Thinking Fast and Slow.... and Pain: Part 2 | Modern Manual Therapy Blog

Thinking Fast and Slow.... and Pain: Part 2

“Everything we hear is opinion, not a fact. Everything we see is perspective, not the truth”–Marcus Aurelius
The previous post, (, introduced the concepts of System 1 and System 2, and how their interplay guides our thoughts and actions. The concept of “associative coherence” is another one that Kahneman discusses that I find also blends well with pain processing phenomena. Here is an example from the book:
Take a look at the following words: Bananas Vomit
You probably experienced several unconscious reactions including a facial expression of disgust, pulling away slightly from the computer screen, and increase in heart rate. You may have even developed a temporary aversion to bananas (it will pass).
The complex constellation of responses occurred quickly, automatically, and effortlessly. You did not will it and you could not stop it. The events that took place as a result of your seeing the words happened by a process called associative activation: ideas that have been evoked trigger many other ideas, in a spreading cascade of activity in your brain. Th essential feature of this complex set of mental events is its coherence. Each element is connected, and each supports and strengthens the others. The word evokes memories, which evokes emotions, which in turn evoke facial expressions and other reactions, such as a general tensing up and an avoidance tendency”
He goes on:
All this happens quickly and all at once, yielding a self-reinforcing pattern of cognitive, emotional, and physical responses that is both diverse and integrated–it has been called associatively coherent. In a second or so, you accomplished, automatically and unconsciously, a remarkable feat. Your System 1 made as much sense as possible of the situation. It evaluated the possible threat (mild to moderate) and created a context for future development by preparing you for events that had just become more likely” 
And on just a bit more:
“In the current view of how associated memory works, a great deal happens at once. An idea that has been activated does not merely evoke one other idea. It activates many ideas, which in turn activate others. Furthermore, only a few of the activated ideas will register in consciousness”
As Kahneman illustrates, most of these perceptual processes happen below our conscious level. The interpretations and assumptions we make are based on our perceptions of reality and what makes sense to us at a given moment. As we will see later, some of our perceptions of reality are based on things we see and hear, of which a majority may not be accurate, but are built up or accepted in our minds as truth.
“An odd feature of what happened is that your System 1 treated the mere conjunction of two words as representations of reality. Your body reacted in an attenuated replica of a reaction to the real thing, and the emotional response and physical recoil were part of the interpretation of the event. As cognitive scientists have emphasized in recent years, cognition is embodied: you think with your body, not only with your brain.”
Lorimer Moseley tells a story from his own experience that highlights the unconscious workings of System 1 and “associative coherence.” I will give the condensed version here but for a much more colorful and and entertaining version, follow the link below.
Professor Moseley recounts the time when he had been camping in the Australian outback. He woke up one particular morning and decided to take a walk down towards a stream. Along the way, he felt something touch the outside of his lower leg. Seeing as how he had spent many a day in his youth and as an adult walking in the “bush,” as they say, he didn’t give it much mind. His reasoning was that it was most likely just a branch or twig and nothing threatening of the sort.
He recalls waking up a few days later in a hospital bed, lucky to be alive, after being bit by one of the most poisonous snakes in the world. Yet, he had experienced NO PAIN. Based on the combination of his emotional state at the time, the familiarity and comfortableness of his environment, and the memory of previous bumps by twigs or branches, his brain had not recognized a truly threatening situation.
Some time later, he was walking with a group in the “bush” when he felt a similar sensation of something touching him on the outside of the very ankle where he had been bitten by the snake. This time, he fell to the ground in agonizing pain. I am assuming you are already guessing what happened: it was merely a twig that had touched Professor Moseley’s lower leg. However, based on his most recent memories of that sensation, his brain created significant pain to make sure he was well aware of  a stimulus that was now perceived as a threat. All of this happened instantaneously, without conscious awareness. If this same reaction happens to one of the world’s leading pain researchers, what can the rest of us expect?
The world in our heads is not a precise replica of reality…Frightening thoughts and images occur to us with particular ease, and thoughts of danger that are fluent and vivid exacerbate fear.” 
In Aches and Pains, Louis Gifford expounds on how previous experience and memory shapes our reactions:
All the responses, all the little quirks of habit that are in your head that you picked up and learnt from your parents, friends, and teachers, as you grew up and matured, you could call it influence of your little micro-culture; all the various beliefs and bits of knowledge you have…it includes all your past experiences, what you did in different situations, your past behaviors, if you like, and there’s all those things you’re witnessed others do, or seen, heard, or read about via the media…they can all be sampled before you respond in your own unique little way…Your past experience, wired into your system, predicts how you respond given a new experience…”
Is there a way to train our unconscious thoughts so that truly non-threatening actions, emotions, and events are able to be perceived as such? Can the immediate reaction by the brain be not one of pain production, but a more measured and controlled response? Even though certain reactions to words and feelings are pre-wired from an evolutionary standpoint, through repetition and focused practice utilizing System 2, can we override previous reflexive responses with updated version of our System 1?
Part III coming soon.
As always, thanks for reading. Comments and discussion welcome.

Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

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