You Don’t Win Friends With Cognitive Dissonance.

posted in: Research Literacy | 8

I wish I could take credit for the phrase Formal Reality Training. I heard it listening to Steven Novella’s Critical Thinking Course and it struck me as a great descriptor of the process of critical thinking. Not just the process, that’s one thing, but really it started me thinking about what it takes to change a mind, and reconstruct a reality.

What would it take?

Most of us probably like to think that we are not the ‘nothing’ guy and that, when presented with the evidence, we would in fact change our thinking accordingly.

But it really isn’t that simple is it? If it were then there would be no anti-vaxx movement, no climate-change deniers, no magical thinking in manual and physical therapy or in medicine. We construct our own reality based on the information we have at hand and the most accessible biases at our disposal. When that reality becomes a deeply held belief tied up in financial commitment and a way of earning a living (a fairly substantial incentive, yes), we might actually have a vested interest in protecting its integrity.

The Path of Least Resistance

In most cases the obstacles are really stacked up against changing our minds. Take cognitive dissonance, that uncomfortable feeling that happens when you read criticism about your belief systems. The dissonance is not there just because someone said something contrary, or the sarcastic way in which they said it. It’s there because they said something contrary that makes sense and even if you can hold disparate thoughts simultaneously, you can’t believe disparate concepts about the same thing simultaneously. So what to do?

The path of least resistance is usually the first step.not listening gollum

That might consist of closing one’s eyes to the offending material, or as is most likely the case reading it through the filter of the closely held belief and simply dismissing the critique as evidence of ignorance, or as I like to call it the ‘they don’t know what I know’ defence.

I spent five plus years learning the ins and outs of osteopathic practice and many more years in that practice including osteopathy in the cranial field, so I used that defence many times and know the filter well.

Now I’ve harped on about the cranial concept many times in prior blogs, on social media and the like so it might seem like I’ve got a grudge and am somewhat obsessed with its critique. That sounds about right. I spent a lot of time and money learning what is essentially, make believe. So I’m a little pissed, both at myself for being enamoured for so long at what appears to be magic, and at the institutions that keep flogging a concept that by rights should be dead in the water. Yet, here in Canada it is not only not dead, but a flourishing example of how frighteningly complex and entangled magical thinking can become.

The Path of Resistance

I changed my mind, but it was not an easy task in the osteopathic environment I come from. In Canada cranial is not optional, it’s foundational and pervasive, so changing my reality and my mind was a very active and deliberate process. It doesn’t just happen. You have to DO it, but before that you have to THINK about doing it.

Heuristics, On The Face of It

Funnily enough in my first year of school I thought the whole concept was rubbish. Like the majority of the class I couldn’t feel anything except a pulse and my own breathing and it seemed sub-optimal that I, who knew little and could feel even less, would be allowed to shift the cranial bones of my fellow students lest their brains fall out. Several classmates and I joked that if we could treat the corpus callosum with a technique focussed at the saggital suture, then we could probably also do it from across the room. All it took was intention and the cranial face.

Cranial faces
                     Perception vs. Reality

 

Even after years of being told what I should feel, accompanied by learning with simple heuristic devices, when I began to feel construct an osteopathic reality that suited the curriculum I could always feel construct it more effectively when cranial face was assumed.

sutural representationThese simplified learning shortcuts, like the schematic of cranial bone bevels and pivot points, allowed for explanation of a mechanism that didn’t require delving further into the complexities of the anatomy and function of cranial bones and sutures.

This schematic solved the problem that looking at a complex suture presented. Looking at a complex natural human suture was fascinating, truly fascinating, but it could not help me with how the bones moved and was actually unhelpful – given the extensive interdigitations that defy the biomechanics allowing the desired mobility. So even though I couldn’t, no matter how much I squinted, see the resemblance of the suture to that of gills of a fish and therefore not fully understand how that could lead to the realization of an underlying inherent respiratory system, I came to accept that if it took five years to learn all this, then there must be something to it.

