Having talked with people about my last blog entry (Exercising our demons, 16th May 2010), one of the most interesting conversations centred around physiotherapy’s fascination with its heros; the ‘big names’ in the profession that are made famous by their inventions and innovations. The last blog entry touched on this only briefly, and only in the sense that I expressed my dislike for the naked evangelizing of some of the speakers at our conference. But there is a bigger point here that deserves consideration, because – as a couple of my colleagues pointed out – physiotherapy really does suffer, at times, from the cult of the hero.
A good illustration of hero worship can be found in musculoskeletal physiotherapy. Last year I was involved in a project to celebrate the 40th anniversary of the history of the New Zealand Manipulative Therapy Association. As part of the project, I wrote a commemorative history of the group. New Zealand is well blessed with innovators and pioneers in musculoskeletal therapy: (in no particular order) Stanley Paris, Ian Sim, Ian Searle, Rob McKenzie, Brian Mulligan, who for their part followed Cyriax, Stoddard, Kaltenborn and Grieve in developing new ways to manipulate the spine. To this day, some physiotherapists are strictly Mulligan practitioners, while others are firmly in the McKenzie camp, and one wouldn’t need to go far to find a therapist with a strong opinion on Maitland or, heaven forbid, chiropractic or osteopathy.
Now musculoskeletal physiotherapy is perhaps a paradigm case of the cult of the hero, but it is by no means unique in this respect, and while there have been some marginal attempts to define a unifying theory of nearly everything, most practitioners adhere to their preferred brand of therapy.
It occurs to me that our need to associate with certain paragons of professional practice says something about our profession, and reveals something about our inherent lack of theoretical depth (an argument I have made on numerous occasions before). But why does it reveal this? Well, one explanation may be that when we look at the theoretical arguments made by these various experts in their field, they qualify as what Domholdt calls ‘mid-range theories’. In other words, they offer theories that answer some questions about phenomena, but that their range and scope is restricted to a particular pathology, cultural or social phenomenon, specific system or series of operations. Mid-range theories have nothing to say about the ‘bigger’ philosophical questions of how we might/should live; what is the nature of reality; what is being; etc. Thus McKenzie’s approach to back pain has nothing to say about justice, love, or the nature of government – only about the aversive nature of back pain and pathology.
The fact that physiotherapists eagerly differentiate their practices based on whether they are Maitland or Mulligan practitioners suggests that they have little awareness of the common philosophical heritage of all these approaches and its now well argued limitations (references for this argument are far too numerous to list, but the following give a sample of the issues; (Lupton, 2003; Nettleton, 2005; Turner, 1995; Williams, 2003, 2006). Indeed, if physiotherapists were ever exposed to phenomenology, social constructivism, medical sociology, or postmodernism in any fundamentally sound philosophical sense, they might well turn away from such instrumental theories and challenge the very essence of physiotherapy practice.
All my research in and around physiotherapy has led me to believe that our historical affinity with the body-as-machine has been a blessing and a curse. It has given us enormous security as profession allied to medicine, but it has also blinded us to the multifaceted, immensely complex and incomprehensibly subtle (and not to say ‘political’) nature of health and illness.
Thus, when we look to our luminaries to provide us with the semblance of theory to help us comprehend the patterns of health and illness that we see each day in our practice, our eyes reach only to the level of the ceiling. Rarely, if ever, does our vision reach the stars.
Not surprisingly, we are seduced by whatever passing fad or fancy best explains the immediate circumstances, and why it is all too easy for people to waltz into our conference centre and sell us rhetorical candy-floss.
Interestingly, a similar phenomenon was recently identified in nursing. In an editorial in the excellent Nursing Philosophy, Derek Sellman wrote about nurses’ fascination with reflective practice (Sellman, 2010). Like physiotherapy, Sellman argued that nursing practice had been built upon ‘borrowed’ practices and approaches, but unlike physiotherapy, nursing had suffered from a surfeit of ‘grand ideas’. He states:
‘In my own working lifetime, I have seen more than a few ‘grand ideas’ adopted, abandoned, left to fade away, or taken on board with a lesser or greater uncritical acceptance. That some of these ideas were subsequently shown to be merely fashionable and very much of their time hints a the propensity (at least in some parts) of nursing to be swept along in the wake of this or that grand claim originating in another disicpline’ (Sellman, D. 2010, p.150).
And here lies the key for physiotherapy. In the first instance we need to move beyond thinking that mid-range theory will answer anything but the most prozaic professional questions. Then – and this is the vital point – we must learn from the lessons of our sister professions of nursing and, to some extent, occupational therapy, and develop a critical attitude towards all our ideas, both grand and small, so that when we settle on a way of thinking that is amenable to our practice, we do not do so uncritically.
