Humans are social creatures with our capacity for language giving us dominion, as we perceive it, over other species. Given our inclination for spoken and written communication, we humans love to label things. So it’s no surprise that the medical model often goes after labeling the “what” (an issue in the tissue, a chemical imbalance, an anatomical variance) without as much as emphasis on the “why”. But is that always a helpful thing, particularly in chronic neuromusculoskeletal conditions which the U.S. is quite inept at treating? I argue that labeling fundamentally changes our experience and alters our ability to self-regulate.
Labeling, in the form of language, does not necessarily indicate reality. Just because you call something a spade doesn’t necessarily mean it’s a spade, but it does make us more likely to think it is. In using pathoanatomical terms and diagnoses to describe a condition, we cover up one’s experience with words and have thus altered our perception of it. By labeling something personal, as is our human desire given our verbal dominance, we imbue it with a sense of self and as such we start to identify with it. MY pain, MY disk herniation, MY anxiety, MY arthritis. This becomes especially problematic as symptoms persist and neuroplastic changes occur that reinforce sensitization to one’s current status.
Once we identify with something it becomes uncomfortable to let go of, even if we want to. So many of the persistent pain clients I work with struggle to “let go” of THEIR pain, in part because of an identification with it. IT has become part of them and is reinforced both neurologically and psychologically by every x-ray and MRI reading and every stressor that elicits the symptoms. IT becomes as difficult to get rid of as any other annoying habit. It is almost as if one can begin to cling to this identity because is it the most salient part of who they perceive themselves to be.
“Language is not merely a vehicle which carries ideas. It is itself, a shaper of ideas” Man-Made Language
Diagnosis and Behavior
Unnecessary labeling lends itself to the medicalization of problems and it directly influences the treatment. Do bone spurs or disk herniations tell us anything about how that person moves or how they perceive, behave, and experience their environment? Of course not, yet a label (even an unspoken one in the mind of the practitioner) immediately begins to shape the perceptions of both the practitioner and the client before any true cause has been determined. The “what” is shaping and very often bypassing the determination of the “why” because when we lump people into groups it makes them appear more alike and thus reduces our likelihood of individualizing their needs.1, 2
From Croft, et al. “There is increasing concern about such ‘over diagnosis’, in which a pathological lesion or state is identified, and the patient is defined as having a disease, in the absence of any evidence that this state either leads to a poor outcome or defines a pathway of investigation or treatment that clearly advantages the patient.”2
I am not saying that it’s not important to figure out what’s going on, in fact I’m saying just the opposite. In avoiding diagnostic labels, particularly in chronic musculoskeletal issues in which a pathological cause is unclear, both the practitioner and the client are less subject to bias their approach towards a particular symptom which is likely what many non-traumatic orthopedic diagnoses really are (most of what I see clinically seem to be the orthopedic manifestations of maladaptive neuromotor patterns). In other words, when we avoid labeling people with structural issues I think we are better able to see the whole pattern of behavior and less likely to focus on just one area that may or may not be the source. How can you see the movement habits of the entire body if all you’re doing is looking at the painful shoulder, for example? Looking for structural pathology on a tissue level, particularly in those with a persistent problem and without an obvious trauma, is not only misplaced precision it seems to disrupt self-regulation.
From Croft, et al. “There is increasing concern about such ‘over diagnosis’, in which a pathological lesion or state is identified, and the patient is defined as having a disease, in the absence of any evidence that this state either leads to a poor outcome or defines a pathway of investigation or treatment that clearly advantages the patient.”2
I am not saying that it’s not important to figure out what’s going on, in fact I’m saying just the opposite. In avoiding diagnostic labels, particularly in chronic musculoskeletal issues in which a pathological cause is unclear, both the practitioner and the client are less subject to bias their approach towards a particular symptom which is likely what many non-traumatic orthopedic diagnoses really are (most of what I see clinically seem to be the orthopedic manifestations of maladaptive neuromotor patterns). In other words, when we avoid labeling people with structural issues I think we are better able to see the whole pattern of behavior and less likely to focus on just one area that may or may not be the source. How can you see the movement habits of the entire body if all you’re doing is looking at the painful shoulder, for example? Looking for structural pathology on a tissue level, particularly in those with a persistent problem and without an obvious trauma, is not only misplaced precision it seems to disrupt self-regulation.
