THERAPY AS CRAFT

Barrett L. Dorko, P.T.


          When asked for a single bit of advise to give therapy students, I always answer in the same way: "Know the materials you're working to change."

          When I teach, I use this simple analogy to demonstrate the importance of this: I say, "If I were to point at a wall and ask you to make a hole, what would you want to know before you began? I've found that many therapists are so anxious to complete the task that their primary concern is the size of the hole. When they indicate this, I stop them short and ask, "Don't you want to know what the wall is made of? After all, the wall begins in my imagination, not yours. I'm the only one who knows its structure and you haven't any real ideal what that might be. How are you going to choose the best tool or force without knowing this?"

          Having said that, I can spend the rest of my time simply speaking about the nature of the materials we call the human body. These are some of the conclusions I've drawn from my reading of the research and from my life in the clinic:

          -The body is not even remotely like clay. It won't be molded into a new shape no matter how hard you push on it. Its response to external force is typically a combination of retreat and confrontation that is impossible to predict. Ultimately, its tendency is to return rapidly to its original shape once you've removed your hands.

          -There are just two continuous and homogenous tissues that run the length and breadth of us; the skin and the nervous tissue, and these two are intimately connected in several ways. When symptoms spread, when there is a global physiologic response to provocation, consider the involvement of the neural component both chemically and bio-mechanically. The brain is extremely interested in protecting this organ and it does so primarily through protective and corrective muscular activity. Don't mistake this activity for the problem, it is the solution.

          -Although I dislike the notion that the body is something like a soft machine, it does have this in common with machinery; its energy output cannot exceed the energy put into it. If you want to improve its efficiency you have to deal with the issues of nutrition and nutritional transport that are essentially the same in biology and auto maintenance. Improved performance is a function of many internal processes, and none appear without following the laws of energy conservation. I can't put energy into it with my hands alone without performing a miracle, and clinical work is usually harder than that.

          -The body has a strong tendency to solve problems, not create them. It often compensates for weakness or illness in one system by changing other systems in ways that are painless and quietly efficient, perhaps for decades. The body is not out to make us suffer, but rather to function in the best way possible.

          Therapy, at its best, creates an environment that allows healthful behavior to emerge. Whether you are promoting locomotion, fine motor tasks or speech, it all comes down to the same thing; the most enduring therapy comes from the patient, not the therapist. Only when we truly understand the capabilities and limitations of the animated materials before us can we hope to practice successfully.

          You know, a great craftsman often approaches the material at hand as if it knew how it wanted to be shaped. When working with clay or marble or cloth or wood, this is simply a metaphor.

          For us, it is a reality, and sometimes therapy reflects that.