My father, Andrew John Dorko, was the resident poet of Westlake Ohio. During the last ten years of his life he was regularly invited to write and recite original verse in honor of special occasions such as ground breakings, dedications or holiday events. Not long before his passing he did something for the dedication of the new recreation center in his favorite city and another attendee, Congressman Dennis Kucinich subsequently put that poem in the Congressional Record-which was pretty cool.
As I grew to actually know him late in his life, I realized for the first time that his poetry emerged from his center irresistibly; instinctively-as if he had been seized suddenly by some internal freight train that would not let him off until he had committed his words to paper. He seemed not to be in charge of this process-one day he just allowed it to have its way-he was fourteen. He wrote his final poem at the age of 84 while lying in a hospital bed in a skilled nursing facility in his beloved city of Westlake.
I realize now that until he was quite a bit older than I am today, no one encouraged his writing. His parents and seven siblings never read any of it. His six children were collectively indifferent and my mother was, in my memory, totally silent on the matter of being married to a poet. This never stopped him. I don’t think it even slowed him down. And that willingness to continue without external approval is, to me, my father’s legacy.
The approval of others-something we all seek. And in order to acquire it we are obliged to examine and accept what those around us seem to want. In adolescence we call this “peer pressure,” and we admonish our children not to fall prey to it. But adults feel it no less powerfully and have no specific name for it. Its insidious nature makes it even more powerful.
In his latest book, Status Anxiety, the essayist Alain de Botton speaks of it in this way: “Up until a certain age, no one minds much what we do, existence alone is enough to earn us unconditional affection. We can burp up our food, scream at the top of our voice, throw the cutlery on the floor, spend the day gazing blankly out the window, relieve ourselves in the flower pot-and still know that someone will come and stroke our hair, change our clothes and sing us songs. We begin our time on earth in the hands of a mother, who asks little more of us than that we continue to live…But this idyllic state is fated not to endure. By the time we have finished our education, we are forced to take our place in a world dominated by a new kind of person, a person as different from a mother as it is possible to be and whose behavior lies at the heart of our status anxieties; the snob. (Like it or not) we are forced to subsist on a diet of the highly conditional attention of snobs.”
The thing that drives our behavior as adults is what I always refer to as the culture, and I deliver these two words to my classes and patients with a lowered voice and a slightly Draconian implication. Simply put, the culture is a snob. It not only tells us what we should look like and how we should behave, it isn’t the least bit interested in our health-though it may pretend to be.
Now-how does all of this relate to the profession of physical therapy? Well, whatever else it might be, physical pain is, at its root, a consequence of behavior. At times, we’re talking about the behavior of systems over which we may have little or no control. In the face of pathological processes that require chemical alteration or repair in order to resolve the pain, conservative therapeutic methods will probably have little effect. Fortunately, the medical profession is quite competent in such cases.
What I’m talking about are those many instances when pain arises from just enough mechanical deformation to cause it-I’m talking about the ways in which we hold ourselves and allow ourselves to move, and I’m convinced that the culture has more to say about this than most therapists suspect. Is it possible that the greatest challenge facing the profession of physical therapy today is the tendency of the culture to restrict those movements that would relieve pain?
In his remarkable book, Illness and Culture in the Postmodern Age, David Morris in the chapter titled “Utopian Bodies” says this; “Health no longer refers, via metaphor, to the ideal social state that generates it but instead signifies the perfection of a single private self. Further, good health is not exactly the issue. What matters is that the individual body appears healthy. Image is everything. The average family lives in a realm of pictures created with the favored postmodern technologies of camera and videotape where they cannot avoid versions of the same subliminal message: the healthy-looking body is the beautiful body; and the beautiful body is the healthy-looking body.”
I’m suggesting this evening that our profession is often driven toward a sort of practice that attends more carefully to the dictates of the culture than the realities of science. I know this isn’t a popular thing to say, but as I travel and read and especially when I see the ways in which my colleagues approach treatment of nonpathologic painful problems, I am increasingly convinced that we have succumbed to the concept of style over substance; to the seduction of beauty over the complexity of health.
Moreover, the ease with which we can now document and bill for the patterns of treatment typically offered the patient in pain makes the continuity of these methods immune to the naturally occurring changes that are the common in any other medical discipline. Ask an orthopedist what percentage of the diagnoses he or she sees today that they treat precisely as they did ten years ago and they will answer, “About ten percent.” Put the same question to a therapist about the various permutations of spinal and limb pain common to their clinic and they will answer with a much higher number.
Perhaps an alteration in the care we offer will come from a deeper understanding of what physical pain does to all of us- how it effects us in ways the therapy community does not normally consider. In an amazing book published in 1985 Elaine Scarry, then a professor of English at the University of Pennsylvania and now at Harvard wrote of a consequence of pain that I feel anyone treating it should come to know intimately. The book is titled The Body in Pain-The Making and Unmaking of the World. I think this English teacher has discovered something that the leading scientists in physical therapy have overlooked.
