Ep 305 – The Why Behind the What with Doug Nelson

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0:01:06.9 Darren Buford: I'm Darren Buford. 

 

0:01:07.6 KC: And I'm Kristin Coverly. 

 

0:01:08.5 DB: And welcome to the ABMP Podcast, a podcast where we speak with the massage and bodywork profession. Our guest today is Doug Nelson. Doug is the founder and principal instructor for Precision Neuromuscular Therapy Seminars, president of the 20 Therapist Clinic Bodywork Associates in Champaign, Illinois, and past president of the Massage Therapy Foundation. His clinic, seminars, and research endeavors explore the science behind his work. For more information, visit pnmt.org. And, good listeners, Doug is the author of the column, Table Lessons in each issue of Massage and Bodywork magazine. You can read his fine work at massageandbodyworkdigital.com, and in your print magazine if you're an ABMP member. Not an ABMP member? Learn more at abmp.com. Hello, Doug, and hello, Kristin. 

 

0:01:54.2 Doug Nelson: Good morning, everybody. 

 

0:01:56.3 KC: Hi, Doug. Darren and I are so thrilled to have you back on the ABMP Podcast, and specifically today's conversation about critical thinking, which we know is a passion project and topic for you. So we are thrilled to do a little deeper dive into this really important topic for all of our practitioners that are listening. So let's start, though, at the beginning, make sure we're all on the same page, what do you think of when you think of critical thinking? What's your definition?  

 

0:02:25.3 DN: Yeah, so when I think about that, I think about, It's just problem-solving. It's the, In a way, the why behind the what. So techniques are answers, but are they in response to the right question? So I love the part of critical thinking that is just self-reflection, like, How do I know what I know? And if I was doing a session, Kristin, and you came in and you were watching, at any point, if you snapped your fingers and said to me, "What are you doing, and why are you doing it?" I really should be able to answer that question. Right? Everything should have a purpose, everything should have an intention. And for me, it's so rich to be able to practice in that way because we can also... Then it's like, Well, why would you do this? And for me, Kristin, it's really about enriching your practice because for me, I get a chance to engage my hands right through just the challenges of what great palpation are. I get to challenge my head, it's the thinking process, the stuff that the client often doesn't see. But I'm processing tons of information to make decisions about where things go, and then I get to use my heart because I'm working with people who struggle, that's why they're coming to see me. And it's that person, human-to-human connection that is at the center of it all. So for me, as much as I'm crazy about this work, I'm a human being first, and it's that relationship first, and then the therapy part is the second piece of it. 

 

0:04:09.5 DB: Listeners, if you don't read Doug's Table Lessons column, I just cannot recommend it enough. When Doug submits it every two months, the editor is usually fighting over who's going to read it first because he's essentially sleuthing a problem as a client comes in. It's so fun to see where you're going and how you're working with clients, especially for the editors on the publication because we are not massage therapists, so we like to see how you think in your thinking process. But in preparing for this, I knew we were obviously going to talk about critical thinking, and you were part of a larger article that Ruth Warner wrote back in 2021 about critical thinking. And because we asked you at the beginning just about definitions, I thought I'd pop in with a couple here that I thought were enlightening from other people. We'll call them "dignitaries in the profession," about their thoughts about the definition. I like this first one from Alyssa Haynes, which was, "It's being able to step outside my own initial emotion reaction to something and look at it objectively from a variety of perspectives." I like that a lot. I like Susan Salvo, "It's the ability to make professional judgment based on facts." And I love this one, this one's my favorite from the Foundation for Critical Thinking. "Critical thinking is thinking about thinking while you're thinking to make your thinking better." 

 

[laughter] 

 

0:05:34.7 DN: And I thought about that, and that's that thing called metacognition, which is questioning yourself, and that is in some ways part of the richness of it all. And it goes back to that thing I was talking about. If every session is a multitude of decisions, then how and why did I choose what I chose? And I think once you get to a certain level, it's not like there's a right or wrong answer. If I'm going to drive to come and see you guys in Colorado, there's a multitude of ways that I could do that, I could jump on 70 and take a straight shot if I wanted to do it really fast, but what if that's not really my goal? And what if I have a passenger, maybe it's not their goal? So is there a more scenic route? So everything, again, should be based on very clear criteria, and then you design what you do based on where you want to go. And then that becomes the other question. Actually, we're making assumptions about where we want to go. Who decides that? And shouldn't it be the person? And I can think about, "My goal is to take you from your cervical range of motion, from your 37 degrees to 60/40." What they really want to do is be able to turn around and see their kids in the backseat. Right? That's what matters. So it flips it around to make sure that the goals that we choose are the ones that our clients actually... That matter to them. 

