With Maturity

I am sorry, Jordan…

In 1993, I was 16 years old. I knew that I wanted to work with children; I was unsure in what capacity. Many people tried to convince me to be a physician (I had the grades, after all), but I would have none of it. “I want a good paying job,” I would say, “not career.”

I chose to be a physical therapist.

I am sorry, Frankie…

In 1999, with 3 semesters remaining in my academic preparations, I was on pace to graduate Magna Cum Laude. If I aced my remaining courses, I had a chance to be valedictorian.

Kevin, a wonderful man and teacher, pulled me into his office and tried to convince me to strive to finish at the top of my class. “Why?” I asked him. “Because, your patient deserves the best care that you can give them.”

“Really?” I replied. “ I have a hard time believing that they can tell the difference between a 3.85 and a 4.0. Besides, I rarely have to study, can go out drinking every night and have social life. Why would I want to stop all of that for another frivolous thing to add to an already impressive resume?”

I graduated with 3.87 and near the top of my class. I made sure that ‘Magna Cum Laude’ was in bold on my resume.

I am sorry, Amanda…

In 2000, I interviewed for my first job. My future employer asked me the ‘lay-up’ interview question to start off: “Please tell me 3 adjectives to describe yourself.” I replied that I was (1) handsome, (2) charming, and (3) sensitive to the needs of others.

She hired a liar.

I am sorry, Christopher…

As a new graduate in the Autumn of 2000, I worked at a private school for children with Autistic Spectrum Disorder. One of only 3 men on a staff and the only full time physical therapist, I had job security. I knew that I didn’t have the experience of other clinicians, but I had a playfulness that I thought could make up for my lack of wisdom. I would more easily relate to the children. I would be able to reach them in ways that others wouldn’t.

It was a great job with 6 hour work days and summers off. I had plenty of opportunities to pursue personal interests. I was inside in the heat during the winter and in the air conditioning in the summer. My bills were being paid and I had a chance to pick up some extra work on the side.

It would be a good gig for 7 years, until my son was born and I transitioned to outpatient physical therapy practice full time.

I am sorry, Connor…

The school accommodated students from 5 counties; its tremendous reputation for success with ABA therapy placed it on the top of most parent’s lists when trying to determine where they would send their children for schooling.

I was their physical therapist. For the sake of consistency, I would model my interaction with the children after what I would see in the classroom. If the child would display behaviors that were “not desireable” I would simply consult with the classroom teacher, the ‘expert’.

I am sorry, Nicky…

It is now 2013. I am 13 years removed from passing my board exams.

I have not worked in pediatrics for 6 years, and I don’t miss it. I am happy working with adults now; I get to play with my own kids.

My focus now (working in home care) is to serve patients in their pursuits of improved mobility and reduced pain. I understand that novel movement desensitizes the nervous system, reducing pain and improving the adaptive potential of tissues. I strive to be an interactor and I work hard to provide non-noxious input to my patient’s neuromatrix, be it visual, auditory or somatosensory. Diane Jacobs suggests that therapists should “do no nocicepting” . I think there is a lot of wisdom in this view.

I am sorry, Anna…

A friend recently shared this link with me. It is a brief essay on the French philospher Montaigne by Sarah Bakewell. She states:

Montaigne loved such stories [of other cultures] because they lent him an altered point of view from which to look back on his own culture and see it afresh. Most human beings judged what was merely habitual to be what was natural… we are cut off by our very nature from the full perception of reality…It posits a multi-dimensional, endlessly varying world in which each object presents a thousand facets to a thousand different observers. The observers themselves are just as variable, for they shift mental moods and states at every moment. We can never grasp it all. But we can keep ourselves mindful of the world’s diversity and of our own limitations, thus becoming, as Montaigne put it, “wise at our own expense”…Once you have seen the world from someone else’s perspective, it becomes harder to torture, hunt, or kill them.

There is the word: torture, defined as bringing great physical or mental pain upon another.

As a physical therapist, I aim to serve patients whose goal is to reduce their pain, first and foremost. I am a licensed practitioner in a science that is designed to reduce suffering, not embolden it. While working with each patient, I remember that Patrick Wall reminded us that pain is a need state when he said, “Pain produces a need state, like hunger or thirst. Hunger is resolved by eating, thirst by drinking and pain is resolved with movement. Of course, eating and drinking instinctively is probably best. Moving instinctively follows.

I work to help each patient understand the importance of movement in not only reducing their pain, but in taking ownership of that person each calls the ‘self’. In doing so, my role is not to discourage individuals from moving in certain ways, but to encourage them to explore how to move in different – often exciting – ways. This has become the foundation for what I now consider quality care.

I am sorry, Jonathan…

In 2001, quality care meant that I was better than the other people in the room (or at least I thought I was). In 2001, being good was good enough. In 2001, to blindly defer to another to help steer my own interactions with my patients was the easiest path. Those interactions often involved one phrase. I repeated it over, and over, and over, and over…

“Quiet hands, Jordan.”

