The Brain, the Mind and the Osteopath
Originally published Osteopathy Today April 2011 and in The Sutherland Cranial magazine Summer 2011
“The human brain is a marriage of two minds”. “Each half of a mature brain has its own strengths and weaknesses; its own way of processing information and its own special skills. They might even exist in two distinct realms of consciousness; two individuals effectively in one skull.”
Quote and Picture from Mapping the Mind by Rita Carter Ch 2
Introduction
The osteopathic profession is a hugely diverse group of practitioners operating under the single title of Osteopath. The purpose of this paper is to analyse why individuals and groups spread out from a fairly uniform undergraduate training to such a broad spectrum of approaches. In examining the left and right hemispheres of the brain and their functions it is possible to postulate how the tendency of one or other side of the brain to dominate influences the way an osteopath thinks and works, at an individual level, and who assumes authority and makes the decisions on behalf of the osteopathic profession, at a collective level.
This author highlights the current chosen strategy for the survival, health, and development of the osteopathic profession in the UK today and challenges it to evolve.
A major strategy for the ongoing survival of our profession revolves around research and evidence based science. It’s a good strategy but it shouldn’t stand alone. It is too biased towards a singular mind set as this article will explore.
This author sees a need for three further strategies to satisfy the profession as a whole.
1. DEVELOP A MORE COMPREHENSIVE AND COHESIVE UK OSTEOPATHIC PROFESSION.
2. COMPARE OUR UK UNDERGRADUATE TEACHING FORMAT TO THAT TAUGHT IN EUROPE AND CONSIDER MAKING SOME CHANGES BY TEACHING A BROADER CURRICULUM.
3. DEVELOP A CLEAR AND UNIFIED OSTEOPATHIC IDENTITY BASED PROUDLY UPON OUR OSTEOPATHIC PHILOSOPHY OF HEALTH.
This should give individual practitioners a sense of “belonging” to the profession as only by “belonging” can any of them develop and enjoy an individual identity in any stable sense. Ref: Modernity and Self Identity – Anthony Giddens
These suggestions are based on observing the osteopathic profession from a varied selection of professional roles in both the UK and abroad that this author has found herself in over time. This article was inspired by a book read by the author: The Master and his Emissary - the Divided Brain and the Making of the Western World by Iain McGilchrist
Iain McGilchrist is an experienced consultant psychiatrist, a philosopher and an Oxford University lecturer. In this book he explains the characteristic features of the two sides of the brain, backed up by both scientific research and philosophical references. He describes how “the left and right hemispheres coexist together on a daily basis but have a fundamentally different set of values and priorities.”(p5) The theme of the book describes how the left side of the brain is coming to seriously dominate our western world and ultimately defining the world it dominates and taking it on a course of its own self destruction. “An increasingly mechanistic, fragmented, decontextualised world, marked by unwarranted optimism mixed with paranoia and a feeling of emptiness has come about due to the unopposed action of a dysfunctional left hemisphere.” (p6)
This author has found herself applying this pessimistic theory to the UK osteopathic profession.
The Osteopathic Divide
There is an ongoing and ever-growing concern and division within the osteopathic profession that our osteopathic philosophy of health is being replaced by an allopathic model of diagnosis and treatment that requires evidence-based science in order to justify its professional existence and ensure its survival. The divide evolves from two very different mind sets.
One mind set will live and practice by their osteopathic principles grounded in a philosophy of health as described by the founder of Osteopathy – A. T. Still. They will apply these principles to each and every patient, irrespective of the patients’ signs and symptoms and irrespective of the practitioners’ technical approach of choice. The osteopath will rely on the patients’ inherent self regulating and self healing mechanism to take charge of the repair process. They will be unable to focus on a single symptom or any tissue in isolation as they see the body as a unit. In some mind sets, that unit goes beyond the soma to include mind and spirit. Their primary aim is to identify where there is lack of motion (voluntary or involuntary) hindering fluid dynamics and the ensuing predisposition to disease. The dynamic and reciprocal relationship between structure and function will promote an unpredictable, experiential and unique treatment approach and response in each individual patient.
The alternative mind set is to rationalise, justify and analyse what it is an osteopaths does, why they do it and how and whether it works. The
tissue-causing symptom is of prime importance in understanding what is wrong with the patient and how the patient must be treated. In that way a diagnosis and a prognosis can be formulated, a treatment can be planned, a letter can be written to the GP and perhaps a contribution can be made to an ongoing clinical trial on whether osteopathy is effective in treating that particular ailment.
The divided brain concept goes a long way towards explaining why we have such opposing mind sets, and the broad spectrum that sits between them, existing within our single osteopathic profession.
The Divided Brain
1. Fields of Attention
The difference between the two hemispheres lies primarily in the type of attention that they give to the world.
- The right hemisphere demonstrates a broad, flexible and global level of attention. It alone deals with peripheral vision and receives and responds to sensory information from both left and right visual fields. In evolutionary terms this level of attention and its sustainability is vital in constantly being on the lookout for predators and being able to place oneself within the context of the world around us. The outcome of this profuse and diffusely-organised attention is that the right hemisphere is able to construct a richly diverse 3D world in space.
