The Thinking Practitioner Podcast:

Episode 177: Clinical Reasoning, or Clinical Improvisation? (with Whitney Lowe & Til Luchau)

Whitney Lowe  

Welcome to the Thinking Practitioner podcast,

 

Til Luchau  

a podcast where we dig into the fascinating issues, conditions, and quandaries in the massage and manual therapy world today.

 

Whitney Lowe  

I’m Whitney Lowe,

 

Til Luchau  

and I’m Til Luchau. Welcome to the

 

Whitney Lowe  

Thinking Practitioner.

 

Til Luchau  

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Whitney Lowe  

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Til Luchau  

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Whitney Lowe  

I kind of ran over you there, so

 

Til Luchau  

that’s good. That’s fine. Let’s let’s see how we can run over each other today around this topic. You got you got an interesting one in mind.

 

Whitney Lowe  

This is something we haven’t talked much about this, but this is I think pertinent, especially for folks in the earlier part of their educational practice, but also a good overview for for a lot of folks looking at where they are at different points in their practice today. So,

 

Til Luchau  

I see it as being really relevant, certainly to thinking about how our education happens. But there’s a phase in everyone’s career when they look at how do I move beyond the recipes, for example, that I was taught the protocols.

 

Whitney Lowe  

Yeah,

 

Til Luchau  

so that’s where captured my interest. How do you want to cue it up? Where do we? Where do we? What do we talk about first?

 

Whitney Lowe  

Well, I kind of like to start just by talking about some of the the basic formats of education and why our topic is kind of like looking around, looking at protocols and routines and methodologies for learning the manual skills that we learn. And you know, I’ve thought about this a great deal, especially as an educator. And this is an interesting thing, I think, that from an educational standpoint. And this is probably true in a lot of other things too. You know, there’s a lot of fundamental skill building, and then there comes a point which you have to sort of let go of those kind of fundamental ground rules and learn to, you know, be a little bit innovative and different. But this is particularly relevant for the way that we tend to teach a lot of massage and manual therapy is around sort of protocols or routines or guidelines that are, or you know, do this set of specific psychomotor skills this particular way, and this is how you will get these results. And that is absolutely helpful for somebody who’s just starting to learn something. Having that kind of structure is really beneficial, but in the end, I certainly believe you’ve got to learn to let go of that structure because things oftentimes come up that are just not going to fit that particular model pretty really well, and so that’s that’s kind of why we’re getting to the difficult point today. Is like, how do you recognize when you’re in this and and that you get to. That point of feeling like you can kind of let go of it as well,

 

Til Luchau  

and then what do you do when you let go of the protocol? How do you even know where to start, what to do next, how to finish? All those questions.

 

Whitney Lowe  

So you know, we talked about you know from an educational standpoint, one of the main reasons that we sort of use some of these guidelines is because we like to learn in categories and structures that helps us organize the information that we’re learning. And there certainly are some important factors about, you know, safety, for example, or building particular skill sets so that you do things a correct way at the very beginning. So those guidelines are certainly important at the early stages, mainly, but especially if somebody has not got a whole lot of skills yet. Having strong guidelines like that is particularly important.

 

Til Luchau  

Yeah, you can define what should be done, maybe what shouldn’t be done, so it keeps us keep mixing safe and make sure that we can do this powerful work we do in a way doesn’t harm people.

 

Whitney Lowe  

And but you know one of the other things that I think is is challenging for people is we aren’t maybe told or really given the understanding when we’re learning those things in a structured format like that that there’s going to come a time when you’re probably going to want to hold on to that much more loosely, and we tend to hold those guidelines like, “Oh, I learned it this way, so I got to do it this way because this is the way my teacher did it. Now, you know, I’ve got to do this particular thing according to the so and so protocol or the you know the shoulder routine or whatever it is, and it’s like you said, can be a little bit unnerving to to know when to kind of like let go and do things differently and not be adhering to those particular guidelines.

 

Til Luchau  

And there are really interesting and heated often debates around that process. How much do we need to be true to the original ways things were learned and taught, and at what point do we turn it over to the circumstances, to the individual practitioner, or what’s going on in the practice room to shift those sessions. 

 

Whitney Lowe  

absolutely.

 

Til Luchau  

You cue me up. I’m gonna. I want to. I’m gonna lay out the groundwork here, but at some point, tell me when I can tell some stories from the Rolf Institute where we debated these kinds of things quite a bit.

 

Whitney Lowe  

I think this is a great time to hear that because that certainly is one of the things that comes to mind. So let’s let’s jump in and hear about it. Well, okay,

 

Til Luchau  

just for context, there’s a lot to say, and then it’s going to be. I want to I want to hear what you have to say here, but for context, Rolfing structural integration is the kind of work I specialized in first, and I taught there at the Rolf Institute for 20 years, and traditionally, Ida Rolf taugh, the founder, taught her recipe of ten Sessions, and there, at the time I was training, there was a real schism philosophically between those that felt they should be preserving her vision. She died a couple years before I trained, so people were wanting to preserve her vision by keep staying true to her recipe, to her protocol, and those who felt like, well, maybe we’re learning some things she didn’t know about, or maybe experiences showing some other possibilities, and are wanting to modify things, and these were really heated debates. And it’s a classic schism between, you could say, orthodoxy and reformed ways of thinking. How true do we stay to the original, how much do we evolve? But but it brought up a lot of great points around the role of these protocols. Some argued it was just a teaching device; it allowed people to learn it. Others argued that no, it was a structure that kept us safe and kept us clear forever. I remember one of my first continuing education experiences at the Rolf Institute. We came, and as a group, we went around the circle and talked about how things were going in our practice. One guy said, “You know, I found that I really like doing arm work later, um sorry, earlier in the series than it is traditionally. Is toward the end of the traditional series, and he says, ‘I’m getting great results starting early. And the teacher, who shall remain nameless, but was a very senior student of Ida Rolf at that point, says, “I think that’s really dangerous. And he was shocked, as we all were. He says, “Yeah, I don’t to think that you could re-engineer the protocol to improve upon it. Is speaks of hubris and danger. So there was what you’re talking about. Yeah, the the safety piece being elevated to the level of dogma and or toxic.