This is not an easy book to read. Scarry gains her understanding of pain’s effect through what she’s learned from the victims of torture. And although that circumstance leading to painful sensation is not something we are commonly familiar with, the perception of pain secondary to nociception otherwise is not essentially different.
She says that pain “unmakes” us. That it systematically destroys our familiar world by reducing our ability to live in it in our familiar ways. First and foremost it destroys language, and it is well known that finding words to accurately describe our physically painful experience is a difficult task. It “unmakes” us even further by restricting the pursuit of movement that had previously been part of our lives-the ways in which we express ourselves nonverbally. When a child is told to “sit still and sit straight and to be quiet,” something eerily similar occurs.
What Scarry says about the consequences of pain surprises no one that I know, but it is what she proposes is best done to resolve this that I feel may surprise you. Fortunately, it mirrors precisely what I’ve been saying for many years, though that’s not been met with a whole lot of external approval.
Scarry says, “Physical pain deconstructs the territory of creating-it brings into sharp focus the relation between it and the ability to imagine.” While in pain, patients will commonly tell you that they don’t have any idea in which direction they should move though, since their pain is intermittent in nature, they must have done this many times before. Scarry is certain that it is only through some creative act that the consequences and perception of pain might be reversed. She says, “Though the capacity to experience physical pain is as primal a fact about the human being as is the capacity to hear, to touch, to desire to fear to hunger it differs from these events and from every other bodily and psychic event by not having an object in the external world. Hearing and touch are of objects outside the boundaries of the body, as desire is of x, fear is fear of y, hunger is hunger for z; but pain is not of or for anything-it is itself alone. This objectlessness, the complete absence of referential content, almost prevents it from being rendered in language but this is also what may give rise to imagining by encouraging the process that eventually brings forth the dense sea of artifacts and symbols that we make and move about in.” In other words, our personal and unique creative activity. And we all know that creative activity, both its pursuit and what it might produce, is vitally dependent upon the approval of others. As the poet Mary Oliver intones, “Homesick for moderation, half the world’s artists shrink or fall away.”
Couple this insight with the conclusions of Patrick Wall, arguably one of the greatest neuroscientists who ever lived-a clinician and theorist almost without peer and a man focused on the study and treatment of human pain for over sixty years. In his final text, Pain-The Science of Suffering, he says that pain creates a “need state” as does hunger or thirst, that can only be terminated by the appropriate “consummatory act.” At this banquet each of us has terminated our hunger and thirst by acting in a fashion we all know is best done in an instinctive manner, rather than in the ways the culture encourages us otherwise.
Wall makes it clear that the need state produced by physical pain is best terminated by the consummatory act of movement-a thing our profession prides itself on knowing something about-and that that movement must be the final act of a sequence of responses hard-wired in the brain, instinctive and inherent to life-and-a movement that only the person in pain knows precisely how to do. It will surprise them as it appears, as does every creative act. This movement is unlikely to be found in the protocols of care we’ve developed for weakness and dysfunction. Providing only these for patients who need something else hasn’t gotten us anywhere in our attempts to resolve pain with movement-and, of course that is the very thing we are expected to do.
Is there a place for creative movement in either traditional or modern physical therapy practice? I think not. In my travels I see that physical therapy is rarely about anything other than training, whereas, to me, the creative act begins with care.
Training takes place in a space full of effort, repetitions, charts noting progress and specific goals. An imagined future is as important here as the present, and the present is unacceptable.
But there is something about a unique connection between an individual therapist and one patient at a time. This connection is possible only when there aren’t insulating layers of machinery and generic protocols between them. It is then that the therapist has an opportunity to attend to the patient’s story and not just to their diagnoses. When caring is the primary mode of treatment, the therapist is willing to allow the stew of symptoms, frustrations, fears, denial and bargaining emerge from the patient in no particular order. When caring is present, the patient is allowed to speak of the disruption of their life. When caring is present, measurement is replaced by acknowledgement and judgment by acceptance. But I’ve noticed that it seems no longer possible to expand any clinic or private office without turning it into a place where only training is available, and creativity is a foreign concept. No wonder their struggle to relieve pain.
And so, if I’m right, our profession faces these specific challenges:
· To recognize and encourage the instinctive and creative movement Drs. Scarry and Wall suggest are absolutely necessary for pain relief.
· To find a way of explaining this to our patients and the medical community.
· To figure out a way of billing for it.
· To make it, as I feel we should, the essence of physical therapy for pain relief.
On a spring afternoon in 1934 my father’s right leg led him over the hurdles set up on the track at West Tech High School-here in Cleveland. In the lane beside him was another hurdler from East Tech named Jesse Owens, and Andy Dorko came in second that day. In 2001 that same leg was amputated in an effort to relieve his pain, and I can tell you it didn’t help much. But while the limb was still attached, he wrote his final poem and during those moments of creative movement, as for seventy years he had been compelled to do, he felt no pain. I know this because I was beside him and he added my name as co-author. The poem spoke of the care he had received during his final illness, specifically in the physical therapy department. This poet never mentioned the training.
What do you suppose my father was trying to teach us?