Physiotherapy: A Process Based Therapy: Part 3

Warning: This blog is lengthy, contains jargon, waffling and rabbit holes.

In one of the scenes in the movie The Matrix, Morpheus introduces Neo to the Matrix for the first time. Morpheus explains the construct, a loading program, where anything can be loaded from clothing to equipment, training simulations, anything they need.

Cue abstract from the movie:

“Neo– Right now, we’re inside of a computer program?

Morpheus – is it really so hard to believe? Your clothes are different, the plugs in your arms and head are gone. Your hair is changed. Your appearance now is what we call residual self-image. It is the mental projection of your digital self.

Neo – This… This isn’t real? (touching the back of a chair)

Morpheus – What is real? How do you define real? If you’re talking about what you can feel, what you can smell, what you can taste, and see. Then “real” is simply electrical signals interpreted by your brain. This… is the world you know.”

I want to try and pick this scene apart from an ontological perspective, and then attempt to relate it to a Functional Contextualist and dispositional viewpoint. I hope to make key distinctions between both, and probably leave this blog on a bit of a cliff-hanger!

What is Ontology?

Firstly, we should define ontology.  Ontology is the philosophical study of existence, reality and being. So, immediately we can see the ontological references in the above scene from The Matrix. Perhaps more simply, ontology is what you and I determine as real – What an object is? Commonly the word epistemology is linked with ontology. Epistemology is the philosophical study of knowledge, how we know and how we obtain knowledge. It is the why that accompanies the what an object is – why is the object what it is? Both terms derive their meaning from the interactions humans have with their social context. What’s important is the language (or content) that is used to describe the context. For the moment we will park ontology and come back to it later.

The importance of language

Understanding language and cognition is key to understanding human behaviour. Most of us use language, either publicly (such as talking) or privately (such as thinking) constantly. We are continually describing, categorizing, relating, evaluating, talking about, writing about, reading about, and thinking about everything around us.

Language seems to be at the root of much of human suffering. We use words to construct hateful and prejudiced beliefs about others, form negative opinions about ourselves, obsess over and “re-live” traumatic events, and develop rules for acting that can be ineffective and harmful. Our excessive use of language and thinking can also make it difficult to maintain “contact” with the present moment.

The Matrix Scene

So let’s pick apart the Matrix scene starting with Morpheus’s line.

Morpheus – is it really so hard to believe? Your clothes are different, the plugs in your arms and head are gone. Your hair is changed. Your appearance now is what we call residual self-image. It is the mental projection of your digital self.

Morpheus talks about Neo’s appearance, how his clothes are different, the plugs in his arms and head are gone and his hair is changed. From an ontological perspective this “reality” that Neo is experiencing is based on his epistemological (knowledge and understanding) of how he views himself. However, in the Matrix that knowledge and reality had to come from somewhere? Neo was never truly born into the “real world” he was grown and harvested by the machines. Thus his reality and knowledge was likely constructed and implanted by the machines.

Morpheus – What is real? How do you define real? If you’re talking about what you can feel, what you can smell, what you can taste, and see. Then “real” is simply electrical signals interpreted by your brain. This… is the world you know.”

In response to Neo’s bemusement Morpheus responds with questions that resemble Humean discourse . He asks Neo what is real and how do you define it, concluding that “real” is simply electrical signals interpreted by your brain.  I feel that Morpheus is downplaying consciousness here. How we turn those “electrical signals” into our experience is highly complex. However recall that Neo was a slave to the machines in the real world.

This line also relates back to ontology and epistemology because the sensations that Neo experiences are associated with the content and context of what he has come to know, which has once again been implanted in his brain by the machines.

So what?

The reason I point out these two lines from the scene is that “our reality” is not to dissimilar. What do I mean? Well society has contributed to our contextual realities and science (empiricism) has contributed to the content of our realities. Simply, what we engage with and how we have come to know it i.e. ontology and epistemology.

Ok, you could argue that your knowledge hasn’t been implanted by a machine that is harvesting your energy to power an entire machine city, and whilst you are reading this blog, you are actually in an implanted alternate reality. How ridiculous…! Right?? RIGHT!?

What is really interesting is that we all experience sensations of some form, but our interpretation (or perception) of those sensations can differ. The meaning and language we attempt to apply to these sensations has come from our engagement with society.

