Courageous engagement

There is grandeur in this view of life, with its several powers, having been originally breathed into a few forms or into one; and that, whilst this planet has gone cycling on according to the fixed law of gravity, from so simple a beginning endless forms most beautiful and most wonderful have been, and are being, evolved.

--Charles Darwin, Origin of Species, close of first edition, 1859

Source: Left: http://upload.wikimedia.org/wikipedia/commons/1/18/Charles_Darwin_by_G._Richmond.png; Right: http://upload.wikimedia.org/wikipedia/commons/a/a0/George_Richmond_-_Emma_Darwin_-_1840.jpg accessed 17 November 2012

Charles Darwin, whose biological observations led to the development of evolutionary theory, and his wife Emma loved each other very much.

Their many letters to each other over the years (preserved online in the Darwin Correspondence Project) stand as a testament to how much they thought, cared, and worried about each other.

In one letter, written around February 1839, Emma expresses her wish as a faithful believer, but at the same time, also admits to her doubts in her own hope:

The state of mind that I wish to preserve with respect to you, is to feel that while you are acting conscientiously & sincerely wishing, & trying to learn the truth, you cannot be wrong; but there are some reasons that force themselves upon me & prevent my being always able to give myself this comfort.

--Darwin Correspondence Project, Darwin, Emma to Darwin, Charles [c. Feb 1839] accessed 17 November 2012

She wants to feel secure that, if she (or he, or anyone) is really trying diligently and sincerely to learn what is true, that that effort guarantees that she cannot possibly be mistaken about what she is learning. The reason she is so concerned about this is that she was devoutly religious, and she knew that Charles had doubts about religion.

To be impossible to be wrong, through sheer effort and sincerity, is a lovely wish--and yet, in the same sentence, she admits to her beloved husband that even she herself cannot always keep up that belief.

She was right to be concerned about that issue--the history of science at that time in England contains many examples of geologists, paleontologists, biologists, and other scientists who set out on a journey to find evidence in the material physical natural world that proved the stories in the Bible to be literally true.

For example, if the story of Noah's Ark and the Flood were literally true, you would find evidence of it in the layers of rock in that part of the world. The scientists who set out to find it discovered that that evidence is not there, but other evidence, showing that other things happened, is indeed there.

The scientists who set out to demonstrate that the earth is literally only a bit more than 6000 years old demonstrated instead that they would have to reject all the other multiple sources of repeatable, verifiable evidence that showed the earth to be much older than that.

Darwin himself demonstrated that--rather than the Genesis creation story that species were created one time in their present and unchanging form--species actually change over time to better adapt to the environments they find themselves in.

When the evidence these scientists found contradicted what they wanted it to say about the literal truth of the Bible, they faced a test of their own moral character in deciding what to do next about that fact:

1. They could ignore the evidence, pretend the discovery never happened, and never face the meanings of the contradictions between the evidence and what they believed, or
   
   Source: http://thinkingmomsrevolution.com/wp-content/uploads/2012/06/fingers-in-ears.jpg accessed 17 November 2012
    
2. They could double-down on their belief, holding on even tighter to it while rejecting the reality of the material physical evidence, or
   
   Source: http://www.examiner.com/images/blog/wysiwyg/image/bad_poker.jpg accessed 17 November 2012
    
3. They could accept the reality of the material physical evidence, revising their beliefs as needed to resolve the contradictions between the beliefs and the evidence.
   
   Source: http://2.bp.blogspot.com/-LSEZYAmp3P0/UEKl9Td19sI/AAAAAAAACKE/m0nhbygv1nU/s1600/alone.jpg accessed 17 November 2012

Some of the most solid scientific knowledge that we rely on every day came from people who had the courage to face the implications for their beliefs that the evidence presented them, and the integrity to not turn away from or deny the contradictions, but rather to engage with them.

The National Certification Board for Therapeutic Massage and Bodywork (NCBTMB) is an independent non-profit organization that offers national certification in massage and bodywork.

This national certification functions as a path to initial licensure (sometimes the only path) for MTs in some states.

The Board has undertaken a major revamp of policies and procedures, one which is causing a great deal of disruption among nationally certified MTs and continuing education providers.

