 Hello and welcome everyone. It's Actinflab Livestream number 44.2 and it's May 25th, 2022. Welcome to the Actinflab. We're a participatory online lab that is communicating, learning, and practicing applied active inference. You can find us at the links on this slide. This is a recorded and archived livestream, so please provide feedback so we can improve our work. All backgrounds and perspectives are welcome and will be following video etiquette for livestreams. If you want to learn more about the livestreams or any other projects at Active Inference Lab, check out activeinference.org. Okay, today in 44.2 we are in our third discussion around the paper therapeutic alliance as active inference, the role of therapeutic touch and synchrony from 2022 by the authors listed here. And Ian and I had a dot zero where we contextualized and went over some of the outline of the paper. Then we had a great discussion last week with several of the authors in the dot one. And today we're here with some of the authors and we'll see who else joins. And we'll be continuing that discussion around the paper. We left a few threads, but also we can just take it wherever people would like to go. And we'll begin just by saying hello. People can say anything they want. And how is this week different than last week? How are we approaching this paper differently? Or what would we like to resolve or address in this dot two that was stimulated by the dot one or that we didn't get to in the dot one? Feel free to add anything in that area. So I'm Daniel, I'm a researcher in California. And one piece in the dot two that I'd like to explore would be what are the entities that we're discussing here at what scales and how to think about that in terms of their generative model and so on. And I'll pass to Ian. Hello. Thank you, Daniel. And yes, I would like to maybe pick up on if we've got time on the topic of synchrony this weekend. You know, what types of synchrony might we be talking about? What things might be oscillating that come into sort of phase lock between two agents that have the potential to synchronize? And then where do they head? Where do they head towards with their synchrony? And then if we've got time, you know, thinking about tying this all back to the some of the sort core ideas about minimizing free energy and what does that mean for in a therapeutic setting? Yes, that's it, I think. Thank you. Awesome. All right. Any of the authors, feel free to go for it. Zoe, ladies first. Okay. So I'm George. I'm one of the authors on this paper. I'm an osteopath and a researcher and where do I see this going forward? I pretty much enjoyed the interaction we had last week and very happy to kind of be left by you guys, Ian and Daniel, and anybody else that wants to join. I think we can definitely explore those ideas about, you know, the synchronization to agents and arguably more than two agents when we operate in a kind of not in a in a dyadic setting, but actually a triadic setting. For example, pediatric care, kind of algorithmic care and so on, where actually there's a next an additional agent in the whole thing. So what do I, you know, look forward to the discussion, kind of, stimulate some ideas about, you know, ways in which we can move forward with this to the more empirical states of the research. Great. Zoe? Hi, I'm Zoe. I'm an osteopath as well, based in Singapore, and I'm the primary author for this paper. Yeah, happy to be led by anyone that wants to where we want to go, but definitely happy to talk about synchrony. I think as George said, it would be important to talk about not just dyadic, but tragic or otherwise, because I think that adds a lot of depth to it. But also, it's easier to sort of discuss the effects of synchrony and also the fact that you can be Okay. Laws, Zoe, for a second. Anyone that wants to ask a question. Okay. Also, Zoe, is there like any other microphone to use or could you speak closer to the microphone? I'm just using my laptop, so there isn't really a microphone. I can take my headphones off. Does that make a difference? It's fine. It's just a little quiet, but it's fine. But, okay. Sorry. Oh, no, it's all, it's totally okay. Just want us to check. Okay. All right. Let us pick up with the synchrony then. So, I guess just to kind of recall, how was this question of synchrony approached in the active inference literature and maybe even outside of the active inference literature? And then how was synchrony approached in this paper? Like, why was that such a core topic in this approach that the authors took? I think we started synchrony as the main part, mainly because when we were talking about the therapeutic alliance, synchrony and getting on with the other person is kind of key. And the way that we approach this paper primarily in terms of a lot of the aspects of how we achieved that good therapeutic alliance was through synchrony. So that's kind of where we, that's one of the reasons. Through active inference, it was also about we started, I started the research when I was looking at it right from sort of the start and looking at how communication worked and how why people would want to sort of synchronize together and why people, to implement active inference into the sort of the structure that we had. It was important to kind of see why