Certain Acquired Talents

There were always nagging doubts and I often flirted with the idea that I was just making shit up as I went. Even when making stuff up felt deliberate because I needed some sense of certainty, it didn’t matter because I could feel interpret the outcome of patterned cranial bone movement and rhythmic PRM given enough time, concentration and cranial face. At the end of my five years of osteopathic training, among other acquired talents, I was fully convinced I could treat a person via their cranium to clinically beneficial effect. Granted, I figured that my uncertainty (is that a rotation or a torsion … wait, possibly a sidebending… now it feels normal, nope, definitely a rotation) would eventually become certainty with practice.

Ironically it was the thesis portion of my studies that led me to critical thinking and an informal, self-directed reality training. My critique of palpation reliability studies, of which there were many more than there should have been given that the results were essentially the same, led me to the conclusion that palpation reliability by therapists on humans or models could not be established. That was a bummer because I was conducting a palpation reliability study, but, like any well-constructed reality, the edges of it could be blurred a little and I, like those before me, was convinced that we just needed more and better research.

Except it wasn’t blurring the edges so much as fraying them. In the back of my mind there was a question that kept dancing through … “what does it really mean if we can’t feel what we say we can feel?” That question might not be too problematic for some manual therapies, but for a manual osteopath who relies on the precision of palpation it’s potentially life-changing.

When Paths Converge

This is often where the change process goes off the rails because reality in a world of make-believe is an impolite guest and because of that most of us will ask it to leave. In this case the reality is pretty simple. Can I feel what I say I can feel? Not that can be demonstrated, and I looked. I really looked. What I found was not what I was looking for and was not congruent with everything I’d been led to believe was actual. Talk about cognitive dissonance.

Palpation reliability – not a thing. It has nothing to do with lack of evidence, and everything to do with a lot of evidence that has consensus of a negative result.

Cranial bone mobility – not a thing. Now some will say that studies show pliability of the suture like that changes something. And studies do indeed show pliability of the suture, but it changes nothing because what does it really mean to have pliability at the suture? How does that pliability become osteopathic cranial mobility? Short answer, its functional for cranial growth and it doesn’t mean shit for osteopathic cranial bone mobility.

PRM – not a thing. Rhythm, rate, expression and mechanism not established, highly debated, lots of alternate hypothesis, some more or less supported by physiology but nothing resembling the currently established parameters.

Normal cognitive function – oh, that’s a thing. And if that’s a thing, a normal thing, what does it really mean to be a human with normal cognitive function? Short answer, it means that if we don’t really truly THINK about it, we will construct a reality that fits our desire. Even shorter answer, we are egotistical first, thoughtfully reflective someways down the road, maybe.

Are there other possibilities for the reported outcomes by patients? Many. Several of which are even physiologically plausible. And let’s get this clear, given the above impediments to determining accuracy of either palpation or reality, it doesn’t matter what the therapist thinks happened to bring about that outcome. If what we think we feel is the underpinning for developing a treatment for our patients, then that’s all the more reason we shouldn’t make up stories to explain our feelings simply because they’re osteopathic and that’s the paradigm from which we operate.

Change Perception, Change Reality

It is not ok to want to continue to be wrong, when there are less-wrong options available.Brain_Change

Though initially I didn’t seek out information inconsistent with my cranial beliefs, I also didn’t ignore it or the direction it was taking me. The cognitive dissonance became squirmingly uncomfortable and I wasn’t able to find consistency with the information I had. So I started to deliberately seek out contrary information. If I couldn’t sufficiently answer the hard questions being asked with the information I had or could find, then I had to change the answers. I couldn’t use a lack of understanding excuse unless I recognized my own lack of understanding as well. Sure, they couldn’t feel the same things I could so they didn’t understand that my reality was REAL. But what I didn’t understand was that I was missing large amounts of data and information that, if I didn’t ignore or distort to fit, would change my reality.

What did it really mean for the cranial concept that there are other, more physiologically plausible, less-wrong explanations for the reported outcomes? It meant that the proffered osteopathic mechanism for cranial bone mobility has no play on the outcome at all. But I like to think of myself as ‘not the nothing guy’ and if anatomy, physiology, biomechanics and psychology as they are currently, scientifically understood were to be drastically changed enough to incorporate the complex cranial mechanism as plausible, I would be the first to change my mind, and then tell you all about it.

