87: Shared Decision-Making (with Walt Fritz)
Episode Transcript
Summary: Shared decision-making: In this episode, Whitney talks with Walt Fritz about key challenges in the world of manual therapy. We delve into:
- How he got started in manual therapy
- How manual therapy differs in physical therapy and massage therapy
- Ways to break down silos between our professions
- How important are specific techniques in our treatment strategies
- The value of working with clients in shared decision-making
- …much more
Get the full transcript of their conversation on Til or Whitney’s sites:
- Til Luchau’s Advanced-Trainings.com
- Whitney Lowe’s Academy of Clinical Massage
Resources:
- Free talk on shared decision-making
- Walt’s website
- Kolb, W. H., McDevitt, A. W., Young, J., et al. “The evolution of manual therapy education: what are we waiting for?” Journal of Manual & Manipulative Therapy 28(1) (2020): 1-3.
- Roy, N., Dietrich, M., Blomgren, M., et al. “Exploring the neural bases of primary muscle tension dysphonia: A case study using functional magnetic resonance imaging.” Journal of Voice 33(2) (2017): 183–
–194 - Roy, N., Dietrich, M., Blomgren, M., et al. “Exploring the neural bases of primary muscle tension dysphonia: A case study using functional magnetic resonance imaging.” Journal of Voice 33(2) (2017): 183–
–194
Whitney Lowe:
Welcome to The Thinking Practitioner. Our podcast is supported by Handspring Publishing. Their catalog has emerged as one of the leading collectors of professional level books written especially for body workers, movement teachers, and all professionals who use movement or touch to help patients achieve wellness. Handspring has recently joined with Jessica Kingsley, publishers’ Integrative Health Singing Dragon Imprint. Head on over to their website at handspringpublishing.com to check out their list of titles. Be sure to use the code TTP at checkout for discount. Thank you again, Handspring.
We’re also sponsored this week by the Academy of Clinical Massage, where our mission is to help you become a better practitioner working with pain and injury conditions. 2023 is bringing a complete overhaul to our comprehensive orthopedic massage program. We’re excited to announce some new opportunities to make our training even more accessible. Our full professional program package now includes numerous perks in addition to the coursework. We have just introduced a new payment plan for that program to make it fit your time and budget even better. Check out more details of that program over at academyofclinicalmassage.com.
Welcome everyone to Thinking Practitioner. I’m absolutely delighted to have my friend Walt Fritz in with me today. Good day, Walt. How are you?
Walt Fritz:
I am doing well, Whitney. Thanks so much for having me here. Really appreciate it.
Whitney Lowe:
Great. For our listeners who might not have been introduced to you yet, can you tell me a little bit about your background experience, what you’re doing, what you’ve been doing, and what you’re up to right now?
Walt Fritz:
Absolutely. I’m a physical therapist based out of upstate New York and been a physical therapist for a long time, 1985, graduate of the University of Buffalo. Since then, been doing a lot of different things, pediatrics, home care, general hospital, developmental disabilities. Throughout that path, I’ve kind of… Well, no, not kind of. Got into manual therapy, because PTs, we touch, we do manual therapy, but possibly in different ways or from different perspectives than the massage therapist.
I was introduced to manual therapy via Myofascial Release, cranial psychotherapy, zero balancing. That’s what got me started, which I kind of followed the Myofascial Release route for a number of years, and then for a lot of reasons, ended up leaving that model and looking for a new sense of self and a new community. That’s what, over the last 15 years, led me on my own path of where I’m at right now, which is teaching and practicing manual therapy from a very non-traditional non-conformist type perspective of shared decision making. I hope we have an opportunity to talk about that, if you’re interested.
Whitney Lowe:
Absolutely, yes.
Walt Fritz:
Yeah, because it’s really been the focus of my work, my research, my writing, and my practice for the past, really, 6, 7, 8 years is the shared decision making model. I continue to teach Continuing Ed seminars. What started more as massage therapy PT directed classes has taken an interesting left-hand turn. I’m now primarily teach speech pathologists, and other people working in voice swallowing, breathing, oral motor disorders, but that includes a fair amount of massage therapists who come to my classes for various reasons. That’s my nutshell.
Whitney Lowe:
All right. Well, that’s got a rich group of things that we want to dive into. I want to go all the way back to the beginning here and we’ll wheel our way through some of those things there. Tell me a little bit about your beginning entry into manual therapy. The whole issue of manual therapy is viewed, at least from my perception, a bit differently within physical therapy from what a lot of our listeners do who do this on a regular basis. What was it that got your interest piqued about doing more hands-on manual therapy work? Because I know a lot of people in the… A lot of my colleagues that I’ve talked about who are in the physical therapy world feel like they don’t get time to be able to do that kind of thing because of the pressures of some of the economic models with the insurance reimbursement, things like that. What got you going down that path?
Walt Fritz:
Well, we had a fair amount of manual therapy education in college. It was a bachelor’s degree program back then, so a lot less time for each module, so to speak, versus the doctoral program of the present day. But that included, we learned massage. We had two very compressed and rather lame weeks of massage training, which technically, legally licensed us to massage, having helped the patient who actually relied on me for that kind of care. But manual therapy is a broad term.