 

0:07:08.9 DN: So I love that from the VA, I think it's this thing of, "It's not what's the matter with you, it's really what matters to you." And flipping it around that way. And oftentimes with my clients, those have been startling conversations of... It takes a little bit to figure out, What is really the goal here? And to one of those quotes that you mentioned, Darren, sometimes it's important to step back and step out of it and think of it not from your perspective, but from their perspective. And then my job in a way is to figure out a methodology that will help them attain that goal, assuming that it's in my capacity to do that. 

 

0:07:56.6 KC: Doug, I'm curious, for the listeners who are getting excited about the idea, but now are almost overwhelmed about the idea of making a multitude of decisions during a session and really focusing on a mutual client goal. If they're not used to doing that and it is starting to feel overwhelming to them, even though they might be excited about it, what advice do you have for them to start changing how they think during a session or how they communicate with a client? How do they get started on that path?  

 

0:08:26.6 DN: If I can step back one step from that, Kristin? Again, I think it's being comfortable with uncertainty, I have to say, when I look back at my own career, in the past, I hung on to things, and it was rather rigid because I was more comfortable with that, and I was afraid to step out and afraid to fail. And unfortunately, at that time, what I didn't understand is, If you're not struggling, you're not learning. And being willing to embrace uncertainty is a really important thing because that is the way that you learn, and through that, you develop the confidence to continue along that process. It's funny, my wife and I have this little joke when she says, "How's your day?" It's like on the edge of greatness or total incompetence. 

 

[laughter] 

 

0:09:17.6 DN: In a way, Kristin, it's about confident humility, understanding for me that I don't know, and that creates doubt, and doubt actually is a good thing because from that, there are many things. You can have doubt and then close the door or you can have doubt and say, "There's stuff I don't know, therefore I need to do that." And that creates curiosity, and then curiosity leads to discovery, and hopefully discovery leads to implementation. And then suddenly, you know more than you thought you did. It's funny, I saw this cartoon this morning that is really appropriate, it's called Savage Chickens, but I'm going to adapt it to massage therapy. Step One, Just practice in the clinic. Just do what you do. And then Step Two, Make mistakes. Step Three, Learn from your mistakes. Step Four, Then you just repeat steps one through three until wisdom is created and feel good about that until you get to Step Five, which is, you realize the wisdom you had isn't really on target after all and now you have new wisdom. And Step Six, Repeat steps one through five for the rest of you. 

 

0:10:36.8 DB: Oh, you savage chicken, genius. 

 

[laughter] 

 

0:10:41.2 DN: But it's really true, and boy, have I lived that over decades of practice, that I just was willing to out-kick my coverage and then fail and struggle and then learn something and then, wow, okay... And then realize, "Oh, well, that isn't the whole story, and then, oh, well, that isn't the whole story." But you have to be willing to fail. And what I also find amazing is that clients are so willing to give you that leeway to fail if you are connected to them. And so many times clients have just remarked to me that I was the first person who said to them, "I don't know." But there are different kinds of I don't know. There's an I don't know, which is, door closed, and there's an I don't know, which is door open. And I could grab my phone and look at this text, but I'm seeing someone... I saw someone before the podcast, I didn't plan on doing that, but I couldn't stop myself, and I'm seeing somebody right afterwards, and the providers that he went to see for his hand pain said, "Don't come back because we don't know what to do for you." Like, oh, my gosh, with no like... And here's where you might... But just like, "We're out of it, you're on your own." And it's that... At one point, Darren, you and I were talking about the "fix it versus learn something" model. 

 

0:12:16.5 DN: And that was part of what came up in that Table Lessons is, Oftentimes people will see practitioners and it's like, "You don't have what I do, therefore I'm out of it." And you're left to your own devices. And for me, it is that I tell people, "If we do this, I am in this till it's over. Even if I'm not the person who solves it, I'm still involved. I will get you to be... And I will stay with you during that whole process, tracking how you're doing." "So just before we start this?" "No, you're going to have to put up with me through the whole thing because I'm full-blooded Norwegian, we don't solve problems, we just bore them to death." But it's that tenaciousness, what Leonardo da Vinci called "ostinati rigore," it's that just tenaciousness of not letting go. So to new therapists, I would say, Be willing to fail, embrace uncertainty with confidence. 

 

0:13:20.6 KC: Doug, I'm so excited about your approach because I think it is vastly different from what most practitioners do in a session. How should they approach expanding their education and expanding their reasoning skills?  

