Wednesday 4 July 2018

A sudden rush of blood to the head: Why words really do matter in EVERY domain

So ... it seems there has been a proper furore and rush of blood to the heads (sorry ... that was a feeble attempt at a haemodynamics link ) of some folk, over the use/choice of a word in the @thecsp (UK) PR campaign ‘Love Activity, Hate Exercise’. 

The whole affair highlights the incredibly emotive power of words/word choice and how interpretation is entirely dependent on perspective and context. 

Love activity, Hate exercise?

Image: CSP
A similar attempt at influencing opinion was run by the American Heart Association  @american_heart (USA) in 2017, they called it ‘5 Steps to Loving Exercise ... Or At Least Not Hating It’. That blog campaign successfully conveyed the message that not everyone likes #Exercise and gave some practical tips that were designed to help non-exercisers begin to #LoveActivity or even exercise.

As well as promoting movement and physical activity (and exercise), one of the key messages of both campaigns seems to be that #Exercise adherents and promoters (I would place myself into that category) ... may find it challenging to see things from a non-exerciser's perspective ... The suggestion being that anything that helps facilitate a greater understanding of the patients perspective, and helps start a conversation, can only be helpful, surely?

That said, HATE is an incredibly emotive word and I've always encouraged my kids never to use it ... so I see the antipathy to its use. However, I can see the value in backing the #LoveActivity campaign, because if a patient uses the 'hate' word (and they do) as therapists we have to have the empathy and skills to deal with that ... It is a psychosocial phenomenon of our times and something we challenge our students to consider the realities of. 

Seems like Marmite ... you'll either LOVE it, OR H*** it … AND quite frankly, it is entirely your choice.

The ugly divisions that have ensued within the profession (and are still going on) are also a psychosocial phenomenon of our times, and times past. The only thing that has really changed is the platform and the players. There have always been differences of opinions and schools of thought. Social media has simply opened up debate and discussion to all. That is probably a good thing in a profession that is striving to change. However, what is clear is that it becomes very easy to create divisions, factions/tribes and to polarise opinion.

Q. Is that a good thing?
A. Maybe, maybe not. It depends on the context, perspective (and perhaps motive).

In Jeremy Lewis and Peter O’Sullivan’s recent BJSM editorial Is it time to reframe how we care for people with non-traumatic musculoskeletal pain?   
They suggested, “… Evidence informed self-management is the key. To achieve this, the efforts of many institutions, including educational, healthcare, political and professional organisations, health funding bodies and the media, need to be involved.” In essence what they were saying was that there is a need for a cohesive and consistent message from ALL invested and concerned with improving patient care. Those cohesive messages whether they are about assessment/treatment methods/modalities, or exercise/advice interventions, need to be evidence informed, consistent and convincing. Most folks are cognisant with the concept that nothing is written in stone, evidence evolves, and what we seemed quite certain about today, may be proved entirely wrong tomorrow.

Q. So, where does that leave us?  
A. It leaves us all, frantically trying to make sense of an ever shifting environment, conflicting stories, personal opinion, interpersonal/tribal battles and #FakeNews.

Q. OK … so what is the solution?
A. That is the 64 million dollar question!

It is also a question I been battling with for a while. Unfortunately, I can’t pretend to know the answers either … and I expect the answers will differ anyway, depending on a range of factors, not least the psycho-sociological environment from where you view all of this. It is my guess that regardless of your environment most folks will feel elements of uncertainty and confusion, whether they are (Physiotherapy) clinicians, researchers, teachers/academics or indeed patients … and it is worth reminding ourselves (wherever we may fall on that spectrum) that everyone his their own ‘coal face’ and everyone contributes to the landscape highlighted by the BJSM editorial.

Here are a few tips or considerations on how to survive in a constantly changing environment.

1.     Evolve or die: Sounds a bit harsh, I know, BUT it is a fact of life. History reminds us, that emerging research has challenged much of our previously accepted knowledge. In addition, much of what we believe to be true today will become obsolete within a decade or so. It may be helpful to recall that one previous profession linked to ours did eventually get 'wound up' ... they were known as Remedial Gymnasts

2.     Be less dogmatic: 1. Above, dictates that dogmatic thoughts or deeds are unlikely to yield results. No system, method, school of thought works for all of the people all of the time. There are (pretty much) always exceptions to any rule.