Postscript
From my own perspective, I hope we never do ‘settle’. I hope we never consolidate on an approach to practice, for fear that we ossify in ways that we have increasingly seen physiotherapy ossify in recent years. If we can be certain of one thing, it will be that uncertainty is an unavoidable condition of future practice, and that we will need to be agile to survive. But before we can develop our flexibility, we need to do a bit more stretching.
References
Domholdt, E. (2005). Rehabilitation Research: Principles and Application. Philadelphia, Elsevier.
Lupton, D. (2003). Medicine as Culture: Illness, Disease and the Body in Western Society. London: Sage.
Nettleton, S. (2005). The Sociology of the Body. In W. C. Cockerham (Ed.), The Blackwell Companion to Medical Sociology (pp. 43-63). London: Blackwell.
Sellman, D. (2010). Musings on reflective practice as a grand idea. Nursing Philosophy, 11, pp. 149-50.
Turner, B. S. (1995). Medical Power and Social Knowledge (2nd ed.). London: Sage.
Williams, S. J. (2003). Medicine and the Body. London: Sage.
Williams, S. J. (2006). Medical sociology and the biological body: where are we now and where do we go from here? Health, 10(1), 5-30.
The original post ‘The cult of the hero’ was posted on 10th June 2010. These comments followed:
BOP (best of premises)
There is much in what you say, but I am unconvinced about your solution that suggests we should forever be skeptics. I take skepticism to mean that real knowledge is not possible to us mortals, that real knowledge is possible from some form of omniscient being (the Platonic, theistic version) or opinion is all we have (personal or social). The battle is as old as civilization first crystalized by the Platonic / Aristotelean dichotomy, but more latterly the apparent dichotomy of the empiricists and rationalists. In musculoskeletal practice the clash is easy to see. On one hand you have the empiricists (Maitland, Mulligan) and on the other the rationalists (Kaltenborn and the chiropractors). The empiricists typically are what can be called concrete bound phenomenologists – do this and see what happens. If it results in improvement, great – carry on, if not try something else. The rationalists start with a theory (Kaltenborn at least started with a construct that was experimentally sound – the concave / convex rule. The chiropractors started with a theistic faith like construct – life force and how it is influebces by another article of faith – the subluxation). The rationalists care little for experimental proofs or validation and the empiricists have little time for theoretical explanations as to why their methods work or fail.
This empiricist / rationalist dichotomy closely mirrors (and may have its roots in) the analytic / synthetic dichotomy, a formal theory that remains implicit in most modern philosophical systems. No point in explaining this here but suffice to say that it has been effectively exposed and debunked by Leonard Peikoff (The Objectivist May 1967). There is however a third alternative to this apparent choice between theories without validation in experimental evidence, and existential data accumulation without integration into a coherent and consistent conceptual structure. This alternative does not divorce concepts and rational, logically derived theoretical constructs from facts derived from observation and experiment. It derives its theories from the facts observed and constructs systematic theoretical structure using propoer logical methods.
You are right regarding the hero problem (I would prefer the word ‘guru’ as I have no problems with the idea of heroes). Out profession’s fixation on these gurus is akin to the theistic model of knowledge except that the sources of revelations are not gods but people. However we do wind up by treating them as somewhat godlike.
The only two historical figure that have attempted the rational (not rationalistic) integration of fact and theory were Cyriax and McKenzie, but as is typical, many have elevated both to godlike status. Cyriax behaved like a god as doctors often did in those days, and McKenzie is certainly treated like one by many. When I knew McKenzie in the 70’s and 80’s he was an excellent integrator of fact and theory (for the current state of knowledge). he observed certain phenomena (centralization and dierctional preference) and devised systems to manage and these facts of reality. he attempted to explain the phenomena using (then) current knowledge of mechanics and anatomy. Excellent! However he got his fingers burned and in the last 15 years has retreated to more empiricist focus. A shame in my view because I believe is was on the right track. He was the first to integrate behaviour, technique and theory. Not bad for smeone who knew nothing about psychology or philosophy.
By the wat David – we exorcise out demons, not exercise them!
Friday, June 11, 2010 – 06:09 PM
Barbara Gibson
Thanks for this Dave. In response to the previous comment, I wonder if your wish that we remain skeptical was misinterpreted. I took it as a maintaining a critical wakefulness given the ease of slippage into complacency. If we remind ourselves that knowledge can only be provisional and subject to revision than our heroes/gurus lose the sheen of infallibility.