Its CEO, Mike Williams, states that the purpose and effects of this change are

streamlined online processes, enhanced communications, and improved programs that elevate the profession and better serve the public.

--NCBTMB front page accessed 17 November 2012

Some of those changes may well have that effect--I am not personally nationally certified, and I have not yet examined the changes in depth as other MTs and bloggers such as Laura Allen have.

But in the FAQ about the new procedures for approving continuing education providers, there is--for me--an absolute deal-killer.

Q: Will NCBTMB continue to accept alternative courses like energy work, aromatherapy, animal massage, etc?

A: Yes. Massage therapy is part of the holistic profession as are several other modalities and techniques. NCB will continue to accept modalities and techniques that can be legally practiced by a massage therapist without another healthcare provider, (i.e., DC, MD, PT) present. As long as the technique or modality can be shown to be embedded in the lineage of massage, it will be accepted. This means that if the core information of the technique or modality can be referenced as a derivative of another technique or modality that is within the massage therapy scope of practice it will be accepted.

--NCBTMB Approved Providers FAQ accessed 17 November 2012

The argument over the relationship between massage and "energy work" is nothing new.

In the early 1990s, when I was in massage school, the NCBTMB was developing the first national certification exam--the National Certification Examination for Therapeutic Massage and Bodywork (NCETMB). Eventually, as a result of consumer pressure, they were forced to offer an energy-free alternative, the National Certification Examination for Therapeutic Massage and Bodywork (NCETM), for those MTs who did not want to be coerced into an anti-evidential belief system as the price of their professional training and licensure.

Although the argument is nothing new, there was a fresh opportunity to do something innovative here among the other disruptive changes--but NCBTMB did not take that opportunity.

Instead, they opted to permit teaching any information (which includes misinformation and malinformation) as approved continuing education, as long that that can be shown to be "embedded in the lineage of massage". Considering the long history of "massage myths", documented by Laura Allen (here and here), Lee Kalpin, Paul Ingraham, and many others, it is clear that just because an idea has been embedded in massage, even for a very long time, that does not mean the idea is correct.

NCBTMB had an opportunity to stand up for the principle that, in the therapeutic encounter, a professional should provide only validated warranted (justified or justifiable) high-quality information to the client.

They did not take the opportunity to stand up for that principle, and as a result of that decision, I cannot participate in their new process. I will not go on to apply for national certification as a practitioner, nor will I become an approved continuing education provider under those standards.

I regret those facts, as I consider them massive missed opportunities. But I cannot do it, because our first principles on these matters are so far apart as to be irreconcilable.

Don't misunderstand me here--I am positive that the NCBTMB members are well-intentioned, and that they wanted to do the right thing. I genuinely believe that they were attempting to have the best of both worlds for the benefit of all massage stakeholders, and to not hurt anyone's feelings.

I respect them as the kind, caring, motivated, passionate people that they clearly are.

If that, by itself, were enough to be right, as Emma Darwin wished, we would not have to have this very serious and difficult discussion.

But evidence doesn't work like that--you can't pick and choose which evidence you accept, and which you reject. Either you accept all the evidence, and you go courageously wherever those implications take you, or you just don't accept the evidence.

If they are going to accept massage's traditional explanation of "energy work"--no matter how many times that explanation has been shown by the evidence to be mythical--as validated approved continuing education with their official imprimatur, then they are not preparing MTs who are taught that explanation for modern translational science. Holding on to old ideas even after they have been disproven is an active obstacle to understanding these new developments.

The environment of massage is exhibiting selection pressures toward a type of massage that is integrated with validated high-quality information, and that prepares MTs for understanding advances in neuroscience, cognitive science, endocrinology, and pain science, and translating that understanding into clinical practices that are client-centered and effective.

As a direct response of those pressures, biopsychosocial massage is breaking off from the main lineage of massage to provide a new massage lineage that is fully consistent with those principles.

Source: Darwin's first documented sketch of an evolutionary tree, around 1837, from his notebooks http://www.sciencebuzz.org/sites/default/files/images/myers_darwin_tree.png accessed 17 November 2012

You can consider this the official birth announcement of a new lineage of massage.