3.     Get comfortable in the grey: This is difficult but essential. Most folk prefer black and white answers of absolute certainty. I’m sorry, but 1 & 2 above dictate that you may have chosen the wrong profession if you expect or demand that from Physiotherapy.

4.     Be less divisive and collaborate:  When Lewis & O’Sullivan (BJSM) said “the efforts of many institutions, including educational, healthcare, political and professional organisations, health funding bodies and the media, need to be involved (in change, sic)”… they meant it! Clinicians, and patients, clearly play a vital part and social media opinionists require a sense of social responsibility, if they really want to be effective change makers.

5.     Don’t buy into phoney wars: Physiotherapists have always been caught up in hierarchical factions and been led by colourful gurus, still (unfortunately) are. Why there is a need to create divisions’ remains a mystery, perhaps it is the frailty of humans? Regardless, the created phoney wars, appear to serve no one (except those who create them) and simply retard progress.

6.     Recognise how language can be manipulated: Controversial … not really, just a reality of life in a World of fake news. Unspeak is a language style adopted by commentators who wish to make counter arguments untenable. It is a tactic (weapon) used by those who prefer to perpetuate division or phoney wars. It relies heavily on opinion (not evidence) and emotion. It is created to make any alternative viewpoint seem abhorrent or untenable.

7.     Be … pro-honesty, pro-community, pro-evidence and anti-division (if you really have to be anti-anything): See 6 above and ‘Unspeak’ below.

Q. OK … so what is ‘Unspeak’ and what on earth has it got to do with physiotherapy?

A. Unspeak is a term that was coined by Journalist Steven Poole in 2007 in his book ‘Words Are Weapons’. Unspeak has crept imperceptibly into the narrative of Physiotherapy discussions. It is a tactic to make controversial issues unspeakable and, therefore, unquestionable. 

This VIDEO is an interactive documentary investigating the manipulative power of language. Watch it! Once you have recognised it, you will always be able to spot the tactics in ANY environment.
There are many examples; perhaps the easiest to follow is the pro/anti abortion one. Pro abortion campaigners began to call themselves ‘pro-choice’ … after all everyone wants CHOICE, don’t they?

But … in a clever manipulation of language, the anti-abortion lobby quickly countered their opposition, by referring to themselves as ‘Pro-Life’ … because who on earth would argue that they were ‘Anti-LIFE’?

Q. Yes, and …?
A. Oh sorry. The reason this came up again, is because it has been part of the narrative of physiotherapy for a little while now, to demonise certain elements of physiotherapy practice by referring to them (without evidence) as ‘harmful’ … or ‘low value’. It has been highlighted again by the recent and ongoing 'Hategate' controversy.

Q. So what is the problem with that … ?
A. Well here at last, we get to the point … ‘harm’ is a very emotive word, a little like ‘hate’, in fact the two may be associated or linked e.g. “the deaths and horrific injuries (harm) that occurred in the fight, were associated to the long standing hatred between the two gangs”. An extreme example YES, but one that illustrates that harm can truly be emotive. 

To allocate the ‘harm’ to a harmless modality (name your own example HERE .................…………..) seems somewhat disingenuous to say the least. If a modality has been shown to be ineffective or uneconomical (from a health economics perspective) then say so, that is fine. When I railed against this on SoMe lots of folk misinterpreted my stance, but since the ‘hate controversy’ has blown up, we are back full circle to the harsh reality of word choices.

Q. Can you give me an example?
A. Sure. At my particular ‘coal face’ (UG and PG Physio/Sports Rehab Teaching), we have to try and make sense of all of the incoming information (from researchers, clinicians, policy makers, SoMe commentators etc.) and contextualise and disseminate it for inquisitive minds. With the luxury of both time and resources, we do our best to keep up to date, and appreciate how busy clinicians must find that really challenging. We also know a lot more about how the words we use in a clinical environment with patients can affect them adversely (or not, depending on choice).