To physical therapists, manual therapy can mean joint manipulation, joint mobilization, and very frequently in the literature, manual therapy is codified for joint manipulation, spinal manipulation, but it really is the broader term that I view it at as any kind of touch based interventions. I know that in the early late eighties, early nineties when I was a new practitioner, working in a more generalist model, I was doing early intervention at the time… we hired a physical therapist at the clinic I was working at who had done some training in Myofascial Release cranial psychotherapy back in the eighties. He did a healthy amount of real and metaphoric arm twisting to me to get me to take a Myofascial Release cranial psychotherapy class.
I was reluctant because at the time, my national organization, the American Physical Therapy Association, was really down on manual… I’m sorry, down on Myofascial Release, especially, and was doing a concerted effort of trying to discredit it. I read that every month. I really had no interest in it, but the arm twisting worked. I took a class and I got hooked. It was… Without sounding like I’m sexualizing it, it was very seductive. It was very intriguing, what happens when you get in a room with a speaker who’s good at speaking, who’s good at selling, is good at convincing. I don’t mean that in a negative way at all, but the story becomes very compelling. Combine the story with the actions, the “outcomes”, yeah, I went head first into that rabbit hole. I went hard. Went hard into the Myofascial Release rabbit hole especially, so much so that I then worked for that particular person for 10 years as a teaching assistant.
I learned a lot. I learned a lot of really good hands-on skills. I learned a lot of really good interaction or relationship pieces with not only my patients, but also all the students that I was responsible for helping. It wasn’t until later that I really realized that in order to see the force for the trees, I had to leave that model and try and get some good critical thinking skills embedded in my brain beyond just that secret story of the fascial and everything else.
I’m a PT. This is what I do. I have a very small practice here in upstate New York where I do accept some insurances. You talked about the economics issue with traditional physical therapy therapists having trouble applying manual therapy. It is more time intensive. It doesn’t fit well with that model where you’re in a big clinic with multiple people, both support staff and clinical staff, with a huge budget, et cetera. Reimbursement dollars aren’t always the greatest. As a result, the PT is seeing multiple people at once, but I continued to see one person at a time, I think probably just like you, Whitney, and just a lot of your listeners. If you walked in my office, it would look a lot more like a massage office than it would a physical therapy office. It’s just some of the things we do.
Whitney Lowe:
There’s been a lot of buzz and talk within our profession in the massage therapy world about improving our training standards and credentials. We’ve talked on this podcast with a couple different guests about that. I’m curious to hear what your thoughts are about the move to the DPT model in the physical therapy profession and how that’s impacted individual practitioners, or the access to care from patients.
Walt Fritz:
I look at it in two different ways, and both of them really are oppositional. I think as a professional accomplishment, as a notoriety for the profession, as well as really having some really high standards, I think the DPT has been really good. I think it’s a bit overkill. I think they could have stopped at the masters and got enough education and information and clinical experience to students in back then, but they moved right along to the doctorate profession. I know that it is, in many cases, it’s priced the student, a lot of students, potential students, out of the market because any doctorate program is really expensive, especially when you then look at the commensurate pay that you’re getting for a doctoral level position and job that doesn’t quite keep pace with some of the other doctor professions.
I don’t know. I’m a moderator of a lot of groups on Facebook. One of them is a massive physical therapy group that it seems like every week there’s somebody really questioning their choice as a physical therapist. A lot of it comes down to economics and the crushing caseload that a lot of physical therapists are expected to maintain. You know what? I’ve been able to stay away from that, having my own practice and doing things my own way. I’ll probably retire doing this. It’s not a great concern of mine, but I know it is for the profession.
Whitney Lowe:
Yeah, I’ve probably read a lot of those very same threads that you were talking about because that’s what kind of got me wondering about this, was seeing a lot of discussion in a number of those different physical therapy groups about these very issues and just wondering like, “Wow, are we trying to stare down that rabbit hole and go down this same pathway of continuing to..?” There’s some discussion about, somebody called it credential inflation, I think was the term that they were using, about just constantly feeling like we need to up the level of credentials and keep pushing and keep pushing. So many of the physical therapists in practice were doing a lot of what chiropractors and physicians were doing and that type, in terms of the level of involvement with the assessment and treatment process and thinking like, “Well, we should be doctors also.” I think that’s part of what drove that model to the DPT.
Walt Fritz:
I do think that the… Well, the evidence-based model really didn’t come into play until the nineties. I graduated from PT school well before evidence-based practice was the required norm, the expected norm in the physical therapy profession. There’s a lot of detractors of evidence-based practice. I understand some of those concerns, but I think a lot of the concerns stem from one’s own beliefs and experience not aligning well with current based evidence and the expectation of an evidence-based practitioner. I do see from clinicians coming out with that DPT, and certainly the masters of physical therapy, and maybe to a lesser extent, older people like me, really a solid understanding of what it takes to make an evidence-based model is it’s lacking in people like me, but that’s really at the forefront.