 

Whitney Lowe  

I’m curious to know because I think this could certainly be relevant with the example that you’re that you’ve given here. I’ve I’ve often talked here on the podcast and some other places about the the legacy model of education that we use in the manual therapy community-that’s much more driven by individual personas and personalities and things like that. And do you think that that that gives a lot more weight to the the feeling of necessity of following a particular guide because it was developed by the leader, whoever is the guru?

 

Til Luchau  

Yeah, I’m also feeling the need to like give a fairer picture of the Rolf Institute. That’s you know that’s an exceptional story that happened almost 40 years ago, and I know the work has gone on to evolve and there’s much more nuanced interpretations of that. But yes, I think it does have to do with being true to the founder and that cult of personality and all the good and bad things that can come from that. There’s the old Sufi story about the sect of Sufis that would shake their left foot whenever they went to the mosque, and they saw this as their really defining side of their of their brotherhood and their practice. And then it turned out that it was because their leader had a sticky sandal, and he would also have to take it off. So everyone started doing it that way, and that became the way to do it. Drivers like to tell that story.

 

Whitney Lowe  

Yeah.

 

Til Luchau  

So, what way? When do protocols perpetuate something unintentional? Til, like an interesting question.

 

Whitney Lowe  

Yeah. So, do you think, in terms of like, with your experience there at the Rolf Institute, did that? I don’t say like quash, but do you think that that did decrease the likelihood of innovation that people felt comfortable with because they felt they had to adhere to that guideline?

 

Til Luchau  

That was that was certainly the argument. That was certainly part of that side of the debate. Let me put it that way. And and I guess speaking personally, yeah, for me it did eventually. Not that we were being forced into that protocol over the 20 years that I taught there. There was much more interesting things that happened, including a principles-based education and not a protocol-based education experiments with that. But yeah, I think it it it was the tension between innovation and legacy, perhaps that was the difficult one. Yeah, there.

 

Whitney Lowe  

So what? How did that shift? I mean, was it just time? Do you think, like, or because I certainly feel like I sent have sensed a great deal of shift and change from the structural integration community now towards a lot more diversity and and

 

Til Luchau  

again, in all fairness, it’s been 15 more more years since I’ve even taught there, so I’m sure there’s much more that’s happening that I’m not even aware of. But that that split between the ones who wanted to stay true to the original recipe and those of us who wanted to look at what else was happening really catalyzed a lot of debate and thinking, and we did some really interesting experiments around. Let’s not even teach a recipe. Let’s not even teach a protocol. Let’s teach the principles that

we’re that we’re trying to accomplish with those things. Yeah, and that was a wonderful exercise to take it apart and really identify those together. It proved to be really hard to educate from that point of view, and there were a couple classes that did it that way, and then pretty soon the recipe came back in, because it was really hard for beginners to grasp enough of the territory to even understand the principles. They really just needed to know where to put your hands and what do you do, and then once you’ve done that for a while, then maybe the principles could emerge as as things to understand over the phone.

 

Whitney Lowe  

Yeah, so there’s a strong emphasis on a lot of the what at the at the very beginning, and then later on we’ll talk about the why and the the how and like that sort of thing.

 

Til Luchau  

Too in our case, yes. Yeah,

 

Whitney Lowe  

I’m also reminded of, and this is a little bit slightly different subject, but similar kind of concept. I saw this social media thread. I don’t know. It was about a week ago. It wasn’t very long ago. On one of the massage educators’ forums, and they were talking. This individual was talking about having a very good, pretty extensive background in education and and teaching in a lot of different locations, and had applied to teach at a massage school, which has a pretty good reputation, and they were told that no, the school didn’t want them because they were too experienced, and they wanted people who had come through that school to be able to continue transmitting the things done that particular way. So it’s another one of those kind of like, in my opinion, way overprotective kind of shelters of keeping. It’s almost like we don’t want free thinkers here. We want people who’ll do what we tell them. You know, the

 

Til Luchau  

shadow side of that for sure. Yeah. At some point, I mean, yeah. I’m still now. You got me in my Rolfing stories mind, but at some point, Ida Rolf stopped training chiropractors. Originally, she was doing continuing education for chiropractors mostly, and at some point, she says, “No, this isn’t working. I need to start people from zero, and really interesting into our way of thinking.

 

Whitney Lowe  

Yeah,

 

Til Luchau  

and not just have to be an add-on to what they’re doing.

 

Whitney Lowe  

Yeah,

 

Til Luchau  

but yeah, again, the shadow side of that is like the one true school. 

Whitney Lowe  

Interesting. You had some interesting.

 

Til Luchau  

Sorry, you had some really interesting topics and questions here. I don’t want to distract too much. I’m like, want to get back to you somehow.

 

Whitney Lowe  

So where do you go next?