Biopsychosocial massage (BPSM) is massage understood and practiced in a biopsychosocial model. It understands massage, health, wellness, and illness, and the knowledge bases underpinning those concepts in an evidence-based, natural (meaning, not supernatural), organic way that draws on what we know about biology and other natural sciences, psychology, sociocultural aspects of being human, and the emergent effects that arise from interactions among these various factors.

Over time, here at POEM, we will be following that evidence where it leads, and courageously engaging with the meanings that it shows for the practice of massage therapy. I expect intense, passionate, and fruitful discussions here over the next few years.

UPDATE, 18 November 2012, 11:01 AM PT:

Biopsychosocial massage (BPSM) by Ravensara S. Travillian is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License.
Based on a work at http://poem-massage.org/content/biopsychosocial-massage-bpsm-new-lineage.

It's a lovely idea to think that there are no limits, and that we can have everything we want.

Certainly, a massive part of the US advertising industry is dedicated to selling that dream, precisely because it's such an appealing one. There is no shortage of people who will pay good money for the hope of living without limits.

In the realm of dreams and ideas, there may well be practically no limits to what we can imagine. But the material physical world imposes constraints, or limits, on what matter and energy are capable of, and what they cannot do.

We don't understand everything about why matter and energy behave the way they do, but over the centuries, we've observed them in enough different situations that we're pretty good at describing how they behave in those situations. It's very much like the situation with gravity--there are several different and mutually exclusive proposals for what gravity is, and why it works the way it does.

But we don't need to wait until those questions are decided to be able to predict how gravity will behave well enough for hundreds of thousands of airplanes worldwide to take off and land safely (for the most part) every day. We can predict its behavior so accurately that in 1970, when the Apollo 13 spacecraft suffered an explosion and fire on the way to the moon--an explosion which left the spacecraft badly damaged, and low on fuel to get back to earth, and oxygen for the astronauts to breathe--ground control was able, on the fly, to improvise a plan that took advantage of the Moon's gravitational field to act as a "gravity slingshot" to propel the spacecraft and all 3 astronauts safely back home.

Source: http://upload.wikimedia.org/wikipedia/en/f/fd/Gravity_Assist_analogy_Kohlhase_Hovland.jpg accessed 7 October 2012

Source: http://upload.wikimedia.org/wikipedia/commons/f/fc/Apollo_13_timeline.svg accessed 7 October 2012

The same is true for matter and energy. These behaviors are so reliable that their descriptions are called "laws of physics"--metaphorically, it's as if they "know" they have to "obey" certain "laws", so they always do so.

Of course, science never says anything is definitively, 100% certain. Some things are very uncertain, and they're likely to be revised as we learn more about them.

Other things, while not 100% certain, can be almost 99.9999% certain--so the effect is as though it's perfectly certain, even though there's always that tiny 0.0001% chance it will be changed someday in light of new evidence, if that new evidence ever does show up on the scene.

The limits of the material physical world around us have been observed, described, and discussed for thousands of years, and, because they are so reliable, you can see, many times, the same description of the consequences of those laws of physics being discovered independently in different cultures far away from each other in time and space as ancient Greece and medieval India.

Source: http://upload.wikimedia.org/wikipedia/en/8/89/Panini%2C_the_great_Sanskrit_grammarian..jpg accessed 7 October 2012

One of those consequences, borne out time and time again by the behavior of matter and energy, has been described as the "principle of non-contradiction"--that, in the material physical universe, something cannot both exist and not-exist at the same time, or that something cannot be both true and false at the same time.

Did that statement make you think of Schrödinger's Cat? If so, then that's an excellent question you raise!

At first glance, it seems as though the cat might provide an exception to that rule: the cat is both dead and alive at the same time in this thought experiment.

Yet it doesn't really, and here's why.

