The first trap is a reluctance to admit complexity.
The second trap is a confusion between experience and memory.
The third is the focusing illusion, and there’s just no way of getting it right.
So is the introduction by Daniel Kahneman in his TED-talk about happiness and how our cognitive biases sets traps that messes up our perception of it. We as physical therapist should be aware of our own cognitive traps and traps within the patients perspectives.
The first trap is easy to acknowledge and relate to physical therapy as we still struggle to cross the chasm from a simplistic biomedical-postural-structural model of reasoning to the biopsychososial frame for reasoning. This neglect of complexity may be at the core of over confidence, as Trisha Greenhalgh describes being a professional vice in evidence-based clinical practice:
The vice of overconfidence engenders a dangerous triad of cognitive biases:
The illusion of understanding (the “expert” assumes that they know far more about the natural history of the disease than is actually known) – we think we know more than we do.
The illusion of validity (the “expert” assumes that their mental model of causation and prevention is correct) – where we are confident because we have a coherent explanatory story, but don’t allow for what we don’t know.
The illusion of control (the “expert” assumes that for example active screening will improve outcomes, whereas not screening a population is likely to lead to harm) – because we take action, we think that means the outcome is more amenable than if we don’t act.
«Overconfidence also gives us a tendency to fail to recognize inherently unpredictable environments, assuming wrongly that everything can be analysed with reference to our own narrow knowledge base.»
The second trap is exemplified by Kahneman through someones experience of listening to a symphony:
«It was absolutely glorious music and at the very end of the recording, there was a dreadful screeching sound. And then he added, really quite emotionally, it ruined the whole experience. But it hadn’t. What it had ruined were the memories of the experience. He had had the experience. He had had 20 minutes of glorious music. They counted for nothing because he was left with a memory; the memory was ruined,and the memory was all that he had gotten to keep.»
Of all our experiences, we tend to remember the best and worst, and dispatch the rest. Or we remember something that adds new memories. A 2 week vacation is twice as long as 1 week of vacation in experience. But for the remembering self, if the two weeks are similarly good or bad, the remembering self barely distinguishes them. The second week add no new memories, the story hasn’t changed.
If you have had treatments from two different therapists, and were to choose who to go to for the next treatment, you would choose the one that has the memory that is less bad. If you had a wonderful and loving relationship for 10 years that ended with one year of misery, you would probably remember the whole decade as miserable, neglecting the 9 years of wonderful experience. Your experiencing self is pushed out by the bad memories of the last year – the remembering self.
This is a «duration neglect» (extension neglect) which is the psychological observation that people’s judgments of the unpleasantness of e.g. a painful experiences depends very little on the duration of those experiences. Multiple experiments have found that these judgments tend to be affected by two factors: the peak (when the experience was the most painful) and how quickly the pain diminishes. If it diminishes more slowly, the experience is judged to be more painful. Hence, the term «peak–end rule» describes this process of evaluation.
Could this also play as traps and affect therapists (and patients) experiences? In what is experienced through or after exercise or manual treatments? Do these traps lurk in the path of our communication? Words that harm; are those remembered as a peak or from the end, clouding all other words no matter how reassuring or comforting? An unpleasant experience of exhaust or pain, will it drain everything else from the experience of the meaningfulness of a good exercise? Repeat business treatments may not add new memories. Over confidence may hamper opportunities for adding new and sustainable memories to patients as one fall into the trap of not admitting the complexity, or the patient context.
A happy patient after the 6th weekly lumbar manipulation could have all the five first weeks deleted in change for the end memory. And so the illusion manifests that the whole treatment series is probably needed to reach the desired effect (though maybe it all was the natural history of that back ache). And as for the therapist: During my clinical manual therapy master course I was told that spinal manipulation treatment should have an effect-limit of 6, meaning that if the desired effect wasn’t achieved to some degree within 6 treatments, another approach should be tried. That is probably more the natural history, luck by chance and conceit bottled into an illusion, or a professional vice if you will, than a significant experience – from a peak-end memory.
«We actually don’t choose between experiences, we choose between memories of experiences.»
The 3th trap is an anchoring fallacy; the tendency to rely too heavily on the first piece of information offered (the «anchor») when making decisions. The first impressions are difficult to change, right? Does observing a patients posture ring any bells? We’ve probably all been there. Or palpating that hard muscle? Anchoring to one piece of information that confirm your own narrative?
Kahneman also states: «It’s the unfortunate fact that we can’t think about any circumstance that affects well-being without distorting its importance.» That’s why I think reflecting and understanding the cognitive biases that makes our reasoning a minefield are essential for clinical reasoning. And here I have only touched on some of them.
The remembering self both feed our professional confirmation biases and chooses on behalf of the patient. Kahneman says: «Even when we think about the future, we don’t think of our future normally as experiences. We think of our future as anticipated memories.»
Patients past experiences may have profound impact on future choices and expectations, just as a therapists own past experiences may guide, or even dictate, future decisions and treatments. Be aware of the traps that the remembering self lay out to cloud meaningful experiences within the experiencing self. The patient perspective and expectation is always biased, as are the therapists, and creates cognitive double-traps.