Critical thinking is critically important

Introduction: Our dilemma

Often those of us in the clinic are torn by a dilemma. We want to be respectful of clients/patients who sometimes---because of some previous negative experiences in the healthcare system---are quite weary of biomedicine. At the same time, we want to engage in healthy skepticism and evaluation of evidence as part of the quest for knowledge about those patients' conditions. Part of the disconnect between these alternatives for some clients/patients (and for some of us as well) arise from unhappy connotations of the word criticism, which in turn have caused discomfort with the concept of critical thinking.

For those of us who are massage practitioners, it is essential to be supportive of patients: to be an advocate for them. Many massage practitioners work with patients who have experienced physical or emotional or sexual abuse (where the abuser used destructive criticism for control). Other patients have experienced ineffective or bad medicine in established medical practice (where the provider criticized the patient who was seeking other means of support). 

The latter problem is so widespread that in his landmark study of CAM usage, Eisenberg found that 72% of the patients he had surveyed who used CAM did not inform their medical doctor that they had done so, one major reason being their fear of the physician's criticism [1]. As we develop into a profession, we want to learn from our colleagues' history, and avoid falling into the traps that some of them have fallen into.

For these reasons, we tend to be fastidious about not behaving in a way that can be perceived as similar to those bad experiences---and so, we often stay away from confrontation and opposition, promoting support and encouragement. Massage practitioners are not the only ones faced with this dilemma---there is a large body of nursing literature which deals with this same issue, for example. Nurses too want to be supportive of patients, and some are concerned that critical thinking will conflict with that process. We can make common cause as we journey along similar paths and encounter similar challenges.

(However, being supportive of clients/patients and refraining from destructive, unfair criticism does not mean that bad behavior from people who claim to be professionals gets a free pass. Those are two entirely different issues, and as aspiring professionals, we have an affirmative duty to call out destructive, dishonest, or dysfunctional behavior in order to serve as advocates for clients and for the profession. For example, Laura Allen does a stellar job of calling out unprofessional behavior, with specific, concrete examples, in this post at her blog [2].

The way to tell the difference between this kind of constructive calling-out versus destructive criticism is to ask yourself: how does this criticism that I am considering act in the best interests of the client? "You made me abuse you" is the kind of criticism that will never pass that test; "As a professional, I stand up against bad behavior and misinformation on the part of others for the benefit of the client" will pass it. Constructive criticism, critical thinking, and critique are all desirable things, as opposed to destructive criticism or enabling through silence.)

The scientific approach has a unique value when it comes to evaluating the certainty of medical claims, but it is often all too easy for the value of that process to become lost when providers fail to be respectful, supportive, encouraging, and kind. So our challenge is to develop a way to practice constructive critical thinking in order to achieve the patient-centered goal of providing the best possible care, without engaging in destructive criticism.

Distinguishing critical thinking from criticism: empowerment versus undermining

In this vein, I would like to respectfully propose that we try to separate the concept of critical thinking from the negative connotations of criticism. It is possible to practice critical thinking in the appropriate domain—evaluating outcomes claims—while remaining supportive of patients. Massage practitioners should not feel forced to choose between supportiveness and critical thinking; but rather be given the tools and resources to be flexible and deploy each approach as appropriate.

As bell hooks observes in the following video [3], critical thinking can be fundamentally and immensely empowering, especially to those who do not share the power and resources of the upper classes of society.

Navigating the video

The embedded video contains 2 talks by bell hooks. The talk discussed on this page is the second one, and it begins at 3:16 (3 minutes and 16 seconds after the start of the video). To locate the second discussion, you can drag the slider until 3:16 to start from there.

If you watch the first part of the video--and it is quite interesting, as it deals with the instantiation of social messages about class, difference, otherness, transgression, and diasporic culture in popular media--you should know beforehand that there is a warning that it contains strong language and images of graphic violence and nudity in the clips from movies and TV that it uses as examples.

The most enabling resource that I can offer, as a critic or an intellectual professor, is the capacity to think critically about our lives. I think thinking critically is at the heart of anybody transforming their life, and I really believe that a person who thinks critically--who, you know, may be extraordinarily disadvantaged materially--can find ways to transform their lives that can be deeply and profoundly meaningful in the same way that someone--who may be incredibly privileged materially and in crisis in their life--may remain perpetually unable to resolve their life in any meaningful way if they don’t think critically.

--bell hooks

Dr. hooks makes an excellent point--but how do we take critical thinking from her general and high-level principle to something practical that any MT can use in everyday practice?

Andrew Vickers, a research methodologist for the Integrative Medicine Service at Memorial Sloan-Kettering Cancer Center, shares their experience in teaching critical thinking to CAM practitioners:

It can be argued that it is only possible to promote research in complementary and alternative medicine once the importance of critical thinking is understood. Critical thinking can be defined as

• the adoption of a cautious approach to beliefs and claims, and
• the process of analyzing beliefs to see whether they are valid and useful.