 

Whitney Lowe  

Let’s see. Well, I did want to mention one thing here that a little bit. Earlier that we had kind of like talked about the the issue of cognitive load in the learning process because I think that is a really helpful method for using this kind of structure and guidelines. And for those who are not as familiar with the concept of cognitive load, it just basically refers to how many things or how much can you sort of load into a person to learn and take in all at one time, and you know, I know as an educator, this is something I’ve been attuned to, and watched a lot of other educators grapple with this a little bit. For example, when we’re teaching a hands-on manual therapy class, and this is true, especially a lot in in entry-level massage training, when I would watch some of the the new instructor trainees going through the process of trying to learn how to become a teacher, and you know they they had been taught things about you know body mechanics or position or like you know standing in a certain position or holding your head in a certain position, making sure you don’t do this, and and I would see them going around and trying to correct some of these postural things, and noting like this is a mistake because yeah, that’s not a great postural thing right now. But right now we really need to focus on what this person is doing with their hands and how they’re reaching this particular thing. We’ll get that posture thing fixed later. But if you keep trying to dump more and more things on somebody to try to fix and correct at the very beginning when they’re just learning something. There’s just the cognitive load is too much, and you won’t. You just won’t get it. So,

 

Til Luchau  

and you’re you’re saying that a protocol could actually help relieve that cognitive load, but it’s keeping it clear what

 

Whitney Lowe  

Yeah kind of like to keep it simple. You know, to keep it simple at first, and then we try to refine it a little bit later on, and it’s a it’s a hard one as an educator to let go because you see things like oh we got to fix this because this is not right. But you can’t fix all those things all at once when it’s when somebody’s just first learning something.

 

Til Luchau  

You were you were writing there about how we teach in terms of techniques our traditional education at least teach techniques in isolated. You know, here’s a discrete thing you do, rather than you said adaptive tools.

Whitney Lowe  

Yeah,

 

Til Luchau  

what would the difference be between a discrete technique and adaptive tool?

 

Whitney Lowe  

Well, you know, this I’ll get on the soapbox for just a minute about this because you know I think certainly as a CE educator, I have a pretty strong opinion and bias about the way a lot of continuing education is taught in our field. That being very technique driven, that it’s all so much of it is about learning these particular techniques. That people look for you know I want to learn these new techniques. I want to do these kind of things without recognizing a lot of the underlying physiological mechanisms, and certainly some of the narratives around some of these techniques, just aren’t physiologically accurate. We now know this just from additional research. But focusing too much, I think, on some of those technique concepts limits an individual’s ability to really recognize some of the broader aspects of what really goes on in a massage and manual therapy world that’s really making the biggest difference, and a lot of times it’s not that I used my thumb with you know four centimeters of pressure per second moving in this particular direction. It’s the fact that I just I really connected with this person and I got their nervous system to really tune into where I am and what’s going on in this particular time, and that’s really what made the change. But it’s a lot easier to ascribe those changes to a particular technique, and especially when we’re marketed and told, you know, this thing will get all your clients better in three easy sessions or whatever it is. You know,

 

Til Luchau  

There’s that emphasis on procedure and what we do, and you’re saying there’s so much more to it, including the presence or the ways that we do it. Like yeah, it’s harder harder to teach.

 

Whitney Lowe  

The sort of we mentioned this you know a few moments ago, just getting into the why, the why, the when, and some of the how processes are a lot more complex, oftentimes than just the what to do with your hand sort of thing, which is what we end up teaching a lot.

 

Til Luchau  

Yeah. Well, are we ready to define the protocol paradox?

 

Whitney Lowe  

Let’s kind of let’s talk about that a little bit.

 

Til Luchau  

What is the protocol paradox?

 

Whitney Lowe  

Well, to me, the paradox is, this is something you need. I think you really benefit greatly from these guidelines and protocols and and stricter methodologies at the beginning when you’re learning

something, and you need to learn to let go of them later on, and and be more open to a diversity of different things, and recognizing that like yeah, you learned this thing to do with somebody’s neck, but like a lot of times it just doesn’t work. So what do you do if you’re rigidly locked into that protocol? Like this is what I do on the. And it doesn’t work, or it causes an adverse reaction. Now, what do you do? This is, in essence, the the very essence of what you and I have talked about for five years as the thinking practitioner. You know, letting go of those kind of guidelines to become more of an of a an individual thinking clinician who’s going to recognize I got to do something different or why is this doing this you know what’s happening here?

 

Til Luchau  

Well, and then you got real cases, real people where there’s lots of things happening at once, overlapping factors involved. Maybe that doesn’t make sense to work on the neck until we get them breathing. For example, maybe there’s so much they’re doing in their job that we can’t they can’t accommodate what we’re asking them to do with their hands.

 

Whitney Lowe  

Yeah,

 

Til Luchau  

differences in clients, how they deal with touch or their pain mechanisms, all these things that you’ve thought about here and laid out for us. What what do you want to flag in terms of the reasons that we need to embrace this paradox?

 

Whitney Lowe  

Well, I think you you really hit on it right there, which is that it’s one thing, for example, when you read about or learn about particular types of problems or conditions or something like that in a textbook, and it gives you a relatively simple explanation for it. But the people who walk through our doors are really complex individuals with highly advanced, you know, nervous system issues going on, and incredible, unique histories of things that are happening, and they just often don’t fit into that picture, and so trying to it’s it’s kind of like the square peg in the round hole thing. Sometimes trying to fit fit your treatment methodologies to make it work on this person, but this is not what their unique need is, and so that’s that’s the the in essence the challenge I think for the the more advancing practitioners, recognizing when are we stepping out of this, and and this is why I continually emphasize as an educator the extreme value of learning about a lot of different types of physiological and pathological conditions and problems and things that may occur to somebody because you don’t think of those things oftentimes if you don’t know much about them, and so knowing more about them gives you sort of like a bigger landscape to look at to to recognize. Oh, I remember hearing about this one time. Let me go look some things up about this. Maybe this is one of those kind of situations, and that recalls for me to do something very different, you know, than my traditional method of of dealing with this.