- The left hemisphere is dominant for local, narrowly-focused attention. It attends to the tiny proportion of our visual field that actually comes into focus. It excels in precision and detail. It sees only part objects, and reconstructs them to form a whole. The outcome of this focused attention results in the left hemispheres ability to finely discriminate, to categorise and to analyse using linear and logical reasoning.1
Picture from Mapping the Mind by Rita Carter Chapter 2
A good way of demonstrating the above is seen in subjects with unilateral brain damage. They show complementary deficits in their drawing skills depending on which hemisphere has been compromised. Those with right hemisphere damage, relying therefore on the left hemisphere, can lose overall coherence and integration. They identify the elements but struggle to assemble them into recognisable forms. Those with left hemisphere damage, therefore relying on their right hemisphere, exhibit relative poverty of detail but present the image based on the shape of the whole.
How is this relevant to Osteopathic Observation?
As individual practitioners we collectively view our patients across the whole spectrum of attention. Some see the pattern and shape of a whole person in relation to and within the context of their environment. Others see detail and focus on specific parts or localities of the body. Of course there is generally an attempt to do both but individuals naturally excel in different parts of the spectrum. Over the last 25-30 years, the tendency of the undergraduate schools (some more than others), has been to draw the undergraduate students towards the left brain view. This coincides with the writing and the popularity of the” Pathological Sieve” as described in ‘Osteopathic Diagnosis’ by Audrey Smith BSO 1984. Students with a dominant right brain have struggled in this environment and been judged harshly alongside genuinely poor students.
As a Final Clinical Competence (FCC) examiner this author has regularly witnessed students forced into differentially diagnosing between lesions of the Sacroililac, Lumbosacral or L4/5 joints; a facet, a disc or a ligament. They have struggled horribly as their interest lay in the shape of the curves, the pattern of forces, the gross dynamics of motion, the heavy shoulders of a sad bereaved partner - anything but the tissue-causing symptom.
Historically, some osteopathic colleges have tried to preserve this broader and more diffuse osteopathic approach, which I will call The Flavour of Osteopathy. At best, these colleges have been criticised and given guidance on how to change for the better for subsequent FCC exams. At worst, they have failed the validation criteria and have been closed down. An example would be the Wernham College of Osteopaths. This author had the great pleasure of clinic tutoring some of those students that moved across to the BSO when their college was closed down and learnt a great deal from their broad outlook and approach to their patients.
This author has frequently heard the comment that a student was weak at undergraduate level and so ended up practising cranial osteopathy. Some readers may be nodding their heads in agreement at this statement but others will regard it as truly bigoted and requiring some self reflection by the head nodders.
Perhaps it is the cranial and more classically orientated osteopaths that evolve from the students that see the patterns, shape and whole in context? The right-brain dominants. One group looks at involuntary motion, the other looks at voluntary motion: one uses indirect techniques, the other, direct techniques. However they both apply each and every one of their osteopathic principles to each and every patient that they see. As right-brain dominants they thrive therapeutically in a dynamic changing world of experience. Experience – not Facts. It is the current undergraduate programme that is simply not designed for them. It does not accommodate their way of observing, thinking or working.
The Divided Brain
2. Flexibility
The flexibility of the right hemisphere is seen in its attention to novel experiences, learning new skills and receiving new information. In a problem solving situation the right brain will present an array of different solutions. It recognises and embraces the importance of ambiguity, is prepared to shift and is comfortable with uncertainty. The left hemisphere deals with what we already know and is efficient in routine situations. Typically, the left side will take a single solution that seems best to fit what it already knows and latches onto it. The left hemisphere needs certainty and needs to be right. However the left hemisphere lacks the ability to discriminate unique cases from generalised categories and demonstrates a tendency to confabulate.2
How is this relevant to Osteopathic Diagnosis and Treatment?
An editor in one of the osteopathic research journals made a suggestion, some time ago, that it was high time that the profession offered prescriptive treatments for some of the more common complaints - allopathic medicine in a nutshell! Whoever agrees with this statement can quite firmly presume that they are a left-brain dominant. A condition would be named, such as a subacromial bursitis. There would be a number of techniques the practitioner would run through, perhaps in a certain order.
Others would view this statement with trepidation, to put it mildly. The right-brain dominant would question how you could possibly have a single approach to anything. They may acknowledge the subacromial bursitis (depending on how far right they go in the brain department), but see it as the ‘tip of an iceberg’ and it is the ‘iceberg’ in its totality that draws their attention. They might see a heavy fall onto the sacrum creating an ascending strain pattern up through latissimus dorsi; a chest infection on top of an asthmatic posture; a historic tumble onto an extended arm; a bereavement – perhaps the loss of a child; recent dental work that has altered the occlusion...the list is endless and the items of that list exist in infinite combinations. How could there possibly be a single prescriptive treatment plan for a subacromial bursitis?
Who is right and who is wrong? Far more relevantly - who is to say who is right and who is wrong?
Divided Brain
3. Do they listen to each other?
The right hemisphere serves the peripheral vision and both visual fields and the left hemisphere is concerned with more focal vision and serves the right visual field only. Following a right-sided stroke, the left hemisphere’s concern with only the right side of the body can lead to the condition of “hemineglect”. The left half of the body and everything in the left part of the visual field, the side served by the right hemisphere, fails to materialise. Even though they are able to see them they may fail to acknowledge anyone standing on the left; they may not wash, shave or dress on the left. They may even regard their left leg or left arm as alien.
