Back in massage school, we knew everything there was to know about medicine and medical practice. We had a neat, clean system for organizing our knowledge and we were supremely confident in our command of the facts. We knew, for example, that conventional medical practice was reductionistic and therefore “bad,” but that alternative therapies such as massage were holistic and therefore “good.” Surgery, drugs and chemotherapy were “Western” and therefore “bad,” but chiropractic, homeopathy and massage were “alternative” and therefore “good.” Doctors were agents of darkness who cared for nothing but profit, but alternative practitioners were champions of healing and light.
We reinforced this classification system every day by sharing our personal stories with one another. Everyone knew of at least one person who had been ravaged by conventional medicine and dozens who had been healed by alternative therapies. The facts were obvious to us: our East-West, conventional-alternative, good-bad classification system was both true and reliable. It served us well and we were quick to teach it to our families, clients and patients.
Of course, in the years that followed, many of us came up against harsh and disruptive realities. Some of us suffered bike wrecks and car crashes, only to be patched up with great effectiveness by the surgical methods of “evil” Western medicine. Others discovered that they had wasted immense amounts of time and money on alternative practices with no therapeutic value. Still others found relief for their conditions by taking matters into their own hands with exercise and lifestyle change. And so, confusion set in and we began to ask some hard questions about medical effectiveness, evidence and proof. Arguments raged, doubt began to grow and suddenly, our original classification system began to look like a child’s cartoon, drawn with a blunt crayon.
But what then, were we left with? Our rock-solid system with its neat boxes and handy labels was in tatters. Those evil Western practices, we were forced to admit, might actually have some value and the alternative methods might simply be, in some cases at least, nonsense on stilts. So how were we to make sense of it all? Who were the real healers? Who were the quacks? What can we really say about the various styles of medicine and health practices?
evidence-based medicine and fitness
Of course, many medical observers and philosophers of recent years have come up against this very same challenge and decided that the only sensible solution is to evaluate the various arts and practices strictly in terms of effectiveness, judged by hard evidence. Under this model, we would make our distinctions, not on the basis of personal anecdote, history or style, but on the measured outcomes of laboratory tests, coherent theory and double-blind clinical trials.
When we look at it this way, the whole field of medicine suddenly breaks down into two simple categories: practices that work and practices that don’t. In this light, we have no interest in where a practice comes from or what it looks and feels like: all we care about is whether or not it actually has a genuine therapeutic effect on the body.
This would seem to be a move towards certainty and might even be the last word on the subject, but even here, things are not as cut-and-dried as we would like to think. That’s because there are two huge monkeywrenches in the works. The first is the placebo effect, the power of suggestion and belief to promote pain relief, tissue healing and performance. Placebo and nocebo effects lurk in every health and fitness environment, modifying the effectiveness and outcomes of every modality, for better or for worse. To make matters even more complex, culture gives us expectations and beliefs about the body that can transform the healing process; practices that are effective in one culture may be spectacularly ineffective in another. (For a fascinating look at cross-cultural medicine, see The Spirit Catches You and You Fall Down by Anne Fadiman.) Consequently, it is often hard to tell who or what is really working in a health, fitness or medical setting.
classification by agency
So maybe there’s another way to group health and medical practices. I suggest that we can throw some light on the problem by looking at medical practices, not in terms of origins or even effectiveness, but in terms of agency. In this model, we ask a very simple question of health and medical practice: Is it something done to you or is it something done by you?
This distinction was first suggested by Dr. Herbert Benson in his landmark 1979 book The Relaxation Response. As a professor at Harvard Medical School and a pioneer in mind-body medicine, Benson was forced to wrestle with the typical East-West, conventional-alternative classification system. Wisely, he resisted being pigeon-holed one way or the other. His research demonstrated conclusively that meditation and similar practices produce measureable and substantial benefits to individuals, but these practices were not something administered by outsiders. Rather, they were something done by you. This led him to the realization that self-authored health behaviors were an immensely powerful, but largely uncharted area of medical practice.
This to you-by you distinction provides us with a completely new picture of health and medical practices. Things done to you include surgery, drugs, acupuncture, massage, rolfing, chiropractic, herbal treatments, nutritional supplements and homeopathy. In contrast, things done by you include: exercise, meditation and related stress-relief practices, cognitive repatterning, personal food choice and other lifestyle modifications such as changes to social life, time management and workstyle. (And yes, there are some practices such as physical therapy that include a mix of both to you and by you methods.)