There are a lot of believers who have spent a lot of time and money to learn and Confirmation Biasmaintain a system of cranial make-believe. They have the acquired knowledge, language and explanatory systems and they have patients (probably not as many as they think – see normal cognitive function manifested as confirmation bias) who report outcomes that are positive. So what does it matter if they fool themselves into believing they have the power to feel and move cranial bones for specific or even general therapeutic benefit? It matters because they are fooling others as well. Patients, students, colleagues. And they are making claims they cannot support that could be as physically, psychologically and financially harmful as often as they appear to be helpful.

What does it really mean to claim that a treatment has a therapeutic effect on a medical condition when that claim can’t be supported by current knowledge? At the very least it’s unethical, and that’s a subject that requires a whole lot more discussion.

I’ve read many-a-critique of cranial osteopathy and where once they caused a certain discomfort and noticeable stress response I now read them and nod along enthusiastically. Feelings of cognitive dissonance now come with reading websites and blogs that offer courses and espouse the virtues and mechanisms of cranial osteopathy. Though I’d like to achieve a neutrality in my reading response, I’m aware of the bias at play. I’ve gone from cranial practitioner and enthusiast to wanting very much to see cranial, as it stands now, stripped from the osteopathic curriculum. I was fooled into thinking it was real. I fooled myself into thinking it was real. I would like people to stop fooling themselves and each other into thinking it’s real.

As a cranial practitioner, I’ve been there … and back again and the ‘you don’t know what I know’ defence will not work on me, because I do know. I understand what it feels like to feel PRM through the cranial system and all of the interpretive entanglements that go with it. I understand what it feels like to know that I, through learning, response and confirmation biases and other normal cognitive functioning, perceived and defined the very feeling I interpreted as belonging to another.

I changed my mind. I changed my reality. And then I changed my practice. It was (and still is) an active, deliberate process but I had to DO it, and before I did it I had to THINK about it. It has not been easy or comfortable, but it has resolved that feeling of dis-ease (see what I did there) I had around telling patients there was something wrong with them, something only I could feel, interpret and fix.

As for what my fellow Canadian osteopathic practitioners think of an attitude that could feasibly be described as heresy … so far, crickets, but maybe I expect too much from social media. I have had to distance myself from the osteopathic community here because my reality doesn’t fit with the general consensus and this probably will not get me an open-armed welcome, because what I do know is you don’t make friends with cognitive dissonance.

Many-a-Critique

Cranial osteopathy: It’s fate seems clear

Dubious Aspects of Osteopathy

Craniosacral Therapy is Not Medicine

A Review of Craniosacral Therapy
Science, Fads and Applied Behaviour Analysis

Why Cranial Therapy is Silly

Cranial Manipulation and Tooth Fairy Science

Cranial osteopathy. Bad Science, Ben Goldacre

Does Craniosacral Therapy Work?

Bibliography (representative, not exhaustive)

Palpation and PRM

Moran RW, Gibbons P. Intraexaminer and interexaminer reliability for palpation of the cranial rhythmic impulse at the head and sacrum. Journal of Manipulative and Physiological Therapeutics 2002;24(3):183–90.

Norton JM. A tissue pressure model for palpatory perception of the cranial rhythmic impulse. Journal of the American Osteopathic Association 1991;91:975–94.

Hartman SE, Norton JM. Interexaminer reliability and cranial osteopathy. The Scientific Review of Alternative Medicine 2002;6(1):23–34

Norton JM. A tissue pressure model for palpatory perception of the cranial rhythmic impulse. Journal of the American Osteopathic Association 1991;91:975–94.

Tettambel M, Cicora RA, Lay EM. Recording of the cranial rhythmic impulse. Journal of the American Osteopathic Association 1978; 78:149.

Wirth-Pattullo V, Hayes KW. Interrater reliability of craniosacral rate measurements and their relationship with subjects’ and examiners’ heart and respiratory rate measurements. Physical Therapy 1994;67(10):1526–32.

Ferre JC, Barbin JY. The osteopathic cranial concept: fact or fiction? Surgical Radiology and Anatomy 1990;13:165–70.

Green C, Martin CW, Bassett K, Kazanjian A. A systematic review of craniosacral therapy: biological plausibility, assessment reliability and clinical effectiveness. Complement Therapies in Medicine 1999;7(4):201–7.

Gard, G. (2009). An investigation into the regulation of intra-cranial pressure and its influence upon the surrounding cranial bones. Journal of Bodywork & Movement Therapies,13(3), 246-254.