that would be beneficial because we wanted to use or we like to say that the synchrony enables us to work together to then therefore save free energy, be more efficient. And then that's how we kind of, we very much used it to apply the active inference, sort of framework around it. And so I felt that it was very key, without the synchrony element, it would be very, it was kind of the backbone into which a lot of the aspects of active inference in the way that we achieved therapeutic alliance seem to sort of center around without that connection between different people. We wouldn't be, we wouldn't be able to save energy to work together to have a better relationship with our practitioners. We wouldn't, with the patients and practitioners, we wouldn't be able to get the clinical applications and benefits from it. So I saw synchrony as sort of the key medals to sort of get to where the sort of paper was. So it was sort of a key concept to use in order to implement it all together. George? Yeah. Let's say when we, when we started the project, actually, kind of putting some ideas along the lines of how could we apply predictive processing and the free energy active inference within, within osteopathy and within the, the osteopathic setting. Synchrony came along actually after the initial discussion with Carl Friston that kind of suggested it's actually, you know, look into this stuff because it actually could be quite a robust way of, of, you know, of understanding what goes on in the, in the, in the clinical room when two people are working together in a specific kind of aim. There is a little bit of literature in psychotherapy kind of demonstrating that actually the therapeutic alliance becomes much more robust when two people synchronize and both at the kind of, you know, behavioral but also biological level. And, and it was nothing about sort of, okay, you know, this is about pure verbal communication, nonverbal but primarily by kind of copying body movements and so on. To think, okay, you know, how can this be applied in the context of actually an approach that is largely hands-on based, you know, the manual therapy. So that's where it kind of started from. It was one way of, of trying like, like Zoe said, kind of looking at therapeutic alliance and when people interact to try and understand what goes on in the dyadic setting kind of two people but also a little bit behind that, you know, it kind of what happens when there's actually more people involved in that therapeutic relationship that need to be consulted, need to be involved in the process and so on. And so that's, that was the kind of early stage and yeah and then we thought that actually this is a good way of, of understanding a little bit more about how we can create the conditions of developing a strong kind of ecological niche that is based on that synchrony of that sort of understanding of that give and take, like a little bit like we talked about last week, the kind of the bird song, you know, people taking turns, kind of understanding, listening, okay, acting, kind of taking on, go back and so on and that's sort of in a sense like a kind of a nice wave that goes back and forth but it is a kind of very nice and tranquil kind of wave, not a one that just crushes and destroys everything but actually one where, you know, one step kind of goes on, a little bit like the pendulum kind of analogy. Once you introduce that nice pendulum kind of things happen, that's where we sort of thought, you know, it could be one way of exploring the whole process of care. Thank you. Ian? Thank you. So yeah, you know, I'm fascinated by the topic of synchrony and the little bits I've read in the literature about how, you know, measurable things that might be able to synchronize between one or two or more people so, you know, Daniel, I think we discussed this in the dot zero so choirs singing together, they have been shown their hearts rates kind of synchronized with their breathing and I think in the paper there was some references cited for similar sort of stuff in drumming circles, for example, so that really interests me and I can kind of begin to see how in a therapeutic setting that kind of synchrony could lead someone who's maybe stressed and anxious into a kind of more healthy increase the parasympathetic activity and that is conducive to healing. But I've also got these other sort of nagging things about synchrony as well that maybe I touched on in the, you know, the dot zero, which is what are we synchronizing towards and is it always, you know, beneficial. So, you know, this kind of the less kind of lockstep synchrony that you talked about, Daniel. So maybe it's just, you know, let's say a child saying, mummy, mummy, mummy waving their arms around and then the mum synchronized, they synchronized their attention together. So you get mother and child and then then you've got a choice. So there's some aspect that's synchronized, you know, that I think in the paper, it talks about the arms and, you know, the limbs and the voice kind of synchronizing, but, you know, and the facial expressions, but, you know, a caregiver might then lead the child to a soothing kind of parasympathetic way, soothe it or it might say, you know, give it a click behind the air and say, you know, children has to be seen and not heard