Finally – truth and opinion

This is the last post in this mini-series on why I use science when deciding what interventions to use as a therapist.  As I did yesterday and the day before, I refer to William Palya’s book on research methods – it’s easy to read, available on the internet for free, and although it gives only one view of scientific method, it’s a good start.

After having discussed the first onus – which is to be ethical, and the second, which is to be pragmatic, the third is to use a method to help achieve one or both aims. There are two basic things you need to do:
(1) Demand truth and
(2) Have good understanding

So, what is truth?
Well this can get into murky waters – especially if you listen to the philosophers! But for practical purposes, we can assume that ‘truth is an accurate description of something that is real’. It’s process of building up evidence from many sources, at different times, in different places that describe the same thing, using the least number of assumptions or appeals to special factors that can’t be tested, and describing the majority of the thing under examination. We can use the word ‘phenomenon’ instead of ‘thing’, or ‘event’ or ‘factor’.

Empiricism is one way that is used to determine ‘truth’. Something that is empirical is observed – through technology, to be sure, but can in some way, correspond with something that exists in the real world. As Palya puts it ‘If we wish to claim that something we cannot experience is real then the burden is on us to prove it to a skeptical audience; that is only fair.’

The evidence needs to be reliable – that is, if you look at it more than once, it should be the same. It should also be the same if anyone looks at it.

There should be more than one source of evidence for the ‘thing’. Palya’s example may help – ‘The more evidence from the wider a variety of sources, the more believable. If the police find a finger print the same as yours at a murder scene, maybe it means you are guilty, maybe it doesn’t. However, if the police also find your wallet there, and the murder weapon in your house, and the tire tracks of your car at the murder scene, and the victim’s jewelry at your house, and your teeth marks on the victim’s throat, and a VCR tape of the murder with you in the starring role – well, then you’re in trouble.

You can’t be the only person to say it’s so – and the others that agree with you also need to hold to the same ideas about what is ‘true’ and ‘real’. ‘If several observers who abide by the “rules” of science all agree concerning an event then it is probably true. It is reliable, it is objective. If only one person observes something and others do not observe the same thing then it is subjective.’

The phenomenon needs to be carefully defined so we all agree on what it is and that it describes the essence of the phenomenon. ‘The concept of a horse is false if it includes the saddle or fails to include four legs; it is false if it includes speaking English or fails to include galloping.’
The implications of this aspect of ‘truth’ is that the words we use to describe need to include the critical or essential elements, while excluding those that are not essential. A good definition is unambiguous with respect to what is included and what is not.

The definition you provide must actually have an impact on something that can be measured – because if you can’t confirm that it affects something, it might as well not exist.
Things cannot be said to exist outside the impact they have on sensation (resulting measures) or the impact on other things (functional definition). If your idea of the correct concept of a thing exceeds its operational/functional definition, the burden of proof or burden of communication is on you to prove, explain, and communicate the difference.’

I leave the best summary again to Palya: ‘we start with the notion of empirical, reliable evidence with multiple converging support which is operationally/functionally defined and has consensual validation and ask what is beyond. If someone wants to offer something else as a “truth” it must be proven. Truth does not mean anything anybody wants it to mean. Anyone wanting to extend the meaning of truth to something beyond what science has already substantiated must explain to us what they are talking about.’

Some people say that because various ideas that were once strongly supported by scientists have been rebutted in recent years that there is no such thing as ‘truth’ and science is nothing more than a set of opinions that change all the time. (eg disc prolapses on MRI were once thought to indicate the source of back pain and therefore needed surgery, now they are thought to be incidental and possibly a ‘normal’ variant in many cases)

Some things do change over time – not because the ‘truth’ part changes, but because more information comes to hand that explains more, or explains more with fewer special assumptions, or has more robust support than the previous ‘truth’. This is, in part, why we describe ‘truths’ as theories – theories can be and should be continually tested and as a result, refined. If a theory cannot be tested – then it’s really a model and needs to be evaluated in terms of how useful it is. If it doesn’t help with making decisions that can be tested, then it’s not useful at all.

Whew!! That’s a lot of theory and philosophy of science!
I think though, that it’s really important that we, as therapists, work out why we use the interventions we do, and that we can point to a method that means we feel we can rely on the interventions – and that we really do understand what we mean by evidence and science. Otherwise we are only reciting by rote, or working by habit and convention rather than seeking to understand.

