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Routine therapy

By Timothy Cocks Science and the world 05 Mar 2014

Rise and shine: the daily routines of history’s most creative minds

“Benjamin Franklin spent his mornings naked. Patricia Highsmith ate only bacon and eggs. Marcel Proust breakfasted on opium and croissants. The path to greatness is paved with a thousand tiny rituals (and a fair bit of substance abuse) – but six key rules emerge.

One morning this summer, I got up at first light – I’d left the blinds open the night before – then drank a strong cup of coffee, sat near-naked by an open window for an hour, worked all morning, then had a martini with lunch. I took a long afternoon walk, and for the rest of the week experimented with never working for more than three hours at a stretch.

This was all in an effort to adopt the rituals of some great artists and thinkers: the rising-at-dawn bit came from Ernest Hemingway, who was up at around 5.30am, even if he’d been drinking the night before; the strong coffee was borrowed from Beethoven, who personally counted out the 60 beans his morning cup required. Benjamin Franklin swore by “air baths”, which was his term for sitting around naked in the morning, whatever the weather. And the midday cocktail was a favourite of VS Pritchett (among many others). I couldn’t try every trick I discovered in a new book, Daily Rituals: How Great Minds Make Time, Find Inspiration And Get To Work; oddly, my girlfriend was unwilling to play the role of Freud’s wife, who put toothpaste on his toothbrush each day to save him time. Still, I learned a lot. For example: did you know that lunchtime martinis aren’t conducive to productivity?

But for anyone who thinks of their work as creative, or who pursues creative projects in their spare time, reading about the habits of the successful, can be addictive. Partly, that’s because it’s comforting to learn that even Franz Kafka struggled with the demands of his day job, or that Franklin was chronically disorganised. But it’s also because of a covert thought that sounds delusionally arrogant if expressed out loud: just maybe, if I took very hot baths like Flaubert, or amphetamines like Auden, I might inch closer to their genius.”

Routine has two definitions; “a sequence of actions regularly followed” and “performed as part of a regular procedure rather than for a special reason”.  I think manual therapy (other therapies too probably) can satisfy both of these definitions at various times. In relation to the former, a systematic approach to assessment and treatment is what I was taught was “good therapy” – the encounter with a patient followed a set trajectory of subjective examination (history taking, body chart, aggravating and easing factors etc etc) objective examination (range of motion, movement tests etc etc) treatment (pushing, poking, heating, cooling, rubbing, twisting, wiggling, massaging, electrocuting…) and re-examination.

But all of this can sometime become, well, routine – in the latter sense. A guest blogger suggested recently that our patients will pick up very quickly when this other form of routine comes into play.

A question begging to be asked, is “where do these routines come from?” At least one answer would be that they are blindly followed because some therapy guru does it that way (and I paid a lot of money to attend the course and give up my weekend and they told me that it had to be done just this particular way, with my feet pointing in this direction and my knee bent like that and my hands placed just so, otherwise it wouldn’t work). Is there an element of the addiction and delusion mentioned in the piece at work here? A belief that if I theramobipulate someone exactly like [Insert guru name] then I too will achieve the miraculous results that they (claim to) achieve; with an addiction to attending ever more workshops and trainings?

I know personally that for a large part of my career the answer was yes. I suspect also from the huge response to David Butler’s noinote on the professional roller coaster that I might not be alone.

I’m interested then in how we can develop therapeutic routines (frameworks, paradigms, systems) that don’t become too, routine. What bits of routine might be useful to adopt? How do you keep it ‘fresh’? How does one get off the roller coaster, break the delusion and kick the addiction (all without resorting to drink and drugs)?

-Tim Cocks




  1. davidbutler0noi

    Thanks for this Tim,

    There are some critical elements here to discuss re professional burnout, and there is also a patient element. I have always thought that curiosity is a critical cognition that a patient must return with – a “what is next” neurosignature. Maintained curiosity has to be a vital element in goal achievement. Therapeutic routine may destroy this.

    I love wearing colourful clothing , in fact I have very little beige, grey or “physiotherapy navy blue” in the cupboard. In my clinical life I have been aware that curiousity about ‘what will he be wearing today” will be a small part of a patient’s overall curiousity and it will also provide a varietal context for therapeutic engagement.


  2. There’s a certain attitude that can make repetitive tasks enjoyable, however I’m not always that good at applying it. I have looked very deeply into this issue and have experimented a lot, so I have learned a few things…

    Trying to make Physio interesting and fun is problematic. I’ve tried. The further I went in the direction of “what makes this interesting and fun for me?”, the more I found myself moving away from the needs of the patient. Since the patient is paying good money, I need to make his need my focus and yet the practical application is about as interesting as washing dishes!! It can seem like the patient’s and therapist’s needs are at odds, but this needn’t be the case. There is a meeting point, a ‘sweet spot’ where both our needs can be met simultaneously and it is in present moment awareness (Presence). This is why I bang on about various philosophies (and religions occasionally), because this is the only place such matters are properly confronted and understood.

    I developed my own techniques regarding this ‘presence’ thing, and they seem to be pretty effective. Without such an approach, I would be bored numb by physio, because it’s simply not a job that provides much in the way of mental or physical stimulation. But to look for stimulation is the wrong approach and doing so will lead to intense frustration. That’s the difficulty and the beauty of working in healthcare. It is only for those who can happily let go of their own need for interesting (pleasurable) stimulation. Physio gives the practitioner very little (apart from a modest living) and there’s no greater challenge.

    Physio is my discipline. I get my stimulation from my other job.



  3. First of all thanks for the post Tim! I want to air my opinion on noijam for the first time, been peeking for quite a while now…. First of all I don’t want to discard routine completely, it has it purpose (why would it be an emergent phenomenon in human and animal life), routines can provide the necessary stability to try and objectify a complex system (maybe it is an energy economical way to survive in a complex world), to try and grasp its understanding….. But routines are not resistant through time… As physio, neuroscience evolves routines get old fashioned (like navy blue physio clothing) and needs freshing up…. And this is where it gets complicated, as a routine is a low energy cost phenomenon, it takes effort to change routines…. And by changing possibly ending up in a situation where you might get confused- as a therapist you not only start to question your techniques, you start questioning what you did with patients and possibly start to doubt yourself as a person…. Call it a state of entropy, and that is all but comfortable….

    So my take on how to avoid routine; keep learning, reading, talking to other therapists…. And evolve with baby-steps, but make it a continuous process!


  4. timcocks0noi

    Hi Wouter, thanks very much for stopping by and commenting. I’m with you on not discarding routines and I think you’ve hit a key point with the idea that routines can be comfortable while changing what we do, for some, can be quite the opposite; requiring effort in divesting old routines and developing new ones. I can also think of nothing better than continuous reading and learning to prevent routines becoming routine.

  5. Learn to “jam” my friend like all great musicians. Learn the rules and routines then throw them to the wind and fly from the seat of your pants……..reckless? Less so than routines……..medicine is an art based on and not ruled by science…..

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