and try and stop the attention, you know, the attention is synchronized, but the action may not be therapeutic. So, yeah, I'm just sort of thinking about where, you know, where just because something's synchronized, does it mean it's always minimizing free energy or just because it's, you know, things in the therapeutic world go in and out of fashion. So, frontal lobotomies, okay, we don't do that anymore, but that for a while there was some kind of synchronized thinking in the therapeutic world that that's a good idea for people and, you know, there are ideas that I hear in the wider kind of therapy world that fashionable, but and they're being applied, but, you know, they in 50 years time, we may look that they may have been leading people away from minimizing free energy or improving health. So, yeah, then my thoughts. Okay, awesome. Yeah, a lot there, George. I think the interesting thing, you know, is there are nagging questions there for sure. The first one, do we always synchronize and, you know, when if you don't synchronize, what we're going to do? Because, you know, clearly there are cases where we know the therapeutic relationship is going nowhere. Okay, we can say whatever, you know, we can try our best, but actually there is resistance to change from the patients. We end up not understanding each other and, you know, arguably that's a relationship that will not evolve and well, you might even get to a point at the end, you know, maybe the good idea to go and see a colleague of mine kind of thing. Okay, so do we synchronize with everybody? No, clearly not. Is there any value understanding this stuff by sometimes understanding that some kind of gestures and sort of body language and so on, voice, sound, sort of communication style, were probably giving us cues to maybe to adapt a little bit, sort of to try and synchronize a little bit better. I think that's useful. I think important in order to be a good communicator. I think first and foremost, you know, sometimes people worry too much about the technical skills and the ability of doing X and Y and doing some some miracles and so on. Arguably, you know, what's the first thing that people need to be in a clinical setting is a good communicator and a pretty good nice person. Okay, and I think, you know, if that's if that's there, I think we've got we create the conditions in good communicators is likely to to have potentially better outcomes that guys that basically don't care and sort of they're the experts and so on. The other question is, you know, is it always about minimizing free energy because, you know, there are situations where probably, you know, you want to short circuit the whole thing, you know, you want to sort of flatten a little bit of that sort of sensory states, you know, you want to create a condition where and the only way you can you can sort of change the generative model is actually by creating a massive surprise, a massive prediction error that arguably surprises the system in a way like, wow, what just happened, you know, and actually, oh, okay. So it's, I don't think it's always about minimizing free energy as in that. But sometimes I think, you know, you want to shock the whole thing, because the system on the other side wants to minimize free energy for sure. You know, if you mind, if I'm a kind of chronic pain patients, and I, you know, I'm scared of moving, and he told me to move and so on, the reaction is, you know, I anticipate the likelihood of movement leading to pain, I anticipate the consequences of actions in the future, the typical active inference model, and you know, a lot, I don't move. So I probably want to short circuit the whole thing to create the condition where, you know, it's actually okay to move, because not going to cause any harm. And so is it true synchrony? Maybe it isn't, okay. So I think, I think that's not a sort of, I think a kind of one size fits all kind of thing. And I don't think, you know, it's just about sort of, always that minimizing free energy, because I think creating change that is meaningful change probably needs a little bit more of, it needs to, it needs to destroy that sort of strong prior kind of thing, so I can implant another chip kind of thing, yeah, in a metaphorical way. And that's why we know, in some mental health conditions, why some types of drugs like ketamine and so on, create that condition, you know, that sort of zeroes the whole thing is a bit like, you know, you reset the button, the computer is stuck, what you do, you try everything, you unplug the computer, and then you try again, the whole thing reboots, isn't it? So I think sometimes that's the analogy of maybe what we want to achieve in the setting. Is it through synchrony? I personally, I don't know, and I'm not entirely sure. I think if you, of course, if the people started understanding each other, then that creates the conditions for this thing probably to happen, because if you don't understand me as a practitioner, I don't understand you as a patient, it's pretty hard that actually I create the conditions for change. So maybe it's through synchrony, but again, you know, it's as a sort of big question marks really. So thanks. So just yes, Zoe, please. Yeah, so I think going off what George said, yes, I think, I mean, overall, the goal would be