What’s understanding?
It means you can describe, predict, know how to influence, synthesise and explain what you are actually doing.

This is from Palya’s chapter – summarises it quite neatly I think!

Have a great weekend – it’s Friday here, and I’m about to look for a Friday Funny. Be back soon!

Science and therapy

Yesterday I blogged about why I am so keen to use science to help me work ethically with clients. I talked about the basic onuses that we accept when we decide to become therapists, and showed how these are no more than what I would hope to receive if I saw a therapist or plumber or accountant.

I refer much to William Palya’s Research Methods pages not because it’s the last word on scientific methodology, but because it’s a starting point, and he writes in a very readable way.

Today I want to move on to being pragmatic.
This is the second onus that we usually accept – these are the skills that we need to be secure and successful in our clinical practice, and lead to the reason for using the scientific method as the way to meet both obligations. Once again, I’m quoting mainly from Palya’s work, but paraphrasing and applying it to health practice across all disciplines.

To be pragmatic, you need to:
a. Be a Good Consumer / Separate Illusion from Reality
All theories claim to be correct and all therapies claim to be right. If you are to become a good consumer or practitioner of health care knowledge you must be able to separate truth from fiction even when appearances are deceiving.
b. Ability to Implement Complex Information
You must be able to understand the advanced and sophisticated knowledge of health care in order to properly function as a therapist. Knowledge of people, health and therapy has exploded in the past 20 years and to sift through it all requires skill.
c. Solve Unique Problems by Applying Concepts
Technicians can cope with problems once they are trained to step through that particular solution. A professional on the other hand can solve problems which have never before occurred because they are trained how to identify underlying patterns and apply principles to novel situations. In general, a professional must have the analytical skills necessary to unravel complex behaviors into understood functional relationships, and the competency to design procedures which will clarify causal factors or which will alter behavior.
d. Make Consistent Progress
If you are to succeed at what you are doing you must be right more often than you are wrong. If you are to make consistent progress then you must know when things are getting better and when they are getting worse. With accurate feedback, errors can be eliminated and correct solutions obtained. ‘Common sense’ moves you back and forth in no consistent direction because there are so many competing and opposing ‘common beliefs’. (e.g., it’s never too late, you can’t teach an old dog new tricks / he who hesitates is lost, look before you leap).
e. Prove Effectiveness
You will be required to demonstrate the efficacy of what you do because when the people supplying your income become good consumers, they will demand it of you. This will include: Funding agencies, the Courts, to ensure ongoing employment.

To be both pragmatic and ethical, you’ll need to use a scientific perspective as the only perspective. Why?
Because you need good evidence that things are true before you believe in them. Think of the coin toss result hidden in my pocket – if I gain from your choice, why would you trust my word? You’d really want someone else (if not yourself) to check it out.

Finding ‘truth’ or what approximates it given the current state of knowledge is not as simple as it sounds.
1. Unfortunately, truth is not necessarily obvious, what you like, nor the easiest.
2. Neither is common sense an acceptable arbiter of reality. Common sense can be as dangerous as helpful. Common sense is often true only in the sense that ‘home truths’ predict everything, for example “opportunity knocks once”, and “it’s never too late.” One or the other is certainly true on any one occasion. The need is to know in advance not after the fact when it is too late.
3. Just because your mother, teacher, or best friend believes something does not make it true either. That your friends support your view is no help. Everyone, including a psychopathic murderer, has a mother, a best friend and a dog that believes in them.
4. The fact that something is popularly known is also no reason to believe in it. Everything that is now known to be wrong was once thought to be true by people in the street.
5. Knowing or feeling that you’re right is of no help. Even though most people do believe that they can be wrong, few people ever believe that they are wrong “this” time. Most people (including you) can be talked into believing a nonsensical theory especially if it’s full of jargon, and the person talking to you has power, seems charismatic and you’ve paid for their advice.

You need to accept that any special “inner ability to understand people and recognize the truth” could be the problem rather than the solution. The only way to move past guesswork or habit is to determine what in the past has been shown to produce truth as opposed to procedures which only produced strong emotional commitment but make little lasting change.

