The figure comes from a recently published research paper (1) on the attitudes, beliefs, and behaviours of osteopaths who reject the evidence-based guidance on low back pain (LBP).
Why would osteopaths, for whom LBP makes up at least 50% of their case load, and from all parts of the profession, (established practitioners; new ones; students; their tutors), behave in a way contrary to the scientific consensus?
The researchers concluded that through the process of their training and practice osteopaths acquire a strong professional identity characterised by autonomy, authority, and distinctiveness.
(Do these characteristics remind you of any other profession?)
The paper suggested a metaphor of a lens to describe how the traditional evidence pyramid gets viewed upside-down. In the traditional evidence pyramid expert opinion is the lowest regarded form of evidence but to the osteopaths in the study expert opinion appeared as the most highly valued evidence. And the way they valued evidence-based guidelines and research was flipped too. In fact these were actually seen as threats to professional identity.
Incidentally, one finding which I found especially interesting and of potential relevance to hypnotherapists (at least conceptually), was how osteopaths modified their treatments when working within the NHS. The NHS for the most part these days requires adherence to evidence based practice. It’s no longer possible to give treatments for which there is insufficient evidence of efficacy.
Despite some of the limitations of the research paper the study seemed interesting and, for me, the ground it covered had a familiar feel. Let me explain:
I’m a physiotherapist as well as a hypnotherapist. 25 years ago physiotherapy was just starting to get to grips with the demand for evidence based practice. Change is not always easy and for us it was far from smooth as we had to put much-loved traditional practises to one side. I’ll say a bit more on that below. But because most physios work in the NHS there was no choice. Getting with the program was the only option — if you worked in the NHS. In private practice you can still give traditional treatments (it goes without saying that professional ethics and standards are a foregone conclusion, but then, they always were).
The osteopaths, who are essentially in private practice, seem about a decade or so behind physios in terms of the adoption of evidence based practice. My impression is that hypnotherapists, another profession consisting of private practitioners, are only just milling around the starting blocks at this stage.
Here are some recollections of adopting evidence based practice.
Back then we valued expert opinion highly. To be fair, it was all we had. The body of research for physiotherapy back then was sketchy. In the UK it had only just become a degree-based profession and UK post-graduates and researchers were incredibly thin on the ground. The Australians led the field because they’d had the longest running post-graduate research programs. Today’s reasonably common knowledge about “core stability” when talking about exercise — all that originally came from Australian research and when the Aussies brought their training and courses over here I think every musculoskeletal physiotherapist took a “muscle imbalance” course and went on to do a side-line in Pilates. (Funnily enough the core stability pendulum is swinging but now’s not the time or place to go into detail.)
Of course it’s the nature of research to ask more questions than it answers so, slowly at first, the research gathered momentum and expanded into different areas. Today you couldn’t possibly hope to keep up with all the research which is produced.
Back then though, as evidence based practice was being adopted, the profession fell into at least two camps. There were the zealots. You knew you were talking to one because you had to include academic references in your conversation. It was like playing Research Paper Top Trumps. You’d give an opinion and the zealot would question it… with a reference. So you had to counter with a reference of your own and better still, a criticism of the inadequate methodology used in their reference. Looking back it was a bit amateurish but I guess it got us into the swing of things.
The other camp in the profession contained the old guards. They believed they didn’t need any references and wanted to carry on just as they’d always carried on. Their practice was guided by the roll call of gurus who’d established the profession: Maitland, McKenzie, Cyriax. These gurus were not researchers, they were clinicians and pioneers. Their approaches and treatments were not without merit. And like I mentioned, it was all we’d had.
It strikes me that this is roughly where hypnotherapy is today. Erickson, Elman, Bandler — it’s gurus all the way down.
Briefly, physiotherapy did lose something for a long while during the transition to evidence based practice – which incidentally, took years. Physios older than me recall demonstrations on stage with “the gurus” using real, live, patients. This was how the information was spread. All of this disappeared for years. It reminds me so much of when I’ve watched the demonstration of a hypnotic technique at a convention or on a course – real clinicians working with real people. It’s valuable, I don’t think we want to lose this. I’m really happy to say it’s coming back to physiotherapy but with a twist. Last year I saw physio techniques performed live on stage, with real patients. The irony was that it was by a professor from Australia who’s not a guru – because only because everything he does is backed to the hilt with evidence from the research labs. That’s the twist.
Things will change. It changed for physios because
1) We were compelled to adopt evidence based practice.
2) Our research base expanded. First from Australia, then the US, then we grew our own.
It’s possibly changing for osteopaths — especially where they have to comply with the requirements of NHS contract providers. I’m going to predict that their distinctive professional identity, the creator of the “lens” which currently inverts the traditional evidence pyramid, will require a native osteopathic research base for the profession to avoid becoming marginalised from a scientific point of view like the acupuncturists and homeopaths.
I think this is the challenge for hypnosis and hypnotherapy. For me it’s like watching history repeat itself to some extent. If all goes well the research will emerge from the labs and into clinical practice. I.e. the profession will draw clinical practice from an expanding post graduate research base utilising principles of science based medicine. Furthermore, unless we create something like this then hypnotherapy will never be able to make a transition to mainstream medicine and eventually all we’ll be left with are gurus and the company of the other marginalised professions and traditions. Of course that begs the question of whether hypnotherapists want to make a transition to mainstream medicine. Perhaps some will; others, won’t.
(1) Figg-Latham, J. and D. Rajendran (2017). "Quiet dissent: The attitudes, beliefs and behaviours of UK osteopaths who reject low back pain guidance - A qualitative study." Musculoskelet Sci Pract 27: 97-105.