Labels and Self-Regulation
From a neurological perspective, using pathoanatomy (aka bulging disc, torn rotator cuff) only serves to reinforce our hypervigilance and amplify the resting tone of the nervous system. And it certainly doesn’t lend any security to the situation. Diagnostic labeling disrupts self-regulation because it emphasizes an external locus of control3 and places the dependence of a fix on specific techniques, a mobilization or modality or rigid exercise, which we know mostly don’t work in isolation. Humans are a system of systems and when we stick labels on things we break the system down into parts, often neglecting the whole. And I think this affects one’s perceptions of themselves and reduces their ability to maintain a loose, connected state free of excessive tension and effort.
When we contribute to one’s belief that they are not in control of their own bodily systems thru unnecessary labeling we deny them the empowering experience of modifying their own movement habits. And it is this alteration of movement and behavioral patterns, often needing specific techniques but based upon an all-encompassing assessment, and the permission to heal that seems to get people moving in the right direction and regain an internal locus of control.
Conclusion
When we stop trying to cover up experiences with labels that only describe symptoms in a superficial manner, we allow for a deeper sense of connection with the client and allow the “why” to manifest thru a systems-approach to movement and behavior with less bias.
– Seth
Further Reading
1. Subliminal: check out Chapter 7, in which Mlodinow discusses how merely placing people in groups alters our subsequent judgements of them, making people grouped together appear more alike. I think this has interesting implications for those classified with unclear diagnoses such as chronic pain or fatigue, fibromyalgia, etc. Each individual has unique differences (n=1) and likely needs a specific tailored approach, but I wonder how we often can’t see those differences because of our labels.
2. The science of clinical practice: disease diagnosis or patient prognosis? Evidence about “what is likely to happen” should shape clinical practice. Really interesting piece on how perhaps prognosis and risk-stratification tell us more than diagnostic labeling.
3. Locus of Control and Self-Efficacy: Potential Mediators of Stress, Illness, and Utilization of Health Services in College Students. Stress, illness, and medical utilization is higher in those with an external locus of control.
2. The science of clinical practice: disease diagnosis or patient prognosis? Evidence about “what is likely to happen” should shape clinical practice. Really interesting piece on how perhaps prognosis and risk-stratification tell us more than diagnostic labeling.
3. Locus of Control and Self-Efficacy: Potential Mediators of Stress, Illness, and Utilization of Health Services in College Students. Stress, illness, and medical utilization is higher in those with an external locus of control.
I love this piece! It made me think of two things:
1- I was just reading an article discussing what makes people resilient, that proposed that a major factor contributing to “resiliency” was an internal locus of control:
http://www.newyorker.com/science/maria-konnikova/the-secret-formula-for-resilience
Also, notable in this article, and related to your post I think is the idea that an event is not traumatic until a person experiences it as traumatic. Analogously, could you say that pathoanatomic findings are not a problem until a person experiences it as a problem?
2- I wonder if the concept of “learned helplessness” can inform some of client’s responses (i.e., inabilities) to learn adaptive behaviors- either physically developing new motor patterns or psychologically developing new approaches to experienced pain/injury etc.? This phenomenon has mostly been proposed (from my knowledge) as an explanation for depressive thinking and behaviors, however I could see it having utility within a motor-pattern re-education paradigm as well. Thoughts? Thanks for the good brain food, keep it coming!
Hey Leda,
Thanks for reading. 1)I agree with your point that if someone sees pathoanatomical findings as problematic if it is of sufficient discord from their perceived self-image, it is indeed traumatic to their perceptions. Often, these pathoanatomic findings are presented as fact, in very serious and grave tones rather than as possibilities and as such alter our perception of self if not resilient enough to manage – which most aren’t when they’re in pain. A “disk herniation” is a much bigger deal to someone who hurts as opposed to someone who doesn’t hurt, despite the fact that the actual image may be the exact same.
2) Absolutely, all movement is behavior and cannot be separated from the emotional and autonomic patterns with which it is associated. As such, one who has been conditioned to believe that movement re-education is not possible finds great difficulty in doing so. Negative labels, in my opinion, contribute to such conditioning.
-Seth