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.
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.
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.
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.
These 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.
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 maintain 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.
A Review of Craniosacral Therapy
Science, Fads and Applied Behaviour Analysis
Cranial osteopathy. Bad Science, Ben Goldacre
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