 

Til Luchau  

Tell me how you think about this in terms of symptoms or symptom chasing, because that was the critique of either neuroph institute in the old days. Again, it was either okay, are you just working on 

symptoms? Are you helping integrate the whole person? Integrate the whole person in that case, meant doing the protocol, doing the whole body recipe. How do you think about it? Because you mentioned,

 

Whitney Lowe  

yeah, and again, everybody looks at this a little bit differently, and and I have a very kind of like left brain sort of analytical mind, so that’s the way I tend to look at these things. But from sort of an assessment and evaluation standpoint, I really put a lot of emphasis on listening to the person and talking with a very complex clinical history at the beginning, and trying to get a sense of number one, is this a localized type of problem? But also, you know, let’s even backing up further from that, what are the goals that this person came here with? You know, is are they looking to have me help them get out of pain or are they looking to just have a really magical kind of sensory experience that will really help them kind of get in touch with their body? Those that’s going to drive a very different kind of approach to what we’re dealing with here. But certainly, I mean, my focus has tended to be a whole lot more with dealing with more localized kind of sometimes localized, sometimes not localized pain problems, but people getting people out of pain, and so to me, that really requires a look at well, what’s the cause, what’s the the factor because again, if we we tend to sort of like you said chase symptoms like well their arm hurts or their leg hurts so let’s rub their leg, but a lot of times that’s not really where this is originating from and there’s a much more convoluted type of thing going on and you got to put on that detective hat and start peeling back the layers and finding out why does this leg hurt. Well, it’s not a sciatic nerve compression thing. It’s something else that’s going on with them, and maybe there’s metabolic and systemic infection factors, or all kinds of other things that can definitely be flaring up this pain problem that they have. And so, you know, I I kind of tend to look at this as. Being that detective to recognize, you know, where do where does my approach fit into what’s really going on with them? How do you see that when when you’re sort of looking at that kind of thing with with people?

 

Til Luchau  

I think it’s very similar. I think I I can also be pretty linear and cognitive in my approach, and I think a lot of my personal development was around not overemphasizing that. So I to to shift it because I I love getting technical and I love getting really detectiveish biomechanical reasoning things, and in full recognition of all those limitations you just named, there’s another leap that happens when I think about it artistically. Yeah, think about like how how do we go to esthetics rather than mechanics? How do I create a flower arrangement of these factors my client is giving me, rather than a Jenga tower of reasons stacked up. Yeah, it’s like this esthetic approach that looks at the whole picture. Is it just a different ways that I’m always trying to help encourage myself to go to? Not that not that either one is wrong. Ida Rolf described it a lot. Still in the Ida Rolf mode, she described it like becoming a cook is a first stage in education, and then later it’s becoming a chef. Yeah, chefs don’t cook from the recipe books; they know the ingredients, and it can blend and flow with that. Yeah, that process more than just following the steps.

 

Whitney Lowe  

I have oftentimes too felt a similar kind of analogy with the idea of how this translate a lot in in similar fashion to what happened with the developments in physics around the turn of the 20th century with Niels Bohr and Einstein and all those guys that we’re recognizing that at a certain level Newtonian physics works really well, and at a certain level it just doesn’t work any longer. Doesn’t mean it’s wrong. 

It’s just that it doesn’t work at that level. Once you get down into the subatomic level, everything behaves very differently, and so

 

Til Luchau  

both things can be

 

Whitney Lowe  

true at the same time. You know,

 

Til Luchau  

that’s right. Yeah,

 

Whitney Lowe  

you can have simple mechanics and you know forces and you know gravity and all this kind of stuff can can certainly be impacting things. But at the same time, there’s a whole nother level where the fact that you’re watching subatomic particles changes their behavior. You know, it’s like that’s just kind of weird, but it it’s true and it it happens. So,

 

Til Luchau  

well, it’s there’s back to the beginning too. So, like Pablo Picasso’s quote about something like learn learn the rules like a pro, so that you can break them like an artist. He said,

 

Whitney Lowe  

“I like that. Yeah,

 

Til Luchau  

learn the rules like a pro, so you can break them like an artist.

 

Whitney Lowe  

Yeah, and that’s too. Just I was gonna say, you know, a similar kind of thing is like musicians who learn the fundamental skills of you got to practice your scales. You know, you got to do all this kind of stuff so that you can let it go and become an artist and really become musical and be different and everything like that. But the the development of those strong foundational skill sets in a really more structured and rigid manner definitely play or play a part in that.

 

Til Luchau  

That’s right, and it’s by knowing the scales, then we are capable of responding and improvising to what’s showing up in front of us. Yeah, if we got to go drag out the the scale, the fingering key, we get a problem in front of us, then we’re going to be still working at that that protocol level.

 

Whitney Lowe  

Yeah, yep, absolutely.

 

Til Luchau  

What’s why do you want to go next? You got so many great ideas here. I’m not even sure which one to pull out.

 

Whitney Lowe  

Yeah. So you know, we we talked a good bit about we talked about some of the symptom symptom chasing and all that kind of stuff. The bigger picture here too, we we kind of haven’t sort of named and labeled that, but I think you and I are both sort of talking around the same thing with sort of different directions. But the the the critical importance of what we’re kind of getting to here is this idea of clinical reasoning? It’s like following some guidelines about what’s the rationale. Again, it’s the why behind the reasons that we’re doing the things that we’re doing, and that that stuff I find. And I’m curious to hear your take on this too. As an educator, I find this some of the very hardest stuff to teach, because it’s one thing to teach specific skills or teach you know concepts or you know theoretical models or teach anatomy or kinesiology. This muscle does this and that thing does that, but the whole idea of teaching that thought pattern and the the reasoning process of how did you get there. That’s a that’s a really that’s a tough one.

