A reminder of the great mind and gentle humanity of Stephen Tyreman.  I was honoured to be sent this to publish on the blog, and hope that through writings such as this, he can continue to enlighten and inform us.  He wrote it in response to a piece by Monica Noy on “cognitive dissonance”.

 

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Cranial Concept, Reality and Perception

Thanks Monica for this honest and thought-provoking piece and also to Penny for drawing my attention to Monica’s thoughts.  It takes a lot of courage to speak out against the prevailing assumptions, practices and mores of any group and particularly of osteopathy which continues to be defensive and therefore somewhat ‘touchy’ about its identity and status in respect to other parts of healthcare.

I suppose I’m a bit closer to Penny’s view on the cranial concept, which is that while the theoretical ‘foundation’ of cranial work is very suspect with little supporting evidence, there is something beneficial that happens when hands are placed on a patient.  In my opinion, although some of what we do involves modification of body mechanics, we need to focus more on understanding what happens in that haptic interaction between two human beings rather than assume that everything we do can be explained by mechanical models of bone articulation and fluid (or energy!) flow, where the hand is no more than a highly sophisticated tool.  There is much evidence about the physiological, psychological, social and emotional benefits of touch—as well as the harm inappropriate touch can do—that doesn’t seem to have come within the radar of osteopaths; not much anyway.  This is despite the fact that we are professional ‘touchers’ along with others working in different areas of manual therapy.  Is this because we are fearful of losing our reputation for having magical skills, or of osteopathic technique being downgraded and seen as nothing more than social grooming?  I agree that some might seek to denigrate us in this way if we focus more on the psycho-social rather than the instrumental effects, but being more honest with ourselves might also open the way to a better and more effective understanding of what touch does and for such information to be channelled into more effective treatment.

To make it clear, I’m not saying that psycho-social support is all that we do through palpation; clearly, some of it is mechanical modification of functional body parts, but it’s probably a much less significant part than we once believed.  The point is that we don’t know.

Important as this issue is and much as I’d like to see it come to the fore in osteopathic discussion forums, I don’t want to dwell on it now, but to comment on issues raised in the blog around what we understand by ‘reality’ and ‘perception’ as these are key concepts for how we understand palpation and particularly the subtle senses of touch that pervade in cranial work.  Like touch, I think they also are complex, under-explored issues that would benefit from deeper analysis and understanding.

Let’s start by clarifying what the problem is; what are we trying to explain when we use the term ‘reality’?  It is an issue that Descartes famously grappled with and which continues to exercise the minds of philosophers and, today, neuroscientists.  How can I know (with certainty) what the nature of the world outside of my body is when I am restricted to contacting it through my (limited) senses?  I can only be aware of those aspects of the external world that I can see, hear, touch, etc.  What if there are things out there that I cannot sense, or aspects of those things of which I am aware that I cannot perceive?  Here we enter the area of metaphysical speculation, something that the positivist end of science denies.

Putting that to one side I am conscious of an external world that I see, hear, smell, touch and taste that not only makes sense to me, it enables me confidently to engage predictably with it; but I also know that sometimes what I think I see, hear, etc., turns out to be mistaken.  The relationship between whatever is ‘outside’ what I think of as ‘me and that internal self-awareness that I associate with the ‘me’ that perceives it is at best unreliable.  Descartes went further by asking himself, “what if all my senses are deceiving me?”; what if instead of a real world out there that my senses sometimes misinterpret there is a demon that puts the idea of a real world into my head?  This notion has been a favourite subject for science fiction writers.  The film, The Matrix, for example, portrays a world that we sense as real, but in which we are all simply elements in a complex computer programme.  How do we know we are not?  Thinking about this invites madness!

Human beliefs about reality, i.e., the real nature of a world that is external to my subjective experience, has, very roughly, gone through three stages, but all of which still exist today: reality as a remote ideal; reality as the natural world that we experience through our senses; and reality as an anthropocentric interpreted experience.

The first of these is exemplified by Plato’s view that our experiences on earth are merely imperfect copies of a heavenly ideal.  In heaven, which is the perfect utopian state, there are perfect trees, chairs, hats, cats and human beings while, here on earth, we make do with imperfect copies.  Plato seems to have picked up something in the human psyche about, and our desire for, the perfect.  Look at how many adverts in the run up to Christmas describe what they are selling as being able to create ‘the perfect Christmas’.  Artists strive to produce the perfect painting, compose the perfect piece of music or perform the perfect dance that expresses some emotion or idea after which all others are mere copies.  We go shopping for the perfect shoes, gadget or tool.  We choose apples based on a ‘perfect’ apple that is ‘apple-like’.  We buy the best we can afford for a new baby to give them a perfect start in life.  The recent political cataclysms in the USA and Europe are, arguably, based on a desire to achieve some mythical state of nation perfection—‘make America/Britain great again’—where we can pursue all the ideals of what it is to be British, American, Italian, etc., unhindered by foreign (and, by definition, un-British, un-American, etc.) influences, cultures, legal systems and so on.  It is as if there is, somewhere deep in our being, a hazy and imprecise sense of perfection that we are trying to make real.  Religion for a long time picked up on this idea that life on earth is inevitably imperfect, involving suffering and pain as the manifestation of imperfection, but with the promise that in the future—after death or following some transformational event—we will experience perfect reality.  A. T. Still echoed this idea in his understanding of the body as potentially perfect because it was designed by God, the supreme architect.  As human beings on Earth, therefore, we experience an imperfect body that is prone to illness and disease, but if we strive to achieve perfection by ensuring proper structural alignment, we will know health and all will be well.

