Shallow Dive - Essays on the Craft of Manual Care by Barrett L. Dorko

The South Africa Journal of Physiotherapy
Book Review by Pamela K. Hansford


Barrett L. Dorko, a physical therapist in practice in Ohio, is a clinician with a passion for sound scientific reasoning, a teacher who focuses on learning and a writer with a poetic and metaphorical bias. This recently published book offers the reader a challenging compilation of his brief, thoughtful and provocative essays, many of which originally appeared in "From Dorko's Desk', a column run regularly in PT Forum from March 1990 to June 1995.

Gregory Bateson in 'Mind and Nature: A Necessary Unity' (1979) explores epistemology, discussing how organisms, or aggregates of organisms, know, think and decide. Philosophically he explores the limits and other characteristics of these processes, centring on quality by quoting Jung who said Break the pattern which connects the items of learning and you necessarily destroy all quality. Bateson explains that metaphor provides the pattern which connects and this of course is the strength of Barrett's writing. He is an experienced practioner who was senior clinician at the Atlanta Back Clinic, between graduating in 1973 and establishing a private practice in 1979. By linking literature and poetry with practice of therapy and personal experience, he develops his holistic approach to therapy. He sees the body as metaphor for its own inner process, a means of expression (very often for what it most wants to hide) and the interface or point of connection between patient and therapist. He invites us to explore the patient-therapist relationship for ourselves, particularly with regard to how the therapist too changes in the course of the interaction.

Barrett says of his patients that he would prefer that they use me as a resource who helps them understand that the solution to their problems lies within themselves. Barrett recognises that people heal from within and that our job as therapists is to reveal and disclose, rather than impose. To do this we need to get people into the position where they feel safe with our touch. Safe enough to allow the pain of their lives to rise to the surface so that by gentling ourselves and following their lead, we can enable them to reveal their pain and their needs, and we in turn can enable them to find and develop their own corrective movement. We need to learn to follow in order to learn how to lead.

The effect overall is a display of intellect and compassion, as Barrett contemplates his practice as clinician and teacher, and reflects on this. He invites us as therapists in turn to reflect on our own practice. I have shown this book to many people since I received it in August. Therapists in Cape Town and Johannesburg, therapists from Africa and from Europe participating in the recent WCPT-AFRICA Regional Conference in Harare and others who have had dealings with therapists have responded with enthusiasm. One therapist described the way in which these brief essays invite connections with our own daily experience by commenting that when you read an essay, it stays with you all day.

I discovered Barrett's writing by responding to his offer on the physio@mailbase.ac.uk list to send material to anyone interested in using poetics with physiotherapy. When I received this book it opened up at The Vase, in which we are asked to imagine that we are each holding a vase of great value in our hands and being paid for being entirely responsible for caring for it. Barrett feels that although the role of a physical therapist should include an appreciation of the body that is reflected in the way that we hold it, most patients come to us fearful of being poked, prodded and painfully bent because that's what their friends got for similar conditions. He concludes with My hands are not unusually sensitive, nor are my skills especially difficult to acquire. But when I'm with others on the job, I can sense their worth, and I hold them with care.

The Vase, like the others in the book, is a one and a half page essay. The entire essay is visible at a glance - but this is only the apparently simple form as set down on the page. Barrett's style of writing makes his wisdom easily accessible and then allows further layers of meaning emerge gradually in the process of reading. His wisdom is derived through sensitivity in response to gentle touch with one's whole being, from recognising our own humanity in the others and from challenging conventional thinking with a delightful subtle sense of humour.

Barrett feels that it takes courage to express oneself on paper - to delve within and then to expose ourselves just as we expect our patients to do on a daily basis. He reminds us that our patients aren't impressed by our credentials or who we are or where we've been or whom we've worked with. They are what they are. And unpredictably that. Each day I begin again, just me and the patient with nothing between us but what we think we know and what we are about to learn.

The word courage hasn't been much used in physiotherapy. Barrett Dorko's writing has drawn my attention to this fine unseen thread which runs through our work connecting us as therapists with our patients. Courage is part of the fabric of the lives of the people with whom we work and in what we do each day. It takes courage to express our feelings and ideas in words, releasing our stories to others. For most of us revealing not only our weaknesses but also our strengths is equally difficult. I always marvel at the courage of the parents of a young baby as they hand their precious child over to me and let me handle the baby as I choose. And so I tell them how much I value this bravery and love of theirs, and that it takes courage for me to handle that child too. To command trust and respect, we must first grant it. How often do we abuse this trust by not respecting the person within when we demand compliance? Do we always remember that terror and pain are one and the same and that they heighten the sympathetic response, thus inhibiting the parasympathetic response we choose to facilitate?

Barrett reminds us that those of us who have chosen to enter a kind of work that not only requires that we touch others, but touch them in a way that they cannot ignore, are doing something that requires courage. Doing this we must remain steady in our resolve to remain present with the changes that inevitably occur and this requires an endurance and intellectual strength only study and some passion for the work itself can supply. But at the same time making too much of the therapist's skills often blinds us to something no real craftsman would ignore: the materials. Barrett hopes that others will learn that painful technique is largely unnecessary for profound changes to occur and believes that this is true because the materials of my craft have shown me this again and again. The answers are in the patients and they are the one's who have inspired this book.