The Research Council for Complementary Medicine has considerable experience teaching critical thinking to students and practitioners of complementary and alternative medicine. We use several tactics to ensure that such teaching has maximum impact: stressing that criticism does not pose a threat, using an interactive approach, avoiding abstract or esoteric discussions, giving examples from conventional medicine and from everyday life, and so on. The actual structure of a class involves a series of logical steps: stating the reasons for critical thinking, linking beliefs to belief-forming processes, linking beliefs about health to personal experience, explaining why personal experience can be unreliable, completing the "skeptical argument" that many health beliefs are unreliable, discussing the implications for practice, etc. Learning about critical thinking in such a manner can be an important prerequisite for undertaking or using the results of research [4]. (emphasis added)

At POEM, we will be returning again and again to this concept of critical thinking, and I will ask you to try to keep its denotation—the “dictionary literal definition”—separate from its connotations, or conceptual baggage brought to it by the emotional meanings we attach to the terms “criticism” and “critical”. (By the way: critical also means highly necessary, as in “good health is of critical importance”.)

When we refer here to critical thinking, we mean nothing more and nothing less than Vickers prescribed above: subjecting all claims (even those of accepted biomedicine!) to the level of ongoing skepticism necessary to make sure we can keep learning about the entire holistic biopsychosocial treatment of a client/patient’s healthcare situation.

Here's how we approach it on this site, applying the principles Vickers outlined in the abstract we just looked at:

Stressing that criticism does not pose a threat

Perhaps it would be more useful to refer to "critique", rather than "criticism", as what we do here, in order to avoid the personal and threatening implications of "criticism". Wikipedia provides a brief explanation of the differences, which will prove useful to us here:

Critique is a method of disciplined, systematic analysis of a written or oral discourse...Another proposed distinction [between "critique" and "criticism"] is that critique is never personalized nor ad hominem, but is instead the analyses of the structure of the thought in the content of the item critiqued. This analysis then offers by way of the critique method either a rebuttal or a suggestion of further expansion upon the problems presented by the topic of that specific written or oral argumentation...

Critique is an accepted and established process of orderly scholarly and public debate. In the fine arts and the humanities, and especially in writing, critique is influenced by the scientific method of analysis. Critique is based upon an informed opinion, and never upon personal opinion. Informed opinion is accepted as being technical knowledge, personal or professional experience, or specified training. [5]

These types of analyses span centuries of history, and many cultures:

The term "critique" implied from Ancient Indian term "kriturq", meaning an opposite opinion or suggestion or argument.

The term critique derives from the Greek term kritikē (κριτική), meaning "(the art of) discerning", that is, discerning the value of persons or things. [5]

The assumption here at POEM is that we are all on the same side--we want to understand what is really going on with massage. We may not share the same interpretations, and that's ok--we don't have to always agree on everything, and in fact, it would be really worrisome if we did. But disagreements are worked through here in a way that does not threaten or attack anyone else.

To draw on the connotations of the preceding Greek term κριτική (kritikē), we could refer to it equally well as "skillful discernment". We skillfully discern good information from dubious or questionable information, so that we can provide the best service possible to our clients.

Disagreement among learners, in and of itself, is not a threat. Reasonable people can interpret information in different ways. As long as there is justification or warrant for an interpretation, it's a reasonable subject for discussion here.

Opinions don't carry the same strength as warranted knowledge, but at POEM, we stand 100% behind the human rights principle of freedom of conscience. You can believe anything you want, and, if you wish to share, you can state, as a fact, that you believe a particular principle, even if it is counterfactual. You can, in that case, expect civil, professional pushback on the facts, but no one will be permitted to threaten anyone else over a belief, no matter what.

If you have not had the same educational opportunities as other people have had, and you fear participating in discussion because you don't have the knowledge that other people draw on, please understand that this situation will not be permitted to threaten you. You don't need to know everything already--you can ask for help, and--in a professional, non-threatening, respectful way--other members of the POEM community can accompany you on your journey to make sense of the facts. Anyone who behaves in a bullying or threatening manner because they know more than someone else will lose their posting privileges. You do not need to fear any sort of threats, just because you do not share the educational background that some POEM community members have.

The policies document for POEM is quite long and detailed for this very reason. POEM is a safe and empowering place for discussion, and no one--even if mistaken about the facts--need fear personal attacks or sense themselves threatened. Disagreements will be hashed out here in a professional and civil way, and if those policies are violated, the poster will not be permitted to continue posting.

The POEM community does not need to be concerned that engaging in critique, critical thinking, or skillful discernment will pose a threat to anyone here.

Using an interactive approach

 In order to have a dialogue, rather than just a lecture, we use up-to-date technology to deliver learning content. This approach also works to accommodate the different learning styles and preferences that are found in a diverse audience of adult learners. A great deal of Socratic dialogue, and other pedagogical techniques to draw out knowledge from student, is supported by these technologies, and practiced at POEM.

In this way, the community can build the body of educational material together, through interaction and communication. We hope that this kind of content is more current and useful to learners, MTs, teachers, clients/patients, and other massage stakeholders than is content developed non-interactively.