The left hemisphere fails to acknowledge the existence of the side that their brain does not attend to.3
Where we regard the corpus callosum as being a major communicating pathway between left and right hemispheres, it turns out that a large percentage of fibres running through it are inhibitory. Predominantly, they serve to inhibit information from the right hemisphere moving across to the left.4
“The more flexible style of the right hemisphere is evidenced not just in its own preferences but also at the “meta” level in the fact that it can also use the left hemisphere’s preferred style whereas the left hemisphere cannot use the rights. The left hemisphere actually inhibits the breadth of attention that the right hemisphere brings to bear”. Iain McGilchrist (p41)
Picture from Mapping the Mind Rita Carter Ch 2
How does this explain divisions and intolerances within our profession?
The common assumption is that it is those that deal with “factual knowledge” are correct and assume a superiority over others who put more emphasis “experiential knowledge.” A perfect example would be Steve Hartman, Dept of Anatomy, College of Osteopathic Medicine, University of New England, Maine, USA discussing his views on “cranial osteopathy” in a letter published in IJOM, 10(2007),pp.80-2. Here are some extracts from that letter: ....”For cranial osteopathy, no evidence supports a biological mechanism, diagnostic reliability or efficacy. In this letter, I will explain why this failed subspeciality of osteopathy persists....” “...Over the past century, prescientific medicine has been recognized for what it was: a millennia long history of magical thinking, guesswork and failure”.... “.....Not just limited scientific evidence for efficacy but none. Not just limited diagnostic reliability but none. Under the circumstances, ongoing contentions of efficacy are extraordinary claims that should be considered seriously only if accompanied by extraordinary proof. Until such is forthcoming, other sceptics and I will be obliged to adhere to the paraphrase of an old aphorism: If it walks like a failed technique and quacks like a failed technique, probably it is a failed technique”.
As we already know, the left hemisphere is comprehensively unaware of what it is unaware. Interestingly, it is the left hemisphere that expresses angry outbursts and owns the faculty of speech, courtesy of Broca’s area courtesy of the left Frontal lobe.
The right hemisphere specialises in non verbal communication. 5,6,7
The Divided Brain
4. Biomechanic or Biodynamic
The left hemisphere has an affinity for manmade inventions, the right hemisphere for what exists before, after and beyond us, namely nature.8 The left brain is concerned with abstract categories and types; the right brain is concerned with uniqueness and individuality.9 The left brain understands the explicit and the literal and the right brain processes the non literal aspects of language – implied meaning, humour - where everything is seen in context.10
Right and left hemispheres see the body in very different ways. The left sees the body as something from which we are relatively detached and as an assemblage of parts. The right senses the body as something “we live” and that is part of our identity.11
The right side has greater connections with and therefore a closer influence over our limbic system (our emotional centres) and our sympathetic nervous system. This is relevant in terms of evolution in determining our state of arousal in response to the new, the uncertain and the emotionally demanding. The left, in contrast, has a closer influence over our parasympathetic nervous system and its association with the familiar, unchallenging and emotionally neutral situations.12
How does this influence our description of what we “diagnose” and what we “do”?
A medicalised diagnosis, treatment plan and prognosis will be harder for a right-brained dominant practitioner to describe clearly in their clinical notes. It is too linear, too fixed and without a ‘living’ dimension. They will find it harder to convey their ‘experience’ as opposed to the left brain dominant practitioner who describe the ‘facts’ as they see them and the ‘actions’ as they performed them.
In terms of research the right-brain dominant believes life never keeps still long enough to measure anything important; each individual is unique and therefore comparison is pointless. The format of any research based questionnaires rarely appeals to them due to their inherent aversion to categorising, singular responses and linear grading. They may start to fill in a questionnaire with good intentions but it will inevitably end up in the bin as they sense the increasing hopelessness of the task. I would suggest that any results emerging from such research, in any field of life, revolves around a left brain perspective – IJOM, 2010, 13, p169
The Divided Brain
5. Who assumes authority?
Remember that the left brain holds the faculty of speech but the right brain is predominantly silent. The left brain speaks but at the same time it cannot see what it cannot see. In other words it speaks, full of self conviction, but of a narrow tale or only part of the story.
The right brain is not articulate but it sees everything as it stands in context with the rest of the world; the patterns, the connections, the relevance, the humour and the sadness. However his or her views are rarely, if ever, acknowledged or understood by anyone in authority.
It is, generally speaking, only through speech that we assume any position of authority.
One Osteopathic Profession – Two Brains
The members of our profession, as in any population, will range from the truly left- brain dominants to the truly right-brain dominants – the two ends of a Bell curve distribution. Take the example of a ‘facet, ligament or disc type’ or ‘biomechanic’ practitioner busily counting, measuring and grading anything that he can versus a ‘breath of life’ or ‘biodynamic’ practitioner who, to any onlookers, can appear to be utterly passive, vague and, worst case scenario, starts talking about God. The ‘biodynamic’ practitioner will understand where the ‘biomechanic’ is coming from, although he will regard his opinion as simplistic and futile. The ‘biomechanic’ will not and cannot understand where the ‘biodynamic practitioner’ is coming from. Honestly – they are never going to get on.
However, the majority of our profession sit in the middle of a Bell curve distribution– some of us tending towards the left, some of us tending towards the right, but ultimately we are, most of us, of two minds. It is this group, the vast majority of osteopaths, that need to be responsible for bringing cohesion to our profession and the way we do that is to understand and therefore respect how one another think and work.