Ok… so what has this got to do with dispositionalism and Functional Contextualism?

Great question! Before I attempt to answer that I shall attempt to discuss the ontological viewpoints of both.

What is the ontological viewpoint of dispositionalism?

I’ve touched on this before (here), and so for the sake of brevity I’ll share an abstract from part 1:

Dispositionalism, is a philosophical theory of causation. The theory infers that causality is context-sensitive and the empirical science lacks the ability to capture this component of causality.

Anjum, (2020) states, ‘A disposition is seen as plausibly real because they can explain what actually happens – the underlying principles of the behaviour of things.’ Moreover, Anjum, (2020) states, ‘Dispositions are thus useful for making prognoses for illness and recovery, bu also for making the correct diagnosis.’

In part 1 of this series of blogs, I discussed the comparisons between process-based reasoning and dispositionalism and made the below statement:

‘What Dispositionalism and PBT propose is that in order to provide quality of care to people living with illness or disease, using a model of reasoning that is linear or unidirectional is insufficient. I think with the two combined* (one a philosophical reasoning model, the other determining dynamic processes of change*) we can focus more on the individual, working towards impacting outcomes of interest and for who or what matters to the person (put simply think about what people yearn for in their lives? Is it coherence, meaning, feeling, a sense of belonging?).’

What is the ontological viewpoint of Functional Contextualism?

Functional contextualism is the philosophy of science of how something works in a given context. Drawn from Peppers (1942) root metaphor theory, it is suggested that every one of us constructs hypotheses based upon personal and social experiences within our world and that we adopt a root metaphor or basic analogy to interpret and/or organize our experiences.

What do I mean by root metaphor?

Pepper (1942) proposed four principal world hypotheses (ways of viewing the world) – Formism, Mechanism, Contextualism and Organicism. World hypotheses go beyond the empirical perspective of science, which proposes that all knowledge is based on experience derived from the senses. In empirical science, knowledge is gained through experimental research. World hypotheses in contrast are metatheories, unrestricted in their subject matter.

Within each of the four principle world hypotheses is a root metaphor.

World HypothesesRoot Metaphor
FormismThe root metaphor of formism is similarity, categorizing objects such as paper, blades of grass, intervertebral discs, tendons, ligaments, bones, muscles, nerves
MechanismThe root metaphor of mechanism is the machine. Associated with empirical philosophers such as Locke, Berkeley and Hume, mechanism explores mechanistic notions including “push and pull”, lever systems and “cause and effect”
ContextualismThe root metaphor of contextualism is the historical event. Yet this does not mean a past event. A contextualist would view history as a way to re-present events. Therefore a real historic event is when it is going on in the present.
OrganicismThe root metaphor of organicism is the process of organic development, as in living, growing, organic systems. Consider the aging process in humans. There is a stage by stage process that occurs.  

Ok you are waffling now, get to the point!

You’re right, I am waffling aren’t I.

Ok, firstly I respect the positions of both dispositionalism and Functional Contextualism. My quandary is that whilst both agree that context plays an important role, dispositionalism adopts an ontological viewpoint.

In contrast, Functional Contextualism adopts an a-ontological viewpoint. A-ontological does not mean that it is anti-ontological or non-ontological. It merely chooses not to adopt an ontology. If you recall earlier I discussed the relationships between ontology and epistemology.  Ontology and epistemology are linked in such a way because one can help us understand the other.  For example, take the word catastrophizing. I know what catastrophizing is through learning about it. That knowledge can help me determine my (or a patients) reality. I do that through my understanding of language. There are a few points I want to make. Let’s stick with the term catastrophizing.

  1. Whilst the term catastrophizing has its roots as far back as the 16th century. It was Albert Ellis that coined catastrophizing and emphasized the term as a prime element of emotional dysfunction (Neblett, 2017). So, does this mean that catastrophizing is always seen as a negative?
  2. We know from our understanding of iatrogenics that interventions we impose upon people can have negative effects.  That means education, words, language use etc. What if we were to label a behaviour of a particular personality type with the term catastrophizing (and if associated with pain for example), it may end up defining them (and perpetuating their pain state)
  3. Functional Contextualism doesn’t care about the term or the label because it risks stereotyping or perpetuating the stereotype.
  4. Functional contextualism focuses on the context without the epistemic assumption, removing the ontological reality of how the person is behaving in that moment (catastrophizing).