From other professions, I see it really easy to sell people on things that are counter evidence-based. It almost develops a cult like following to not be evidence-based. That’s not just in our shared professions. Look at the world today. Without even getting political or social, it’s almost like… We’re running in parallel universes and there’s just thousands of these parallel universes. If you spend any time on social media, you’re reading all these things in a niche group. It’s all about the fascia, it’s all about the trigger point, it’s all about the neurotics, it’s all about this and this and this. It’s like, man, oh man, aren’t we working with a human being and not a collection or an isolated tissue, or pathology, or view of how things work?
It’s a frustration for me. I’ve been very frustrated. I’ve been very vocal. I’ve been probably not the most popular person in some groups because I’m not afraid to say that the emperor has got no clothes, but they’re not always popular things to hear and say.
Whitney Lowe:
Yeah. I want to follow that thread a little bit farther and call back… I’m pretty sure… Well, I think this is something that you said to me. Somebody said this to me one time, and I think it was you when we were having that conversation we were just talking about in the green room before our thing, about when the last time we were together in Winnipeg, I think it was, having lunch at a conference. I believe it was you that said this to me. If you took three or four different practitioners and put them in a room and videotaped what they were doing and took the sound off, and then asked what was being done in those treatment sessions, what techniques were they using, what modalities were they using? It would be really hard for the observer alone to say what was being done just based on what they’re seeing performed, that so much of this has to do with the narratives that we create around those types of techniques. I don’t remember if that was actually… Was it you? Do you remember?
Walt Fritz:
Yeah.
Whitney Lowe:
Yeah. I thought that was such a brilliant analogy. I’ve stolen that and used it many times in talking about this, but this issue about these particular modalities or silos that we create seems to produce a lot of obstacles in that way. I think that was a great way to break some of those barriers down.
Walt Fritz:
Yeah. I see it in the massage world. I see it in the PT world. I see it now that I’m in these other world speech pathology and oral facial mal functional, that we’re all so blinded by the narrative of our story. I really, I guess I’ve modified that story since we met in 2015 a bit, and maybe a bit smoother to tell that story, but it’s still true. You step far enough back and basically we’re touching another person, but yet as you get closer, we get closer to each one, then the story gets magnified of what we think we’re touching, what we think is wrong with the person, what we think that our touch is capable of influencing.
You and I have been there, and hopefully you and I aren’t in the driver’s seat of teaching people this, but it gets really tough to say no to a really good story when you’re presented not only with the work and the outcomes and you feel better from it, but then somebody gives you what is said to be evidence in science to support that.
When I was taking this work back in the early nineties, I didn’t have enough critical thinking skills or research based chops to really adequately question evidence as it was presented to me. I basically just accepted it because the work was so helpful. It’s a classic inroad to postdoc fallacy. It’s like people tell you something, this stuff works, and you believe their story when those two things might not have anything to do with each other. I think it’s really unfortunate.
I do think that I, or we, are in minorities there, and it’s tough when you start going out there. You know this, because you’re out there on the road, and you start talking to people who have a firm set of beliefs, and it’s not just manual therapy beliefs, it’s social, it’s political, it’s religious belief. We don’t like to change our mind, because why should I?
Whitney Lowe:
Do you think… This is something that I pondered in talking about this with a lot of people around this whole issue of these narrative models around our theoretical ideas, what we think we’re doing, a lot of times some people, does that matter? Does it influence the treatment at all? For somebody who is really bought into this particular model and they get really good results and what you often hear, “Well, I don’t care because I get great results and it works for me.” Does it matter then that we’re really trying to make those narratives more accurate? I’m curious to hear your take on that.
Walt Fritz:
Yeah. You can almost step back from that and ask almost at a philosophical level, is it a lie if you don’t know it’s a lie? Is it a mistruth if you believe it to be true? I don’t know. That’s a real moral and ethical type of quandary for each person.
I look back at my MFR days and I was telling what I thought were truths. My great undoing was this soma simple debate of 2005 where I went head to head with some really smart people who knew a different story than I did. That made me… That was a five year whirlwind of me having to really look at everything that I believed and trying to make amends for that.
I don’t know. That’s a hard one. I believe that the more I learn, the less of which I’m certain, which is really a difficult thing because I sounded really smart 15 years ago when I was an MFR expert. Now, I think I know a lot more, but I may not sound quite as knowledgeable because I know there’s a lot of uncertainty in everything that you and I do and teach. I actually enjoy that uncertainty. I’m really comfortable sitting in uncertainty, but I do understand that number one, a lot of people are not comfortable there. Number two, we get so invested in our leader, in our mentor and our teacher and our guru, whatever that is, that it’s painful to actually even have to open that door and say, “Was this person, not wrong, but not totally correct?”
I can understand and empathize with clinicians’ difficulty. You’re on a bunch of the same groups as I am on social media. There’s a lot of constant hand ringing. It’s like, “How do I come to grips with all of this?” Everyone’s in charge of their own path.
Whitney Lowe:
Yeah. One of the metaphors that I’ve gone back to over and over again about dealing with that myself, because I certainly have had those same quandaries and instances in which my former world model of how I thought everything worked in the manual therapy world got really cracked and fractured and led me to question a lot of the things that I was doing. But a metaphor seems to give me some sense of solace or comfort around that is a comparison with the world of physics. I’ve always been fascinated with that.