The best way to understand anything is experiential.
This author teaches at an osteopathic college in Europe where the students embark on a six-year part time Masters in Osteopathy. They have to be qualified doctors or physiotherapists to be allowed on the course. Remarkably about 15% of the students are medical doctors, some at consultant level. On questioning their motives for embarking on the course the recurrent theme is their frustration at prescriptive based medicine and the desire to acquire some more intuitive skills.
The six-year course places equal emphasis on the structural/biomechanical approach, the cranial approach – based along similar lines as the nine-modular Sutherland Cranial College (SCC) course - and the visceral approach. All students are examined in each of the three disciplines before they can call themselves an osteopath.
What is the outcome of this course design?
All the qualified osteopaths appreciate the depth of knowledge acquired and the work involved to become an effective and knowledgeable visceral practitioner, an effective and knowledgeable cranial practitioner and an effective and knowledgeable structural practitioner.
Nobody, but nobody, can call themselves a cranial osteopath or a visceral osteopath without having completed a thorough and complete education programme. Interestingly, these practitioners do not even think to differentiate between the three disciplines.
The course, by nature of all the practical work that they do alongside their theory, is experiential. All those initially cynical left brainers grapple and struggle with the fact that they personally palpate, personally see and personally experience the impact of working with the IVM over five years. Without fail, they realise there is far more to it than they ever could have assumed – at the same time as appreciating that it is nearly impossible to rationalise, categorise or verbalise.
Importantly, those that choose not to go on and work with the IVM do not have to limit their practise to C1 and below. They have a thorough understanding of the relevance and the importance of the development and structure of the mid face and breathing. They can discuss the influence of mandibular development and occlusion on posture; plagiocephaly and scoliosis; the temporal bone and inner ear dysfunction. They can differentiate between a neurological and muscular squint and diagnose the cranial nerve implicated. They understand about pituitary function and adnexa; the continuity and responsiveness of fascia and how that relates to Still’s principle of the body as a whole. As for their applied anatomy of the cranium and their listening/ palpatory skills.....................................The 6th year is dedicated to a research project in order to achieve their masters.
Note the diversity of research projects going on in Europe listed in the IJOM.
Flavour with Content
Would it work if we had a similar undergraduate programme in the UK?
In which case would the UK osteopathic profession start to attract the allopathic practitioners and invite them into their world rather than the osteopaths trying to fit into a medics world? Would this restore the profession's autonomy and the pride that goes with it? A pride that is prominent amongst European colleagues and students and, most importantly, the patients know it.
Back in the UK....What percentage of the editors and contributors to the IJOM, Osteopathy Today and The Osteopath, the employees and elective council of the GOsC, the BOA and, finally, the Principals of our Schools of Osteopathy, could be classified as left brain dominant? Certainly not all, but this author would guess a large percentage.
As a profession, osteopaths need the left brain dominants. They give a voice, a professional framework, they drive the profession forward in this aggressively modern world that demands ‘registration,’ ’validation’ ,’accreditation’, ‘process’, ‘definitions’ and ‘measurements’. The obstacles that need to be negotiated, the hoops that need to be jumped through, the hurdles that are put in the way – most osteopaths shy well away from. Where would the profession be without those prepared to take on such roles within it? The UK osteopathic schools are financially viable but have retained their independence, the profession has a degree of respectability and security –they have been rigorous and complex tasks to accomplish. The homoeopathic profession did not achieve registration as members in their profession resisted it and they are paying a heavy price indeed. However, the left brain dominant heroes need to appreciate that they represent just one end of the Bell Curve that encompasses their whole profession. A profession, I would guess, that actually holds more than the population’s average share of right-brain dominants.
So, how does the profession move towards cohesion and mutual understanding and respect?
For the extreme left brain dominants it would be very helpful if they could shut out the angry outbursts of their left frontals. It does not help cohesion. “ If they see the right brain dominants as full of uncertainty, then they need to dwell on the thought that the more certain we become of something the less we see. They need to appreciate that their talent for division, for clearly seeing parts, is of staggering importance – second only to a capacity to transcend it in order to see the whole ".... ...."The structure of the periodic table of the elements came to Mendeleyev in a dream"... ...."Great mathematical thinking takes place in 3 dimensions and is therefore right hemisphere mediated”.... ....." Einstein is quoted as saying ‘the words or the language as they are written or spoken do not seem to play any role in the mechanism of my thought’.” McGilchrist (p107)
It is a common and ignorant misconception by the 'left brainers' that 'right-brain dominant' stands for 'not knowing'.
The 'right brainers' need to find some way of becoming more integral and vocal so that others are aware of how many are out there. 'Right brainers tend talk to each other but not to outsiders. They become tight knit and exclusive – inevitably. However they can write. The SCC magazine has recently had some thought provoking, intelligent, uplifting articles full of constructive thoughts and broad ideas – often talking about research from other fields and always talking about osteopathy from a pure principle perspective.
They need to broadcast to the whole profession - but be careful. Do not alienate others by talking about the IVM and the breath of life to practitioners who do not work with these tools. The unchartered anatomy, the embryology, the paediatrics, philosophy of health and patient presentations are all common language full of educating, interesting and entertaining osteopathic content.