So what am I saying?

Well, my interpretation is that dispositionalism focuses on the epistemic assumptions that a practitioner understands and depending on the strength of the ‘causal power’ (or disposition) will determine a tendency towards the manifestation of symptoms and the resultant ontology. If the epistemic assumptions are presumed to be negative then can it be concluded that if you have a tendency to catastrophize then this is inevitably bad. There are many contexts where catastrophizing may be helpful. In addition, dispositionalism claims to ‘revive a realist view of causality’. This further solidifies the ontological and epistemic assumptions of an overarching capital ‘T’ truth* criterion to any given presentation. Now don’t get me wrong this is an important consideration when we are determining a diagnosis.  Yet in the context of persistent pain it can be challenging to determine a diagnosis.

In contrast, Functional Contextualism does away with all of that and focuses specifically on the here and there, the now and then, the you and I aspects that allow us to recognize our ‘sense of self’ in a given context. It recognizes terms such as catastrophizing but it doesn’t emphasize a capital ‘T’ truth in the given context. Rather, Functional Contextualism focuses on what is true for the individual in the given moment without the use of terms such as catastrophizing. Instead, we look to identify what the person may be fused with or avoiding, acknowledging both and using techniques to find workable ways to support patients move toward what is meaningful in their life.

In the case of Neo in the Matrix, it could be concluded that his reality is based upon his knowledge of himself and how he engaged in the reality of the Matrix. However, he soon came to realize that the Matrix was an implanted reality. We see this at the start of the movie when Trinity says to Neo, “it’s the question that brought you hear… you know the question as I did”

What does this all mean?

If you’ve managed to get this far then I commend you because my brain is completely fried!

I will start this reflection with an admission that I may completely be misinterpreting dispositionalism. I look forward to the ensuing deeper discussions. Dispositionalism appears to take the stance of a practitioner centred viewpoint. This is because of the epistemic assumptions that determine the ontological “reality” of the person living with pain. When it comes to working with people living with pain, do we want to be resorting to stereotyping, stigmatizing and perpetuating injustice. People living with pain want to get rid of it, yet are we not at risk of perpetuating disability and pain by using associated language.  In some respects it could be argued that dispositionalism continues to draw from a positivist position as it infers epistemic assumptions (determined by empiricism) upon a person. Let’s not infer that this is bad because there is and always will be an implicit bias within a therapeutic relationship where one party is a health professional and the other party isn’t. Thus there may be an expectation that one of the parties “knows best”.

Pain is a complex topic and can be associated with stigma, stereotyping and injustice. Labels and terms can potentially compound and perpetuate pain for a person particularly if they have fused with a term such as catastrophizing.

Functional contextualism takes the stance of not caring about labels and terms to sub classify a person. It merely looks at how the person thinks, feels and behaves within a certain context not caring about the content and asks the person to notice the thoughts feeling and behaviour, hold them lightly and find workable ways to move towards what’s important in the person’s life.

Thanks for having a read

TNP

*Bloody Hell! What (the fuck) is capital ‘T’ truth man!?

I’m sorry, I completely understand if you want to accuse me of talking psychobabble. I just find this stuff really interesting. Simply, capital ‘T’ truth is a term that is used to explain ontological claims (Hayes, Levin, Plumb-Vilardaga, Villatte, & Pistorello, 2013) – i.e. the person is catastrophizing.

References

Anjum, R. L. (2020). Dispositions and the Unique Patient. In R. L. Anjum, S. Copeland, & E. Rocca (Eds.), Rethinking Causality, Complexity and Evidence for the Unique Patient. Gewerbestrasse: Springer Open.

Hayes, S. C., Levin, M. E., Plumb-Vilardaga, J., Villatte, J. L., & Pistorello, J. (2013). Acceptance and Commitment Therapy and Contextual Behavioral Science: Examining the Progress of a Distinctive Model of Behavioral and Cognitive Therapy. Behavior Therapy, 44(2), 180–198. https://doi.org/10.1016/j.beth.2009.08.002

Neblett, R. (2017). Pain catastrophizing: An historical perspective. Journal of Applied Biobehavioral Research, 22(1). https://doi.org/10.1111/jabr.12086

Pepper, S.C. (1942). World Hypotheses: A Study in Evidence. University of California Press.

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