As the comments following Professor Tyreman’ s recent blog swirled higher and higher above my head, I ceased trying to understand them.  However I have been roused from intellectual torpor by this piece, which is a follow on and clarification of that first one.  It is ostensibly an answer to one comment in particular by Rasmus Schroder, which you can see at the end of the previous blog.  A few key phrases and points stand out for me, and for those of you who need a bit of enticement or encouragement,  here they are, heavily paraphrased, to whet your appetite before you get your teeth into the substance of this short essay.

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Maybe we should stop thinking we have a marketing or PR problem, or blaming other people for not understanding what we do.  Maybe a period of self-examination and reflection is appropriate for the osteopathic profession.

We might well ask – are we doing what we say we’re doing?

Is there over-reliance on what can only be described as an osteopathic metaphysics of how the body works that bears little or no resemblance to current thinking in science and medicine?

We might need to change our notion of touch, and redefine it as a subtle interaction, or even language, between two living organisms.  We could usefully call this interaction “haptic engagement”.

What is it about the osteopathically developed human mind that enables us to make sense of touch?  (And what does “make sense of” mean in this context.)

Is there something about what we do when we engage with patients physically and verbally that enables them to make sense of their engagement with the world.

In trying to explain what we do using ‘osteopathic terminology’, we may be trying to reinvent something that already has nearly 200 years of thinking behind it

The problem we are up against is that of trying to communicate what we feel and then how we use those feelings to inform our actions.

Touch, as neurological stimulation, and the meaning structure it informs are separate things.

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Rationality and Touch – by Professor Stephen Tyreman

How Should We Explain What Osteopaths Do?

Oh, dear, I can sense another essay-blog coming on! First, thank you to Rasmus for commenting on what I wrote and for coming up with some interesting ideas that are highly relevant to osteopathic practice. We share similar concerns regarding the way osteopathic practice has failed to be reflexive in recent years regarding what its rôle is or to take a radically new and bold review of what it is osteopaths do and particularly, of how we understand, describe and communicate it. Osteopathy has been the focus for critical comment mainly as a result of new understanding of pain and the accumulating evidence that biomechanics is far less significant than we once thought. There is still a view that the problem we have is because we are not able to sell our product well enough, or it is other people’s fault for not understanding us. But perhaps we need to take a close and honest look at ourselves, what we do and what we say we do, which are not necessarily the same.
Let me start by reiterating and perhaps clarifying what I was trying to say in my response to Monica’s blog and then I will address the criticisms that Rasmus has of what I wrote in the earlier paper on Osteopathic Principles.
Monica’s quite proper concern was with the claims that are made by osteopaths working in the cranial field. Is cranial work effective and more specifically, do the explanatory theories stand up to scrutiny? Particularly, and this is a broader point, does what we say we do to patients’ bodies through our haptic interventions fit what is going on? Is there over-reliance on what can only be described as an osteopathic metaphysics of how the body works that bears little or no resemblance to current thinking in science and medicine? Of course, it could be that current thinking is wrong and osteopathic ideas are right. Even if that is the case, we are not explaining the model that we are working to very well. The philosophical foundation is flimsy and confused, and the scientific evidence sparse, even if we can agree (and justify) what counts as evidence.

What is Touch?

The point I was trying to make in the blog was two-fold: first that how we understand touch might need to change; touch, I suggested, is not simply an instrumental sensory mechanism that transmits true knowledge about objects to our fingers, but a deeper, more subtle interaction, even a language, between living organisms. I referred to this hands-on effect as ‘haptic interaction’, but I think that ‘haptic engagement’ may be more appropriate as a term to describe what is happening. The point that I wanted to draw attention to was how we understand ‘reality’ and whether there is something outside our internal human experience—how I feel in myself—that is objectively ‘true’ and whether as human beings we can map it as a true representation of what is ‘out there’. I’m not disputing that there is something ‘out there’; I am not arguing for a solipsistic position, which is the idea that only I exist and everything else is in my imagination. The question is whether what we understand by ‘out there’ is properly depicted by human knowledge, particularly scientific knowledge. Is it reasonable to think, as scientistic thinking does, that it is possible to know the outside world as it really is—how it ‘is in itself’—not merely as we perceive it from within our human frame?
I argued that our access to ‘reality’ – the world outside out human bodies is dependent on our sensory mechanisms (and instruments we use as extensions of our senses) and that we learn to ‘make sense’ of the myriad of sensory data that comes to us. Because, as human beings, we cannot receive and understand isolated units of data, we contextualise them through minds that make sense of our various perceptions of the world – what Kant termed ‘transcendental idealism’. This is what develops in infancy when a baby and young child learns about the world, which is not to be understood as ‘learns what the world is really like’, but as, ‘learns how to make sense of their experiences and perceptions.’