Halma, K.D., Degenhardt, B.F., Snider, K.T., Johnson, J.C., Flaim M.S., & Bradshaw, D. (2009). Intraobserver reliability of cranial strain patterns as evaluated by osteopathic physicians: A pilot study. Journal of the American Osteopathic Association, 108(9) 493-502

Sommerfeld, P., Kaider A. & Klein, P. (2004). Inter- and intraexaminer reliability in palpation of the “primary respiratory mechanism” within the “cranial concept”. Manual Therapy, 9, 22-29.

Cranial Sutures

Rogers JS, Witt PL. The controversy of cranial bone motion. Journal of Orthopeadic Sports and Physical Therapy 1997;26(2):95–103.

Opperman, L. A., & Rawlins, J. T. (2005). The extracellular matrix environment in suture morphogenesis and growth. Cells, Tissues, Organs, 181(3-4), 127.

Zollikofer, C. P. E., & Weissmann, J. D. (2011). A bidirectional interface growth model for cranial interosseous suture morphogenesis. Journal of Anatomy, 219(2), 100-114.

Herring, S. W., & Teng, S. (2000). Strain in the braincase and its sutures during function. American Journal of Physical Anthropology, 112(4), 575-593.

Critical Thinking

Huang G, Newman L, and Schwartzstein RM. Critical Thinking in Health Professions Education : Summary and Consensus Statements of the Millennium Conference 2011.Teaching and Learning in Medicine. 2014; 26(1), 95–102

Bassam G, Irwin W, Nardone H, Wallace J. Critical Thinking: A Student’s Introduction. 5th Edition. New York: McGraw-Hill Companies; 2013.

Pigliucci M. (2015). Scientism and pseudoscience: A philosophical commentary. J. Bioethical Inquiry. 2015; 12(4), 569-575.

Paul R, Elder L. The Miniature Guide to Critical Thinking Concepts and Tools. California: The Foundation for Critical Thinking; 2014.

Smajdor, A. (2013). Reification and compassion in medicine: A tale of two systems. Clinical Ethics, 8(4), 111-118.

De Neys, W., & Bonnefon, J. (2013). The ‘whys’ and ‘whens’ of individual differences in thinking biases. Trends in Cognitive Sciences, 17(4), 172.

Trippas, D., Verde, M. F., & Handley, S. J. (2014). Using forced choice to test belief bias in syllogistic reasoning. Cognition, 133(3), 586-600.

Other

Knuf, L., Aschersleben, G., & Prinz, W. (2001). An analysis of ideomotor action. Journal of Experimental Psychology: General, 130(4), 779-798.

Massen, C., & Prinz, W. (2009). Movements, actions and tool-use actions: An ideomotor approach to imitation. Philosophical Transactions of the Royal Society B: Biological Sciences, 364(1528), 2349-2358.

Dorko, B. L. (2003). The analgesia of movement: Ideomotor activity and manual care. Journal of Osteopathic Medicine, 6(2), 93-95.

8 Responses

  1. Rosalinda Batson
    | Reply

    Great article, Mon. Love the combination of you talking through your experience, your new thoughts on a complex issue as well as explaining cognitive dissonance and how we work so hard to maintain our model of the world. Beautifully written. Thanks.

    • Monica Noy
      | Reply

      Thanks Roz, I’m glad all that came across. Not quite as crisp as some of your offerings, but I’ll get there.

  2. Penny Sawell
    | Reply

    I only just got round to reading this. It’s excellent, Monica. I love your description of the feeling of cognitive dissonance and also the charting of your own personal journey. I can’t believe there aren’t a whole stream of comments but perhaps there are. On Facebook somewhere. I have a somewhat similar experience to you but am still a whole lot more favourable to cranial, and gave up on the moving bones types of courses years ago. There are plenty of people out there teaching a very different framework to the magoun type of thing, but I’m not sure how much consensus there is amongst them. I have ended up finding the caginess and guruism frustrating and the expense of these courses just too much. By the way I have never heard that expression crickets, maybe it’s a Canadian thing. Keep up the good work, we need more people like you!