You look at something like mechanical, classical mechanics, which is Newtonian physics about how forces act on things at a certain level. There’s rules and guidelines that are helpful to give us an understanding, to give us a framework to be able to understand some of those things. But when you get down to the subatomic level, those things don’t work anymore.
It’s not that we should throw them out. It’s not that we should completely say this is irrelevant because the stuff at the subatomic level has told us none of this really works. That’s not really how it works. At a certain framework and at a certain level, that’s a pretty good model for describing the sense of reality of what we encounter, but also recognizing that at another level there’s a place at which it breaks down and you need to shift your frame of reference and be able to look through a different lens at things. I do think that’s challenging, but often also think it’s helpful to give us some models of ways to look at it.
Walt Fritz:
Yeah, I know it was interesting because when I started teaching… Well, I taught for John Barnes and Myofascial Release, God, for a while as a TA for him. Once I left that model, I moved off on my own. It was interesting because in that, when I was still teaching Myofascial Release back then, I had evidence. Or I had the evidence that other people thought was important.
Basically, I was quoting, or writing. If a study was complimentary to Myofascial Release, then I used it. I cherry picked that. If it wasn’t, then it didn’t go on my reference list because it wasn’t proving what I wanted to prove. That worked for a while. I don’t want say it worked because it was PTs and massage therapists, it worked because that’s the model I presented from. I think that’s probably the most fair.
But then, in 2013 when I started getting introduced and got invited into the speech pathology community to start teaching to them manual therapy, there was a very different structure on how they look at work, what kind of evidence they need in order to even consider. Then that was part of really part this long process of saying, “I need to be able to better support not only what I do, but how I explain it.” That big wall between outcome-based studies, which is we need them. We need outcome-based studies when we do… I’m going to use Myofascial Release. When we do Myofascial Release, a person got better, but what is that study saying? This took a long time. What is that study proving? Is it proving that fascia was restricted, or is it proving that when we do things that we call Myofascial Release, that’s helpful?
Unpacking that, and to me, the past five years really getting to the core of some of the explanations of mechanism of actions about touch, both from that tissue-based quality, the neuro center qualities, the behavior qualities, the autonoma… Everything that co comes into play there, it’s really frustrating, it’s confusing, it’s deep. It’s just magnificent work because there’s so many possibilities for why a person is helped when we touch them, but yet, each of these little camps breaks it up into this small little thing instead of saying, “You know what? We’re touching a human. Anything else is just… It’s speculation.”
Whitney Lowe:
Yeah. With that being said, and this is a question I hear a lot from people as they start to grapple with these difficult models and difficult questions. How much does that technique matter in comparison to some of these other things that we say are relevant aspects of that human interaction and that therapeutic alliance?
Walt Fritz:
Sure. Well, what is a technique? To us, as we’re taught it, often the technique is how we place our hand, the direction we move, the amount of force we use, all those things that come as an enmeshment of the modality or model that we learn. But when you really look at what a technique is, there’s incredible contextual aspects to it. People don’t like the word placebo because it seems… They mistake what it is and what it isn’t. But when someone comes in to see me, “expert”, that carries context. That carries value in and of itself, especially if it was a referral source from somebody they really trust.
They’re walking into our room hoping and expecting from us to have the answers. Here we go. We tell them this story of fascia, or muscle. Fill in the blank of the thousands of things we talk about. They sit there and they nod their head like they really understand. They’re just saying, “Okay, come on, get on with it. Help me. Help me.” How much is it? How much is the technique of the actual physical thing that we believe we’re doing to the tissue? How much of a technique are those larger aspects?
I’ve been reading a lot lately of the concept of interoception and how C tactile afferents feed into interoception via contextually appropriate touch, et cetera. Interoception, to simplify it for myself, is a person’s ability to self-regulate. When we touch somebody in a certain way, we’re turning on a person’s… I hate using some of these words because they get a little colloquial, like self-healing mechanism. That can go a lot of different directions. But the human being’s ability to self-regulate our own internal environment, there’s actually evidence out there that says our contextually appropriate touch can actually foster those centers in the patient by simple transmission through C tactile afferents. That’s not about technique at all. That’s almost about effect versus technique.
Touch is complex. There’s so much good evidence out there. It’s not just in the manual therapy literature. It’s in the behavioral, the psychological literature that’s talking about some of these… All these overlayments of how touch can impact the human being, not the muscle.
Whitney Lowe:
Yeah. Let me ask you this in terms of when you’re working with some… I’m going to create a hypothetical situation here because I’ve had this happen numerous times. You’re working with somebody who comes in very much attached to a particular narrative about what’s going on with them. My fascia is twisted, my trigger points are on fire, whatever it is the story. That story doesn’t really fit with what, let’s say, our current understanding is of the evidence, but they’re on this story and very attached to this story. How do you work with that? Because I’ve made some bad mistakes early on by trying to correct those stories and created a really dysfunctional non-therapeutic relationship problem there that was then ineffective. How do you deal with that?