The 'extreme right brainers' are generally a world unto themselves; casting no judgement on others, imposing no standards; quietly doing what they do. The problem here can lie in public perception and how they represent the osteopathic profession, particularly those working with the IVM. They often struggle to explain to the patient what it is they are doing and how it works. Assuming that the treatment is beneficially therapeutic the patient then often walks away with the impression that their osteopath has healing hands.
In truth they are hands that have acquired a skill over many years of practice. The way they apply their skill is through the three dimensional way in which they perceive their patient in context with the environment that they inhabit. If they cannot explain what they do to the patient and how it works then it is the responsibility of the right-brain dominant osteopath to, first and foremost, value experience before relying heavily on intuition, to be inherently wired to work that way and to be effective at what they do. Otherwise they must find another way for the sake, in the context of this article, of other osteopaths. There is no room for fakes, self delusion or gurus.
As for those that move fluently from left to right brain, right to left brain, verbal but three dimensional - for those who can deliver flavour with content, please let the profession hear you. You should be music to their ears.
“Reason along with imagination is the most precious thing we owe to the working together of the two hemispheres.” McGilchrist (p7)
Ultimately, we are all of two minds.
The Future
Darwin suggested that survival does not rely on those that are the strongest or the fittest, but those that are best at adapting to change.
The profession should be making a collective decision about which direction those changes should take place. The predictable argument would be to continue along the line that is currently being tread. This certainly allows osteopaths to fit into the conventional and modern way of doing things. However there are rumblings everywhere if one knows where to look and to listen. The obsessive way in which the western world wants to factualise, quantify and reduce everything to statistical analysis is being questioned and criticised in many corners. Clever people are talking (.... the TED lectures, The Schumaker College.....) of the devaluation of intuitive skills, quality, common sense and the inherent intelligence of nature and its forces.
The Principles of Osteopathy are pure common sense. They require osteopaths to qualitatively assess their patients and use intuitive skills to apply a treatment that will remove obstacles to their health. The profession would be well placed to get a head start on the “rumblings” if this is so.
In Summary
_The need for research is undeniable, however that research needs to be based on osteopathy and its principles as a guiding force with less emphasis on manual therapy and its effectiveness in treating allopathically diagnosed conditions. (There is a limited rationale to competing with sports therapists, physiotherapists, a chiropractors, or highly trained pilates instructors - there is far more rationale to distinguishing ourselves as apart from them by pointing out that we follow a different philosophy of health.)
There is a need to incorporate the simple Principles of Osteopathy into all teaching at undergraduate level, be it clinical studies, technique classes, anatomy, neurology, pathology.. This has been neglected over the decades creating a profession lacking foundation, identity, pride and a common understanding of what it is they are trying to achieve in their osteopathic treatment of the patient . A module in Osteopathic Concepts is not the answer. Every member of the teaching staff should be living those principles. In truth, when Principles of Osteopathy are applied in their simplicity they, in themselves, provide a sound rationale to a comprehensive patient approach and absolve the need to “scientise.” Insecurities about what an osteopath is doing and why he is doing it evaporate.
The profession needs to ensure all osteopaths practising cranially and viscerally are fully (not partially...) educated in these fields of osteopathy by incorporating them wholeheartedly into the undergraduate programme. The UK profession is currently risking standards. In doing so a more cohesive and mutually respectful UK osteopathic society will evolve, at the same time as hugely increasing the diversity of patients that they can help.
The profession needs to embrace the diversity of brain types encouraged into our profession, at student entry level, through their passage of education and after they have qualified. All great industries, corporations, organisations go out of their way to make sure that their businesses have the correct balance of left and right brainers. The UK osteopathic world has focused in on those who attend to their left hemispheres and the schooling, the journals and the conferences reflect this. It is creating its own environment exactly as Ian McGilchrist describes: “The kind of attention that we pay to something or someone changes the nature of that something or someone that we attend to.”
The Europeans have been moving the other way. The doctors and physiotherapists who are fed up with listening to the prescriptive side of life have moved across and are opening up their senses. As a profession they are thriving, enthusiastic, excited and positive.
Note the BOA chief executives commentary in Osteopathy Today, Nov 2010, is embracing the prospect of bringing Europe into line with the UK in terms of validation and standards.
Question : Does that make your (A) head nod or (B) heart sink?
A selective list from the extensive bibliography of Iain McGilchrist can be found on the BOA website.
Recommended Reading:
The Master and his Emmissary, The Divided Brain and Making of the Modern World Iain McGilchrist
Mapping the Mind Rita Carter
Cognitive Neuroscience, The Biology of the Mind – Michael S. Gazzaniga, Richard B. Ivry, George R. Mangun
Osteopathic Diagnosis Audrey Smith BSO
The Tyranny of Numbers David Boyle
Modernity and Self Identity – Anthony Giddens
Teach us to sit still, a sceptics guide to health and healing – Nick Parks
www.ted/jillboltetailor.com – a fascinating talk from a neuroscientist who suffered a left sided stroke and watched what happened from the ‘inside’.
www.ted/kenrobinson.com -another fascinating talk about school education, but you can apply his philosophy to osteopathic education
© Copyright - All rights reserved by Joanna Wildy 2010
3. Do they listen to each other?
The right hemisphere serves the peripheral vision and both visual fields and the left hemisphere is concerned with more focal vision and serves the right visual field only. Following a right-sided stroke, the left hemisphere’s concern with only the right side of the body can lead to the condition of “hemineglect”. The left half of the body and everything in the left part of the visual field, the side served by the right hemisphere, fails to materialise. Even though they are able to see them they may fail to acknowledge anyone standing on the left; they may not wash, shave or dress on the left. They may even regard their left leg or left arm as alien.
