If I let you down, well I'm sorry again
But I was only doing whatever came easy to me
Yeah I wanna survive, but I'm not sure
Because I heard the cure's worse than the disease
- Brad Sucks, How to Not Kill Yourself
Sleepwalking
How does your computer work? The simple explanation is you power it, boot it, send emails or watch videos or view tiktoks or make a fool of yourself online. But that's the simple explanation. How does your computer actually work? What do the parts do? What do the switches do? What happens when you combine software, hardware, and peripherals, and can you control that output? How does your car work? The simple explanation is that you stick the key in, turn it, the engine cranks, you take it out of park and put it into gear and go get your icecream. That's the simple explanation. Can you explain how turning the key in the ignition sends a start signal to a controller that runs the engine components and gets the car going? Can you explain how the parking sensors, electrics and the brakes all work? How does your body work? You get up in the morning, get out of bed, comb your hair, brush your teeth, dissociate in the shower for a little bit and go to work. That's the simple explanation. Can you explain how your muscles and bones work? Can you explain why it's important to brush your teeth?
I'm not taking shots or calling anyone stupid here. Let he who is without sin cast the first stone, and all that. I mean to suggest that through our lives, and that includes our experience of living in our bodies, in our community and in a world that changes, our experience of living is made easier by relying on and accepting assumptions consciously and unconsciously. We assume how a microwave works, thanks to standard manufacture of that appliance. We have an idea that when we put heat to something it will become warm, thanks to an implicit understanding of physical science. We predict that when we bend over to pick up something off the ground that we'll be able to stand up without feeling like a grenade went off in the base of our spine, thanks to our experience of our bodies. Assumptions are shorthand that we use to make our lives easier by helping us construct streamlined expectations of the world around us and thus using those expectations to navigate our lives.
Problems happen when our assumptions fall through.
Cotton Candy
The earliest of these shorthands that we use to construct our world come from our parents. That's their job - they can't hope to explain the complexity of the world to a child; a child's brain couldn't handle it. So the adults in our life paint the world in simple colours and with simple language and statements, like that adults with authority and power are always there to help, people are always deserving of respect, if you work hard you'll be successful, as well as other fanciful notions that typically get revised as we grow older. As we do grow older, as we go through life and as we experience things, cracks start to form in that simply painted facade. It's convenient to excuse those experiences that don't line up with what we've been told as a one-off deviation, or something that usually doesn't happen. We, our parents, our peers, or our communities tend to fill in the cracks with situational or ad-hoc explanations so that our worldview isn't challenged too explicitly and we don't get thrown into an existential panic. Our assumptions about ourselves and the world are a series of foundation stones that let us build a stable life. To challenge them too rigorously invites undermining confidence in the bases on which we rely to function. To not challenge them at all leaves us vulnerable to what happens when our beliefs about ourselves and the world are upset completely and intimately by something that doesn't just shake our foundation but invalidates it entirely. There are many ways that this happens.
Pain is an existential challenge to a person's worldview because pain, discomfort, dysfunction and disability all attack a person's conception of themselves as healthy, vital, and well. Subject someone to enough pain over a short enough timespan and they need therapy. Pain is a deeply unpleasant, visceral sensation that needs a framework to understand beyond a certain level of intensity or duration. Even for someone who uses their body for work and play and so might have a more nuanced conception of their abilities, pain is something that can upset even that more resistive awareness. There's nothing worse than feeling like a stranger to your own body, or even worse being subjected to your own body. If you're cold you can put on clothes, if you're warm you can take those clothes off, if you're thirsty you can drink and if you're hungry you can eat, but if you're in pain you can't escape it when it's there. You can't magic the pain away, negotiate with it, or intellectualise it. You can't get up and leave the room because the pain is in you and it's a part of you. Where blind confidence once was, now there's confusion and a lack of clarity. That leads some people to make even more assumptions that may not be correct - that they've permanently disabled themselves, that some things are unsafe, that the simple act of moving can cause structural damage to their body, or that simple strain-related problems are due to intractable structural underlying factors. Given enough time, these compensatory assumptions can trap people in boxes made out of their very sincere desire to make sense of their discomfort, and the whole experience can seem hopeless. It's entirely possible to paint and paper yourself into a corner by adding layer and layer of justification to try and think our way out of a situation or a worldview. The challenge then becomes peeling back that facade of rationalisation and getting to the truth.