Walt Fritz:
I deal with that by, first of all, never feeling like I have to take their story away from them. All right. I want to form a therapeutic alliance with this person. Often, that means don’t do anything to break it. If I immediately start just tearing their beliefs apart, and whether it’s their internal belief system or someone else from their past and present who’s helped them adapt that story, it seldom works out well if I end up demeaning them, or demeaning another person. What I do is I bide my time. If they turn it into a question to me, that’s when I have an opportunity. I’m pretty good at staying quiet anymore, which is an art for me. It took a long time to learn, but you know what? Somebody’s story, it’s their lived experience. No matter how much you and I know, we’ve not lived their life, so don’t insert that into that, that I know this person’s life, but should you, Whitney, say to me after we do our evaluation or whatever is we’re doing, “What do you think about those trigger points, Walt? Are they worse then you ever felt?”
I could say, and this is kind of how I model this with my patients as well as with when I’m teaching this work, it’s like, “You know what? A lot of people think that those tight spots are trigger points, or are really our trigger points, or fascia restrictions,” or fill in the blank. Then what I like to do is insert an alternative narrative. Now, that narrative tends to come from my perspective. I tend towards more neuro centric explanations. I said, “It could be that trigger point that your doctor told you about, or it could be a neurologic remnant from a past injury that your nervous system simply hasn’t let go of yet.” That’s not exactly a perfect science-based explanation there either. It’s simply giving them the opportunity to see that there might be more than one way to look at a problem.
There was a study that I wish I had my hands on it. I read it years ago, but it was at the onset of the pain science movement, when things were shifting from tissue-based stories to the pain is a construct of our brain, et cetera. There’s a lot of talk about something that’s just guaranteed to start a flight on Facebook. It’s about pain science, but what it was was a study done for physical therapy for non-specific low back pain where what they wanted to figure out was, did pain science education make a difference in a patient’s beliefs? What they did, they constructed this study where the physical therapy session was simply an education session. They did a pre-interview and a post-interview with the patients.
Basically, the patient came in, they said, “Okay, patient, what do you think is going on with your body?” Invariably, it was something along the lines of tissue damage or muscle weakness. Those are two classic things, or other their posture. All those other things that we like to blame.
In essence, it was an hour long education session by the PT providing them the most up-to-date pain science education, dumbed down a bit for the patient to understand. Then they did the post interview. This tremendous majority of people walked out still believing what they believe when they walked in, which is either really, really bleak, how much does their education matter, or more of an eye-opener for us that narratives are tough to change. Mine are, yours are, and so are the patients.
Whitney Lowe:
To me, that was really… I’ve read the similar study. One of the things that struck me about that was, and I’ve mentioned this a number of times on the podcast, I have a passionate obsession with learning science in addition to what goes on with our clinical work here and learning a lot more about neuroscience and the process of learning, and the idea that we can have somebody walk into our clinic and instruct them on the complexities of the neurological system and these concepts in a few minutes of an interview discussion process with them and have them really get it, when it took us, often, many of us, clinicians, years and years and years of gradually moving towards that by constructing and assimilating knowledge based on compiled understanding of things. It’s a little bit naive to think that we can do that in just that short few minutes.
Walt Fritz:
It is, yeah.
Whitney Lowe:
Another thing that’s kind of about this in terms of the way people look at things, and this kind of gets back to the whole brain science thing. My wife often makes fun of me because I cannot find things that are right in front of me. I’ll go look for it. “Do where my teacup is?”, and it’s sitting on the counter right in front of me. I know this is of course getting worse with age now too, but the thing that’s interesting about that is the part of brain function that’s happening there, which is that I’ve got a picture of what that particular thing looks like and where it should be. If it’s not right where I think it should be, I will actually not see it. Really, my brain will actually not register that it is actually there, even though, visually, it might go through my eyes. The brain which assimilates all that visual information just will not see that. I think that’s a lot of times what we’re talking about with the frameworks that people come in with. They have that framework and you just cannot change that in a session or two. It’s not going to happen.
Walt Fritz:
In terms of evidence, et cetera, people are often asking me, what’s the evidence you use to support your work? Which is a valid question. There’s one paper, there’s one, whatever, that totally sums up an entire process. I actually just wrote, I just wrote a little post, or put it on social media a week or two ago. If I really had to evaluate myself and take a look at what I’ve learned, and especially in the last five years with all the writing, et cetera, that I’ve been doing, I think there’s one paper, Whitney, that was really most pivotal in getting me to see the forest for the trees, if you will, on that.
Believe it or not, it’s a 1957 paper by psychologist Carl Rogers. Carl Rogers, and I so love this paper for what it says and what it doesn’t say because Carl Rogers, in 1957, wrote this paper and presented it at a psychological conference that basically got him ostracized from the profession. He presented a paper which said, in essence, that it’s not the modality that you use. It’s not the tool that you apply that creates change in another human being. It’s the relationship that you build with them.