Source: http://upload.wikimedia.org/wikipedia/commons/9/91/Schrodingers_cat.svg accessed 7 October 2012

It is typical of these cases that an indeterminacy originally restricted to the atomic domain becomes transformed into macroscopic indeterminacy, which can then be resolved by direct observation. That prevents us from so naively accepting as valid a "blurred model" for representing reality. In itself, it would not embody anything unclear or contradictory. There is a difference between a shaky or out-of-focus photograph and a snapshot of clouds and fog banks.--Wikipedia, "Schrödinger's cat" accessed 7 October 2012

—Erwin Schrödinger, Die gegenwärtige Situation in der Quantenmechanik (The present situation in quantum mechanics), Naturwissenschaften
(translated by John D. Trimmer in Proceedings of the American Philosophical Society)

 

When we're talking about the cat being simultaneously dead and alive, we are talking about a phenomenon at only the subatomic level of organization--what Schrödinger called "an indeterminacy originally restricted to the atomic domain".

When we're engaging with clients in a therapeutic encounter, however, we are not engaging solely on a subatomic level--we're engaging at many levels, up to and including the organism level: Schrödinger's "macroscopic" level.

To confuse the subatomic level of organization with the organism level is to make the same mistake as to assume that--because both sodium and chloride as elements are immediately and painfully deadly to humans at the atomic level, then their compound--salt--also shares those properties. (Although it is true that too much salt over too many years can wreck your health, but only in a very different way from elemental sodium and elemental chlorine.)

To confuse those levels of organization with each other is to "naively accept...as valid a 'blurred model' for representing reality". At the subatomic level, without an observer, we can use words or images like the previous one to imagine a cat that is simultaneously dead and alive.

In our macroscopic material physical reality, the moment an observer looks at the cat to see what is going on, the subatomic waveform collapses--it definitively commits to one state or the other, but not to both at the same time--and we have either a dead cat, or a live cat, but never both simultaneously.

Unlike the poor cat (sometimes), the law of non-contradiction is still alive and well at the organismal level of material physical reality, where our therapeutic encounters with our clients take place.

Our metaphorical "waveforms" also are forced to collapse in one direction ot the other at this point, but--unlike the electron--at least we get to choose which of the two mutually-exclusive options we commit ourselves to.

This principle shines a spotlight on where a number of the most heated battles in massage's culture wars are currently taking place.

We have to decide one way or the other on the following question--because of the law of non-contradiction, we can't just say "both", and hand-wave our way out of the profound philosophical and scientific questions it raises.

As a first principle, do we accept or reject the reality of the material physical universe?

We have the freedom to choose either answer, but--no matter how much we may want it--we can't have it both ways.

The answer we choose to that question will determine what we have to offer to clients, as well as how we relate to one another.

This, in turn, will set in motion what history will tell about how our future of massage turned out.

While cherry-picking--the act of suppressing evidence that doesn't support our own particular biases--is something to be avoided, berry-picking, on the other hand--carrying out our searches for information in a way that is not strictly linear and that incorporates cognitive questions, by allowing those searches to evolve and change in response to what we initially come across--is not only to be encouraged, but can be absolutely delightful in the unexpected directions it leads us.

This morning, berry-picking took me in a most unexpected direction. On the way to looking up something else, I came across this:

Risks of consuming fermented foods

Alaska has witnessed a steady increase of cases of botulism since 1985. It has more cases of botulism than any other state in the United States of America. This is caused by the traditional Eskimo practice of allowing animal products such as whole fish, fish heads, walrus, sea lion, and whale flippers, beaver tails, seal oil, birds, etc., to ferment for an extended period of time before being consumed. The risk is exacerbated when a plastic container is used for this purpose instead of the old-fashioned, traditional method, a grass-lined hole, as the botulinum bacteria thrive in the anaerobic conditions created by the air-tight enclosure in plastic.--Wikipedia, "Fermentation: Risks of consuming fermented foods accessed 3 October 2012

Slightly off-topic, but interesting (I think!), in a berry-picking way, since we care about calling people by the names they want to be called: Did you notice that the paragraph used the word "Eskimo", and did that perhaps seem a little strange to you, because you've heard that you shouldn't use the term "Eskimo" when you mean the Inuit people, since the word is derogatory or pejorative or insulting?

You're not wrong, if you remember hearing that--the word "Eskimo" probably does, historically, have connotations that are belitting and insulting, and Native American and First Nations people have spoken out explicitly and firmly against the use of the word.