This view of reality as a hidden or unachievable ideal that we are forever striving to realise, was challenged (along with the authority of the church as the means of accessing this perfect reality) by what is familiarly described as the Enlightenment.  Through ‘natural philosophy’, figures such as Francis Bacon and Isaac Newton in the 18th Century argued that reality is what we experience around us and this reality can be mapped and defined through formulae and correlations based on observation through our senses, together with the tools that extend those senses.  The world outside our skins is just what it appears to be if we experience it in the correct way, where the ‘correct’ way is to subjugate our senses to our rationality. Our senses, as Descartes had argued, are subject to error and can’t be trusted to show us what things are really like as opposed to how they appear; but if we apply rational thought and sceptical analysis to those erroneous sensations we can uncover the real truth.

Natural philosophy morphed into what we now know as science where scientific knowledge is defined by the scientific method; that is, of subjecting mere experience to rational interrogation and making it into something better that can then be given the moniker ‘scientific’.  Only if the scientific method is followed can the findings from it be accepted as true, scientific, knowledge.  Reality, on this reading, is no longer some remote ideal that we sense imperfectly, but something that can be known with (scientific) confidence through appropriate, i.e., scientific, interrogation, experimentation and analysis.

The third phase of what we believe reality to be, started at the very end of the 19th and became stronger in the middle of the 20th Centuries.  There were two main influences: one was that of the German philosopher Immanuel Kant, who I’ll come to in a moment, and the other, a reaction against what was perceived as a quest (by science) to reduce everything to mechanism explained by mathematics.  I’m not going to say much about this second part, but refer you instead to Anne Harrington’s excellent book, ‘The Reenchantment of Science: Holism in Germany from Wilhelm II to Hitler’ in which she explains the almost romantic desire that motivated scientists, particularly biologists and doctors, to rethink what it is to be human.  Surely, they argued, we are more than mere puppets manipulated by the forces of nature and subject only to their powers?  They looked at the experiences of the 1st World War and the devastation of Europe as a clear demonstration of the awful power of inhuman machines if allowed to proceed unchecked.  Human culture, creativity and the values that characterise human being were in danger of being destroyed in the pursuit of power and dominance through de-humanising science.  What was needed was a science that could take proper account of these insensible but highly significant aspects for human being, not by eliminating science, but by questioning some of the assumptions on which it is based.

One of the people who motivated some of that thinking was Immanuel Kant who reconciled the works of two other philosophers: the rationalist, Gottfried Leibniz and empiricist, David Hume.  Rationalism is the view that a rational theory is a basic precondition for all knowledge, including knowledge about the external world.  It is only through having a rational account of what the world is like that it is possible to make sense of all the experiences we have as human beings.  We fit our experiences to our world-view.  Empiricism on the other hand, is the view that knowledge comes about through experiencing the world without preconceived ideas; allowing the experience to present itself to us for analysis to uncover the hidden theoretical rationale underlying it.

Until Kant, it was assumed that these two positions were opposite and irreconcilable.  You either interpreted the world according to a theoretical/metaphysical assumption that gave structure and meaning to those experiences, or you shaped the mind to conform to the reality of the external world through empirical observation.  Either the mind shapes the world or the world shapes the mind, but it can’t be both and there can’t be a middle position.

It seems to me that it is this centuries-old issue that underlies the problems with the cranial concept.  On one hand the ‘believers’ interpret their perception of cranial motion, etc., in accordance with a metaphysical understanding of what the body is and how it is structured and functions, while the sceptics argue that the empirical evidence, i.e., the objectively derived, measured experience of cranial motion and its effects, is either incompatible with or insufficient for developing a coherent theoretical account.  The lack of intersubjective reliability in respect to palpation findings, for example, means that no theoretical explanation can be identified.  Hence the impasse; rationalism and empiricism are incompatible.

The position that Kant took (and simplifying it) was that the human mind must be constituted in a certain way first for the external world to be made conscious to us in the way that it is.  In other words, there must be a possibility for knowing objects prior to the knowledge being gained from experience and being made real.  Kant termed this a priori knowledge; it isn’t something we can learn, rather it is a state of the human mind, something that is a precondition in order for us to become conscious of other things.  Examples of a priori knowledge are our mind’s capacity to sense space and time, together with concepts such as cause-effect and persistence, all issues that Hume had famously identified as non-deducible.  We assume a causal connection between the ball hitting the window and the window breaking; and that the house we go into when we get home from work is the same house that we left that morning; but neither the causal effect of the ball, nor the persistence of bricks and mortar can be derived, in a scientific way, from our sense experiences of them.  At best the relationships are mere correlations, a linear series of events that follow one another.

