Detailed guides to painful problems, treatments & more

The ultimate paradox of pain and therapy

 •  • by Paul Ingraham
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Weekly nuggets of pain science news and insight, usually 100-300 words, with the occasional longer post. The blog is the “director’s commentary” on the core content of a library of major articles and books about common painful problems and popular treatments. See the blog archives or updates for the whole site.

One of my colleagues shared an example of particularly bad, overconfident physical therapy on Facebook (doesn’t matter what, there’s a zillion of ‘em). Sigurd Mikkelsen, a Norwegian physiotherapist of my acquaintance, composed this beautiful comment, which would apply to any claim of miraculous treatment efficacy:

The ultimate paradox of pain and therapy: the problem is not that nothing works. The problem is ANYTHING can work … usually just long enough for someone to empty their wallet!”

That’s pure &#@!% poetry right there. Bloody brilliant. Dozens of us therapy wonks liked it. Adam Meakins made this picture out of it:

What but does it MEAN?

But I’d like to elaborate a bit for my readers, so here’s the wordier version …

These days it seems like science is telling us that “nothing works”: every study of practically every treatment method seems to be bad news. But there’s this maddening contradiction between all that bad news and what professionals and patients are routinely experiencing, which is that almost anything seems to work, at least at first. This glaring disconnect between clinical experience and science has caused many arguments. But as the science creeps forward, the key to the puzzle has been coming into focus …

It’s not quite that “nothing works,” it’s that anything really can work but usually only temporarily, because that is the nature of pain. No matter what’s causing it, pain can be tuned by any comforting and reassuring experience, and good therapists can cleverly fiddle with ten thousand variables to create that experience for their clients, creating potent illusions of efficacy... but, in most cases, the benefits don’t last long, or they last just long enough for natural recovery to assert itself, creating a strong impression of a true cure. Generations of therapists have made a living by “amusing the patient while nature cures the disease,” creating an endless stream of elaborate treatment rationales, entire methods of therapy, commercial empires, all based on the idea that they are “fixing” something, when in fact 95% of it is just theatrical, irrelevant variations on the same basic principle. They almost all work a little bit for a while for the same reason, but everyone’s selling a different reason. Therapists really are helping people... but not the way most of them think.

Sigurd condensed all that down to an artful handful of words. My own explanation, much wordier, may be helpful to many people. But boy did he nail it! Thanks, Sigurd.

I asked Sigurd if I had translated his comment well. Here’s his reply, worthwhile in its own right:

That is fantastic, Paul! Thanks a lot for elaborating on the content of that paradox, and you’re of course spot on. I love how you put it directly into its daily-life setting — that there is a contradiction between that constant bullying by evidence and what therapists/patients experience. What happens then is again succinctly summarized by Voltaire in that quote — the art of medicine/therapy is amusing the patient while nature cures the disease. The twist here, is that this will happen whether or not the therapist or the patient knows that they’re in that exact theatrical play.

From Humphrey and Skoyles;

”When people recover from illness under the influence of fake treatments, they must of course in reality be healing themselves. But if and when people have the capacity to heal themselves by their own efforts, why do they not simply get on with it? Why ever should they wait for third-party permission — from the shaman or the sugar pill — to heal themselves?”

Anyway, the dilemma here is - so what? Should I just go open up a coffee shop instead, “because nothing matters and nothing is true anymore”, or is there another way?

To quote (since we’re already in that quoty’ mood) Peter O’Sullivan:

“...we have to change what we value in a consultation. The advice we give and the strategies we empower people with are maybe way more important than the (manual) techniques we apply.”

“...but I’m in there with my hands. Because touch is a powerful communication tool that can guide people to safely move. The (manual) skills are very useful, but the thinking is different.”

Since anything can work, we need to take ethical and sustainable decisions about how to use manual touch, for what goal. It is then much more about becoming a manual “strategist” or a “process manager” about the processes and phases ahead in a therapeutic pathway. And that I find hugely rewarding.