I thought, okay, we can only transfer so much of that to a manual therapy, physical therapy context, et cetera. But that view is something that needs to be looked at today where social media and every other kind of advertising is just loaded with all these camps, all these modalities, all selling the best things since sliced bread. We need a good dose of Car Rogers saying, “What’s the common denominator in each and every one of these interventions?” It’s the relationship that we build with another human being.
Honestly, that’s where more of my interest, not interest, but learning has been over the last five years, is looking almost at those psychological and philosophical aspects of the relationship that I have with a patient and I have with a learner in my classes.
Whitney Lowe:
Yeah. Yeah. That’s fascinating. Interestingly, Carl Rogers wrote the book that ended up being my very favorite book that I read during my time in college when I was a psychology student. He wrote a book called Freedom to Learn, which was about the learning process. It was sort of a groundbreaking book for me because I had been, up until that time, very attached to this model of you have to go to school to learn X number of things. That’s where you go get your learning done, and then you leave. That book really opened my eyes to understanding that learning is really all about what you want to do, when you want to do it, and how you make it apply to all kinds of things. As a 20 year old college student, you use that book as an excuse for, “Well, then it really doesn’t matter if I study after the test or before the test, because yeah, if I really want to know this stuff and learn it, I can learn it later on.” That was my excuse for not getting good grades on things sometimes.
Walt Fritz:
There you go. Yeah, yeah.
Whitney Lowe:
Well, listen, I want to change track, or shift track a little bit here and talk about your shared decision making model and that clinical reasoning process, because this is another topic very near and dear to my heart. Tell me what you’re into in exploring now along those lines.
Walt Fritz:
Well, okay, can I do a shameless plug here?
Whitney Lowe:
Yeah, go for it. Yeah, we’re all about that here on the Thinking Practitioner.
Walt Fritz:
Perfect. I got a book coming out. The book is called Manual Therapy and Voice and Swallowing, A Person-Centered Approach. It’s being published not through Handspring, sorry, but through Compton Publishing. As a result of that book, that really forced me… Not forced me, I chose to do it. That, plus I embarked on a master’s program during Covid when nobody had anything to do. Between the masters, as well as the book, it essentially allowed me an excuse and a reason to really reframe how I look at my work, how I explain the work and the underpinnings of my work.
The thing that kept coming up repeatedly is the distinction between the clinician as expert model and the shared decision making model. Diane Jacobs, who you’re probably familiar with, and Jason Silvernail, they wrote a paper back in 2011 on the operator versus the interactor model. The operator is, in essence, the clinician as expert model. People come in to see us. They deferred to us just about all concerns, all decisions to a certain extent, certainly it’s variable, but they need help. They come to us because we’re experts. They’ll often defer to us to allow us to make choices for them.
Quite frequently, let’s face it, Whitney, that’s how you and I were probably trained. I can’t speak for you, but I was. That we’re expected to know what’s wrong with them, and we’re expected to know the best intervention. That biomedical model, that works. It’s been proven for decades now, but there’s been a movement over the last couple decades of trying to recalibrate the power in that relationship.
Diane and Jacob and Jason talked about it as instead of being an operator, one person basically running the machine, as two people interacting with each other. I think there’s a lot of similarity between their theory, or their proposal there, and a lot of the evidence in shared decision making, both in behavioral as well as the physical sciences.
Essentially, the way I bring that to the public is through the statement, “I know a lot.” I’ve learned a lot, I’ve trained a lot, I’ve experienced a lot, but there are key things missing from my knowledge. That’s essentially knowing your lived experience, knowing your values and expectations, knowing your fears and hopes, et cetera. What I try and do is incorporate my version of a shared decision making model by, in essence, let’s just pretend here a moment we’re looking for a problem that my training said to me, “Oh yeah, there’s that fascia restriction. We found it.” We’d tell them about it, and then we’d make suggestions on what we should do with it.
But in a very simple form, what I try and do now is I still do that palpation model. When I feel it, or what I think to be it, instead of saying, “Walt, you’re so brilliant, you found it,” what I do is shut my trap and say, “What do you feel? Whitney, what are you feeling right now?” Without guiding, without leading them on to say, “What do you feel here?,” or, “Do you feel your pain?”, by trying to keep these open-ended questioning. What do you feel gives a person chance to answer from a very wide lens. I feel pain. I feel pain. I feel fear. That makes me anxious. Whatever. Giving them the opportunity to answer with an open lens instead of a very closed lens. Instead of me telling them what should be done, to me, evaluation and treatment are… Now, I use the slow static dry engagement that’s very typical of Myofascial Release.
I don’t call what I do Myofascial Release anymore because I don’t think I’m treating fascia, but I still use that model. Instead of me then doing the things I was taught where it’s taken up direction of ease, and they’ll take up the slack and all those things, I use that kind of model in a wandering exploratory style fashion, but by telling my patient that I need their help. I need them to tell me what feels like it might be helpful, what feels like it could be a positive engagement, or conversely, if there’s anything that feels threatening, or a waste of time. Patients sometimes really balk at a shared decision making model because I don’t… Force is too strong of a word, but I highly encourage them to become an active participant in it. Some patients relish that, other patients really… “No, I don’t want to do that. They go. They leave. They go look and find somebody who will be the expert and tell them what’s wrong with them and what should be done.”
