatedly thinking we are going to get different results. Our failure to become aware of and understand where our beliefs are rooted only hurt the forward progression of where medicine needs to transition.

So where do we go from here? Existing models have been proposed over the past few decades calling for such change, but many people become lost in translation with how they interpret those models. Opinion pieces and different perspectives continue to get published criticizing the nature of how we interpret these models with suggestions to move forward towards newer philosophies that give clinicians a different model to understand the complexities of dealing with pain. But we don’t need another model. We don’t even need another philosophy to show us a better way to understand and explain pain.

What we need is to take a HUGE step backwards. So far back that we explore what worldview we are living in and where our beliefs are rooted. As mentioned earlier, medicine was founded within a mechanistic worldview believing the body was a machine. We have made some progress in the 21st century recognizing and acknowledging the limitations that exist with mind-body dualistic perspectives, yet we replaced all these old theories with the neurocentric belief that the brain is a machine that can control everything. We didn’t actually change our root worldview, we just shifted from one perspective to another with a very similar reductionist thought process.

Now before I go on criticizing the mechanistic worldview, I would be remiss to acknowledge all the benefits that have occurred because of it. It was because of this worldview and its associated beliefs that the field of medicine now has the capabilities to prescribe certain pharmaceuticals and perform surgeries that are lifesaving. If you are a surgeon removing a cancerous tumor from the spinal cord or a physician prescribing the appropriate life-altering medication, you may not care as much about the context involved in the situation and instead do what is necessary to fix the mechanistic problem the individual is dealing with. But that doesn’t mean this worldview applies to everything in medicine. When it comes to pain, it is time we recognize that we can’t live in a mechanistic worldview and adequately treat it.

Stay tuned for Part II where we discuss the importance of shifting worldviews to better understand and apply interventions associated with pain.

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Process-Based Rehabilitation – The Way Forward

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Rehabilitation, and much of healthcare, has reached a point of reckoning. We are stuck in a world where we operate in “protocol-driven clown suits”, putting on an entertaining simplified show for the world to watch. These suits ultimately relegate us to the future of becoming replaceable technicians (hello AI & robotics) that worship the idol of a “specific diagnosis” leading to some sort of step-by-step cookbook approach to intervention. We see this growing daily as all around us as “evidence-based” healthcare providers are scraping, bruising, and poking needles into people like pins into pin cushions based on false “specific diagnostics” and a poor understanding of neurophysiology. While many of these providers are well meaning and attempting to help the person in front of them, ultimately, whether consciously, or unconsciously, they are entering into a theatrical show that sells a false value of their shiny interventions. The show continues to grow in popularity despite access to the evidence that consistently demonstrating no additional value from their new treatment addictions. This show goes by the name “XYZ might just be the thing that finally works!” even when it doesn’t, because we haven’t even defined what “working” is and what it is “working” for. This show is not just about our hands on interventions, but it also speaks to our exercise interventions where we randomly throw exercise based on such false diagnoses as an “instability” of some imaginary sort, without knowing what the exercise actually does for that individual, in what context under what instruction. The show can also sometimes sell this idea that exercise alone is this holy grail. Exercise is medicine, right? …But do they really need medicine right now? Are we medicalizing something that does not need to be medicalized? There also is this lingering belief, often from academics, that we can save the day by protocol-based clinical reasoning. Graduate education, post grad courses, certification, residencies, and fellowships promise clinical reasoning and critical thinking but all they’re doing recycling the same inadequate protocol driven drivel that has very little to do with the person in front of us.