Stimulus Response
In clinic, physiotherapists typically see a lot of neck pain, back pain, and shoulder pain. Many clients are professionals who work desk jobs and get their health fix through a brisk walk, some light yoga, or a bike ride to work. A dramatic onset of back pain that makes it hard to walk, stand, bend and sit is something that's very confronting for people - all of a sudden a person's assumption of how their body works and what they're capable of is challenged intimately. A common thing that is said is, "Something like this has never happened before and I don't know what to do." When someone says this, they're really articulating three points - firstly they're literally saying that they don't know what to do and they need professional guidance. Fair enough. Secondly, because something like this has never happened before, the client might not have a frame of reference or understanding to make sense of what's going on. Thirdly, and flowing on from the second point, because something like this has never happened before and the client can't make sense of it themselves, they might not know what it means for them in the immediate moment or in the context of their life. All three of these deficits can be addressed with a simple question: "What's your understanding of the human body and human anatomy?" With that one question it's possible to establish what someone knows about their own body, and once the assessment is done then the gap between what they know and what they need to make sense of their own body can be filled - not with cotton candy but with something much more valuable: information that has explanatory power by virtue of the fact that that understanding will guide and structure the program of rehabilitation undertaken for that problem. Information presented in a contextually appropriate manner and given weight through relevance is the chisel that peels away the layers of paint and paper and makes sense of the truth.
Physiotherapy is more than managing discomfort - that's just the first step, like filing off the chipped paint so that the crack in the wall can be repaired properly. The next step is to fill the gap with information that makes sense - this is empowerment. This step is tricky to fit in because if someone's discomfort has been taken care of, what more do they need to know or do? The problem's been solved, hasn't it? Well not entirely - simply managing discomfort is providing an answer to the immediate issue. Without spending time making sense of how and why something happened and what it means, the process is incomplete. Empowering the client means helping them address and make sense of their own assumptions regarding their body, and showing them that they have the ability to do more, live more healthily, and exert themselves if they so wish. By helping the client interrogate their assumptions, beliefs, and behaviours regarding their own body, the clinician guides them to a point where they can make decisions for themselves with the right information. The last step after that is trickier - the last step is something the client has to do themselves. People can come to clinic once a month for their entire lives but they'll never improve until they start taking steps in their own lives as well. Peoples' assumptions don't just apply to their bodies, their careers and their characters but also the world around them. Even beyond our youths, our understanding of society, community, and the broader world still has shades of the pastel-paint that got thrown up on the walls as a child. If pain is an existential challenge to a person's conception of themselves, then a person's process of understanding themselves can be the beginning of empathy - by understanding that other people may be in that kind of pain all their lives, or might not be able to resolve their discomfort because of poverty, access or capacity.
Orientation
Our relationship to our body and the world is one that is built on assumptions, models, and inferences. This is so that we can make our way through our day without being crushed by the burden of needing to make sense of our lives on a minute-by-minute basis. When our assumptions are challenged, it can cause anything from a minor inconvenience like missing a train or needing to darn a hole in a sock, to a calamitous challenge that forces us to adjust the trajectory of our immediate or even ongoing lives. Assumptions are useful because they form a generally reliable scaffold, but they are also vulnerable if they fail and we have no backup, no safety net or no way of finding our way out of the situation in which we now find ourselves. In clinic, the physiotherapist's goal is to address and interrogate the assumptions a person has regarding their body, and then orient and guide that person from where they are to a place of comfort and empowerment. More broadly, it's our job to at least be aware of our assumptions if not questioning and reflecting upon them directly. Just as those who use cars, electronics and their bodies have a more grounded understanding of how those machines work, based not simply in inference but in experience, so too must we who live in societies, communities, and in families with many people with individual and vibrant lives be aware of the assumptions, small and large, that we make and maintain through our day. We assume these things on a daily, hourly, and minute-to-minute basis. The most obvious, important realities are often the ones that are hardest to see and talk about. The things we believe implicitly and unconsciously about ourselves, our lives, and our worlds are the hardest to recognise, harder still to articulate, and almost impossible to reorient.
But that's just what we have to do.
It was such a long time ago, I can't remember
If it was always this slow but it's taking forever
There's such a long time to go, I can't remember
How it used to go - but it's taking forever, yeah
It's taking forever