Principles That Underlie Treatment
Jeffrey Maitland in the Embodied Being makes a case for understanding organizing principles that allow us to be successful in the delivery of our treatment plan and application of techniques.
“A common mistake involves confusing the principles of other related endeavors with the principles of intervention.”
What does Maitland imply?
“Often theorists believe they are articulating the principles of intervention when in fact they are discussing the importance of evaluation, outcome assessment, or the proper application of techniques.”1
It is often quite difficult to articulate a principle because a principle has to be inviolate, that is, it must be true each and every time. Mostly what is stated as a principle is more akin to a description of the use of technique.
Robert Ward whom I use in my Fascial Therapy manual and online program regarding principles of assessment states; “Palpatory evaluations should test the same sites passively, because passive testing gives more accurate information.” 2
This statement is not a principle of intervention but a recommendation on how to conduct a proper evaluation on the basis of an important observation about palpation.
Its’ great to show practitioners ‘tips’ on how to treat ‘signs and symptoms’, what to do with specific pathologies, and I and other instructors have derived our ongoing income from such endeavours with regarding to the demonstration of technique.
Does what I show work each and every time? No, it does not. Why?
As Maitland suggest; “Obviously, being able to evaluate somatic dysfunction, recognize normal function, state the goals of therapy, appropriately apply a wide range of techniques, assess functional outcomes, and create the proper client/practitioner relationship all occupy an important place in the clinical decision-making process. The important point is, however, that without an explicit or tacit understanding of the principles of intervention, these factors taken by themselves or collectively give us no clear and rational way to decide what to do first, what to do next, and when to finish.”3
What Maitland articulated was so simple, yet so difficult, by asking three fundamental questions; 1. Where do I begin? 2. What do I do next? 3. And how do I know when I’m finished?
Maitland contends we do not understand really what a principle is?
Before we can understand how to apply any principle, we have to understand what we are actually defining regarding a principle.
“The relevant meaning of the concept of “principle” is a rule on the basis of which a chain of reasoning or clinical decision-making process proceeds. An easy way to grasp what a principle is and how it functions is to consider a simple game. In a game, we can distinguish between two kinds of rules: constitutive rules and strategy rules.”4
Maitland uses the game of checkers as an example. “Constitutive rules are the rules that define how the game is played. Since the constitutive rules define the game itself, breaking one or more of these rules is tantamount to no longer playing the game. If one of the players moves his or her piece off the board and onto the table to avoid losing, the player is not exhibiting great gamesmanship and creativity but quite simply no longer playing checkers.”5
“Strategy rules, in contrast, are rules of thumb. They do not define the game. Rather, they state generalities based on experience about which moves are most often considered the best under certain recurring situations. 6
Unlike constitutive rules, breaking a strategy rule does not imply that one is no longer playing the game. “Always” and “never” cannot under any circumstances apply to strategy rules. If a beginning player loses because he or she consistently breaks strategy rules, we would see the player as an inexperienced opponent. We would not accuse him or her of no longer playing checkers. If we were to observe a player who always wins at checkers, but breaks many strategy rules, we would not conclude that the player is no longer playing checkers or that he or she is a poor player. We would conclude that the player is a highly skilled, creative, and experienced player.”7
“In the holistic paradigm, the principles of therapeutic intervention function much like the constitutive rules of a game; strategies and tactics function like rules of thumb. Unlike strategies, principles define the therapeutic arena and state the conditions under which normal and enhanced function occur. Unlike strategies and tactics, they are small in number and under consideration every time we attempt to intervene or formulate a treatment plan. Like the constitutive rules of a game, they cannot be cast aside at the discretion of the practitioner. However, the principles of intervention are unlike constitutive rules of a game in two important ways: they state the necessary, but not sufficient, conditions under which normal or enhanced function is obtained, and they are not stated in temporal language like strategies, tactics, and rules of thumb are. Strategies and tactics say, “Do X before Y”; principles say “X is a function or condition of Y” and leave it entirely open as to whether X or Y should be done first. Just as breaking any rule that defines a game amounts to no longer playing the game, ignoring or casting aside any principle of intervention amounts to no longer engaging in the holistic approach[…]” 8
“Strategies and tactics state the temporal order in which interventions are to be applied, and principles state the basis upon which this temporal order is formulated. Therefore, any time we discover a statement that purports to be a principle but contains temporal language, we can assume that it is probably a strategy rule masquerading as a principle. ”9
“Principles are regularly confused with strategies, the goals of therapy, the “laws” of normal function, the principles of some other related endeavor like the therapeutic relationship, the philosophical values of a particular discipline, and so forth. Because many of these non-principles can be amended or cast aside during therapy and because many of them are somewhat debatable, it is not at all surprising that practitioners conclude that principles can sometimes be abandoned.”10
Mailtland goes onto state that for a principle to be successful, “necessary and sufficient conditions need to exist”.
