The Power Of Touch And Presence Vs. Modality Specific Beliefs
Disclaimer: I teach continuing education seminars for a living.
When we touch patients in a therapeutic intervention, how many different “things” or actions can we really be accomplishing? How many different structures can we really make contact with or elicit change?
With higher levels of training come apparent deeper and more precise technique and expectation, while the beginner is viewed as less-than. If your practice is like my own, you receive referrals of people who have seen a multitude of manual therapists of all sorts. At the onset of the initial encounter, they invariably share what others have said about their problem as if all of that information is necessary to get to the bottom of things.
I patiently listen as they rattle off a list of claims made about their problems, with many trending into the catastrophizing mode (the WORST trigger points that therapist had ever seen!).
We are all touching the same body in much the same places, but most are believing we are feeling and finding vastly different structures and problems, both normal and aberrant.
To stay in the first person, my brain filters this information and tries to put it all into a framework of my evaluation findings and beliefs that I was taught and I will typically come up with a different language of what the problem might be. In the past I would have spoken in fascial-based language, calling palpated tightness a fascial restriction and telling a very compelling narrative on how these fascial restrictions, ignored by most in medicine, cause crushing pressures on pain-sensitive structures and only with the application of light, sustained pressures of myofascial release will they ever have a hope of resolving their issues. My language now is quite different, as are my beliefs, and I am much more circumspect about how I explain patient’s problems.
As I teach and travel I have a distinct privilege of meeting with and sharing beliefs with hundreds of therapists and professionals from a wide range of pressures. I am also active on hundreds (yes, hundreds) of niche’ manual therapy groups on Facebook and LinkedIn. Playing the fly-on-the-wall allows one to hear or read conversations that range widely from comparing and contrasting the effectiveness of various modalities to reading people’s suggestions for how to handle a problem case.
Well-meaning inquires regarding how to treat a difficult case are often met with a range of emotionally charged suggestions, most speaking to their favorite modality and citing the “inherited narrative” that goes along with this modality. (Thanks, Phil Greenfield!). As that fly-on-the-wall, I am struck with the hundreds of different modalities and narratives that therapists use in daily conversation.
It takes little effort to see that there really are hundreds of different modalities and sub-classes of modalities available to us as continuing education. But can we really be doing all of the things under the skin that those hundreds of seminar lines profess?
It is beyond the intent of this post to deconstruct any modality in this post. My point is to look at the commonality of our actions. Though our touch can often vary from light to deep, with holds that fluctuate from short duration to long, is there a simpler way to explain our touch rather than the often pained and convoluted models put forth by the various lines of teaching? Is it necessary to invent a new way the body works or a new way to describe how we impact the body in order to sell seats in classes? (A rhetorical question, as it apparently is.)
When we treat, we touch people in a manner that is intended to soothe, to improve the quality or ease of movement. This sounds too simple for many, especially those with advanced training. Many in our shared fields are working to simplify the explanatory model, rather than trying to make it more complex or secretive.
Join the Skeptical Massage Therapists group on Facebook, if you would like to see how this works. Read through the long list of threads and attached links to research and other reference materials. Take a side trip over to SomaSimple for a bit of mental flossing. These are very deep rabbit holes; ones that may cause you not to recognize yourself when you finally emerge. Don’t be surprised if you become defensive or angry as you read how others view your modality or its creator, but give it all time to sink in. How we affect someone when we touch cannot be as complex as many make it seem. Simple, well-meaning directed touch and presence may explain much of our outcomes. And this is not a bad thing
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Your blog was the most inspiring and stimulating message I have received for a long time! I am so on the same page, and so dismayed at the ideological arrogance currently displayed by practitioners, new and old, about the “scientific” proofs that their respective modalities are the one and only answer to effective therapy.
There was a study conducted many years ago that demonstrated that the personal development and empathic presence of the practitioner had a far better correlation with beneficial results than the particular method they were applying. Sorry, I can’t give you a direct reference to this study–it was so long ago that I read it.
My own teacher for 25 years, Dr. Milton Trager, said so many times that restrictive and inhibitory patterns are “all in the mind; if we do not reach the mind with a new quality of feeling state, and reach the unconscious to alter past habituated patterns, no effect can be lasting.”
The Trager Approach uses gentle rocking, undulatory waves of the tissue and the heightening of pleasurable sensory messages to induce in the client a state of relaxation, awareness of tissue, and a deep sense of peacefulness that suffuses the mind and projects to the tissue a feeling of “how it should be, what relaxation and release feels like as a concrete and lasting mental and physical experience. Awareness is the strongest medicine there is, and the presence of the practitioner is the key to awakening its power.
My entire 42 year of practice has been dedicated to this approach. To my way of thinking, there are three pillars of effective coping with traumas and dysfunctional patters of all kinds: 1) sensory awareness, 2) improved self-regulation, 3) successful adaptation to all of life’s bumps and grinds. Sensory awareness is primary to our bodily consciousness–if you cannot feel it, you cannot change it. From heightened sensory awareness flows the capacity to access our own abilities to self-regulate the changes in habituated patterns and develop new, more healthy and functional ones, and from this flows the ability to successfully adapt our future development of pattern of posture and movement that serve us better and stimulate healthy changes in muscular habits, chemical physiology, and neurological control of our lives.
There are two startling facts that underlie all motor movement and habituated patterning: 90% of the nervous system is involved in one way or another in motor control (this is the assessment of Roger Sperry, a Nobel prize winner in neurology–his website rogersperry.com is fascinating). These involvements include the sensorimotor cortex, the cerebellum, the vestibular organs of balance control, the limbic emotional centers, the frontal cortex areas of memory and association, the brain stem, and the spinal cord’s plethora of reflex sensorimotor arcs that respond to the brain’s voluntary commands. And 90% of these processes are subconscious. It is no wonder that our development of motor patterns can lead us so catastrophically astray if we are not aware of how we are responding to our live’s injuries and traumas and how our compensations to these effect every aspect of our mental and physical experience of ourselves and our possibilities of healthy recovery.