 

0:13:33.3 DN: In some ways, Kristin, it's the value of experience and practice, it's, you read, you study, like for instance, if someone has back pain, people will go, "It's the quadratus." Like boom. Right? And it's like, "Okay, fine." And then if I ask them more questions, suddenly it's like, "Oh, that doesn't really make sense." So what else would explain that? And what happens is in your little internal database, you have one thing and then you have two and then later you have three and you start building this out, but the one thing I would say about that, Kristin, of course, that takes time and takes study, but everything you add, you also have to find a way to take it away because at some point you can have a multitude of things and you're thinking, "Oh, screw it, I'm just doing like more general stuff because they're like they're 87 things anyway. It's like everything that you add to the list, you have to find a way to take it away. That does not include treating it with your hands because otherwise, it's too inefficient. One simple example, someone has pain in their neck and their range is restricted. Is it worse if I put them in extension and then check their range or if I put them in flexion? Does it matter?  

 

0:14:52.7 DN: Like if I put them in extension and then actually the range is reduced, it tells me that maybe the problem is something in the front, not the back because I've stretched the front and slackened the back. It's not perfect but it actually really helps. So is there some way I can include and exclude it? Because just sensitivity to touch is not necessarily the most accurate thing. And again, here we go, if you take low back stuff. Is the low back hurting because it's restricted and hyper mobile or is actually the low back hurting because it's doing too much because something else is doing too little? So now you get into this thing of, It's not just what muscle, but what role is it playing? And I never understood that until years ago. One of my clients, who was a psychotherapist, brought in this book, and when I said, "Oh, what are you reading?" He was like, "Oh, you wouldn't be interested." Well, you know how that goes, like, "Oh, yeah." And then I won't even say it because if I say the name of the book, everybody will want to get that book. All I'll say is, The book was on family systems. And I read that book and I realized, "Oh, my gosh, I need to think that way when approaching muscles, not just this one thing, but how does that one thing act in the larger context?" And that was transformational for me at that point. 

 

0:16:14.7 DB: And I think most of the leaps in my understanding in the musculoskeletal, the domain that I live in, have come for me outside of my own discipline because inside of my own discipline, I actually think I know, and I don't realize I don't really know, but when I'm outside my own discipline, I know I'm an idiot, so my mind is open, and I'm just applying those principles and translating them back. And then we're back to that, "Understanding you don't know is the doorway to greater understanding." 

 

0:16:51.3 KC: Let's take a short break to hear a word from our sponsors. 

 

0:16:54.8 KC: Anatomy Trains is excited to invite you to our latest in-person fascial dissection workshop, April 10th through 14th, 2023 in Boulder, Colorado. Join Anatomy Trains author, Tom Myers, and master dissector, Todd Garcia, on this voyage of discovery. Visit anatomytrains.com for more information. Let's get back to our conversation. 

 

0:17:22.7 DB: Maybe I'd add to that earlier definition just critical thinking, thinking about other things, as you've mentioned, not related to what you already know about because those are really transformational things. We do that all the time, and hopefully in our department, maybe not as much as we used to, but we'd like to get back to doing more of it. We like to have people outside of their comfort zones just to see how they brainstorm in various situations. Or not relying on the same people or the same group to always brainstorm or taking people completely out of environments that are in their comfort zone. For instance, we've taken graphic designers multiple times to art museums to get out of their head and to get into their thinking that influenced some of their training to begin with. 

 

0:18:09.4 DB: You bet. And for me, that's why when people ask me about just learning and whatever, having a discipline like arts or athletics, when you understand the process by which people go through this. When I've been around, I've been around some of the best of the best in both the athletic world and the artistic world, and when I see their process by going through that, it teaches me something about, Am I applying those same kind of disciplines and principles to my own craft? I remember hearing two artists being interviewed about creativity, and every time the interviewer said that, they just looked so annoyed. And finally, the interviewer said, "Am I saying something wrong?" And they said, "Yeah, we just call it 'going to work.'" 

 

[laughter] 

 

0:18:54.5 DN: Like you create something and it really stinks and then you work at it, it stinks less, and then at some point it's like acceptable, and you just keep working at it. And Da Vinci had the Mona Lisa with him for 40 years, yeah, when he died, like, "Really?" Yeah, but that's that constant reflection and, "I could do this better, I could do this better." 