This to you-by you distinction is exciting because it forces new thinking and brings a host of surprises, controversy and strange bedfellows. Suddenly, our minds are forced out of traditional ruts and new ideas are free to emerge. For example, when we think about things done to you, we find that surgery, acupuncture, root canals, crystal healing and craniosacral bodywork all belong in the same category. If someone applies a treatment to you, no matter its nature, history or cultural affiliation, it belongs in this category. Even shamanism–if it involves an intervention, spell or potion cooked up by a shaman–may very well be lumped into this category as something done to you.
On the other hand, if you change your behavior with exercise, food, ideas, self-talk, people or environment, you are the author of your treatment and your process. Even if that behavior is inspired or informed by a coach, therapist, trainer or teacher, the operative agent is you.
I find this to you-by you distinction immensely valuable because it gets us away from tired, unproductive polarities of East-West, conventional-alternative. Conventional distinctions such as reductionistic-holistic suddenly lose their power to tyrannize our thinking. This system gets around common assumptions and forces us to look at the roles being played by patient and healer. As you’ll see, this will not only scramble our standard world-view on medical practices, it will also generate some fascinating and powerful conclusions.
history and expectation
Our to-you, by-you distinction gets right down to the core of our relationship with medicine. Throughout history, we have always hoped and prayed that healers, shamans and physicians could heal our injuries and diseases with procedures and substances, but sadly, the vast majority of those early efforts were ineffective. Many things were done to us, but the actual healing came, when it came at all, from the power of the placebo.
Finally, in the early 20th century, we began to experience a new medical reality of germ theory, vaccines and antibiotics. We learned that real medicine, especially the powerful, effective stuff, was something done to you. My parents and grandparents were awed by the powers of antibiotics and vaccines. I will never forget my experience as a child, when our family went to the local high school to receive the sugar cube spiked with polio vaccine. It was very nearly a religious event. The prospect of preventing and curing a dread disease with a simple sugar cube convinced us that procedures and substances done to you were the very essence of medicine.
This cultural experience has now been passed from generation to generation. Even today, as many infectious diseases have been either eradicated or controlled, most people approach doctors, trainers and other body professionals with a clear expectation: this person is going to do something to me. It might be a procedure, a potion or a prescription, but in any case, the locus of judgment and action lies outside of ourselves and our bodies. We have little or nothing to do with the process. All we have to do is report our symptoms, comply with the procedure or prescription and we’ll be healed. Medicine, whether it be surgery, pharmaceuticals, radiation or physical manipulation, is something done to us.
a new challenge
But today, a new paradigm is emerging and with it a new appreciation for the power of individual agency. We are now beginning to realize that while things done to us remain important, things done by us deserve a lot more attention. Exercise and diet are the most obvious examples: Every day we hear about new research documenting the immense power of exercise and nutritional choice to not only improve cardiovascular fitness, but to improve the performance of every system in the body, including the brain. And, much as we might like to have it otherwise, exercise and food choices are always things that are done by us. This realization comes at us with a challenge. No longer can we simply sit back and swallow the sugar pill or sit still for the injection: we must now put our lives directly into contact with risk, engagement and action.
Every day brings fresh evidence for the power of individual action in health. In his new book, The Relaxation Revolution, Dr. Benson shares the startling discovery that sustained meditation practice can have profoundly beneficial effects on gene expression; a consistent practice of focused relaxation affects hundred of genes that in turn have powerful effects on the health of the body. This cannot be done to us by any known technology or external method. It must be done by us.
The entire field of stress medicine sends much the same message. We now know that most of today’s lifestyle diseases (heart disease, high blood pressure, obesity, diabetes, depression and neurological disorders) are exacerbated by stress. But compared to the threats posed by bacteria, viruses and other pathogens, stress is an altogether different kind of challenge. It’s all about our relationship to the world around us. In this context, it is things done by us (interpretation, narrative, attitude, perspective) that will have the greatest impact.
The to you-by you distinction also forces us to come to grips with personal responsibility in matters of health and our bodies. Who is in control of your life and your body? Where does the responsibility lie? Would you prefer to have the locus of responsibility inside or outside your self?
We can be sure that many patients and clients are attracted to things done to you precisely because they remove any sense of accountability or responsibility: The patient can simply lie back, relax and submit to whatever procedure the expert decides to administer. If the surgery fails, it’s the surgeon’s fault. If my knee still hurts after a procedure, it’s the physical therapist’s fault. The onus of success or failure lies with the person doing the treatment.