    • Monica Noy
      | Reply

      Thanks Penny, I share the needing more people sentiment about you. We don’t always agree, but you have tackled some controversial topics up close and personal, with interviews, which I really enjoy. I know you have spent way more time within an osteopathic framework than I have, and I get the sense that in Aus and the UK, there are bigger, more organized, active and diverse communities than here.

      Believe me, I would love to keep cranial as a set of techniques without the current mechanistic explanations because they could be plausibly explained. I actually really enjoy it as part of a treatment and find it deeply relaxing, which is a much undervalued outcome IMO. But there is so little give in osteopathic educational settings in Canada that I don’t know how to offer the alternative and more plausible explanations without first dismantling the current way its being presented (which has been done by others, but roundly ignored – an example of crickets). We shouldn’t have to wipe the slate completely clean. We could treat it like a palimpsest and write over the current narrative without erasing it completely. It really is time for a new story.

      Speaking of crickets, every time I write one of these posts I expect a storm, but it usually never comes even though they get widely read. This time has been no exception. If I critique myself, then probably my writing style is not inviting the kind of debate I’d like to see. Back to the drawing board!

  3. Penny Sawell (Osteofm)
    | Reply

    Hi Monica, I only just caught up with this comment as I’m looking to raid your blog because I don’t have a new one to go out tomorrow! I am guessing it’s ok, as you said it was before, and I’m just going to put a link on so they’ll all end up on your blog anyway. Yes my first cranial one DID invite a storm, and got maybe the most views ever – I think it was well over a thousand in the end, maybe even 2000. But then thinks went totally quiet on it. Maybe the rest of the cranial community (of which I DO feel a part, if slightly out on a limb) don’t tend to engage for various reasons. I’m going to interview Greg Wade in Auckland at some point when I have time and a list of questions, as he seemed to talk very intelligently about it, but somehow most people tend to hide away. Your website is looking fantastic, I just love it. Thanks for keeping on writing and researching, I’m thinking of doing a course in Jan with the Mick Thacker crew, maybe finally get a bit up to speed with pain science, wher I have a bit of a knowledge hole.

  4. Jonathan Edis
    | Reply

    Thank you. I totally agree and sympathise with you as I tried an IVM approach but just couldn’t believe. I think the models of IVM you describe are what a Goethean scientist, such as the late quantum physicist Henri Bortoft, would describe as ‘going beyond the phenomemum’.