Kant termed these necessary preconditions ‘transcendental knowledge’, the knowledge, or more accurately the unconscious assumption, that there is space, time, causes, persistence etc., and it is these that enables us to experience the ‘phenomenal’ objects of the world in the way that we do; for them to become real to us.  Without a priori transcendental knowledge we cannot have knowledge of other aspects of the external world; the world, says Kant, cannot be known ‘as it is in itself’, there is no objective external reality that we simply have to observe and map.  Kant is therefore focusing not on external objects themselves as empiricism does, nor on abstract theories that are adopted (or not) by the rational mind to shape and unify our experiences as rationalism does, but on the given nature of the human mind as a mediator between inner consciousness and the external world.

The human mind is characterised by the fact that it possesses transcendental knowledge.  Our sense of reality, according to Kant, is derived from our minds’ being as they are with their transcendental ability to perceive and make sense of things in the world, whether objects or events.  We can only have ordinary knowledge, or be conscious of the external world as specific phenomena if the phenomena associated with such objects and events can be perceived by the human mind in accordance with its transcendental capacity.  This leads Kant to his dictum that, “Thoughts without content are empty, intuitions (perceptions) without concepts are blind.”

Transcendental knowledge then, is knowledge that enables us to make sense of the relationships between things; it helps us contextualise them.  We cannot know ‘the world as it is in itself’ as Kant said, but only through the means we have for perceiving it.  We have to come to it from a specific direction and that direction is dictated by our transcendental knowledge.  It also means that function (like causation) is transcendental knowledge, not knowledge that can be deduced from observation.

The point that I’m trying to make through this over-long-winded response to Monica’s original post is that we need to be clear what we are arguing about when we assume that what we feel when touching a patient must necessarily map what is ‘really there’.  To feel/palpate we necessarily require a priori knowledge that enables us to feel anything.  A new-born baby doesn’t feel objects with her hands in the sense that we feel with our hands.  Her mind must develop the transcendental knowledge that enables her to feel.  The point is that how we acquire that knowledge is individual.  It raises the question of whether the transcendental knowledge that enables us to feel, or see, or hear, or smell is identical for everyone or do we each produce a synthetic proposition (to use a Kantian term) each time we interact with external objects, i.e., produce a conscious awareness of a given object, that is different from other peoples’ awareness of the same object?  In other words, two people may feel the same knee, or look at the same sunset, or listen to the same sound, and  each experience the knee, sunset and sound differently.  If the object is clearly the same in each instance, the difference must be derived from the transcendental knowledge that is used to make it ‘real’ to us.

There is much more that could be said on this very important issue as it has implications, not just for cranial osteopathy and manual therapy in general, but for many other areas of life from referees and umpires making decisions in sport, our understanding of the role of ‘experience’ in all walks of like, to how we appreciate art and music and even how we interact with one another.  What it does mean though is that science itself and the belief that science is the way of viewing the world is just as much a human construct, framed by our transcendental knowledge, as are beliefs about cranial work.  This doesn’t make them equivalent or equal but it does mean that we need to go beneath the surface assumptions of both to explore what the transcendental knowledge is that structures both.  This is why philosophy and philosophy of science in particular is so important.  The whole area of phenomenology, which derives from Kantian thought, explores this issue in much greater detail.  It takes as its starting the point the question of how we experience, what must the world be like for us to experience it as we do and what does it mean to ‘be’ human what is the nature of being?  This is the more important question for those of us involved in healthcare.

One other philosopher who is worth looking at in respect to how we develop our transcendental knowledge, though he doesn’t refer to it in those terms, is Ludwig Wittgenstein.  In his final book, On Certainty, which is really a series of developing thoughts.  He argues that the certainty we experience and which we can’t doubt, such as ‘knowing’ that ‘this is my hand’, or ‘I feel cold’, comes from our doings in the world.  It is our physical engagement with and experience of the world that gives us the certainty to be able to continue to engage with it.  For more on this, look at:

TYREMAN, S. (2015) Trust and Truth: Uncertainty in Health Care Practice. J of Evaluation in Clinical Practice, 21, (3) 470-8.

WITTGENSTEIN, L. (1969) On Certainty,  Ed. Oxford, Blackwell Publishing.

If anyone has actually read as far as this, I’d be glad of your thoughts and comments.  This is a big issue not just for cranial osteopathy—which may or may not have validity—but for all manual medicine and much else beside.  Basically, what I am saying is that we need to be just as sceptical about the claims of science, i.e., subject it to the same searching questions about the basis of its claims; it is just as much a human construction as are healthcare models.  In the meantime, the question I think we should be asking is whether by touch, sight or sound, do we assume we are mapping a ‘real world’ of body, or is it some more subtle and complex human interaction that we are engaged in?

Stephen Tyreman PhD MA DO