 

0:19:19.9 KC: Yes, and I'm also going to jump in and say, listeners, for those of you who feel like, "I am so busy, I'm overwhelmed already, I don't have time for extra learning and education and reading and expanding my skills." Just schedule it. Put it on your schedule like you schedule your clients, like you schedule anything else. Make it learning and enrichment time, and like Doug said, do it a little bit each day. Build and build, and you'll be shocked at how easy it is to make that a habit. And to start shifting and thinking, then you'll start thinking and looking at the world in different ways, and your excitement to learn will be sparked. What do you think, Doug?  

 

0:19:57.3 DN: Absolutely. Absolutely. And again, the content in Massage and Bodywork, just read one of those articles and then read another one in a couple of days, and then think about a doorway that it opened, and then, "I wonder, what do I need to know about that?" And then you just start exploring other things. But you have to make it a discipline, you have to make it a process. There's a great saying, "Inspiration is for amateurs." I'm a new cello student, and sometimes after seeing a ton of people in the office, I don't always feel like practicing when I get home, but I just show up, and hopefully I'm getting a little better, hopefully. My wife doesn't close the door as much, I must be getting a little better. 

 

[laughter] 

 

0:20:46.1 DB: I think my answer there is to read Massage and Bodywork magazine and People magazine, and the reason I'm going to... I'm serious. The reason I'm going to say this is because you got to get out of your head. And some of the things that I'll do to get me out of my head are some of the things that I don't need to expend any energy on, and whether that's watching a TV show, something that's completely just going to remove me from that. And you won't believe it, sometimes things will just click and all of a sudden you'll connect two things and you're on a different path now. Actually, I need to ask you, Doug, what are some possible errors here? Is there a trapdoor that's waiting out there? And I've got a big one, I think it might be our own biases. Is that correct?  

 

0:21:25.6 DN: Yeah. Confirmation bias is one of the biggest ones, that once you hook onto something, and we've all done this, then you look for things that confirm it. And that's a problem. So to have an open mind in every session and to just question yourself as well, it's really, really hard to do that but that's where the richness is and that's where the learning is. I've certainly seen that in myself and I've seen that in others as well, that confirmation bias is really one of the strongest reasons that struggle happens in that way. So you need to be careful about... We all make assumptions. What is the assumption that you're making? Like sometimes, I'll play for people this picture of someone whose structure is really off. And so their goal is, "Let's treat this and this and this and this and this to make that person much more symmetrical." 

 

0:22:35.8 DN: But the reason for this person standing that way is, they're standing that way because it is the only way they are no longer in pain. And so the central focus of "find a way to right the structure" is actually a disastrous methodology. So it starts with that premise of, "Oh, if the structure is symmetrical, everything will be good." In that case, incorrect. And yet, there are other cases where that really does make a difference. So you just need to be too careful, you need to be careful about those assumptions, always question them, and know that in five years, the same thing that you came to, you're going to be horrified by. When I look back at stuff that I did years ago, it's just cringe-worthy, which I might say... 

 

0:23:25.1 DN: You could say it this way. If you look at your high school picture and you think your picture and your hair looks good, you should really worry because, like, wow, you still think... Yeah, okay. And if I look back at stuff I was doing five years ago, 10 years ago and felt really great about it, I should be really worried because hopefully it would mean I didn't really learn much. But it's always learning, always evolving, and that's why for us, like we print... I just sent in the manual orders for this weekend. We print the manuals for every seminar every time because we keep tweaking it, keep changing it. And we don't really realize those small changes over time really shift things. Somebody came the other day with like a manual from 15 years ago, and I told... "I'll buy that from you. Like, just tell me what you want for it because I want that out of circulation." So I think a confirmation bias is really a central one. And then availability error is another one. Like, for instance, I told you I just saw someone who has a hand problem, the next person I'm going to see also has that, so I have to be really careful. The next person is totally new, I cannot take, "Oh, you know what worked for this person this morning?" 

 

0:24:54.0 DN: You probably don't remember, but I think one of the first years I did the Table Lessons with this guy who came, I did so many different strategies with him, all failed miserably. And at one point, I sent a letter to his doctor and his PT, like, "I did this, this and this and this," and all these these reasons. This is the Norwegian way of saying, "I'm out, I got nothing left." And they wrote a letter back that said, "Amazing clinical reasoning. Keep us posted." And the guy showed me this letter and said, "I don't think you're off the hook." I said, "Well, I don't really know what else to do." And he said, "I'm sure you'll think of something," and he walked out of the office. And it's just, I'm not off the hook, I have to keep working, and and I did, and I ended up... Here's what's amazing, I ended up finding something that just solved it in that session. Game over. Like, God, I don't know how many failures. And then I found the answer and it worked. And later that afternoon, I saw a lady with the same symptoms that guy had, and I did that strategy, and you know what? It failed miserably. But the thing is, I had like 12 things that didn't work for him that I could draw from to treat her. So, again, the learning is in the struggle. Embrace the struggle. The struggle is reality. And oftentimes, when I'm teaching and I tell people that, I know they don't believe me because they think, "Oh, you're just saying that." 