  5. Stephen Tyreman
    | Reply

    Thanks Monica for this honest and thought-provoking piece and also to Penny for drawing my attention to Monica’s thoughts. It takes a lot of courage to speak out against the prevailing assumptions, practices and mores of any group and particularly of osteopathy which continues to be defensive and therefore somewhat ‘touchy’ about its identity and status in respect to other parts of healthcare.
    I suppose I’m a bit closer to Penny’s view on the cranial concept, which is that while the theoretical ‘foundation’ of cranial work is very suspect with little supporting evidence, there is something beneficial that happens when hands are placed on a patient. My view is that, although some of what we do involves modification of body mechanics, we need to focus more on understanding what happens in that haptic interaction between two human beings rather than assume that everything we do can be explained by mechanical models of bone articulation and fluid (or energy!) flow, where the hand is no more than a highly sophisticated tool. There is much evidence about the physiological, psychological, social and emotional benefits of touch—as well as the harm inappropriate touch can do—that doesn’t seem to have come within the radar of osteopaths; not much anyway. This is despite the fact that we are professional ‘touchers’ along with others working in different areas of manual therapy. Is this because we are fearful of losing our reputation of having magical skills, or osteopathic technique being downgraded and seen as nothing more than social grooming? I agree that some might seek to denigrate us in this way if we focus more on the psycho-social rather than the instrumental effects, but being more honest with ourselves might also open the way to a better and more effective understanding of what touch does and for such information to be channelled into more effective treatment.
    To make it clear, I’m not saying that psycho-social support is all that we do through palpation; clearly, some of it is mechanical modification of functional body parts, but it’s probably a much less significant part than we once believed. The point is that we don’t know.
    Important as this issue is and much as I’d like to see it come to the fore in osteopathic discussion forums, I don’t want to dwell on it now, but to comment on issues raised in the blog around what we understand by ‘reality’ and ‘perception’ as these are key concepts for how we understand palpation and particularly the subtle senses of touch that pervade in cranial work. Like touch, I think they also are complex, under-explored issues that would benefit from deeper analysis and understanding.
    Let’s start by clarifying what the problem is; what are we trying to explain when we use the term ‘reality’? It is an issue that Descartes famously grappled with and which continues to exercise the minds of philosophers and, today, neuroscientists. How can I know (with certainty) what the nature of the world outside of my body is when I am restricted to contacting it through my (limited) senses? I can only be aware of those aspects of the external world that I can see, hear, touch, etc. What if there are things out there that I cannot sense, or aspects of those things of which I am aware that I cannot perceive? Here we enter the area of metaphysical speculation, something that the positivist end of science denies.
    Putting that to one side I am conscious of an external world that I see, hear, smell, touch and taste that not only makes sense to me, it enables me confidently to engage predictably with it; but I also know that sometimes what I think I see, hear, etc., turns out to be mistaken. The relationship between whatever is ‘outside’ what I think of as ‘me and that internal self-awareness that I associate with the ‘me’ that perceives it is at best unreliable. Descartes went further by asking himself, “what if all my senses are deceiving me?”; what if instead of a real world out there that my senses sometimes misinterpret there is a demon that puts the idea of a real world into my head? This notion has been a favourite subject for science fiction writers. The film, The Matrix, for example, portrays a world that we sense as real, but in which we are all simply elements in a complex computer programme. How do we know we are not? Thinking about this invites madness!
    Human beliefs about reality, i.e., the real nature of a world that is external to my subjective experience, has, very roughly, gone through three stages, but all of which still exist today: reality as a remote ideal; reality as the natural world that we experience through our senses; and reality as an anthropocentric interpreted experience.
    The first of these is exemplified by Plato’s view that our experiences on earth are merely imperfect copies of a heavenly ideal. In heaven, which is the perfect utopian state, there are perfect trees, chairs, hats, cats and human beings while, here on earth, we make do with imperfect copies. Plato seems to have picked up something in the human psyche about, and our desire for, the perfect. Look at how many adverts in the run up to Christmas describe what they are selling as being able to create ‘the perfect Christmas’. Artists strive to produce the perfect painting, compose the perfect piece of music or perform the perfect dance that expresses some emotion or idea after which all others are mere copies. We go shopping for the perfect shoes, gadget or tool. We choose apples based on a ‘perfect’ apple that is ‘apple-like’. We buy the best we can afford for a new baby to give them a perfect start in life. The recent political cataclysms in the USA and Europe are, arguably, based on a desire to achieve some mythical state of nation perfection—‘make America/Britain great again’—where we can pursue all the ideals of what it is to be British, American, Italian, etc., unhindered by foreign (and, by definition, un-British, un-American, etc.) influences, cultures, legal systems and so on. It is as if there is, somewhere deep in our being, a hazy and imprecise sense of perfect examples that we are trying to make real. Religion for a long time picked up on this idea that life on earth is inevitably imperfect, involving suffering and pain as the manifestation of imperfection, but with the promise that in the future—after death or following some transformational event—we will experience perfect reality. A. T. Still echoed this idea in his understanding of the body as potentially perfect because it was designed by God, the supreme architect. As human beings we experience an imperfect body that is prone to illness and disease, but if we strive to achieve perfection by ensuring proper structural alignment, we will know health and all will be well.
    This view of reality as a hidden or unachievable ideal that we are forever striving to realise, was challenged (along with the authority of the church as the means of accessing this perfect reality) by what is familiarly described as the Enlightenment. Through ‘natural philosophy’, figures such as Francis Bacon and Isaac Newton in the 18th Century argued that reality is what we experience around us and this reality can be mapped and defined through formulae and correlations based on observation through our senses, together with the tools that extend those senses. The world outside our skins is just what it appears to be if we experience it in the correct way, where the ‘correct’ way is to subjugate our senses to our rationality. Our senses, as Descartes had argued, are subject to error and can’t be trusted to show us what things are really like as opposed to how they appear; but if we apply rational thought and sceptical analysis to those erroneous sensations we can uncover the real truth.
    Natural philosophy morphed into what we now know as science where scientific knowledge is defined by the scientific method; that is, of subjecting mere experience to rational interrogation and making it into something better that can then be given the moniker ‘scientific’. Only if the scientific method is followed can the findings from it be accepted as true, scientific, knowledge. Reality, on this reading, is no longer some remote ideal that we sense imperfectly, but something that can be known with (scientific) confidence through appropriate, i.e., scientific, interrogation, experimentation and analysis.
