Hierarchy and heterarchy in care and understanding 

We have long known that our environment influences what we do, how we do it and even how we think. We are beginning to realise how are current environment seems intent on stopping us moving. We use cars for travel, chairs for work and our hunter gather bodies have calorie rich meals delivered to the front door. But what about the way we think? Can our social context can alter perception? How then does the environment influence our perception, even our understanding of anatomy? And how does this affect the way we work?  

In this article we probe further to discover how seemingly distant social and political systems influence our perception of the body and our clinical work. 

Our current system places people, one above the other, in a hierarchy. It has been said that the current elitist system is not far from the Roman idea of masters and slaves. And as we’ll find out, this system of hierarchies is a system that pervades our mindsets, our understanding and our work, in surprising ways. 

If ‘we are a product of our environment’ as author, C J Heck suggests then how is our current hierarchical social system influencing our knowledge and understanding of the body and the client-practitioner relationship?  

A hierarchal system is usually thought of as one that places people in order of importance. In the army it is the general who is at the top, an almost mythical figure, far removed from the privates at the bottom. 

Our current medical system is another example of a hierarchical system, with the surgeon at the top. Unfortunately, it is the system itself that creates barriers, meaning it is rare to talk to many surgeons or other people at this perceived ‘top’. However, many of the surgeons I have spoken too are not the know-all egos one might expect, many are all to willing to embrace other ideas. Often surgeons are imaginative people with a great knowledge that they too don’t know everything.

Hierarchies have existed in political, religions and pervade society throughout history. It was into this variety of strong social hierarchical systems that our early anatomical knowledge was born.

Hierarchical systems are not confined to the organisation of people in society. A hierarchy can exist as a knowledge hierarchy, where facts, rather than people, are ordered by perceived importance. It is this hierarchical system of knowledge that places anatomical parts in order of higher or lower importance. The earliest anatomists show their perceived importance of particular structures by the names they were given: The iris, the coloured part of the eye named after the goddess of the rainbow in Greek mythology; The cartilage that covers the front of the larynx was a piece of forbidden fruit caught in Adam’s throat, the Adams apple; The soul was thought to reside in the sacred bone, the sacrum; Whereas, the word ‘muscle’ translate to little mouse; and Patella, simply means small plate; The sole of the foot is derived from the Latin solum, just meaning “bottom”, and certainly not the grandiosity of Atlas who holds up the world and resides at the top of our hierarchical spine.  

Today the tradition of hierarchical anatomy continues to influence our understanding and possibly our clinical application. Consider which you perceive as more important: the brain or the knee; the psoas or flexor digitorum profundus; gluteus maximus or levator palpebrae superioris. 

Attempting to pick the most important structure will likely create dissonance and debate. The ultimate answer is, it depends. Shall I open my eyes (levator palpebrae superioris) or run up hill (gluteus maximus)? Play the piano (flexor digitorum profundus) or bow at the end of my performance (psoas)? Sit and think (brain) or play football (knee)? Sorry, this last one does a disservice to footballers! Such fragmentised thinking is quite different from the unbroken whole that is the true reality of each human being.

Attempting to place parts into an order of importance may also skew our interpretation of a clients case history. One might perceive a clients back pain of two weeks to be of more importance than the ankle sprained twenty years ago. However, if the sub-optimal biomechanics of the ankle is the root cause of the back pain then the perceived importance needs to be reversed.

On a bigger scale, clinics are often organised in a hierarchical system. This may allow the lead practitioner to dictate their own elevated level of importance. This is often a sign of insecurity, nervousness and the need to prove their worth to the client. In this way a practitioners deep seated inferiority complex maybe interfering with the therapeutic appliance. The overuse of complex anatomical terms may put the client in a lower state, a position of awe at the practitioners amazing knowledge. What is reenforced is the hierarchical idea that the practitioner knows more than the client. My concern with adopting this approach is that the practitioner would now be expected, not just to know more, but to know everything. In this situation the practitioner fails if they consult a book, ask a colleague or turn to the ‘font of knowledge’ we call google. My argument here is that knowledge is not a moral compass. Knowledge does not make me better than, or of higher status than another human being.  

Unfortunately a hierarchical approach often ends up positioning us as master and slave, knower and non-knower. The result is to create a situation where client and practitioner are actually vying for supremacy. A lack of client compliance with exercises is often a clear example of such dissonance.

The philosopher and economist, Karl Marx explains how it will be slaves or workers that will transform the world. The masters, says Marx, are imprisoned in the world made by the workers. The biggest changes come about, not though political ideology cast down from on high. Its not the person with the microphone or at the pulpit that will make the change, the biggest changes come from the masses. And while Marx is talking about a political rather than a clinical ideology I see certain overlaps. “Workers of the world unite: you have nothing to loose but your chains" (Marx). Perhaps it is time for us working clinicians to unite and loose our chains of hierarchical knowledge and change our clinics!

But this is not a call to arms, I am no revolutionary, but a quiet advocate for an alternative. The alternative is a systemic change towards nature. The natural system of things is closer to that of a heterarchy than a hierarchy. In a heterachical system no one person and no one structure dominates the others. In this way authority is distributed. If government took on a heterachical approach, anyone could govern or be governed by others (and with the amount of prime ministers we’ve had recently, perhaps this really is the governments approach!). This may all seem like nothing more than theoretical ideology, however this heterarchical system describes our environment. An environment that can moulds and alter our perception of the body. 

Nature does not have a clue about hierarchies. Ask a daffodil which is more important, its stem or its petals and the daffodil will give you a quizzical look of incomprehension. Sorry to tell you but fairy-tales lie, the lion is not really the king of the beasts. The psoas is not more or less important than any other structure. And our clients are not more or less important than the practitioner. Different, yes, different skills, different ideas, different understanding, but not more or less important. I am only as good as my clients, we success or fail together. 

If we took a heterachical approach would we listen to our clients in a slightly different way? Listen to an insiders view of the body which only the client can perceive. This change in approach would allow the client to be the expert and the practitioner, the student. And a student is not expected to know everything. Taking on the role of a student means you are now expected to ask questions. Not the usual ‘what’ question but the higher level ‘why’ questions. Moving on from finding out what’s wrong, towards  understanding the why that underpins injury and pain.   

In this heterarchy the fact that an old ankle sprain could create back pain would be obvious. The idea that fitting a shoe orthotic could give a client headaches becomes a simple and obvious concept. The result of this change in viewpoint would be the clear necessity to assess the whole system the whole of the time. 

Assessing the whole system is a complex and necessary challenge in our daily work. Thankfully there are methods to allows clinicians to assess the whole system within the confines of the time and space available in clinic. It will be of not great surprise to learn that Born to Move is one such heterachical system. A system of assessment and appreciation of the whole heterachical system. We learn to listen to the whole system, the whole story, to find the cause that underpins the reasons that an individual made the appointment in the first place. The Born to Move system is organised to embrace this heterachical approach to learning and educating. Teachers remain students, students evolve into higher level questioners and so, as a founder of Born to Move, perhaps I am a revolutionary.  

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Thank you for reading.