But to me, shared decision making, well, if you look at the evidence for shared decision making, there’s smaller pockets of evidence in the manual therapies like you and I are doing in the shared decision making can actually ramp up outcomes, but in the larger medical and healthcare sense, there’s ample evidence to say empowering a person in their own healthcare decisions actually improves outcomes, improves patient satisfaction.
Whitney, patient satisfaction is one of the most massive contextual factors that you and I can leverage. In a nutshell, that’s the way I go about shared decision making. When I teach a class, one of the first things I say is that while all of you might have thought you came here to learn some nifty hands-on skills, what I really hope you leave here with is the ability and willingness to apply shared decision making, not just in manual therapy, but everything you do in a therapeutic environment. That really is my goal. I just use touch manual therapy as the way to accomplish that.
Whitney Lowe:
Yeah. Let’s say for people who might be a little bit newer to these concepts and ideas of shared decision making, how does somebody learn more about this, or begin to build skills around this? Because it’s something that I don’t think is covered very well in most of our entry level education programs.
Walt Fritz:
Yeah. Well, okay, so another shameless plug. I have a free one hour course on my website available on shared decision making that covers a… I cover just the tip of the iceberg there. Both if you want the theory, the science, the evolution of shared decision making, but also some more practical ways on how to go about beginning to incorporate shared decision making in your current model.
I teach shared decision making from my slow static MFR style of touch, but I think you can use it with any kind of model. I give the example for physical therapy and exercise. Exercise, shared decision making model. There’s a podcast that I really appreciate because they’re coming from a really strong evidence based in the physical therapy world, but there were two people, the moderator and a guest who were joking when it come to patient-centered care. They joked that it’s not like you can ask a patient what they should do for an exercise.
That got laughs out of both of them. You can’t totally hand it over to them to say, what exercise should I do? Or what manual therapy or massage technique should I do? But I think we can meet in the middle.
Okay. I’m going to use the example of when I had my rotator cuff repaired seven or eight years ago. I did the repair. Then I went to PT and my 13 year old physical therapist, he did a decent job. He seemed like he was about 13, but it felt like he was basically pulling the sheet of paper out of the file cabinet, rotator cuff repair, here’s what you do. Basically hooking me up with theraband, doing this stuff that we do. All the while, I’m grousing because what does this 13 year old know? And all that stuff. Get out of your own way Walt, et cetera.
But there was a really interesting observation on my part that I was doing these exercises and it’s like, you know what? This isn’t quite hitting that note in my brain of relevance to me. I never was a good direction follower in school. I’m 63 now. I’m still not. Because what I did was when he wasn’t looking, I’d start to wander. I’d start to seek and search. I thought, oh, wait a minute. Right there. There’s that feeling right there. I just wish he had taken that time.
It might be part of they don’t have enough time, but I also think that we’re so locked into here’s what we need to do with you, that we don’t hand over ownership of the responsibility, at least from a shared perspective to the patient, because whether it’s that theraband exercise, or the moves that you and I do with our hands, I think if we can open up that gate to allow them to enter into our yard and share this with us, I think we can have a really interesting relationship.
Now, from a massage perspective, and again, I don’t want to go too deep into your field or your listener’s field, because I’m a PT, not a massage therapist, we have a real problem there with shared decision making because it requires active engagement of the patient, active engagement of the client. That sometimes runs counter to maybe one what one might view as a stereotypical massage setting, where the patient is allowed to stay quiet, go deeper, or whatever they want to do. I was taught that at Myofascial Release, that we need to stay away from words, et cetera, so they can dive deep into their emotions.
The more I understood about what a bad narrative that the emotions are stored in the fascia story was, and the more I started learning about this stuff, the more I realized that it’s important for me to educate. Here we go with the air quotes again, educate my person on my patient that this isn’t going to resemble what you might expect. I’m very needy. I’m annoying because I’m going to ask you a lot of questions and I’m going to keep asking them because I want to make sure that we stay doing something that you feel is relevant and that you feel is pertinent to your problem, not that I think is important.
Whitney Lowe:
When you were talking about this, it made me start thinking. Do you think that there’s a graduated process? It gets back to that physics metaphor that I was talking about later, of you have to go through maybe that operator model first to understand how some of the things work in the therapeutic world, and then this is a more advanced level of understanding of becoming an even better clinician. Or can you jump to that earlier on without going through that? Do you think that’s feasible?
Walt Fritz:
I think you can jump through it. I think for most of our shared professions, everybody already learned the operated model, but I have an interesting… It’s an interesting process in my classes, the voice and swallowing disorders class I teach because I’m getting speech pathologist who, while they’re licensed to touch, the vast majority of them doesn’t use any kind of touch base intervention like we’re talking about here. Basically, I’m introducing them from scratch that here’s the way you can do it, not the way it should be done, but here’s the way you can do it. Based on the feedback from the people who’ve been through my program, it can work in that order too. I think that no matter how we learn things, people figure out ways to make it make sense to us.
