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…