At the same time, there is no good inclusive replacement term that includes the Yup'ik peoples of Alaska--if you just say "Inuit" instead of "Eskimo", that's fine if you mean only Inuit people and no one else.

But if you mean Inuit people together with Yup'ik people, then there really isn't a well-known acceptable term that means both. So often, you will see Alaskan Native American (more so) and Canadian and Greenlandic First Nations and Inuit people (less so, or maybe even not at all, per Lee Kalpin's comment following this post) compromising, and using the term in order to be inclusive, despite the connotations that go along with the word.

What's happening in Alaska?

Alaska has witnessed a steady increase of cases of botulism since 1985. It has more cases of botulism than any other state in the United States of America.--Wikipedia, "Fermentation: Risks of consuming fermented foods accessed 3 October 2012

Botulism is a condition that paralyzes people and animals who eat food contaminated with botulin toxin, or who have an open wound through which the bacteria that produce the toxin (Clostridium botulinum) can enter the body. C. botulinum is an obligate anaerobic bacterium, meaning that it is obliged to grow in an environment without air--oxygen is deadly to it.

VERY IMPORTANT WARNING

This is why you absolutely never, under any conditions at all, give honey to babies under 1 year old--they don't yet have the immunity to fight off the bacteria that produce the toxin.

After 1 year of age and older, people can fight off the actual C. botulinum bacteria themselves, so the bacteria can't gain a foothold in their systems to begin pumping out the toxin.

But if the neurotoxic poison produced by that bacteria has already contaminated the food somehow--as opposed to the bacteria themselves--then that toxin can produce botulism in anyone.

Facial paralysis which spreads through the body is a typical symptom of botulism; very bad cases can actually cause death by paralyzing the muscles needed to breathe.

The 14-year-old in these pictures from Wikipedia show the paralysis that's typical of severe botulism. Although he appears dead, he was actually fully conscious, yet unable to move. His eyelids were drooping and his eyes were paralyzed, and the pupils were fixed and dilated. We hope he made a full recovery--Wikipedia doesn't tell us how his story turned out--but even if he did, it would require a long, slow, difficult path to rehabilitation.

"A 14-year-old with botulism. Note the bilateral total ophthalmoplegia [paralyzed eyes] with ptosis [drooping eyelids] in the left image and the dilated, fixed pupils in the right image. This child was fully conscious."

Source: http://upload.wikimedia.org/wikipedia/commons/b/b4/Botulism1and2.JPG accessed 3 October 2012

From 1950 to 1997, 105 confirmed outbreaks of foodborne botulism involving 214 persons occurred in Alaska (there were no confirmed cases during 1947-1949)...All cases occurred in Alaska Natives. The average annual incidence among Alaska Natives increased from 3.5 cases/100,000 population during 1950-1954 to 10.7 cases/100,000 during 1995-1997 [in other words, right about 3 times as many cases as you'd expect, based on history].--State of Alaska Public Health Epidemiology Report: Botulism in Alaska--A Guide for Physicians and Health Care Providers, 1998 Update accessed 3 October 2012

Source: State of Alaska Public Health Epidemiology Report: Botulism in Alaska--A Guide for Physicians and Health Care Providers, 1998 Update http://www.epi.hss.state.ak.us/pubs/botulism/fig_1.gif accessed 3 October 2012

The Rose Urban Rural Exchange, in its own words, "aims to strengthen relationships between urban and rural Alaskans by building mutual respect and understanding, and fostering a statewide sense of community through cross-cultural immersion.".

They have a website where they promote cross-cultural understanding by presenting pictures and reports of daily life, festivals, and other events.

In a post, "The Best of the Whale", one of their writers, Bogdan, presents pictures from Ilisagvik Inupiaq Culture Camp, where elders and others share a meal of traditional foods.

Notice the blue plastic container, and the Ziploc plastic bags--we're going to get back to those in a moment.

Source: http://ecci-2012.s3.amazonaws.com/thumbs/20120814_ecc_grp_iic_awi_70_502ab33f88f97.JPG.poster.jpg accessed 3 October 2012

Bogdan describes the scene:

The most desirable food served at the blanket toss festival is fermented whale meat and blubber (mikiaq). Elders particularly like mikiaq, because it is easy to chew. To keep the audience interested and at the site, mikiaq is served last, after all the other food items have been distributed.