What’s truth? Now let’s leave the Great Debate to philosophers, simply put there must be rules to screen-out ‘knowing-that-you’re-right’, opinion, bias and conjecture from truth. Truth is an as-accurate-as-possible description of something that is real, or works, or explains the most with the fewest ‘special’ assumptions. If three people tell you three different combinations to a safe, the one that works is the truth. It means that the information has passed a reality test.

There are some tried and true ways to determine the truth of a claim: more on this next week.
In the meantime, let me know if this is interesting, challenging or just off the wall!  I know I never learned this when I trained as an occupational therapist years ago – I wish I had, because it has confirmed to me that in order to be honest and authentic in what I offer to people, I need to learn how to check the veracity of what I do.

Science and therapists

I’ll admit I’ve been warped a little by psychologists. No, I haven’t learned to blame my parents for how I’ve turned out (that’s why my mother wouldn’t let me study psychology when I left school!), but psychology as a field of science has definitely made me more thoughtful and critical of how I make clinical decisions – and opened up a whole approach to therapy that I’ve adopted and integrated into my practice.

A strand of thought in clinical psychology is the ‘scientist-practitioner’ model, promulgated in the Boulder, Colorado Conference of 1949 (and argued about ever since!). This model basically proposes that clinical psychologists need to adhere to scientific methods, procedures and research in daily practice.

To quote directly from the Wikipedia entry:
Core tenets of the Scientist-Practitioner model include:

* delivering psychological assessment (Psychological testing) and psychological intervention procedures in accordance with scientifically-based protocols;
* accessing and integrating scientific findings to inform healthcare decisions;
* framing and testing hypotheses that inform healthcare decisions;
* building and maintaining effective teamwork with other healthcare professionals that supports the delivery of scientist-practitioner contributions;
* research-based training and support to other health professions in the delivery of psychological care;
* contributing to practice-based research and development to improve the quality and effectiveness of psychological aspects of health care.
(this is an excerpt from Shapiro, 2002)

How does this play out for me in my clinical practice? And how does this differ from the ‘Problem-solving Process’ I was trained in during my occupational therapy training?

The occupational therapy process involves identifying problems, finding solutions, choosing a solution, implementing the solution, reviewing the outcome. I don’t really have a problem with this except that it omits the critical parts of setting the problem in context and developing a set of competing hypotheses that are systematically tested until the best explanation for the ‘problem in context’ is found.

These two parts are the two I’ve adopted from the scientist-practitioner model. The importance of identifying who has the problem and what the problem is cannot be over-emphasised, and neither can the process of reviewing the context of the ‘problem’. Sometimes the ‘problem’ isn’t actually a problem for the client, but rather, for someone else in the healthcare team.

Let’s unpack that with an example: I was asked to review the case of a woman who had mobility problems after an accident, and who had been assessed as needing a new vehicle so she could get out in the community. The problem was framed as her need to be able to independently drive in and around her community, and the contributing factors were her limited range of movement in her legs, obesity, and pain. She couldn’t sit for longer than 10 minutes or so, but moved very slowly and heavily using a walking frame. She couldn’t rotate around her spine, and she found bending forward difficult.

She had been prescribed a new vehicle because she couldn’t get in and out of the old vehicle she had. She’d recently had a new flat area bathroom installed, had rails throughout her house, a special chair for her in the lounge, and a kitchen that was modified and had a stool for her to perch on with a higher-than-normal benchtop so she could use it from the stool.

What was the problem? The functional problem was that she had trouble getting in and out of the car.
The solution? Get a new car!
BUT then I came in and started reviewing a few things…
What were the contributing factors – although I’ve already alluded to her mobility problems, and obesity, I haven’t revealed that her main problem was low back pain that she developed several years ago when she was involved in a car crash. She has gained weight since the crash, and is now morbidly obese. She has neuropathic pain over her right lower leg, and also has very thin skin that is easily damaged as she has asthma and has been using steroids for many years.

Contextually? This woman lived alone, but had many hours of home help. She had some strong beliefs about her pain, her accident, her right to compensation, her need for support, and her need for home modifications. She had never participated in any pain management programme. She believed her pain should be ‘fixed’ and she was angry that it had not responded to surgery or other medical interventions. The case manager was irritated that this woman had received over $40,000 in assistance not including earnings compensation, and was concerned that although a new vehicle might be nice, it wasn’t entirely necessary. The case manager thought that modifying the old one would be sufficient.