    The third phase of what we believe reality to be, started at the very end of the 19th and became stronger in the middle of the 20th Centuries. There were two main influences: one was that of the German philosopher Immanuel Kant, who I’ll come to in a moment, and the other, a reaction against what was perceived as a quest (by science) to reduce everything to mechanism explained by mathematics. I’m not going to say much about this second part, but refer you instead to Anne Harrington’s excellent book, ‘The Reenchantment of Science: Holism in Germany from Wilhelm II to Hitler’ in which she explains the almost romantic desire that motivated scientists, particularly biologists and doctors, to rethink what it is to be human. Surely, they argued, we are more than mere puppets manipulated by the forces of nature and subject only to their powers? They looked at the experiences of the 1st World War and the devastation of Europe as a clear demonstration of the awful power of inhuman machines if allowed to proceed unchecked. Human culture, creativity and the values that characterise human being were in danger of being destroyed in the pursuit of power and dominance through de-humanising science. What was needed was a science that could take proper account of these insensible but highly significant aspects for human being, not by eliminating science, but by questioning some of the assumptions on which it is based.
    One of the people who motivated some of that thinking was Immanuel Kant who reconciled the works of two other philosophers: the rationalist, Gottfried Leibniz and empiricist, David Hume. Rationalism is the view that a rational theory is a basic precondition for all knowledge, including knowledge about the external world. It is only through having a rational account of what the world is like that it is possible to make sense of all the experiences we have as human beings. Empiricism on the other hand, is the view that knowledge comes about through experiencing the world without preconceived ideas; allowing the experience itself to present itself to us for analysis to uncover the hidden theoretical rationale underlying it.
    Until Kant, it was assumed that these two positions were opposite and irreconcilable. You either interpreted the world according to a theoretical/metaphysical assumption that gave structure and meaning to those experiences, or you shaped the mind to conform to the reality of the external world through empirical observation. Either the mind shapes the world or the world shapes the mind, but it can’t be both and there can’t be a middle position. It seems to me that it is this centuries-old issue that underlies the problems with the cranial concept. On one hand the ‘believers’ interpret their perception of cranial motion, etc., in accordance with a metaphysical understanding of what the body is and how it is structured and functions, while the sceptics argue that the empirical evidence, i.e., the objectively derived, measured experience of cranial motion and its effects, is either incompatible with or insufficient for developing a coherent theoretical account. The lack of intersubjective reliability in respect to palpation findings, for example, means that no theoretical explanation can be identified. Hence the impasse; rationalism and empiricism are incompatible.
    The position that Kant took (and simplifying it) was that the human mind must be constituted in a certain way first for the external world to be made conscious to us in the way that it is. In other words, there must be a possibility for knowing objects prior to the knowledge actually being gained from experience. Kant termed this a priori knowledge; it isn’t something we can learn, it is something that is a precondition in order for us to become conscious of other things. Examples of a priori knowledge are our mind’s capacity to sense space and time, together with concepts such as cause-effect and persistence, all issues that Hume had famously identified as non-deducible. We assume a causal connection between the ball hitting the window and the window breaking; and that the house we go into when we get home from work is the same house that we left that morning; but neither the causal effect of the ball, nor the persistence of bricks and mortar can be derived, in a scientific way, from our sense experiences of them. At best the relationships are mere correlations, a linear series of events that follow one another. Kant termed these necessary preconditions ‘transcendental knowledge’, the knowledge, or more accurately the unconscious assumption, that there is space, time, causes, persistence etc., and it is these that enables us to experience the ‘phenomenal’ objects of the world. Without a priori transcendental knowledge we don’t have knowledge of other aspects of the external world. Kant is therefore focusing not on external objects themselves as empiricism does, nor on abstract theories that are adopted (or not) by the rational mind to shape and unify our experiences as rationalism does, but on the given nature of the human mind as a mediator between inner consciousness and the external world.
    The human mind is characterised by the fact that it possesses transcendental knowledge. Our sense of reality according to Kant, is derived from our minds’ being as they are with their transcendental ability to perceive and make sense of things in the world, whether objects or events. We can only have ordinary knowledge of the external world as specific phenomena if the phenomena associated with such objects and events can be perceived by the human mind in accordance with its transcendental capacity. This leads Kant to his dictum that, “Thoughts without content are empty, intuitions (perceptions) without concepts are blind.”
    Transcendental knowledge then, is knowledge that enables us to make sense of the relationships between things; it helps us contextualise them. We cannot know ‘the world as it is in itself’ as Kant said, but only through the means we have for perceiving it. It also means that function (like causation) is transcendental knowledge, not knowledge that can be deduced from observation.
    The point that I’m trying to make through this over-long-winded response to Monica’s original post is that we need to be clear what we are arguing about when we assume that what we feel when touching a patient must necessarily map what is ‘really there’. To feel/palpate we necessarily require a priori knowledge that enables us to feel anything. A new-born baby doesn’t feel objects with her hands in the sense that we feel with our hands. Her mind must develop the transcendental knowledge that enables her to feel. The point is that how we acquire that knowledge is individual. It raises the question of whether the transcendental knowledge that enables us to feel, or see, or hear, or smell is identical for everyone or do we each produce a synthetic proposition (to use a Kantian term), i.e., produce a conscious awareness of a given object, that is different from other peoples’ awareness of the same object? In other words, two people may feel the same knee, or look at the same sunset, or listen to the same sound and each experience the knee, sunset and sound differently. If the object is clearly the same in each instance, the difference must be derived from the transcendental knowledge.
    There is much more that could be said on this very important issue as it has implications, not just for manual therapy in general and cranial osteopathy in particular, but for many other areas of life from referees and umpires making decisions in sport, our understanding of the role of ‘experience’ in all walks of like, to how we appreciate art and music and even how we interact with one another.
    The whole area of phenomenology, which derives from Kantian thought, explores this issue in much greater detail. One other philosopher who is worth looking at in respect to how we develop our transcendental knowledge, though he doesn’t refer to it in those terms, is Ludwig Wittgenstein in his final book, which is really a collection of thoughts, On Certainty. He argues that the certainty we experience and which we can’t doubt, such as ‘knowing’ that ‘this is my hand’, or ‘I feel cold’, comes from our doings in the world. It is our physical engagement with and experience of the world that gives us the certainty to be able to continue to engage with it. For more on this, look at:
    TYREMAN, S. (2015) Trust and Truth: Uncertainty in Health Care Practice. J of Evaluation in Clinical Practice, 21, (3) 470-8.
    WITTGENSTEIN, L. (1969) On Certainty,  Ed. Oxford, Blackwell Publishing.