Mikiaq is

raw whale blubber that has been left to soak and ferment in the whale's blood.

Fermentation occurs when, under anaerobic conditions (reduced or no oxygen), you convert sugars (carbohydrates containing carbon [C], hydrogen [H], and oxygen [O] atoms as building blocks) like the kinds of glucose here:

Source: http://upload.wikimedia.org/wikipedia/commons/0/06/DL-Glucose.svg accessed 3 October 2012

into ethanol, the kind of alcohol in drinks such as beer, wine, and spirits, a process which rearranges those atoms into this arrangement:

Source: http://upload.wikimedia.org/wikipedia/commons/3/37/Ethanol-2D-flat.png accessed 3 October 2012

Greenlandic to English Dictionary

nuna iterssaliorpâ: digs a hole in the ground, p. 180 (Old orthography)

qasaerdlâq: a seal which has been put by whole and left to ferment, p. 211 (Old orthography)

Back in the old days, fermenting the mikiaq was accomplished by digging a hole in the ground, and leaving it there for as long as it took the process to occur naturally.

Nowadays, just like most of the rest of us reading this, circumpolar peoples have access to modern conveniences like the blue container and the Ziploc bags you saw in the photo from the festival.

Plastic bags, containers, and utensils, no matter how bad they are for the environment, have some convenient qualities that make them so widespread in food preparation. One of those properties is the ability to keep food fresh for longer periods of time.

It does this by sealing the food away from exposure to air that would cause it to decay faster. In other words, it promotes an anaerobic environment.

And that's where the connection to the increased cases of botulism lies.

This is caused by the traditional Eskimo practice of allowing animal products such as whole fish, fish heads, walrus, sea lion, and whale flippers, beaver tails, seal oil, birds, etc., to ferment for an extended period of time before being consumed. The risk is exacerbated when a plastic container is used for this purpose instead of the old-fashioned, traditional method, a grass-lined hole, as the botulinum bacteria thrive in the anaerobic conditions created by the air-tight enclosure in plastic.--Wikipedia, "Fermentation: Risks of consuming fermented foods accessed 3 October 2012

Fermentation in a grass-lined hole, while still an anaerobic process, is less efficient at keeping the oxygen out, since air will circulate in and out of the hole and between the blades of grass. The C. botulinum bacteria have to overcome the deadly oxygen in that air, if they are going to establish a strong enough foothold to produce enough neurotoxin to make the mikiaq dangerous to the people who eat it.

A plastic container, on the other hand, does a much better job of keeping out the oxygen. Less oxygen in the container means a more welcoming environment for C. botulinum, where they can start to churn out neurotoxin.

As plastics have come into wider and wider use in the general population, and as they have made their way to more remote areas, where the convenience appealed to people, they took the existing risk of botulism, and--by providing a better anaerobic environment--sent the cases of botulism much higher than had been the case when mikiaq used to be fermented in the traditional grass-lined hole.

What all this means is that--contrary to what you may have heard--evidence-based practice does not mean that you have to give up traditional practices just because they are traditional, and adopt modern practices just because they are modern.

It means that instead of a top-down simplistic rule-based approach (either "Old = Good! New = Bad!": the "Argument from antiquity" fallacy, or the other way around, "Old = Bad! New = Good!": the "Argument from modernity" fallacy), we take a bottom-up approach of examining the evidence itself, and then deriving more nuanced and accurate rules that we can turn around and apply. Which, in turn, means that everything, traditional and modern alike, gets examined to find out:

• what works in the way it claims to,
• what doesn't work in the way it claims to, and
• the mechanisms for why that is the case.

Once we better understand the answers to those questions, we can better decide which practices fit better into our client-centered model of service, and why they do so. This example was a perfect demonstration of how sometimes evidence supports the traditional practice as objectively better, as measured on the basis of outcomes (number of cases of botulism), than the modern practice.

Source: http://upload.wikimedia.org/wikipedia/commons/e/e2/PSM_V37_D324_Greenland_eskimo.jpg accessed 3 October 2012