How do we touch?

It is against this background that we need to explore the rôle of touch. It may be haptic engagement with ‘the whole person’, as Rasmus suggests, but that engagement occurs in various senses, the most familiar being the way that we can distinguish between, say, someone touching ‘me’ and someone touching ‘my arm’ even though they look to be the same to an outside observer. The physiological process may be the same in both examples, but the meaning is different. How much of what we do is touching a person/patient and how much touching their tissues or feeling motion (however we define that), and how does touching morph into modifying and treating? I don’t think we have much of an idea on this, or if we do we’re not good at explaining it.
The point that I’m asking the profession to ponder on is what is the a priori transcendental knowledge that we need in ourselves (and to generate in students) to make that haptic engagement meaningful to us? And not only to ourselves but to be able to communicate it to others, including patients, other healthcare professionals, funders, regulators, researchers and so on. What is it about the human mind (specifically of osteopaths) that links internal perception with an external world of other people, objects and events? What must the mind need to be like for us to make sense of this outside world of sensation; for the mind to transcend the physical limitations of the human body—internal experiences that I sense as ‘me’—to include and make sense of an outside world? And what is it about touch, beginning with the touch between parent and baby, but continuing throughout life, that facilitates that process? Is this a significant part of what osteopaths do? The questions then relate to what it is about the osteopathically developed human mind that enables us to make sense of what we touch and what ‘make sense of’ means in this context. And is there something about what we do when we engage with patients both physically and verbally that enables them to make sense of their engagement with their world?

Osteopathic Metaphysics

I now respond to Rasmus’s criticism of what I wrote in the earlier paper on Principles (Tyreman, 2013). First, I quite accept that I didn’t explain myself well; I put my point rather crudely and unreflectively as ‘throw-away’ comments that I might have been better leaving out until I could better explain what I meant. So here is an attempt at further explanation.
I have suggested that as a profession we have been guilty of developing a body metaphysics based on a hypothetical energy or life force flowing through the body. This doesn’t link well with the conventional body of knowledge that constitutes medicine. Biology abandoned vitalism as animated mechanism, over 100 years ago. The danger I was trying to warn about is that of substituting polemic for reason, and tribal language for rational debate. I don’t agree with Rasmus that what he terms ‘embodied practice’ isn’t open to rational/intellectual scrutiny (if that is what he’s saying, see below). What he is describing—known more commonly as ‘practical knowledge’—is an idea that’s been around since Aristotle where he talked about phronesis as knowing (in a practical sense) what to do when you don’t know (in a theoretical sense) what to do (Tyreman, 2000). Michael Polanyi (1969) talked about ‘tacit knowledge’, as knowledge embedded within the practices of professions; J L Austin (1979) wrote about concepts being embedded professional practice—professionals can do more than they can say—and Wittgenstein (1969) differentiated between objective certainties—things that we know through our actions—and cognitive knowledge as what we learn about. In addition, Donald Schön (1983) famously introduced the idea of reflecting on and in action, i.e., analysing complex practical situations in order to make them explicit rather than implicit. This leads us to a critical point that we need to be clear about. Rasmus stated that, “An embodied practice … may be partly or wholly unconscious and seldom subject to intellectual scrutiny.” I’m not clear as to whether he is saying it therefore should be so scrutinised—in which case we need to engage with the kind of literature and philosophical thinking I’ve identified—or because it is ‘unconscious’ (which is a problematic concept here) it can’t be, and therefore we are free to develop and follow any kind of explanatory framework that appeals to us. In my view, it is laziness on our part to hide behind the belief that because some knowledge is practical rather than text-book theory it isn’t open to rational enquiry and analysis. Phenomenology, which Rasmus refers to as a form of enquiry (and I presume he is referring to Interpretive Phenomenological Analysis here), is another way of starting to understand this difficult area. Phenomenology focuses on how we experience the world rather than just trying to understand the nature of the objects we experience. My point is that in trying to explain what we do using ‘osteopathic terminology’, we may be trying to reinvent something that already has nearly 200 years of thinking behind it.

