Reframing The Therapeutic Encounter
Historically, physical therapy has been a field of linear thinking: an individual seeks care for a painful problem; the physical therapist’s responsibility is to provide the patient with an assessment including a variety of tests and measures that are historically used to find a specific offending structure or underlying problem that should be predictably managed with a specific routine or plan to alleviate the patient of their primary complaint. The patient presents with ‘B’, the therapist provides ‘C’ and the patient is supposed to be rehabilitated back to ‘A’ again (more on this later).
Of course, the patient does not always get back to ‘A’, so the therapist continues to pursue a variety of reductionist and linear clinical models in an effort to try to find the one that will ‘work’ with the patient in question. Sometimes the therapist ‘gets it right’ on the first try, often they don’t. Perhaps, it is time for the entire field of physical therapy to approach things differently.
Complex systems science is a new way of thinking. It contrasts with a 19th century view of science which is a lot more mechanical and deterministic. In complex systems, the dynamics of the system generally emerges from the interaction of the parts and their agents. And that is not necessarily predictable in the way that traditional science thinks that it should be. Complex systems science is very much computer enabled, because we have to compute the interactions of the agents and find out the way the system dynamics are evolving… Our outlook has changed with regards to what ‘prediction’ means. In the 1960s, the meteorologist Lorenz discovered that there are systems that are sensitive to initial conditions so that a slight change in the conditions at one time can mean the system can diverge greatly at another time. So, our expectations of what we can predict in physical systems has changed a lot in that time.
Let’s state this clearly: only with computer models, running a variety of simulations with an ever-expanding number of initial conditions, could a therapist possibly discover the possible outcomes of their interactions with their patients, be they the environment in which the patient receives their care, how the therapist is dressed, the words/tone that are used in communicating with the patient, the location where the therapist places their hands and how firmly (or softly) they place them, or the expectations that the patient or therapist may have at the outset of a clinical encounter. If at any point in their career, a physical therapist feels that they have seen enough patients to recognize patterns of how they may necessarily be impacting an individual’s experience (B + C → A), they are fooling themselves.
I am not saying that they are poor clinicians, I am only pointing out that the science is informing us that their interactions with their patient’s do not yield results as predictably as one might often think that they do, and even if they are fruitful, they are unlikely to be beneficial in a way supported by conventionally linear thinking. The models that therapists use for thinking need to change. They need to embrace the science of complexity.
Tomorrow – Butterfly Effects: Missing Flights, Wild Turkey and 4th ribs