The left hemisphere fails to acknowledge the existence of the side that their brain does not attend to.3
Where we regard the corpus callosum as being a major communicating pathway between left and right hemispheres, it turns out that a large percentage of fibres running through it are inhibitory. Predominantly, they serve to inhibit information from the right hemisphere moving across to the left.4
“The more flexible style of the right hemisphere is evidenced not just in its own preferences but also at the “meta” level in the fact that it can also use the left hemisphere’s preferred style whereas the left hemisphere cannot use the rights. The left hemisphere actually inhibits the breadth of attention that the right hemisphere brings to bear”. Iain McGilchrist (p41)
Picture from Mapping the Mind Rita Carter Ch 2
How does this explain divisions and intolerances within our profession?
The common assumption is that it is those that deal with “factual knowledge” are correct and assume a superiority over others who put more emphasis “experiential knowledge.” A perfect example would be Steve Hartman, Dept of Anatomy, College of Osteopathic Medicine, University of New England, Maine, USA discussing his views on “cranial osteopathy” in a letter published in IJOM, 10(2007),pp.80-2. Here are some extracts from that letter: ....”For cranial osteopathy, no evidence supports a biological mechanism, diagnostic reliability or efficacy. In this letter, I will explain why this failed subspeciality of osteopathy persists....” “...Over the past century, prescientific medicine has been recognized for what it was: a millennia long history of magical thinking, guesswork and failure”.... “.....Not just limited scientific evidence for efficacy but none. Not just limited diagnostic reliability but none. Under the circumstances, ongoing contentions of efficacy are extraordinary claims that should be considered seriously only if accompanied by extraordinary proof. Until such is forthcoming, other sceptics and I will be obliged to adhere to the paraphrase of an old aphorism: If it walks like a failed technique and quacks like a failed technique, probably it is a failed technique”.
As we already know, the left hemisphere is comprehensively unaware of what it is unaware. Interestingly, it is the left hemisphere that expresses angry outbursts and owns the faculty of speech, courtesy of Broca’s area courtesy of the left Frontal lobe.
The right hemisphere specialises in non verbal communication. 5,6,7
The Divided Brain
4. Biomechanic or Biodynamic
The left hemisphere has an affinity for manmade inventions, the right hemisphere for what exists before, after and beyond us, namely nature.8 The left brain is concerned with abstract categories and types; the right brain is concerned with uniqueness and individuality.9 The left brain understands the explicit and the literal and the right brain processes the non literal aspects of language – implied meaning, humour - where everything is seen in context.10
Right and left hemispheres see the body in very different ways. The left sees the body as something from which we are relatively detached and as an assemblage of parts. The right senses the body as something “we live” and that is part of our identity.11
The right side has greater connections with and therefore a closer influence over our limbic system (our emotional centres) and our sympathetic nervous system. This is relevant in terms of evolution in determining our state of arousal in response to the new, the uncertain and the emotionally demanding. The left, in contrast, has a closer influence over our parasympathetic nervous system and its association with the familiar, unchallenging and emotionally neutral situations.12
How does this influence our description of what we “diagnose” and what we “do”?
A medicalised diagnosis, treatment plan and prognosis will be harder for a right-brained dominant practitioner to describe clearly in their clinical notes. It is too linear, too fixed and without a ‘living’ dimension. They will find it harder to convey their ‘experience’ as opposed to the left brain dominant practitioner who describe the ‘facts’ as they see them and the ‘actions’ as they performed them.
In terms of research the right-brain dominant believes life never keeps still long enough to measure anything important; each individual is unique and therefore comparison is pointless. The format of any research based questionnaires rarely appeals to them due to their inherent aversion to categorising, singular responses and linear grading. They may start to fill in a questionnaire with good intentions but it will inevitably end up in the bin as they sense the increasing hopelessness of the task. I would suggest that any results emerging from such research, in any field of life, revolves around a left brain perspective – IJOM, 2010, 13, p169
The Divided Brain
5. Who assumes authority?
Remember that the left brain holds the faculty of speech but the right brain is predominantly silent. The left brain speaks but at the same time it cannot see what it cannot see. In other words it speaks, full of self conviction, but of a narrow tale or only part of the story.
The right brain is not articulate but it sees everything as it stands in context with the rest of the world; the patterns, the connections, the relevance, the humour and the sadness. However his or her views are rarely, if ever, acknowledged or understood by anyone in authority.
It is, generally speaking, only through speech that we assume any position of authority.
One Osteopathic Profession – Two Brains
The members of our profession, as in any population, will range from the truly left- brain dominants to the truly right-brain dominants – the two ends of a Bell curve distribution. Take the example of a ‘facet, ligament or disc type’ or ‘biomechanic’ practitioner busily counting, measuring and grading anything that he can versus a ‘breath of life’ or ‘biodynamic’ practitioner who, to any onlookers, can appear to be utterly passive, vague and, worst case scenario, starts talking about God. The ‘biodynamic’ practitioner will understand where the ‘biomechanic’ is coming from, although he will regard his opinion as simplistic and futile. The ‘biomechanic’ will not and cannot understand where the ‘biodynamic practitioner’ is coming from. Honestly – they are never going to get on.