“A necessary condition is a condition or set of conditions without which a phenomenon could not occur. A sufficient condition is a condition or set of conditions that, if present, are enough to guarantee that a phenomenon will occur. Oxygen, for example, is a necessary condition of fire. Without the presence of oxygen, fire is not possible. If oxygen were a sufficient condition, its mere presence would be enough to create fire.
Since the mere presence of oxygen all by itself is not enough to create a fire, it is a necessary but not sufficient condition.”11
Thus we get to the ‘nugget’ or the ‘kernal of truth’ which Maitland wishes us to comprehend.
“For the purposes of illustrating how necessary conditions function let us look at what we call the Principle of Adaptability.
The adaptability principle is based on the observation and understanding that the body is a highly adaptable and plastic living whole. When the body is injured, say in an automobile accident, it often develops patterns of compensation in relation to the original pattern of injury.
The automobile accident does not just cause a local problem with some “part” of the body, it creates global patterns of strain that in turn affects the organization and functioning of the whole body in gravity. The original pattern of injury more often than not is laid down on other previous injuries and postural imbalances. Along with the resulting patterns of compensation in relation to gravity, these imbalances and injury patterns result in a complicated loss of plasticity and adaptability throughout the entire body.
Over time further losses in movement, plasticity, and adaptability will appear as the body struggles with gravity in its daily activities. If these complicated patterns of strain and compensation are not released in the proper order, the body will not be able to respond properly to interventions designed to release part of the body, it creates global patterns of strain that in turn affects the organization and functioning of the whole body in gravity.
The original pattern of injury more often than not is laid down on other previous injuries and postural imbalances. Along with the resulting patterns of compensation in relation to gravity, these imbalances and injury patterns result in a complicated loss of plasticity and adaptability throughout the entire body. Over time further losses in movement, plasticity, and adaptability will appear as the body struggles with gravity in its daily activities. If these complicated patterns of strain and compensation are not released in the proper order, the body will not be able to respond properly to interventions designed to release the original injury site or any other area of dysfunction.”12
“Adaptability is clearly important in any conceivable clinical setting—every attempt to restore or enhance function must take account of whether the body can adapt to any proposed strategy of intervention. If the body cannot adapt to an intervention or series of interventions, then either it will revert to its dysfunctional state or further strain will be driven to other areas of the body, or both.
If the body is completely incapable of adapting to any possible strategy within a particular form of therapy, then the system of therapy is incapable of treating the patient’s somatic dysfunction and some other therapy must be found.
Thus, the Principle of Adaptability says “any attempt to restore or enhance normal function is a function of the body’s ability to adapt to the intervention.” The principle does not say that preparing the body to adapt to an intervention must always precede every attempt to restore or enhance function, only that adaptability is a necessary condition of appropriate intervention.”13
All footnotes and referencing excerpted from: Jeffrey Maitland. “Embodied Being.”