Like our psychology colleagues before us, the time is here for a complete paradigm shift in the way we look at the problems of the people who come to see us. The person before us comes with an individual history, a story, and that story in large part determines how that person and their body is operating now. The way the biopsychosocial processes function in this moment was built on years of interconnecting biomechanical, physiological, psychological, and social behavioral relationships and networks unique to that individual in that moment and time. No diagnosis or protocol for syndrome can possibly meaningfully, or practically, be useful in the context of past and present behavior. When someone comes with a report of knee pain, but then also notes significant impairments associated with shoulder pain, and that they have a history of chronic back pain, not to mention they struggle with anxiety and depression, how many diagnoses do we assign them? How many tests do we need to do, how many interventions, how many referrals need to be made, and how many healthcare providers need to be involved only to ultimately not communicate with each other in any meaningful way? Even a single pain complaint is far more layered if we actually ask more closely about the nature of their complaint. Why does lifting their 20-pound child not hurt their shoulder but a sandbag roughly the size and weight of the child in the same manner cause excruciating pain? Why does that shoulder only hurt on Saturdays when doing the same movement as they would on Tuesday at work does not? History and context are key! Even if you are looking simply at sensorimotor and loading capacity variables, what preceded and what is present in the environment and inside of that individual person changes everything! This is the core of a process-based approach to evaluation, intervention, and prognostication, a science-based, critical clinical reasoning approach rooted in learning how to see where people get stuck across of a lifetime and how to help them get themselves unstuck. No more collecting diagnostic labels, no more piles of homework for the client, and no more handing fish to a hungry client when you can teach them how to fish for themselves!

At Dynamic Principles, we are committed to a future of educating clinicians in a process-based approach. We are excited about what this means for humanity in the future of helping people and we hope you’ll join us in this journey!

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Coherence (Part 4 of 4): Bringing worldviews into practice

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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. A form of INCOHERENT ECLECTICISM. 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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Coherence (Part 3 of 4): Drawing lines in the sand

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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” and my observations of INCOHERENT ECLECTICISM. 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.”

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Coherence (Part 2 of 4): Something isn’t right!

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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, a form of INCOHERENCE. 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.”

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Coherence (Part 1 of 4): What is the sense of all this?

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This is a long overdue follow-up series on a post on “Confident Ambiguity” from 2016.

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Most of you reading this post will have some background in the biopsychosocial model, pain science, and movement science. Based on this premise, my assumption is what I am about to say rings true with many of you:

Despite all the knowledge we have gained, the data we have scoured and synthesized, little of what we have learned  “makes sustainable sense” when you throw it all together in effort to make it workable. With increasing knowledge, more gaps are inevitable and gaps in knowledge are never ending. Somewhat haphazardly, we patch the gaps as quickly as we can but the patches we use to bring them together are often mismatched. 

If knowledge feels patched together to you, what does it feel like for our clients/patients?

 

Think about it. We’ve got this biopsychosocial model (framework!), the neuromatrix, the needless distraction of predictive processing, the sensation versus perception arguments, and all these other cool neuroscience things. But what about consciousness, what is it??? There are also aspects of contemporary biomechanics and loading capacity that need to be understood and incorporated. Then we’re dabbling with psychology, we’ve got expectancy violations, graded exposure, fear avoidance, yellow flags, resilience…. But wait, what about social and cultural implications? How can we be so cruel as to expect someone in the worst socioeconomic status to be anything other than trapped, they could never develop resilience and be another self-help success story because nothing of their environment supports it! Then there are arguments of logical fallacies, continuing battles of epistemology and ontology, and, wait is there a value to philosophy? But what about the person in front of us? Their story, their narrative! Surely we shouldn’t forget the person! But what about the new graduate navigating the whizz bang shiny objects excited that by finding that “dysfunction”, poking, scraping, corrective exercising, or constricting the circulation of their client into oblivion hoping for that magical, “that feels better!” verbal response to be provided. What about our patients’ autonomy? And our science! What about our science? Outcomes measure outcomes not interventions, the limitations of the peer review process, the poorly (sometimes fraudulently) performed systematic and meta-analysis, the lack of disclosure of conflict of interest, poor blinding and lack of bias observation in much of everything that is available. Oh. and don’t forget, what about our own self care? Don’t look now, there’s the next social media post and the next article to argue about, wait what are we arguing about? Are we arguing?

            ….If you are reading this paragraph several times, you may wonder, like I have, how most clinicians who fell into this curse of wanting to learn more and do better have not all gone mad. It is no wonder the transference of this information has been poor and slow to take on culturally, it’s like we don’t even have ground. We’re taking on all this information but we have no idea where we stand, how to make sense of it, and not just how to apply it, but how do we meaningfully share it with others?

 

No matter where you are in your career, do you feel that inner turmoil? Read Part 2 of this blog post next week: “Coherence: Something Isn’t Right!”

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