 

Til Luchau  

How do you keep turning the table around? You keep asking me questions. I want to reason. I boy, I got a lot of thoughts about that, but I don’t. I want to hear what you have to say about clinical reason reasoning because we are talking about the same thing, but I don’t think of it as reasoning. I think of it as again maybe esthetics, or just decision making.

 

Whitney Lowe  

Yeah,

 

Til Luchau  

and again, that’s for myself to keep myself out of my cognitive linear traps that I get into for myself.

 

Whitney Lowe  

Yeah,

 

Til Luchau  

but you are a master at laying these things out and getting people to think in a reasoning, ordered manner and giving them ways in. So, tell us something about how you do that.

 

Whitney Lowe  

Well, you know, we talked about this on one of our previous episodes, but this is something. Again, I just want to kind of like throw back to. I’ve been trying to figure out how how to do this most effectively for decades as an educator, like teach this whole concept of clinical reasoning, and have not really found the strategy or way to do that until now. And by the way,

 

Til Luchau  

that’s I know people that say they’ve learned it from you, and they really appreciate what they’ve learned. But go ahead. What do you do now? That’s even better.

Whitney Lowe  

Well, we’re getting there. Like finding ways to further refine this. But the we talked one of our previous episodes about some of the stuff that I was doing with AI and education in our programs and the capabilities now to instead of just deliver content, which is really a one-way process of of transmitting information from one individual one thing to another. The now the way that we have woven AI into our educational activities can actually really help that clinical reasoning process way more than anything I’ve ever done, because it’s you know we have Socratic tutors in there that ask you know you know you’re taking a little kinesiology quiz or something like that and asks you tell me how your skill level is on a scale of one to 10 and you know you scale yourself at nine it’s going to give you a lot harder questions and you scale yourself at two they’re a lot easier and if you ask it a question, it doesn’t just give you the answer. It makes you think about, well, what do you think this thing does? If it attaches here and it attaches there, what would it be doing if you pulled those two things together? And various activities that you know are delving into the treatment planning or constructing a treatment plan process and sort of evaluating is this a good treatment plan or not a good treatment plan? To me, that has really raised the bar and jumped us forward in the capability to try to teach some of these clinical reasoning processes.

 

Til Luchau  

So, not only do you have your methodical ways of walking people through the kinds of thinking that is helpful, but people are now able to tune that to give to challenge themselves more or less, depending on their self assessment of that.

 

Whitney Lowe  

Yeah, and and to me, this is also this is also solving one of the biggest problems that I think we have had in especially in CE education in our field, which is the personalized learning process or the personalized learning challenge, because you can have a CE course and you have a 45-year-old nurse who’s been in the healthcare field for 20 years and practiced massage for a very long time, sitting right next to a 20-year-old student who just got a massage school, and there’s only one delivery to both those individuals in the class or the educational experience most of the time, and that’s just you try to aim for the middle most of the time to try to get a middle ground for that. But that that leaves the very highly experienced people bored and the very inexperienced people struggling to keep their head above water, and so this whole strategy for aiming for a personalized learning experience to me is just-it is super exciting, and I think one of the most important things I have done in my whole career, even so.

 

Til Luchau  

That is exciting.

 

Whitney Lowe  

Yeah,

 

Til Luchau  

 you named something there about the pivot point. What’s it like? Like when we’re we’ve started on a path and we realize that this this plan or this thing we asked that I was going isn’t going to work. How do we? How do we? What do we need to know about that? How do we pivot in that moment?

 

Whitney Lowe  

Yeah, there’s. I think this whole idea of like hold on loosely, you know, to to those kinds of things, and it may come up at different times for people. For me, it came up a lot from my early experiences in in the orthopedic clinic back at Emory, when all of a sudden I was faced with all kinds of things like, wait a minute, they. Did not teach me how to deal with this in massage school, and I had to really let go of a lot of traditional ideas and and things that I was taught that I thought were black and white rules. And I realized, like, oh, the real world of healthcare is really messy. It’s really messy, and it does not adhere to these kinds of of rules and guidelines, so that can be pretty uncomfortable. I think depending on how you run into that, whenever you are you know doing that in your career, whatever is the method that that gets you there. But at that point, I think you know you’re ready to move up to the next stage of of what is that like that sequence of processes of going from unconscious incompetence to you know conscious incompetence to you know conscious competence and then unconscious competence where you just like you don’t know why this is but you know it’s right, and you do it, and you’ve just been doing this for a long time. So that there’s that sequential methodology of moving through those. But yeah, in in the process of getting there, it can be kind of it can be kind of rough to figure out like where are you and how are you how are you making these changes?

 

Til Luchau  

There’s it’s that there’s a paradox here that we’re talking about too, and that’s the paradox of confidence, maybe on one side and openness on the other, because we need a certain amount of confidence in what we know, see, perceive, even to try it, and when we start listing contextal factors, like what are the things we, what are the ways we do things that make what we do effective. Practitioner confidence is a huge one on both results and on on the practitioner’s side action with their work. How confident are you that what you’re doing is helping, for example? So that’s one side of the paradox. The other side of the paradox is that you you wrote about it here. Overcoming the fear of uncertainty, it’s like there’s moments when we just don’t know exactly what’s going to come next.

 

Whitney Lowe  

Yeah,

 

Til Luchau  

and there’s a skill, don’t you think, to hanging out and just seeing what emerges, being being able to respond when something does emerge, but not trying to push something to happen before we know where things are going.