This is why we absolutely love things like antibiotics. Penicillin works wonders, most of the time, and no genuine effort is required. Just show up at the doctor’s office, state your complaint, fill the prescription and swallow. Beyond the basic mechanics of explaining your symptoms and paying your bill, scarcely any participation is required. Once the substance is in your system, the deed is done and you’re off the hook. It’s all so easy.
Things done by you on the other hand, issue a direct challenge and put us right on the crux of personal responsibility. Once we choose to take control of our lives through exercise, food choice, meditation and other by you means, we suddenly find ourselves naked before the world. Here we are, exposed with our habits, our genes, our bodies, our personalities, our families and our lives. There’s simply no place to hide. What kind of life and health shall we create? Suddenly, there’s no one else to blame.
personal control and empowerment
The challenge is stark, but the payoff is potentially immense. By taking on the responsibility of by you methods, we also position ourselves for personal, physical and spiritual empowerment.
This is something that is simply unavailable to us with to you methods. Medical procedures that are done to you (surgery, massage, chiropractic, physical therapy...) may very well be effective, but they do not empower. I speak from personal experience: Some 15 years ago I underwent surgery for a sloppy shoulder joint. The procedure was a success and allowed me to resume the activity that gave me pleasure and satisfaction. I was happy with the outcome and grateful for the technology that made it possible, but I did not feel particularly empowered. The surgeons were responsible for the work, not me. In fact, as the primary actors in the event, they were the ones empowered by the experience. As a passive participant in the process, I took minimal action and minimal risk. I was not engaged. There was no risk and thus, no empowerment.
In contrast, things done by us have the potential to be profoundly empowering and transformative. When I participate fully and engage completely with my life, I take action and I accept risk. When I create change in my life and in my world, I feel a sense of satisfaction and reward. I also feel a greater sense of control, a sense that feeds back onto me to dampen the stress I feel in my life.
Things done to you are at best neutral, and at worst, disempowering. In some circumstances, they actually build dependence. Do you need to rush off to the chiropractor, massage therapist or acupuncturist to fix you up every time your back hurts? If so, are you empowered by the process or are you becoming increasingly dependent on an external agent? In contrast, what if you were to learn a movement or stress-reduction solution done by you, a solution that brought relief on your own schedule and on your own terms?
When I’m successful with things done by me, I move from being a victim to being a creator, a shift of potentially enormous proportions. Not only do I heal my body through self-authored programs of exercise, food choice, stress management and meditation, I also position myself for an entirely new experience of life. The changes that I create ripple throughout my life in ways that are simply impossible with any things done to me. Even more to the point, success at things done by me opens up enormous new vistas of possibility. If I can succeed in these domains of lifestyle transformation, what else might be possible?
So what is the trajectory of health, fitness and medical care in the 21st century? Things done to us will always be important, of course. We have some immensely powerful tools in our toolbox and these tools are best wielded by highly-trained professionals. Surgery, custom pharmaceuticals, transplants and gene therapy will become increasingly refined. We can be certain that innovation will lead to even more effective things done to you.
However, things done by you will also become increasingly powerful, exciting and relevant. We are well aware of the power of exercise for example, and more people are starting to see its true potential, not just for building muscle or losing weight, but for brain development, cognition and performance. Similarly, we are starting to understand the immensely powerful effects of meditation and stress-management practices.
Of course, this by you orientation implies a sea change in the way we relate to our bodies and the health professions overall. It suggests that consumers must start taking more responsibility for their bodies and their lives. No longer can we sit back passively and wait for a professional to do something to us. Instead, we must take our lives into our own hands and create the changes we desire.
This also suggests a newly-refined role for coaches and trainers in the world of health, medicine and fitness. To put it simply, coaches and trainers are in the teaching and empowerment business; we are not in the business of doing things to people. We do not give fish to our clients, patients and students. Instead, we teach people how to fish for themselves. We inspire and inform, listen, tell stories, guide and coach. We help people to change their own lives, to take responsibility for their bodies and their behaviors. When we succeed in this quest, we give people the power to transform their bodies and their lives.
But there’s even more to this story. When we look at teaching from this to you-by you perspective, we discover that education itself is fundamentally a by you enterprise. All genuine and meaningful learning is self-authored; we are ultimately responsible for teaching ourselves. Teachers can model, explain, tell stories and provide context, but in the end, education is up to the student. When we think of education as something done to you, we put it in the same category as surgery, root canals, antibiotics and chiropractic. It is not. Education has more in common with exercise, food choice, meditation and lifestyle change. Our most effective teachers do not perform procedures on or to students. They inspire and lead by example, just like trainers and coaches. The more we embrace the by you perspective, the more empowered we become in health, fitness and education. It’s all one enterprise.