Whitney Lowe:
Yeah. Well, man, these are just fascinating explorations. I know we could go down all of these rabbit holes for a couple different hours doing things. I would like to have you come back and we’ll explore some of these things in greater detail again, but until that time, Walt, how can people find out more about you, your programs, your books, your resources, and things like that? This is opportunity for another shameless plug. Tell us where you are.
Walt Fritz:
Hey, I am at waltfritz.com. That’s probably the fastest and easiest way to find me, waltfritz.com. I’ve got some newly released online courses, not just in this voice and swallowing disorders, but I released a comprehensive whole body course. On an online version, I teach internationally now in terms of that voice and swallowing disorders work. But I really do get a lot of massage therapists coming to those classes, which I love. I love a diverse group. I love conflicting opinion. Fortunately, the fists never fly at seminars, but it’s close sometimes because people are really… You see people struggling with moving away from their beliefs.
The book is on there. The book is, like I said, should be out in a couple of weeks and et cetera, et cetera. Lots of free stuff on the website too, including that shared decision making talk that I gave. You’re welcome to come on and avail yourself with that, even if you don’t do anything except that and see what I have to say. Whitney, I’d really enjoy being back again. Catch up after again.
Whitney Lowe:
Yeah, we’ll definitely do that. I want to explore this in some more detail, but can you just also real quickly, maybe talk just a little bit about this work that you do with the swallowing disorders and with the speech therapist and that group? Because this is something kind of unusual for a lot of the people that are in, at least my profession, in the massage world, of something for them to think about of… Tell me just a little bit about that there.
Walt Fritz:
Well, without going too far down this rabbit hole, 1980 was about the introduction of manual therapies in the SLP, the ENT world for muscle tension dysphonia. Muscle tension dysphonia is a voice disorder, often simplified to say hoarseness. In 1980, a physician wrote about using laryngeal manipulation, and laryngeal reposturing, the view that the larynx was too high. They manipulate it to reduce the tone and repost it. They pulled it down to get a more normal voice.
In their literature, their research, it’s been pretty well covered over the past however many years that it’s been. But what I really like to watch is evolution of a model, evolution of a narrative, because they went from the loss, the what I call the what happens in Vegas stays in Vegas perspective, like you and I probably were taught, that the problem is right here. All I need to do is do this and we drop the muscle tension, or we reduce the trigger, whatever that is.
You start looking at that research and the writings from the nineties, et cetera. It’s all about what happens in Vegas, stays in Vegas. There’s papers that’s in the 2000 talked about, while we think the problem is here, we understand that it’s a cascade of events up and down from the brain. Until, in 2017, Nelson Roy, a PhD from the University of Utah, did a study where they basically handed a woman with muscle tension dysphonia a script. They slid her in an MRI and they had her read the script. They watched her brain. They saw the atypical patterning of her brain when she spoken. They pulled her out of the machine. They did the equivalent of an hour’s worth of Lorenzo manipulation and then tapering to see if she could hold those gains. Then they slit her back in the machine.
She read the same script again. What they saw was a different acting brain, that in that course of one session, that her brain was completely functioning in a different way. The paper doesn’t prove that it’s not in the tissues, it’s in the brain, but what it shows is that interplay between the human nervous system. It’s not just about what happens in Vegas.
If educators could move away from that sense that it’s all right here… There’s a paper, you probably read this one, by Kolb, I think it’s 2019, Manual Therapy Education. It’s time to move on. To me, that’s what people in our field should really be reading and say, “Can we start explaining this work from multifactorial perspectives?”
Whitney Lowe:
Yeah.
Walt Fritz:
I kind of diverged from your original question. Sorry about that.
Whitney Lowe:
That’s all right. I love those divergent pathways that we head down. Like I said, I know you and I can talk about this for hours on end here. I want to thank you again so much for coming to be a part of our discussion today. This was absolutely delightful. I certainly want to have you come back and do this again with us. I hope you’ll do that.
Walt Fritz:
I will. I’m honored to be here, so thanks. Good to catch up again.
Whitney Lowe:
Indeed, indeed. Well, thank you for being with us here on The Thinking Practitioner. Do keep in mind, Books of Discovery has been a part of massage therapy education for over 20 years. Thousands of schools around the world teach what their textbooks, eTextbooks, and digital resources. Books of Discovery likes to say, “Learning adventures start here.” They see that same spirit here on The Thinking Practitioner Podcast and are proud to sponsor our work, knowing we share the mission to bring the massage and body work community closer together.
Thank you to all of our sponsors. You can stop by our sites for show notes, transcripts, videos, audio feeds. You can find that over on my site at Academyofclinicalmassage.com and over on Til’s site. Til is off in Thailand right now, in Asia, so I’m going to be doing a couple episodes without him. He’s doing some training over there and he’ll be back shortly. You can find that over on his site at Advanced-trainings.com.
If you’ve got questions or things you’d like to hear from us, or hear us talk about some more, please do email us at [email protected], or you can look for us on social media. You can find Til over at his name, Til Luchau, and also for me in social media over on my name Whitney Lowe as well.
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Thank you again, my good friend, Walt. Wonderful talking with you here. Thanks everybody else for hanging out with us today. We’ll see you on the next episode.