    If anyone has actually read as far as this, I’d be glad of your thoughts and comments. This is a big issue not just for cranial osteopathy—which may or may not have validity—but for all manual medicine and much else beside. Whether by touch, sight or sound, do we assume we are mapping a ‘real world’ of body, or is it some more subtle and complex human interaction that we are engaged in?
    Stephen Tyreman PhD MA DO

    • Monica Noy
      | Reply

      Thank you Stephen for this thought-provoking comment in essay format, and I did read to the end with pleasure. It is warming to think that something I have written can inspire such thought. Of course it set me in exploration mode and once I googled you, more resources have presented themselves – I’m surprised I missed https://causehealthblog.wordpress.com/ until now, though likely I’ve read some posts without going back to the source.

      It seems to me that philosophy is the next realm when the body is no longer explanatory of its own state. You are not the only person in health who is plumbing these depths. Several people in forums I’m in, and let’s face it SomaSimple.com, also present their philosophical explorations into health and disease, and just being human. I can’t pretend to understand it all. I’m more a boots on the ground type, though I’m always intrigued by more philosophical thought and try my hand and understanding, to a more of less successful degree.

      I would like to say I’m with both you and Penny on Cranial and touch. Perhaps that’s where the boots on the ground comes in to play. My beef is with the continuation of the theoretical concepts as they are now. Here (Canada) they continue not just unchecked but as Jonathan Edis commented they go far beyond even the original theoretical concepts. Until that is addressed, the real questions and thinking around touch and cranial work won’t be addressed because they won’t be allowed to.

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