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Cleveland
State University Prestige Day Banquet Address Barrett
L. Dorko P.T. My father, Andrew John
Dorko, was the resident poet of Westlake Ohio. During the last ten years of his
life he was regularly invited to write and recite original verse in honor of
special occasions such as ground breakings, dedications or holiday events. Not
long before his passing he did something for the dedication of the new
recreation center in his favorite city and another attendee, Congressman Dennis
Kucinich subsequently put that poem in the Congressional Record-which was
pretty cool. As I grew to actually know
him late in his life, I realized for the first time that his poetry emerged
from his center irresistibly; instinctively-as if he had been seized
suddenly by some internal freight train that would not let him off until he had
committed his words to paper. He seemed not to be in charge of this process-one
day he just allowed it to have its way-he was fourteen. He wrote his final poem
at the age of 84 while lying in a hospital bed in a skilled nursing facility in
his beloved city of Westlake. I realize now that until he
was quite a bit older than I am today, no one encouraged his writing. His
parents and seven siblings never read any of it. His six children were
collectively indifferent and my mother was, in my memory, totally silent on the
matter of being married to a poet. This never stopped him. I don�t think it
even slowed him down. And that willingness to continue without external
approval is, to me, my father�s legacy. The approval of
others-something we all seek. And in order to acquire it we are obliged to
examine and accept what those around us seem to want. In adolescence we call
this �peer pressure,� and we admonish our children not to fall prey to it. But
adults feel it no less powerfully and have no specific name for it. Its
insidious nature makes it even more powerful. In his latest book, Status
Anxiety, the essayist Alain de Botton speaks of it in this way: �Up until a
certain age, no one minds much what we do, existence alone is enough to earn us
unconditional affection. We can burp up our food, scream at the top of our
voice, throw the cutlery on the floor, spend the day gazing blankly out the
window, relieve ourselves in the flower pot-and still know that someone will
come and stroke our hair, change our clothes and sing us songs. We begin our
time on earth in the hands of a mother, who asks little more of us than that we
continue to live�But this idyllic state is fated not to endure. By the time we
have finished our education, we are forced to take our place in a world
dominated by a new kind of person, a person as different from a mother as it is
possible to be and whose behavior lies at the heart of our status
anxieties; the snob. (Like it or not) we are forced to subsist on a diet of the
highly conditional attention of snobs.� The thing that drives our
behavior as adults is what I always refer to as the culture, and I deliver
these two words to my classes and patients with a lowered voice and a slightly
Draconian implication. Simply put, the culture is a snob. It not only
tells us what we should look like and how we should behave, it isn�t the least
bit interested in our health-though it may pretend to be. Now-how does all of this
relate to the profession of physical therapy? Well, whatever else it might be,
physical pain is, at its root, a consequence of behavior. At times, we�re
talking about the behavior of systems over which we may have little or no
control. In the face of pathological processes that require chemical alteration
or repair in order to resolve the pain, conservative therapeutic methods will
probably have little effect. Fortunately, the medical profession is quite
competent in such cases. What I�m talking about are
those many instances when pain arises from just enough mechanical
deformation to cause it-I�m talking about the ways in which we hold ourselves
and allow ourselves to move, and I�m convinced that the culture has more
to say about this than most therapists suspect. Is it possible that the
greatest challenge facing the profession of physical therapy today is the
tendency of the culture to restrict those movements that would
relieve pain? In his remarkable book, Illness
and Culture in the Postmodern Age, David Morris in the chapter
titled �Utopian Bodies� says this; �Health no longer refers, via metaphor, to
the ideal social state that generates it but instead signifies the perfection
of a single private self. Further, good health is not exactly the issue. What
matters is that the individual body appears healthy. Image is
everything. The average family lives in a realm of pictures created with the
favored postmodern technologies of camera and videotape where they cannot avoid
versions of the same subliminal message: the healthy-looking body is the beautiful
body; and the beautiful body is the healthy-looking body.� I�m suggesting this evening
that our profession is often driven toward a sort of practice that attends more
carefully to the dictates of the culture than the realities of science.