How can we explain what we feel?

The problem we are up against is that of trying to communicate what we feel and then how we use those feelings to inform our actions. Feeling, unlike other senses, such as seeing, hearing or smelling, are not shareable sensations. Two people can look at an object or listen to a sound and agree on what they are seeing and hearing. The sensations may not be identical, but close enough to make communication about the object or sound meaningful. But I cannot share what I touch concurrently with others and additionally, I can touch in many ways – for texture, firmness, warmth, viscosity, smoothness, size and so on. Touch, as neurological stimulation, and the meaning structure it informs are separate things. Further complicating the issue is that the human body is not a simple object in space, but a dynamic living entity that changes from moment to moment and in which I cannot isolate one part from the rest. I therefore attend to certain sensations and ignore others. Someone else feeling the same body part may attend to or give priority to different sensations. We therefore have a situation in which it’s not clear as what kind of sensation is being palpated or which meaning structure it is informing. Which are the more important sensations? Who decides and on what basis?
These, obviously, are what is usually referred to, derogatorily in some quarters, as subjective experiences. But all experiences we have that come through our senses are subjective; in other words, all our perceptions of the outside world are subjective. Objective knowledge is knowledge of an object’s nature as it ‘is in itself’; and as Kant pointed out over 200 years ago, we cannot know things as they are in themselves, only as they present themselves to us through our (limited) senses. The allegedly clear distinction between objective and subjective where objective is good and subjective bad, is at best simplistic and worst, misleading. All experiences are subjective in the sense that the nature of an object, event or whatever, is subject to our interpretation, whether it is through our senses or through instruments, including scientific instruments.
However, the meaning of ‘subjective’ requires much better analysis. It doesn’t mean, for example, that all subjective experiences are equivalent. The ‘subjective’ view from an x-ray provides more useful knowledge of a person’s bone structure than palpation does, though palpation may provide more useful knowledge than an x-ray of how that altered structure is compromising local soft-tissue function, say. By assuming, simplistically, that x-rays are objective, i.e., they represent things as they really are in themselves, and therefore true, whereas palpation is subjective and merely the opinion and frequently mistaken perception of the person, requires much better understanding. Is it a different kind of knowledge that each generates, and if so how should we determine what it is that links a particular knowledge with a specific investigatory tool?
I completely agree that we need to focus on the person as a whole, not just the biological, but I’m not happy about the body-mind-spirit split, which to my mind simply perpetuates the Cartesian fallacy. However, I’ve already gone on too long so I won’t get onto that subject.
Thanks again for the comments and I hope our discussions will prompt further thought and discussion.

References

POLANYI, M. (1969) The Logic of Tacit Inference. IN M.GRENE (Ed.) Knowing and Being: Essays by Michael Polanyi. Chicago, University of Chicago Press.
AUSTIN, J. L. (1979) A Plea for Excuses. IN URMSON, J. O. & WARNOCK, G. J. (Eds.) J. L. Austin: Philosophical Papers. 3rd ed. Oxford, Oxford University Press.
SCHÖN, D. (1983) The Reflective Practitioner: How Professionals Think in Action, Ed. New York, Basic Books.
TYREMAN, S. (2000). Promoting critical thinking in health care: phronesis and criticality. Med Health Care Phil, 3(2), 117-124.
TYREMAN, S. (2013). Re-evaluating ‘osteopathic principles’. International Journal of Osteopathic Medicine, 16, 38-45.
WITTGENSTEIN, L. (1969) On Certainty, Ed. G. E. M. Anscombe, G. H. von Wright: Oxford, Blackwell Publishing.