 

Whitney Lowe  

Yeah, and I think what you touched on there too with the the confidence level lets you hang out in that place a little bit more comfortably than if you don’t have that confidence because you really feel a whole like the rug is kind of pulled out from under you, and I want to ask you this because this thought just came to me back kind of back to the whole structural integration community thing

Til Luchau  

is,

 

Whitney Lowe  

I think those guidelines and the let’s just call it the protocols for lack of a better word. The protocols are structured strategies and all that kind of stuff.

 

Til Luchau  

Yeah,

 

Whitney Lowe  

also fosters a really great sense of community among practitioners because, like, I saw that a lot in like sort of the people when I was doing a lot of early training with Paul St. John and the the whole neuromuscular community down the in the southeast. Is like these people were the neuromuscular therapists. There was this sort of sense of community because they followed these protocols and they did this, you know, these trigger point techniques this particular way. And like, I mean, do you think that’s kind of also a valuable benefit? Is that sense of community that comes with that?

 

Til Luchau  

Sure, part of our belonging, part of our. I mean, we do that as body workers. We got a set of things we do and share and signal with each other that are part of our membership in this club. But yeah, absolutely, a protocol, and especially in the Rolf Institute at that time, this will probably different different parts of it now. Was a big part of our belonging rituals or our signals to each other around that.

 

Whitney Lowe  

Yeah, yeah. 

 

Til Luchau  

well assessment as an ongoing loop. I was going to ask about that.

 

Whitney Lowe  

Yeah,

 

Til Luchau  

what’s that mean?

 

Whitney Lowe  

Well, you know, I think, and I’m probably partially to blame for this. You know, having been focused on assessment for so long in my career, assessment has gotten to be sort of this idea of something you do in the first time with your client. But this whole idea is assessment is really an ongoing process where you’re gathering information in order to make good decisions about what you’re doing, and this can easily change three sessions into something when all of a sudden you’re realizing like this isn’t working or something really different is happening here or whatever, and I think it’s really important to keep open

to that whole idea of constant input for continual evaluation of what’s going on, and recognizing I might need to adjust my protocol or my methodology or something like that, and do something really different because the way I’ve been doing this is not happening. It’s not working, or it’s having adverse effects, or something. That and this this this means that I got I got to change some things there. So that to me that really needs to be always in the back of your mind is is remembering everything that you do when you have a thought about working with somebody when you’re doing something you have a thought about something you feel under your finger you have a thought about something just like you get an intuitive hit, like I just need to do something on this shoulder here. It’s all assessment. It is all assessment. It’s gathering information and making determinations about you know how do you proceed and how do you adjust your your strategies and methodologies.

 

Til Luchau  

You’ve just transformed this process into something much more than a reasoned cognitive frontal lobe only approach, you’re saying there’s a lot of sensing involved, a lot of taking in information, a lot of listening, and that you’re synthesizing or that you’re responding to that moment by moment.

 

Whitney Lowe  

Yeah,

 

Til Luchau  

what if I mean call it clinical reasoning? What if we call it clinical improvisation,

 

Whitney Lowe  

I like that as the form musician. I like that a lot. Yeah, right.

 

Til Luchau  

I’m teasing you just a little bit, but I think that we are talking about improvisation in so many ways of being being unattached in having a plan. I’m playing, but being unattached enough that I can change. I can change. I can pivot. I’m listening, responding. I’m feeling the vibe. I’m going with it. Yeah, using using what I know to create beautiful

 

Whitney Lowe  

experiences, and just remembering too that improvisation doesn’t just mean winging it without any kind of structure. Because you know, as a former saxophone player and somebody who was pretty serious about music, I spent a lot of time studying and trying to learn improvisation. And you know, there’s a very, very, very humongous chasm between what I would do and what John Coltrane would do with not thinking about anything. You know, just and again, that comes from I think so much of the building of those foundational structural skills to begin with, to be able to let go of them and just like open yourself to the the river of innovation of improvisation of whatever comes through you from wherever that comes from and wherever that place of of inspiration comes from.

 

Til Luchau  

There’s yeah, just making me think too. I mean, there’s cultural traditions around learning and education, and I learned so much by traveling and trying to teach in the ways that I did here, you know,

abroad, and realizing, wow, this is a really culture-bound way that I’m even thinking of it, and improvisation is a great American tradition. I mean, this is the land of jazz and winging it and faking it til you make it. And I remember going to Europe and teaching in the style that I was teaching at that point, which is like do a demo. I would I would outline some of the things I did on the board, but it was a loose outline. It was like an improvisational structure, and then I would say, “Go do it. And some people went and did it and did beautiful sessions, and other people got really upset. And I think it was Switzerland where I finally it was like my Waterloo. That and not to not to generalize too much about Swiss people or German people were also in the program, but they have a great tradition of precision and intentionality, and that way of improvising just upset too many people. And I fought about it where I said, “Just try it, just do it. And at some point, I got tired of arguing. And the next time I came back, I had these little notebooks with the name of a technique and a little picture on each one, and a little description, and oh my gosh, were they happy! And oh my goodness, did we have a good class? Yeah, and we could improvise because we would take and we’d mix the pages off in different orders. We would like you know put notes all over them, change them around. But it was a big lesson to me that without that kind of framework, just to jump in there, try to organize, left a lot of people feeling lost.