I know this isn�t a popular thing to say, but as I travel and read and
especially when I see the ways in which my colleagues approach treatment of
nonpathologic painful problems, I am increasingly convinced that we have
succumbed to the concept of style over substance; to the seduction of beauty
over the complexity of health. Moreover, the ease with
which we can now document and bill for the patterns of treatment typically
offered the patient in pain makes the continuity of these methods immune
to the naturally occurring changes that are the common in any other medical
discipline. Ask an orthopedist what percentage of the diagnoses he or she sees
today that they treat precisely as they did ten years ago and they will
answer, �About ten percent.� Put the same question to a therapist about the
various permutations of spinal and limb pain common to their clinic and they
will answer with a much higher number. Perhaps an alteration in
the care we offer will come from a deeper understanding of what physical pain
does to all of us-how it effects us in ways the therapy community does not
normally consider. In an amazing book published in 1985 Elaine Scarry, then a professor
of English at the University of Pennsylvania and now at Harvard wrote of a
consequence of pain that I feel anyone treating it should come to know
intimately. The book is titled The Body in Pain-The Making and Unmaking of
the World. I think this English teacher has discovered something that the
leading scientists in physical therapy have overlooked. This is not an easy book to
read. Scarry gains her understanding of pain�s effect through what she�s
learned from the victims of torture. And although that circumstance
leading to painful sensation is not something we are commonly familiar
with, the perception of pain secondary to nociception otherwise is not
essentially different. She says that pain
�unmakes� us. That it systematically destroys our familiar world by reducing
our ability to live in it in our familiar ways. First and foremost it destroys
language, and it is well known that finding words to accurately describe our
physically painful experience is a difficult task. It �unmakes� us even further
by restricting the pursuit of movement that had previously been part of our
lives-the ways in which we express ourselves nonverbally. When a child
is told to �sit still and sit straight and to be quiet,� something eerily
similar occurs. What Scarry says about the
consequences of pain surprises no one that I know, but it is what she proposes
is best done to resolve this that I feel may surprise you. Fortunately,
it mirrors precisely what I�ve been saying for many years, though that�s
not been met with a whole lot of external approval. Scarry says, �Physical pain
deconstructs the territory of creating-it brings into sharp focus the relation
between it and the ability to imagine.� While in pain, patients will
commonly tell you that they don�t have any idea in which direction they should
move though, since their pain is intermittent in nature, they must have done
this many times before. Scarry is certain that it is only through some creative
act that the consequences and perception of pain might be reversed. She
says, �Though the capacity to experience physical pain is as primal a fact
about the human being as is the capacity to hear, to touch, to desire to fear
to hunger it differs from these events and from every other bodily and
psychic event by not having an object in the external world. Hearing and
touch are of objects outside the boundaries of the body, as desire is of
x, fear is fear of y, hunger is hunger for z; but pain is not of or for
anything-it is itself alone. This objectlessness, the complete absence of
referential content, almost prevents it from being rendered in language but this
is also what may give rise to imagining by encouraging the process that
eventually brings forth the dense sea of artifacts and symbols that we make and
move about in.� In other words, our personal and unique creative
activity.� And we all know that creative
activity, both its pursuit and what it might produce, is vitally dependent upon
the approval of others. As the poet Mary Oliver intones, �Homesick for
moderation, half the world�s artists shrink or fall away.� Couple this insight with
the conclusions of Patrick Wall, arguably one of the greatest neuroscientists
who ever lived-a clinician and theorist almost without peer and a man focused
on the study and treatment of human pain for over sixty years. In his final
text, Pain-The Science of Suffering, he says that pain creates a �need
state� as does hunger or thirst, that can only be terminated by the appropriate
�consummatory act.� At this banquet each of us has terminated our hunger and
thirst by acting in a fashion we all know is best done in an instinctive
manner, rather than in the ways the culture encourages us otherwise. Wall makes it clear that
the need state produced by physical pain is best terminated by the consummatory
act of movement-a thing our profession prides itself on knowing
something about-and that that movement must be the final act of a sequence of
responses hard wired in the brain, instinctive and inherent to life-and-a
movement that only the person in pain knows precisely how to do. It will
surprise them as it appears, as does every creative act. This movement
is unlikely to be found in the protocols of care we�ve developed for weakness
and dysfunction. Providing only these for patients who need something else
hasn�t gotten us anywhere in our attempts to resolve pain with movement-and, of
course that is the very thing we are expected to do. Is there a place for
creative movement in either traditional or modern physical therapy practice? I
think not. In my travels I see that physical therapy is rarely about anything
other than training, whereas, to me, the creative act begins with care. Training takes place in a space full of
effort, repetitions, charts noting progress and specific goals. An imagined
future is as important here as the present, and the present is unacceptable. But there is something about a unique
connection between an individual therapist and one patient at a time. This
connection is possible only when there aren�t insulating layers of machinery
and generic protocols between them. It is then that the therapist has an
opportunity to attend to the patient's story and not just to their diagnoses.
When caring is the primary mode of treatment, the therapist is willing to allow
the stew of symptoms, frustrations, fears, denial and bargaining emerge from
the patient in no particular order. When caring is present, the patient is
allowed to speak of the disruption of their life. When caring is present,
measurement is replaced by acknowledgement and judgment by acceptance. But I've
noticed that it seems no longer possible to expand any clinic or private office
without turning it into a place where only training is available, and
creativity is a foreign concept. No wonder their struggle to relieve pain. And so, if I�m right, our profession faces
these specific challenges: �
To recognize and
encourage the instinctive and creative movement Drs. Scarry and Wall suggest
are absolutely necessary for pain relief. �
To find a way of
explaining this to our patients and the medical community. �
To figure out a way of
billing for it. �
To make it, as I feel we
should, the essence of physical therapy for pain relief. On a spring afternoon in
1934 my father�s right leg led him over the hurdles set up on the track at West
Tech High School-here in Cleveland. In the lane beside him was another hurdler
from East Tech named Jesse Owens, and Andy Dorko came in second that
day. In 2001 that same leg was amputated in an effort to relieve his pain, and
I can tell you it didn�t help much. But while the limb was still attached, he
wrote his final poem and during those moments of creative movement, as
for seventy years he had been compelled to do, he felt no pain. I know this
because I was beside him and he added my name as co-author. The poem spoke of
the care he had received during his final illness, specifically in the
physical therapy department. This poet never mentioned the training. What do you suppose my
father was trying to teach us? ��� � |