At the end of the day, very few people WANT to do harm. So when a physiotherapy or Sports Rehab’ student asks if say, muscle knots or massage are ‘harmful’ because they heard it said on the Internet. We try to add some context and perspective, and use that as an opportunity to develop critical thinking.

Q. Yes, but you know this is not about physical harm, it is about adverse psychological effects. So what is your problem?
A.  OK that’s fine, I see that they do occur (in some cases). So why not refer to them as ‘adverse psychological effects’ or delays to diagnosis/appropriate care? I just feel uncomfortable (in the same way as those who who perfectly understandably, dislike the use of the word 'hate') with the use of the language as a tool for demonisation, particularly in the absence of either a clear definition or any evidence to support the statements that are made.

Q. The term ‘harm’ is used in psychological literature isn’t it?
A. Yes, BUT ‘harm’ in this case is clearly defined as adverse events such as measured deterioration of old symptoms/appearance of new symptoms, suicidal/homicidal behaviour etc. See, Reporting of harms in randomized controlled trials of psychological interventions for mental and behavioural disorders: A review of current practice. The same applies to drug trials, where harm e.g. adverse, physical or psychological events are defined and clearly quantified. Creating an environment where certain treatments or people who administer them, are seen as 'harmers' in the absence of either definition or evidence, is a disingenuous and divisive narrative.

Q. OK … what about the word ‘Hate’ in the CSP #LoveActivity #HateExercise campaign, it has been suggested that this has made exercise “unspeakable”?

A. Yes, I saw that, and  is an interesting turn of events. Because of my interest in the use/misuse of language I have thought about it really hard. I think it is important to look at the context in EVERY situation. First of all what is the intent? If the intent were (for some reason) to demonise exercise, then you could perhaps make that argument. BUT, as I understand it the campaign … it’s not trying to do that. Rather, as I said earlier, the CSP campaign appears to be a well-intentioned strategy to raise the awareness and importance of physiotherapists prescribing physical activity and exercise. Whilst at the same time, like the American Heart Association information, it recognises that a large part of the population are not natural exercisers. The question mark appears to make that explicit, as a number of commentators have suggested. However, those who are opposed ethically, to the word 'hate' (and many are) will always find it difficult to get behind a campaign no matter how well intentioned, that contains that particular word. 

Q. So how do we all move forward from here?
A. Well personally, I'd suggest that it has become abundantly clear that the power of language can unite or divide and perhaps everyone has learnt from that. Going forward, we should all be better equipped to spot the manipulation of language in narratives, wherever we may encounter it. As for the rest, I would hand this back over to the two evolving sages, Lewis & O’Sullivan

They suggested we should:

1. Frame past beliefs against new evidence.

2. When in conflict, learn to evolve with the evidence.

3. Acknowledge the limitations of current surgical and non-surgical interventions for persistent and disabling non-traumatic presentations.

4. Upskill and reframe of practice, language (in all domains, sic) and expectations.

5. Consider aligning current practice with that supporting most chronic healthcare conditions.

6. Better support those members of our societies who seek care.

7. Be more honest with the level and type of care we can and should currently offer, and the outcomes that may be achieved (Lewis & O’Sullivan BJSM, 2018).

To do all of those things, will require a radical change of mind set which aligns with the current challenging health care climate. It is a global challenge that is well recognised and which Physiotherapists the World over can rise to … IF and perhaps only if, they can bring themselves to end the self-perpetuated, unnecessary conflicts.

Q. Alan … doesn’t that sound a little Utopian.
A. Maybe… maybe not.

Footnote: There is no guarantee that this Blog does not contain elements of Unspeak. 

Author: Alan J Taylor is a writer and critic who thinks about stuff and works as a Physiotherapist, University Assistant Professor and Medico-Legal expert witness ... The views contained in this blog are his own and are not linked to any organisation or institution. Like Bukowski, he 'writes to stay sane'. He once rode the Kellogs Tour of Britain and worked as a cycling soigneur.

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