 

0:26:25.0 DN: But when I have advanced strings and people actually come to my office and we treat people together, people will say, "You are lost." "No kidding, I've been telling you that for years. Like, yeah, that is my normal. This is real life. Anybody who tells you that it's like different... " For every complex question, there's a simple, direct, and wrong answer. And people thought, "You just do this and this." Like, yeah, you can tell those people actually don't have a practice because real life in the practice will humble you. And that's why for me, when I stop practicing, I'm going to stop teaching, because you end up with really simple answers or overarching theories to really complicated questions. I know what it's like to be in the clinic and fail and struggle every day, and I love it because it makes me better. Somebody said yesterday, "Do you ever... Are you going to retire? You're 66, you're like... " "Are you kidding? I'm just getting a clue. No way." 

 

[laughter] 

 

0:27:25.8 DN: I feel like I'm doing the best work of my career, and hopefully, next year I'll feel the same way, in the year following... " And how great is it for us to be in a profession that will continually challenge you? But it will only challenge you if you ask those questions of yourself. If you're comfortable, if like everything is going well, you're at risk, and I've seen that in people, when they just fall into this thing and their practice is full, but they're doing the same thing over and over again. I think, "They are not along for the profession." 

 

0:28:01.6 KC: Doug, speaking of asking questions, you were talking about asking questions of yourself. I'm curious, what kind of questions do you ask your clients in your client intake? Are you doing anything that you think is a little different than what most practitioners are doing?  

 

0:28:15.0 DN: Yet again, I'm clueless as to what most practitioners are doing, I'm so myopic, I have no idea. So all I know for me is, I want them to just tell me as much as possible about the story. In clinical reasoning, there are several different things. There's narrative and interactive reasoning, which is all about that. Tell me everything you can about this, things that make it better, things that make it worse, and things that you think may be disconnected might not be. And what I tell people is, "My job is to take all of that, those pieces of information that you think are random and disconnected. My job is to organize it into a model of understanding, and if I do that correctly, I should then from that model be able to organize a response that would create a predictable result." We call that "treatment." If I can't do that, it says everything about me and absolutely nothing about you. And because in the next Table Lessons that's coming out, I think it's this one, Darren, I never remember because we do them in advance, but it's about invalidation. And the number of people that say that they're experienced practitioners and then the practitioner... Well, that can't be true, those things can't be like... "Really? Like how often do we do this?" And then later realize, "Oh, oh, it was connected." 

 

0:29:49.9 DN: So with training, with experience, my diving into the literature, by all means possible, creating that depth of knowledge is a way to organize that which seems random into something that is not random, and then approach it. But to clients, they need to understand, If I can't figure it out, their experience is still real and it's their experience. And I think that's part of the thing, with that depth of understanding, that's why you work, that's why you read, that's why you study, that's why you practice, to have that rich database so that you can do that. I think that's a really important process. And when I see... I remember hearing this really famous pianist, and I was in this group that was studying the process of memory at the university. And so we asked this pianist, "How do you... " His ability to memorize stuff is crazy but his thing is like he chunks things. He has like these overarching things and can see how all these pieces fit together. I just see a bazillion notes and think, "How do you do that?" He's not seeing a bunch of notes. He's seeing these themes that he connects together. And when you have four themes that you connect together, it's a little different than 11,000 notes. 

 

0:31:15.4 DN: And that's the value of deeper understanding, is that you pick up themes and you don't get lost in details. I don't know who said it, but, "If the devil's in the details, then God is in the greater context." And I think that to have the wisdom to step back and look at that contextual thing just to me is just so amazing and so rich. 

 

0:31:41.5 DB: I want to thank our guest today, Doug Nelson. To learn more about the work Doug is doing, visit PNMT.org, and read his column each issue in Massage and Bodywork magazine. Thanks, Doug, and thanks, Kristin. 

 

0:31:52.5 DN: Thank you. 

 

0:31:52.6 KC: Doug, thank you for another incredible conversation. Our listeners are going to get so much from that that they can apply directly to their practices. 

 

0:32:01.0 DN: It's my pleasure. 

 

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