However, the majority of our profession sit in the middle of a Bell curve distribution– some of us tending towards the left, some of us tending towards the right, but ultimately we are, most of us, of two minds. It is this group, the vast majority of osteopaths, that need to be responsible for bringing cohesion to our profession and the way we do that is to understand and therefore respect how one another think and work.
The best way to understand anything is experiential.
This author teaches at an osteopathic college in Europe where the students embark on a six-year part time Masters in Osteopathy. They have to be qualified doctors or physiotherapists to be allowed on the course. Remarkably about 15% of the students are medical doctors, some at consultant level. On questioning their motives for embarking on the course the recurrent theme is their frustration at prescriptive based medicine and the desire to acquire some more intuitive skills.
The six-year course places equal emphasis on the structural/biomechanical approach, the cranial approach – based along similar lines as the nine-modular Sutherland Cranial College (SCC) course - and the visceral approach. All students are examined in each of the three disciplines before they can call themselves an osteopath.
What is the outcome of this course design?
All the qualified osteopaths appreciate the depth of knowledge acquired and the work involved to become an effective and knowledgeable visceral practitioner, an effective and knowledgeable cranial practitioner and an effective and knowledgeable structural practitioner.
Nobody, but nobody, can call themselves a cranial osteopath or a visceral osteopath without having completed a thorough and complete education programme. Interestingly, these practitioners do not even think to differentiate between the three disciplines.
The course, by nature of all the practical work that they do alongside their theory, is experiential. All those initially cynical left brainers grapple and struggle with the fact that they personally palpate, personally see and personally experience the impact of working with the IVM over five years. Without fail, they realise there is far more to it than they ever could have assumed – at the same time as appreciating that it is nearly impossible to rationalise, categorise or verbalise.
Importantly, those that choose not to go on and work with the IVM do not have to limit their practise to C1 and below. They have a thorough understanding of the relevance and the importance of the development and structure of the mid face and breathing. They can discuss the influence of mandibular development and occlusion on posture; plagiocephaly and scoliosis; the temporal bone and inner ear dysfunction. They can differentiate between a neurological and muscular squint and diagnose the cranial nerve implicated. They understand about pituitary function and adnexa; the continuity and responsiveness of fascia and how that relates to Still’s principle of the body as a whole. As for their applied anatomy of the cranium and their listening/ palpatory skills.....................................The 6th year is dedicated to a research project in order to achieve their masters.
Note the diversity of research projects going on in Europe listed in the IJOM.
Flavour with Content
Would it work if we had a similar undergraduate programme in the UK?
In which case would the UK osteopathic profession start to attract the allopathic practitioners and invite them into their world rather than the osteopaths trying to fit into a medics world? Would this restore the profession's autonomy and the pride that goes with it? A pride that is prominent amongst European colleagues and students and, most importantly, the patients know it.
Back in the UK....What percentage of the editors and contributors to the IJOM, Osteopathy Today and The Osteopath, the employees and elective council of the GOsC, the BOA and, finally, the Principals of our Schools of Osteopathy, could be classified as left brain dominant? Certainly not all, but this author would guess a large percentage.
As a profession, osteopaths need the left brain dominants. They give a voice, a professional framework, they drive the profession forward in this aggressively modern world that demands ‘registration,’ ’validation’ ,’accreditation’, ‘process’, ‘definitions’ and ‘measurements’. The obstacles that need to be negotiated, the hoops that need to be jumped through, the hurdles that are put in the way – most osteopaths shy well away from. Where would the profession be without those prepared to take on such roles within it? The UK osteopathic schools are financially viable but have retained their independence, the profession has a degree of respectability and security –they have been rigorous and complex tasks to accomplish. The homoeopathic profession did not achieve registration as members in their profession resisted it and they are paying a heavy price indeed. However, the left brain dominant heroes need to appreciate that they represent just one end of the Bell Curve that encompasses their whole profession. A profession, I would guess, that actually holds more than the population’s average share of right-brain dominants.
So, how does the profession move towards cohesion and mutual understanding and respect?
For the extreme left brain dominants it would be very helpful if they could shut out the angry outbursts of their left frontals. It does not help cohesion. “ If they see the right brain dominants as full of uncertainty, then they need to dwell on the thought that the more certain we become of something the less we see. They need to appreciate that their talent for division, for clearly seeing parts, is of staggering importance – second only to a capacity to transcend it in order to see the whole ".... ...."The structure of the periodic table of the elements came to Mendeleyev in a dream"... ...."Great mathematical thinking takes place in 3 dimensions and is therefore right hemisphere mediated”.... ....." Einstein is quoted as saying ‘the words or the language as they are written or spoken do not seem to play any role in the mechanism of my thought’.” McGilchrist (p107)
It is a common and ignorant misconception by the 'left brainers' that 'right-brain dominant' stands for 'not knowing'.
The 'right brainers' need to find some way of becoming more integral and vocal so that others are aware of how many are out there. 'Right brainers tend talk to each other but not to outsiders. They become tight knit and exclusive – inevitably. However they can write. The SCC magazine has recently had some thought provoking, intelligent, uplifting articles full of constructive thoughts and broad ideas – often talking about research from other fields and always talking about osteopathy from a pure principle perspective.