 

Whitney Lowe  

Yeah, that’s a fascinating cultural perception about that. Like, and you, you know, from having traveled around, I’m curious to know, like, is that different in Asia? Like, because you spent a lot of time over there teaching. I mean,

 

Til Luchau  

anytime we’re doing generalizations, it’s off base. Yeah, yeah. There’s a story about you mentioned Tom Scott, maybe maybe Sonny Rollins. I’m I’m not remembering the name. A famous jazz musician went to Japan to improvise with Sakahachi players of Japanese flute players. They thought this is the most beautiful music I’ve heard. Let’s play my saxophone. They’ll go wait. We’ll just jam, and he got you know some famous akatuh people in the studio. Had the thing all set up, and they got into it and realized they had no tradition of improvising at

 

Whitney Lowe  

all,

 

Til Luchau  

and they couldn’t do it. So they ended up having to go through and script and write out the music for these improvised.

 

Whitney Lowe  

Yeah,

 

Til Luchau  

and there’s Singapore who just a few years ago put billions into it’s a small you know city state, but lots and lots of money into art, and their argument was that we are really falling behind on innovation. We are so good at our precision and productivity, and our clear adherence to rules and clear structure that

we’re not even at innovating anymore. And I thought the solution was to really fund the arts and bring that back into their culture.

 

Whitney Lowe  

Yeah, and I think certainly the lesson that comes out of that is kind of what we’ve talked about along here, which is that both of those things are really valuable to become the best skilled clinician. You know, having good foundational knowledge and good foundational skills becomes the basis for getting away from those kinds of things. And and I have you know again, I’ll sort of like lay out a clear bias that I have about some practitioners in our field when I talk about you know especially like treating pain and injury problems and people say like oh I don’t bother learning anatomy or stuff like that I just let my hands tell me what to do and there’s certainly a perspective about that for just the free flowing artistry of working with another human and and giving them a wonderful sensual kind of sensory experience about what’s going on there, but if somebody really is trying to determine like, do you have a problem that you shouldn’t even be working on? I don’t like the idea of just like let my hands tell me what to do. You know,

 

Til Luchau  

yeah, there might be some more risk involved in there, or, or it’s a different style. I mean, I I still love getting work from someone who just gets lost in the immediacy of the experience. This is, I mean, now you’re taking back to another part of my history, which was living and teaching at the Eselan Institute, where the motto was, “Get out of your head and come to your senses.

 

Whitney Lowe  

Yeah,

 

Til Luchau  

and so there was a lot of craziness of us getting out of our heads, but there was a lot of emphasis on immediate experience coming to our senses, and their body work there was taught from that point of view. Yeah, I mean, one teacher joked that she taught us to use oil so that we could tell where we’d been, or so in the moment we would forget what we’d worked on. Oils would show us; we can look and see.

 

Whitney Lowe  

Yeah, you know, I don’t know if you had this kind of experience, but I have had frequently a difficult time getting what I really want and or desire from massage and manual therapy sessions when I go to see people because they keep thinking I want them to do what I do, you know, and like I know I don’t have a particular pain problem. I want what you just described. I want that really very free flowing sensory experience of you know kind of like getting out of my head and doing the things of just letting my body receive what’s going on there. But it’s often difficult to get people to to try to do that with me.

 

Til Luchau  

Need to book and book your sessions under a different name. It’s true. Yes, yeah. My wife used to do that. She would she would she got tired of like, oh, are you Loretta Luchau? Are you like, married to Til?

Not that I’m like that famous, but in that zone, the name definition. Everyone was trying to do my work on her, and she didn’t like that.

 

Whitney Lowe  

Yeah, yep, yeah.

 

Til Luchau  

So, yeah, it’s this is such a rich topic. How do you want to bring us home? What else do you want to talk about before we?

 

Whitney Lowe  

Yeah. So I think just that the the closing idea and just sort of the wrap up is recognizing the recognizing the value and the importance of fundamental skill building with those protocols, guidelines, and you know rules or whatever you want to call them, as a really necessary piece of beginning a learning process about something, as we mentioned, you know, from the whole realm of cognitive load to safety to giving you some specific things to start focusing on. Those things are really necessary, and at a certain point, you have to learn to let go of them also, and and be comfortable to some degree with the uncertainty and the the indecision or or lack of of certain. Yeah, I guess the lack of certainty around exactly what’s going to happen and how things are going to work out, in order, at least again, in my opinion, in order to become the really best possible clinician that you can be. Now, some people really love, let’s say, you know, maybe they’re working at a franchise establishment or something like that, and they just want to do their, you know, relaxation routine, and that’s all they want to do. That’s great. I mean, that’s cool. If like that’s what you if you really get into that that kind of thing is is really good for you. That’s great. But a lot of folks, I think, when they’re coming to see us. Really seeking a really unique, tailored kind of of experience, and and that’s going to require you to kind of also expand your horizons for figuring out how to how to be unique and different in that realm as well.

 

Til Luchau  

I think, and this is true in my trainings, and I’m pretty sure it is in yours too. We see people at the moment they want to make that switch. Yeah, maybe it’s the first time they come to a class, or the 10th class they come after studied with us for a couple of decades. They’re looking to go beyond what they get from where they started, from just protocol based or or intuition only based work, and being able to really synthesize or hold both possibilities. Can I really understand the cognitive side of what I’m doing, and not be so rigidly locked there that I can’t feel and improvise and pull and things out, let things go to find moments of not even knowing what’s happening? Those are like the improvisational moments. Those moments when I’m not even sure, like, wow, what just happened and what’s going to happen next? Yeah, terrifying, and they’re the ones that the amazing things follow almost immediately. Yeah, amazing moments come from a from the moment before it. It was like that. What the heck is going to happen?

 

Whitney Lowe  

Yeah, and certainly for me as an educator, this is probably true for you as well. Is that like I absolutely just love that part of being there, when a person goes, “Oh wow, I never thought of that, or “Ah, I can remember a client I had that just I just did this, and it just like this didn’t happen to this this kind of thing.