Avoiding abstract or esoteric discussions

Here, we're going to diverge from Vickers, although on only half of his tactics. We agree that esoteric discussions conflict with the universality and transparency that POEM is committed to:

Esotericism or Esoterism signifies the holding of esoteric opinions or beliefs, that is, ideas preserved or understood by a small group or those specially initiated, or of rare or unusual interest [6].

This runs directly opposite of POEM's commitment, which is to developing and sharing exoteric knowledge instead, to be shared among everyone:

Exoteric refers to knowledge that is outside of and independent from anyone's experience and can be ascertained by anyone...It is distinguished from esoteric knowledge. Exoteric relates to "external reality" as opposed to one's own thoughts or feelings. It is knowledge that is public as opposed to secret or cabalistic. It is not required that exoteric knowledge come easily or automatically, but it should be referenceable or reproducible [7].

However, while it is true that POEM is committed to practical, useful, universal knowledge that MTs can use in everyday practice, we do not regard abstraction in the same way that Vickers refers to avoiding it.

Abstraction is the skill or practice of recognizing relevant features of something in order to classify it with other things like it. Because living things are so wonderfully complex and diverse, being able to make abstractions means being able to separate the relevant features from the irrelevant ones, and it is crucial to the development of new knowledge.

For example, people from different parts of the world can look very different from each other. 

Ida Rolf (Source: http://upload.wikimedia.org/wikipedia/ en/e/ee/Ida_Pauline_Rolf.jpg)	Tokujiro Namikoshi (Source: http://shiatsudo.nl/History.html, posted provisionally while obtaining rights)

Without abstraction, we can only talk about individuals, like the two shown here: Ida Rolf and Tokujiro Namikoshi. We can say that she has a particular skin color, a particular eye shape, speaks a particular language or languages, bore two sons, developed the practice of Rolfing, and so forth--there is a great deal that we can say about the complex individual Ida Rolf.

Similarly, we can list many characteristics of the individual Tokujiro Namikoshi: his skin color and eye shape are different from Ida Rolf's, he spoke different languages than she did, he was structurally unable to bear children, he developed the practice of shiatsu, and so forth. Again, there are many characteristics that this complex individual possesses; it would be impossible to list them all.

Without the capacity for abstraction, which develops during the formal operational stage at around the age of 12, we could never talk about them or others at anything other than the level of individuals: only the unique. Not only is it very difficult to keep track of all the details of all of those individuals, but we could also never develop any knowledge that involved more than one of them at a time--the description of the detailed characteristics of one individual would cancel out those of another individual, and contradict any knowledge that we tried to describe.

Abstraction gives us the power of moving from discussion of the unique to the realm of the universal--if we recognize the contexts in which characteristics are relevant, and those in which they are irrelevant, then we can move past them to classifying groups of individuals on those relevant classes. Ida Rolf and Tokujiro Namikoshi had different skin colors, a fact which may be relevant if you are classifying them on the basis of relative skin cancer risk, but which is irrelevant to their common humanity. In fact, "human" and "people" are abstractions, universals made up of many individuals whose more characteristics contradict each other. Similarly, their respective eye shapes, languages spoken, reproductive anatomy and physiology, and accomplishments may have relevance in some specific classifications, but not in the classification of both individuals as human beings. 

So abstraction is a very powerful tool, and while recognizing the importance of practical, useful, everyday applications of knowledge to massage practice, we do not avoid abstraction or abstract discussions--it's foundational to our development of caring for others, as well as of knowledge of the world around us. It's very important, however, to discern abstractions skillfully: creating false abstractions--a cognitive and logical trap known as the reification fallacy--leads us to make up (to reify) things in our mind that don't exist in the physical world. Acting on these reifications, or false abstractions, leads to a great deal of the confusion and misunderstandings we observe in the current discourse around massage. To protect ourselves against falling into this trap, we will return often to the topic of abstraction here on POEM.

Giving examples from conventional medicine and from everyday life

Problem-based learning (PBL), based on scenarios and issues from real-life therapeutic encounters, provides material that is more directly relevant to a clinical healthcare student than is a list of facts and routines to be memorized by rote. It grounds the principles being taught, and makes them more immediately real and useful to members of the community. For this reason, at POEM we will be making a great deal of use of PBL.

Given the critical importance of critical thinking, we will spend a good amount of time on the topic. It will be intense at times, but I have no doubt that the outcome will be worth it.

I am looking forward to our learning journey together.

[1] Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States. Prevalence, costs, and patterns of use. New England Journal of Medicine. 1993 Jan 28;328(4):246-52.

[3] bell hooks: Cultural Criticism & Transformation (accessed 21 July 2011)

[4] Vickers A. A proposal for teaching critical thinking to students and practitioners of complementary medicine. Alternative Therapies in Health and Medicine. 1997 May;3(3):57-62.

[5] Critique, Wikipedia (accessed 21 July 2011)

[6] Esotericism, Wikipedia (accessed 23 July 2011)

[7] Exoteric, Wikipedia (accessed 23 July 2011)