There are three aspects of injury and trauma and healthy recovery that I consider primary: heightened sensory awareness, changes in the enormous influence of emotions on our muscular performance, and the cognitive memories and subsequent beliefs in what we consider possible for ourselves. Whatever the protocols of our modality of therapy might be, they must address these elements to be effective and lasting. The shift in the mind’s attitudes and capacities is the whole thing. The tissue can only respond to the mind’s influences.
The key to effective therapeutic touch of any modality is the continual empathic presence of the practitioner, the intention of reaching the conscious and unconscious mind with new messages of the possibilities of positive change, and the moment-by-moment response to changes in the tissue and the mental state as the session proceeds. No mechanical intervention of our hands can be truly effective and lasting without this presence and intention.
My own work is directed toward raising sensory awareness through new, pleasant sensations and bringing more and more into consciousness the many unconscious processes that contribute to our successful motor control so that the client can live more fully and with more awareness in their bodies. My favorite bumper sticker: “If you lived in your body, you’d be home now.”
My approach is two-fold: First, through pleasant and lulling movements and sensations to calm the nervous system, heighten sensory awareness, and ease current holding patterns in the mind and in the musculature. Second, to train the mind through interactive applications of resistance and response to more effectively coordinate synergistic muscular areas for increased strength, ease, and available of painless ranges of motion. The lulling of the mind is the essence of the Trager Approach, and the training through concentrated interactive efforts is my own development of what I call Resistance and Release Work. It uses specific vectors of resistance, responded to by the client, in order to awaken extensive synergistic muscle fibers to a new and more effective coordination of organized movement. These resistances are applied through the entire range of full lengthening, contracting to the fullest extent, and consciously lengthening again while maintaining resistance. The effects are rapid and often astonishing: all the mind needs is clearer focus on the process and clearer information of what successful coordination actually feels like in order to respond with new, more functional patterns of effort and movement.
Emotional releases and shifts in cognitive beliefs of what is possible are as common as the release of old muscular patterns, and are indeed part and parcel involved with them. The results are rapid relief of pain and a freer range of comfortable movement. It is simply a matter of fine-tuning the 90% of the nervous system involved in the movement, and of bringing more into awareness the 90% of its motor control processes that are unconscious. Sensory awareness, self-regulation, and successful adaptation.
The process of the work is enormously empowering of the client–gone is the hierarchy of expert practitioner and naively receiving client. We are in a co-creation together of new patterns of movement, and share equal roles in the enterprise. This fosters the all-important information that they are capable of being in control of their own development from now on, and that if they continue to use the all-powerful tool of self-awareness new and better patterns can continue to maintain and to add to their ease of movement and over-all health.
Whew! All of this is in grateful response to your email’s most important point that it is the presence and intention of the practitioner, and not the exclusive domain of their modality’s protocols and beliefs that are the decisive factors in fostering lasting therapeutic results in their work. Without this presence and this intention, it is all just mechanical manipulation. We cannot simply spot-weld the areas of discomfort; practitioner an client must mutually reach the mind with all its history and its profound effects on our muscular patterns and our health.
I thank you for your voice, and for the stimulation it has provided me for this reply.
The two cc’s I have included in this email are my webmaster Alex Kahl and my wife Jessica Turken. With your permission I would like to post this correspondence to all my media outlets, and to share it with my email list of my students. I hope that it will be a fruitful addition to an ongoing dialogue, both between ourselves and our profession at large. You have raised a point that is of utmost importance, one that is lost in many trainings and approaches, and that needs to be a part of all future discussions of hands-on therapeutic interventions.
Thanks so much for your thoughtful comments. A few points I want to take off on; scientific narratives in manual therapy seem to run the gamut from plausible, with what would be viewed by the external medical community as having solid science to support/explain, to less than plausible models of pieced together but essentially disparate factoids which stem from the inherited narrative of that modality. Of course, scientific belief allegiance tends to follow along the political modality camp mindsets, though I do feel we have an obligation to seek the simplest and less wrong narratives whenever possible. With the myofascial release work I use and teach, I’ve moved forward from the thought that I can target fascia (or any other tissue) in a singular and isolated manner to the exclusion of all other tissues. Arguments to these views can and do fill entire volumes, but I do feel that we can work from a hierarchy of plausibility. I agree with you that neurological influence is greatest, in terms of motor control, and I agree with many that our work should occur in a top-dow manner, wherein the brain and central nervous system play the central role in all actions, rather the the bottom-up approaches that many/most of the tissue-specific modalities have taught. I feel that I will be long dead and buried before a consensus is reached on the exact manner in which our touch causes/allows change, but until then I will work toward defining the many options that exist.
Ironically, my myofascial release trainings have taken a direction that you allude to, in that they have become less about the expertise and ego of the clinician and more about the experience and feedback from the patient. I feel that without validation from the receiver, our work is simply acting from ego. Layers of continuing education makes us believe we have greater skills to detect and fix problems, which is a dangerous path. I feel that without my patient perceiving relevance and potential benefit from my touch, obtained through (at times) rather vigorous questioning, my work has little meaning. This empowerment allows the patient a voice in their care, something that is spoken of by many, but essentially given lower priority in deference to ego demands. Mechanical manipulation, as you call it, is too still too prevalent in our shared professions. Emerging and widespread trends into seeing the biopsychosocial aspects of our work and the patients with which we work can only aid in lowering the pedestal on which we often place ourselves and elevating the beliefs, perceptions, and preferences of our patients to a place above our own.