Like I didn’t understand it. Now I get it. Now I see what’s happening there, and sort of getting outside of those original kind of like limited ways of thinking about things, it’s like seeing this from a new lens. That that part of it is so exciting to be a part of. It

 

Til Luchau  

is, and you’re making me think of like our level two certification, where it’s all about application. We just work with clients. No more trying to upload material techniques to. Let’s just watch people and see how respond to what they’re doing. So often, when I’m supervising those sessions, it’s obvious to me that my job is to support the practitioner’s confidence. And so when I, I’m I’m always asking, what do you see? What do you drawn to? What do you think? How do we talk to your client? How do we find out what’s important to them, and then I think probably 80% of the time the plan that they’re coming up with is the one that makes the most sense to support.

 

Whitney Lowe  

Yeah.

 

Til Luchau  

Rather than me coming as a teacher and going, oh wait a minute, if we go back to page three in your book, it actually says we should do this first. Yeah. That is not helpful at that point. And when we’re like improvising with a client, it really is like what is emerging here that’s of interest to both of us, and how do we follow that? And then catch it if it stops being of interest. If it’s not relevant anymore, then we pivot.

 

Whitney Lowe  

Yeah,

 

Til Luchau  

like what’s next?

 

Whitney Lowe  

So interesting little process here of this evolution. I think that we see see people go through. So, and

 

Til Luchau  

what it is a process, it is an evolution that people go through, and it’s this this field is so rich because we do get to synthesize our detailed cognitive understanding,

 

Whitney Lowe  

yeah,

 

Til Luchau  

our reason based procedures for doing things, and the artistry, improvisation, aesthetics, melodies,

 

Whitney Lowe  

yeah,

Til Luchau  

you know, all that stuff. We get to live in all those worlds at once and switch between them, and essentially play on many levels simultaneously.

 

Whitney Lowe  

Yeah. So, I think that’s kind of a good place for us to to leave the protocol paradox. Any anything else that do you think are practical?

 

Til Luchau  

Let’s think of. Oh, do we have practical steps for therapists? What can they do in your next session to help make room for this?

 

Whitney Lowe  

That’s a good thing to think about. So, in terms of a practical thing, I I would kind of like encourage people to you know again think through that process of really asking why. Why are they doing the things that they’re doing? Are they doing this because this is the way that they learned how to work the backside of the shoulder, or is there a is there a either a reason that they’re going to do this, or that there’s a an intuitive sense that this is going to be really helpful for this person, like asking that that why question around all the things that you’re doing. What what’s sort of driving you in that direction? I think that’s a a good place to start thinking about how to move beyond just the the simple techniques that you learn to do something into a more sort of fluid and integrated way of of thinking about it.

 

Til Luchau  

Beautiful.

 

Whitney Lowe  

I’m

 

Til Luchau  

thinking about it’s more important. Well, knowing what to do is important, but it’s even more important to know if it’s the right thing at the right time.

 

Whitney Lowe  

Yeah,

 

Til Luchau  

and so I would say. My practical tip might be like if you feel uncertain, stop. Just catch yourself feeling uncertain, catch yourself wondering, and then actually stop and see what wants to emerge, so to speak. See where you’re drawn. You might even check in with your client and see what’s happening for them. But let something emerge. Maybe it’s going to be the same thing, but maybe it’s something else. Just give yourself those pivot moments, yeah, and your improvisational flow. Yeah,

 

Whitney Lowe  

wonderful. Well, let’s we’ll wrap up here with our closing sponsor from Books of Discovery, and remember that Books of Discovery’s manual therapy textbooks, e-textbooks, and digital resources help instructors achieve their instructional goals, and they inspire students to achieve theirs as well. They find the same spirit here on the Thinking Practitioner podcast, and they’re proud to support our work, knowing that we share the mission of bringing the massage and body work community truly thought-provoking and enlivening content that advances our profession.

 

Til Luchau  

Books of Discovery has just released the new seventh edition of Trail Guide to the Body. This million-copy bestseller takes another leap forward in empowering the next generation of manual therapists with all new palpation video instruction and a new primer on the nervous system. Instructors of manual therapy education programs can request complimentary copies of the new seventh edition at booksofdiscovery.com, and listeners, all of us can go explore the publisher’s full collection of titles at booksofdiscovery.com. Or thinking practitioner listeners save 15% by entering thinking at checkout.

 

Whitney Lowe  

And as always, we would like to say a big thank you to all the listeners and to our sponsors. You can stop by our sites for video show notes, transcripts, and any extras. You can find that over on my site at academyofclinicalmassage.com. Until where can they find that with you?

 

Til Luchau  

Advanced-trainings.com. We want to hear from you with your ideas or input about the show. We want to hear what happened when you paused from uncertainty. What happened next? Hopefully, you didn’t pull out your phone and email us right at that moment. Great. Just hang out there with your client, see what comes up next, and then afterwards, send us a quick email at info@thesthinkingpractitioner.com, or look for us on social media and YouTube, I am At Til Luchau. Whitney. Where can people find you?

 

Whitney Lowe  

Also on socials under my name, Whitney Lowe, on those channels as well. And we would really appreciate it. I know we ask this all the time, but this is actually really important. If you would take just a few moments to rate us on Spotify or Apple Podcasts, those are two of the biggest podcast platforms. It really does help other people find the show. So please take a few seconds to do that. And thanks again, as always, for sharing the word, telling a friend, and we look forward to seeing you again on our next episode.

 

Til Luchau  

Whitney, thanks for this topic and thanks for your ideas. It’s been fun talking to you.

 

Whitney Lowe  

Indeed, enjoyed it as always.