critical thinking

Black and white thinking must be abolished


Black and white thinking, for those readers unfamiliar with cognitive distortions, refers to the tendency to reduce complex ideas and situations into simple, dichotomous, and mutually exclusive categories.

Think of good or bad, yes or no, all correct or all wrong, acute pain or chronic pain, neuromatrix or peripheral mechanisms, cure the pain or manage the pain.

It’s a way of simplifying arguments or decisions that can work well when the situation requires very fast decision-making, or where the options are very limited.

It doesn’t work at all in the messy and complicated worlds of clinical reasoning, theory development, or in discussions to broaden understanding.

I’m pondering this because of the way various aspects of pain management and the science of pain are misrepresented as opposed to each other, when maybe it’s not quite so simple.

I hope (crossing fingers and toes) that I’m not doing prone to doing it too often on the pages of this blog, or elsewhere for that matter!

There are multiple strands of research into pain at present. 

There are the reductionists who focus exhaustively on smaller and smaller elements of biology to explain the processes involved in nociception and transmission from noxious input to the perception of pain and back to the responses as a result. 

There are the phenomenologists who focus on the ‘lived experience’ of the individuals who have pain.

There are those who are furiously investigating laterality and cortical processing.

There are others feverishly working on ways to abolish all pain, and those who are equally enthusiastically researching why so many people are unbothered by their pain even though it’s severe.

Can you see all those opportunities for opposing views? for argument and debate?  It’s common for any of us to think mainly in terms of our own orientation, and there are many factors in human cognitive bias and group decision-making that get in the way of us working towards consensus – or even hearing each other.  And that can lead to trouble within teams, especially multi- or inter-disciplinary teams.

I wonder if it’s time to apply some of the cognitive techniques we can use with patients to ourselves as clinicians.  Let’s take a quick look at some of the basics.

Firstly, why do we use black and white thinking?  Well, it simplifies things.  If we’re feeling a little bit sad, we’re more likely to tell a loved one that we’re feeling “terrible”.  We don’t mean to exaggerate, we’re aiming to get empathy from the person we’re talking to, so we unintentionally use dichotomous language – we think in terms of feeling “amazing” vs feeling “terrible”.   Humans like to identify patterns, and to group similar things together so we can generalise.  We like to reduce an argument into “either – or”.  And when we do this, once again because of our tendency to look for information that confirms our own position, we often fail to recognise other alternatives, or information that doesn’t fit with our own views.

What we can do is step back and carry out some metacognition – thinking about our own thinking.

Some questions we can use to challenge our own position are:

  • How did I come to that conclusion?
  • What’s the evidence for the other position?
  • Is it possible to use “and” instead of “either/or”?
  • What are the other options?
  • Are there parts of my argument that can’t explain something the other position can explain?
  • This idea is only an idea – not my personal possession
  • Consider saying things like “at the moment my position is…”, “I’m attracted to this idea currently…”

I’ve personally found it useful to relax a little and recognise that in the end, the data will speak for itself.  So, for example, I was initially not keen on mirrorbox and laterality training for CRPS.  The studies, especially in the early stages, weren’t carried out in people with the degree of chronicity and complex psychosocial background that I saw.   Over time, and as the evidence has been gathering, I’ve changed my position.  I don’t mind acknowledging this change – in the end, it’s not my ego that’s important, nor “my” ideas – it’s what helps this person at this time with this particular problem.

Having said this, developing critical thinking skills, and in particular, being able to unpack and delve into how a study has been conducted and whether the conclusions drawn are supported by the data is vital.  Cherry picking, or selecting studies that support one view or another while ignoring or failing to account for studies with conflicting findings, just doesn’t do – again I try to relax a little, because in the end the balance of evidence does fall one way or another.  Or, in the case of chronic pain management, maybe there is so much to learn that what we know now is not even beginning to find answers.

If you’re keen to learn more about how to develop critical thinking, Foundation for Critical Thinking has a wealth of information.

On evidence and practise


An opinion piece to restart my blogging after my lovely holiday…

I’ve been reading ABC Therapeutics blog where Chris Alterio writes in response to a long comment by Michele Karnes suggesting that occupational therapists (and by inference all health care providers) ‘should be made aware of treatments that are offered to clients/patients, whether it is traditional or non-traditional, a long existing treatment or new one. This enables our OT profession and professionals to better educate the people they treat and interact with.’

I don’t have any particular concerns about this part of Michele’s comment – but I do have a problem with this part ‘while Evidence Based Practice is on all of our minds, and ultimately the best to utilize with our patients, if we only used treatments for all of these years we would have missed out on the many treatments that OT’s have historically (and still) use.’ (my emphasis)

It raises some concerning things for me – and while I don’t have answers for all of my concerns, I hope to stimulate some debate at least.

Chris writes in his blog ‘Just because people seek out alternative energy healing interventions doesn’t mean that it constitutes appropriate or ethical practice. In an article published in the Journal of the American Medical Association on this topic an author writes: “Given the extensive use of CAM services and the relative paucity of data concerning safety, patients may be putting themselves at risk by their use of these treatments. Only fully competent and licensed practitioners can help patients avoid such inappropriate use... Physicians can also ensure that patients do not abandon effective care and alert them to signs of possible fraud or danger.“‘

I’d add that licensing in itself does not inevitably lead to patients being helped to avoid inappropriate treatments. I also add this:

I think it also takes a critical and educated mind, a systematic approach to reviewing evidence, and considerable determination not to be swayed by forceful opinion. (more…)

A nice lay summary of pain


I ran across this post today in my ongoing search through the net – Why do we have pain?. It’s a very brief article written by someone with fibromyalgia giving a pretty useful description of the difference between pain and injury or tissue damage. And a bunch of links to articles found on Associated Content.

I’m not comfortable with her definition of pain as ‘perception of pain’ because that’s tautological and circular and tells me nothing. So – pain is the perception by the brain of signals that the brain detects as harmful or threatening to the person and wants to ensure action is taken. Howzat for an on-the-run definition? Overall though, I don’t think you can go far from Professor Harold Merskey and co’s original IASP definition of pain. But for lay people, or people in the community, perhaps the definition needs to be a wee bit shorter.

I clicked into the link ‘pain’ on that website, and came across a whole range of brief articles of varying quality about pain and pain management. Like most things on the web, read with a good degree of thought and criticism, and be aware of the quality of what you read. If you’re wanting to establish whether a site has been reviewed for quality, the Health on the Net is a good way to determine whether the author has decided to voluntarily comply with ethical standards. You should also apply your own critical thinking by referring to the literature yourself – and not just a single reference either! You do need to survey several papers on any topic, thinking about the quality of the research supporting any contention, and particularly the generalisability of any research to your specific area of practice, before transferring any new treatment technique into your daily routine!

’nuff said – I’ll be posting on CRPS and an exposure-based treatment later shortly so – y’all come on back now!!