“Guiet hands, Frankie.”

“Quiet hands, Amanda.”

“Quiet hands, Christiopher,”

“Quiet hands, Connor,”

“Quiet hands, Nicky.”

“Quiet hands, Anna .”

“Quiet hands,  Jonathan.”

This was the ABA way.

I am sorry, Anthony

A friend recently shared this blog posting with me by a blogger/writer with autism, Julia Bascom. While watching television programming, she watched a scene where the female character had her hands “quiet-ed” by another (seemingly empathetic) character.

Her posting has haunted me ever since:

…When I was a little girl, I was autistic. And when you’re autistic, it’s not abuse. It’s therapy…

“Quiet hands!”

…I’ve yet to meet a student who didn’t instinctively know to pull back and put their hands in their lap at this order. Thanks to applied behavioral analysis, each student learned this phrase in preschool at the latest, hands slapped down and held to a table or at their sides for a count of three until they learned to restrain themselves at the words.”…

…I’ve been told I have a manual fixation. My hands are one of the few places on my body that I usually recognize as my own, can feel, and can occasionally control. I am fascinated by them. I could study them for hours. They’re beautiful in a way that makes me understand what beautiful means…My hands are an automatic feedback loop, touching and feeling simultaneously. I think I understand the whole world when I rub my fingertips together…My fingers map out a world and then they make it real. My hands are more me than I am…

…They actually teach, in applied behavioral analysis, in special education teacher training, that the most important, the most basic, the most foundational thing is behavioral control. A kid’s education can’t begin until they’re “table ready.”…I need to silence my most reliable way of gathering, processing, and expressing information, I need to put more effort into controlling and deadening and reducing and removing myself second-by-second than you could ever even conceive, I need to have quiet hands, because until I move 97% of the way in your direction you can’t even see that’s there’s a 3% for you to move towards me.

There are no words…

In The Awareness of Movement, Moshe Feldenkrais says, “…it is the feeling of suffocation that forces us to breathe.”

For 7 years, I had a great job. I had earned it. I was better than many at what I did; that was good enough for me.

I never took perspective. I never picked up a book. I never questioned authority. I did the best shitty job that I could for 6 hours per day and I went home. The teachers respected me, my boss adored me and parents thought I was doing what was best for their children. Of course, the children did not have a voice.

How could they? They were suffocating; it must have felt like torture.

No one heard the children speaking of their difficulties with sensory processing. No one was aware of how the primary input and output for their ‘self’ was through their hands. No one could possibly understand how essential movement was to those children. What made them who they were and how they felt was being purposefully extinguished by those who”cared” with the aim of forcing them to abide by arbitrary cultural norms.

This is what happens when someone hires a physical therapist who is just looking for a job, rather than a career. This is the inevitable result of a professional who doesn’t realize that good enough is never enough. This is an example of why there is an important distinction between doing physical therapy and being a physical therapist.

I wish I had the maturity to understand Kevin’s message in 1999. I wish that I had read and internalized Montaigne’s view long before today. My patients probably feel the same way.

All I can say is, “Sorry.”

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4 thoughts on “With Maturity

  1. My gosh Keith. That is one powerful post. Masterful writing. I feel blessed that I discovered a second career as a Feldenkrais practitioner post healthcare management. Yet even with this incredible training, 12 years into it, to choose to be an even better practitioner is a daily, even session by session choice.

    I am touched by your reflection on the past. What I learned in becoming a Feldenkrais practitioner called into question the way in which I had interacted with children, employees, and loved ones. Actions I had some pride over became obviously less than ideal. There is much to be sorry for on the way to maturity. Of course maturity is a journey so we get the opportunity to reflect back on our past ignorance and transgressions as we experience significant shifts. It’s not always fun but a clear sign we are continuing along the path of true life-long learning and in “restoring people to dignity” through flexible minds instead of flexible bodies. A mantra passed through the Feldenkrais lineage.

    Thank you.

  2. Thank you for sharing your journey with us. Powerful words – being in a caring profession means caring not only about your patients, but also about your profession. And in the end, that means learning as much as you can about what does and doesn’t work, so that by caring about your profession, you care for your patient. I’m going to share this with a bunch of occupational therapists who also share your attitude.

    • Thanks for reading, and for the reply, Bronnie.

      One of the triggers for this admittedly long thought process was a student recently telling me that he thought he “knew enough about pain.” Couple with some of the readings linked to in this posting – well, you read the result.

      That was 3 weeks ago. He has reading assignments every night to try to inform him of what he doesn’t know and to remind him how to work/communicate with patients. Last 2 nights, he was to read your 5-part series on Motivating People To Make Changes (your site was one of the first that introduced me to motivational interviewing). It will also be referenced/linked in another month when I plan to have a large posting that will include all of his reading, viewing, listening assignments.

      Thank you for your own contributions to my own professional growth. Hopefully we can steer a young student in the right direction as well.

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