They need to broadcast to the whole profession - but be careful. Do not alienate others by talking about the IVM and the breath of life to practitioners who do not work with these tools. The unchartered anatomy, the embryology, the paediatrics, philosophy of health and patient presentations are all common language full of educating, interesting and entertaining osteopathic content.
The 'extreme right brainers' are generally a world unto themselves; casting no judgement on others, imposing no standards; quietly doing what they do. The problem here can lie in public perception and how they represent the osteopathic profession, particularly those working with the IVM. They often struggle to explain to the patient what it is they are doing and how it works. Assuming that the treatment is beneficially therapeutic the patient then often walks away with the impression that their osteopath has healing hands.
In truth they are hands that have acquired a skill over many years of practice. The way they apply their skill is through the three dimensional way in which they perceive their patient in context with the environment that they inhabit. If they cannot explain what they do to the patient and how it works then it is the responsibility of the right-brain dominant osteopath to, first and foremost, value experience before relying heavily on intuition, to be inherently wired to work that way and to be effective at what they do. Otherwise they must find another way for the sake, in the context of this article, of other osteopaths. There is no room for fakes, self delusion or gurus.
As for those that move fluently from left to right brain, right to left brain, verbal but three dimensional - for those who can deliver flavour with content, please let the profession hear you. You should be music to their ears.
“Reason along with imagination is the most precious thing we owe to the working together of the two hemispheres.” McGilchrist (p7)
Ultimately, we are all of two minds.
The Future
Darwin suggested that survival does not rely on those that are the strongest or the fittest, but those that are best at adapting to change.
The profession should be making a collective decision about which direction those changes should take place. The predictable argument would be to continue along the line that is currently being tread. This certainly allows osteopaths to fit into the conventional and modern way of doing things. However there are rumblings everywhere if one knows where to look and to listen. The obsessive way in which the western world wants to factualise, quantify and reduce everything to statistical analysis is being questioned and criticised in many corners. Clever people are talking (.... the TED lectures, The Schumaker College.....) of the devaluation of intuitive skills, quality, common sense and the inherent intelligence of nature and its forces.
The Principles of Osteopathy are pure common sense. They require osteopaths to qualitatively assess their patients and use intuitive skills to apply a treatment that will remove obstacles to their health. The profession would be well placed to get a head start on the “rumblings” if this is so.
In Summary
_The need for research is undeniable, however that research needs to be based on osteopathy and its principles as a guiding force with less emphasis on manual therapy and its effectiveness in treating allopathically diagnosed conditions. (There is a limited rationale to competing with sports therapists, physiotherapists, a chiropractors, or highly trained pilates instructors - there is far more rationale to distinguishing ourselves as apart from them by pointing out that we follow a different philosophy of health.)
There is a need to incorporate the simple Principles of Osteopathy into all teaching at undergraduate level, be it clinical studies, technique classes, anatomy, neurology, pathology.. This has been neglected over the decades creating a profession lacking foundation, identity, pride and a common understanding of what it is they are trying to achieve in their osteopathic treatment of the patient . A module in Osteopathic Concepts is not the answer. Every member of the teaching staff should be living those principles. In truth, when Principles of Osteopathy are applied in their simplicity they, in themselves, provide a sound rationale to a comprehensive patient approach and absolve the need to “scientise.” Insecurities about what an osteopath is doing and why he is doing it evaporate.
The profession needs to ensure all osteopaths practising cranially and viscerally are fully (not partially...) educated in these fields of osteopathy by incorporating them wholeheartedly into the undergraduate programme. The UK profession is currently risking standards. In doing so a more cohesive and mutually respectful UK osteopathic society will evolve, at the same time as hugely increasing the diversity of patients that they can help.
The profession needs to embrace the diversity of brain types encouraged into our profession, at student entry level, through their passage of education and after they have qualified. All great industries, corporations, organisations go out of their way to make sure that their businesses have the correct balance of left and right brainers. The UK osteopathic world has focused in on those who attend to their left hemispheres and the schooling, the journals and the conferences reflect this. It is creating its own environment exactly as Ian McGilchrist describes: “The kind of attention that we pay to something or someone changes the nature of that something or someone that we attend to.”
The Europeans have been moving the other way. The doctors and physiotherapists who are fed up with listening to the prescriptive side of life have moved across and are opening up their senses. As a profession they are thriving, enthusiastic, excited and positive.
Note the BOA chief executives commentary in Osteopathy Today, Nov 2010, is embracing the prospect of bringing Europe into line with the UK in terms of validation and standards.
Question : Does that make your (A) head nod or (B) heart sink?
A selective list from the extensive bibliography of Iain McGilchrist can be found on the BOA website.
Recommended Reading:
The Master and his Emmissary, The Divided Brain and Making of the Modern World Iain McGilchrist
Mapping the Mind Rita Carter
Cognitive Neuroscience, The Biology of the Mind – Michael S. Gazzaniga, Richard B. Ivry, George R. Mangun
Osteopathic Diagnosis Audrey Smith BSO
The Tyranny of Numbers David Boyle
Modernity and Self Identity – Anthony Giddens
Teach us to sit still, a sceptics guide to health and healing – Nick Parks
www.ted/jillboltetailor.com – a fascinating talk from a neuroscientist who suffered a left sided stroke and watched what happened from the ‘inside’.
www.ted/kenrobinson.com -another fascinating talk about school education, but you can apply his philosophy to osteopathic education
© Copyright - All rights reserved by Joanna Wildy 2010