Let’s put this together.
Here is a woman with a range of beliefs about her entitlement to compensation, a passive attitude to rehabilitation, a system that had provided her with modifications to her house, but had never been exposed to therapy to review how she managed her pain, how to improve her mobility, how to reduce her weight, or even how to cope with the range of emotions she experienced since her accident.

I would lay good money down and bet that every clinician who saw this woman thought they had her best interests at heart. They were solving her immediate problems, and she was entitled to what she had been prescribed. The housing modifications and recommendations for vehicle and home help were all within normal entitlements – and clinically appropriate…
and in this case it’s a VERY big BUT
Although they served to ‘solve the problem’ in the short term, they didn’t help at all in the long term.
Sadly, by providing this woman with ways to avoid confronting her pain and learning to manage her pain effectively, and work through her thoughts, beliefs and attitudes, she had been strongly encouraged (and undoubtedly inadvertently) to remain passive in her own rehabilitation, to fear her pain, to reduce her mobility, and to remain very disabled.

So, where does the science come in?
I think one of the first things therapists need to do is review the reason for referral and be mindful of the bigger picture – in other words, the context. I think the scientific method as depicted in the hypothetico-deductive model misses out on the process of discovery which is all about looking at the bigger picture and seeking patterns.
The pattern evident in this woman’s presentation is that despite receiving all this assistance, she was not becoming any more independent. In fact, she was becoming more dependent on all the modifications and equipment she had received. This would be appropriate if she had a deteriorating condition like multiple sclerosis, but definitely NOT when it comes to chronic pain.

The clinicians also needed to review the science of pain and pain management – what are the evidence-based approaches to helping people become independent with pain management? Equipment prescription and housing modification receive very limited support in the literature.

Clinicians also need to review their basic science – how are behaviours maintained? How do we encourage change? What do we know about how people learn? Reviewing this would have meant this woman might not have had her requests for more and more help reinforced by receiving help.
And it might have been useful for therapists involved with her care to review the long-term effects of providing equipment – OK for short-term needs, not OK for long-term health maintenance.

A problem for many therapists is the lack of critical thinking – why was this referral made? Who has the problem? What alternative hypotheses could be considered to help her?

Being client-centred does not mean being client-directed. This woman would not have identified that she wanted to manage her pain better – she simply wanted it gone, and she wanted a new car so she could go out and about. What no-one seemed to have asked was how she was going to get around the places she drove to!

Being really client-centred would have involved working with her to review all the factors in her presentation, and recommending an evidence-based intervention: good cognitive behavioural therapy for pain management, gradual reactivation, therapy to help her manage her distress and anger over her condition, and possibly even a move to accepting pain instead of resenting it.

Science is about systematically observing and questioning everything – building on current knowledge and context, and coming up with new hypotheses for testing until finally a ‘useful explanation’ is arrived at – ready for the next, deeper discovery that can provide an even more ‘useful explanation’.
‘Useful explanations’ are not necessarily ‘true’ – they are just helpful, explain the majority of the presentation we see, help make predictions about the future, and make the least number of assumptions. The problem with the previous therapists approach for this lady was that they used an outmoded explanation that didn’t fit with the context of her presentation, and didn’t account for many of the contributing factors.

And that’s why I’ve adopted the scientist-practitioner model – because it continually asks the questions: Why? What’s going on here? How come? What would happen next?

For some more readings about science, I’ve really enjoyed the following:

Renewing the Scientist Practitioner Model D. Shapiro, 2002

Bob Dick’s unpublished paper discusses whether it’s time to review the model

Terry Halwes paper on Truth in Science – and the section about Western Science whcih is about 2/3 down the home page

And finally, a book I’m enjoying on ACT, or Acceptance and Commitment Therapy, for anxiety – but equally applicable for pain:
New Harbinger Publications produces a range of science-based self help books. I looked on my desk and I have four sitting there without me even looking! The Mindfulness & Acceptance Workbook for Anxiety is the latest one I’m enjoying. I started by looking for a relatively simple book on how to introduce mindfulness and acceptance to people experiencing pain. I already have the Living Beyond your Pain ACT book, but it doesn’t quite hit the spot for my clients. So I’m hoping to take extracts from both to develop something helpful for the people I work with – something a little less wordy and abstract. Not easy, but that’s me!!

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See you again soon…