You may be interested in a very similar commentary in the Occupational Therapy literature that I just happened to be reading yesterday :
Sacred texts: A sceptical exploration of the assumptions underpinning theories of occupation. Hammell, Karen Whalley, Canadian Journal of Occupational Therapy, Volume 76, Number 1, February 2009 , pp. 6-13(8)
Best
Barb
Saturday, June 12, 2010 – 03:08 AM
BOP
Hi Barbara. Critical wakefulness is fine by me – it is not the same as or even similar to the technical meaning of skepticism that I referred to. If David was referring to critical wakefulness then I apologize for the misinterpretaton.
I accept unreservedly that knowledge is gained by fallible human beings (we are capable of error) but I do not accept that knowledge as such is always uncertain or subject to later refutation. That is clearly another discussion.
While I am not familiar with the content of what you term as critical wakefulness, I am taking the concept straight as it appears. To me this concept refers to mental focus combined with a willingness to accept new data that may or may not support or contradict previous interpretations. Is this a reasonable interpretation?
Sunday, June 13, 2010 – 10:55 AM
Barbara
Yes! (re your def’n of ‘critical wakefulness’). Although admittedly, to the best of my knowledge, I just invented the term. Still you’ve captured my intent rather nicely. Thank you!
Wednesday, June 16, 2010 – 01:01 AM
BOP
Further to the idea of ‘critical wakefulness’, it seems to me that this idea is similar to or the same as the idea of mental ‘focus’. One can be conscious but not attending to reality. Ayn Rand regards this as an epistemological primary. It is the primary act of switching on the mental conceptual machinery anolgous to turning on the ignition of a car. It is the primary act of volition and the origin of free will. Another analogy would be visual focusing (which is actually automatic and it requires a conscious act to unfocus). mental focus on the other hand is not automatic and requires a continual ongoing effort to maintain. Without it, all sensory data and perception is a blur and inaccessible to the coceptual faculty
Friday, June 25, 2010 – 10:51 AM
BOP
David, it seems that you have gone one step too far here. On what basis can you reasonably expect physiotherapists to first of all be philosophers before being a physiotherapist? To expect or demand that a an approach to back pain or anything else within a science to have answers to questions of metaphysics, epistemology, ethics or politics is putting the cart before the horse. One’s approach to philosophy should properly direct the approach to a specialised science, but not the other way around. From what I am learning about phenomenology, social constructivism and postmodernism I think that the specialized sciences may be better ignorant than informed
Friday, July 2, 2010 – 08:14 PM
Kasper Kulak
Most, if not all, of the opposition to the idea of certainty, absolutes or any other form of “knowing” is by those who have a closed conceptual understanding of knowledge. This understanding sees knowledge as a labeling system of putting data into a box and closing the lid on it. In this way each new piece of knowledge is really just a new piece of limitation on the discovery of the new. Whereas, the issue isn’t actually do to with absolutes or certainty, it is to do with the premise of holding such a view on knowledge in the first place. To discover is to identify the essential characteristics of that which is empirically “out there” in reality. To know we must define and to define me must observe the genus and the differentia (this is done automatically in most cases). For example: Man can be defined as an upright animal where animal is the genus and upright the differentia. Man can also be viewed as an animal with a thumb, or an animal with language or an animal with a rational faculty. Each new discovery of how to identify or define ‘man’ is not a contradiction of that which went prior. The fact that people are upright or that they have a thumb or speak a language are still all true. All that has happened is that a new distinguishing characteristic was discovered and the old defining characteristic was subsumed into the genus. This is the open conceptual view on knowledge. Here, certainty and absolutes are congruent with new discoveries; labeling isn’t the art of attaching a ball and chain to the mind but of identifying new “knowledge” further enlightening the mind on new discoveries.
Also, well done to BOP for pointing out the false rationalist/empiricist dichotomy. Care to sum up Peikoff’s argument?
Friday, October 29, 2010 – 01:47 AM
Execellent Dave – I totally agree.
Keep up the spirit. Dont let the critics shut You up.
Youre thoughts are on the right track.
I advise You to read Bracken & Thomas – Postmodern Psychiatry.
They argue very similar to You.
Varm regards.
Jens Olesen, Master of Education
Clinical Supervisor
Physiotherapeutic specialist in rehabilitation
Denmark.
A fascinating post and debate Dave. I wish I had of found it in 2011. It is discussion worthy of a wider audience and participation and does I think cut toward the core of what it is to practice physiotherapy. We need more of it.
I am interested to speculate how much has changed in the intervening four years whether we see much attempt to expand our perspective or if we have simply moved heroes/guru’s and in so doing fool ourselves into thinking we have progressed which touches perhaps on Kaspars comments regarding genus and differentiation.
thank you again.
ANdy