to minimize free energy, but to be able to do that, you have to sort of, at some point, challenge it, right? You're not going to have the same belief that you think is the most efficient when you're born to when you die. The way that you become, you reduce energy is going to change over time. You'll see that especially in sort of pediatrics. You see it in sports. There's a lot of studies with running, for example, that show that the more you run, the more often the more mileage the people do when they run, the more efficient they get. So I think free energy is, yes, we all want to reduce it, but at some point we've got to update it and challenge it, right? So it won't be sort of just this linear thing where you'll constantly just change it. You've got to update it and challenge it at some point. So it will sort of be a little bit of a rollercoaster and have a few dips where you've got to take that risk to see if there's another way that is more efficient that will save it more. Whether synchrony is always necessary, I'm not sure. I think I definitely think that when you're unsure whether or if your prior is not so precise and you're not 100% sure that that is the best way to do whatever you're doing or you're not 100% certain that your belief is explained what's going on, then I think you're more likely to synchronize with others. I think once you're quite stuck on what you think and what you're going to do, then it's a lot harder to synchronize, like with the cognitive sort of immunity when you've got chronic pain. It's a lot harder to change that because you're convinced that you're right. You've had this pain for years maybe and you know what it's like. If you bend forward, it's going to hurt, so why would you bother to challenge that? I think there's a lot of studies that show that especially with sort of babies that they synchronize with their, I think once they, when they're younger, the synchrony is very consistent. Obviously, they need to work with their caregiver to get their specific needs and everything that they need to keep surviving, but it shows that they do still think when they're adults, but the time when they're older or in adulthood that they do think is when they're unsure, with when something has to happen when you are near that caregiver and you don't know. You still sort of rely on them, say, I don't know, you get into a car accident or something and there's a big shock and you're not sure. Often the child will still, no matter how old they are, will look to the parent. Obviously, unless the parent is very elderly, but generally speaking in times of uncertainty, you will look towards someone else. So I think if synchrony is always necessary, no, but I think if you're not 100% sure and with your priors and you are questioning it or there is a doubt on that questioning it, then I think synchrony will play more of a role. And I'll get back to you. Awesome. Thanks. Yeah, just thinking about beliefs in the way that we might talk about them. Hey, Blue. Welcome. Just the way that we might conversationally talk about beliefs. If somebody is unsure about something, that's when they look to be synchronized by some other informational resource. I'm not sure what time this thing opens. So I'm going to look it up in this way or I'm going to ask this person or I'm not sure where to go. So I'm going to follow the crowd. We see that kind of in the ant pheromone trail. We see that in the social media, all these different areas. And then conversely, when somebody does have a more confident, more built up prior, then that's more like going their own way and potentially being more resistant to external contrasting information. And then translating from that one conversational meaning of belief, like I believe that is going to open at this time into a broader Bayesian perspective on Bayesian brain and body and thinking about pain and perception as also parameters that are can be seen as as beliefs in this Bayesian sense. So not always like a psychological experienced belief, but in some statistical way, it's like they're held stances that are updated in some way or partially or completely by certain kinds of incoming information. So Ian and then also like this is going to be, I think it's very interesting to return to the free energy minimization and unpack like what we mean by free energy there. So Ian, go for it. Thanks. So yeah, I'm just sort of wanting to check that some of the language used in other realms of therapy. So this idea of self-regulation and co-regulation, are we are we saying here that this synchrony for in the therapeutic reliance is a form of co-regulation that we hear a lot about in people with problems of their autonomic nervous system. And then we say you go to a therapist to help co-regulate your autonomic nervous system. Is that what we're saying is synchrony is the kind of mechanism for co-regulation, which I believe fits with what you're saying, Zoe, that children need that more. And as adults, we might do that occasionally. And then I'm just thinking also, you know, other forms of therapeutic synchrony and co-regulation. So meeting friends for a coffee, sometimes, you know, I might be having a bit of a stressful week or, or a a wobble in some way. And then I meet some friends and we kind of seek counseling each other, have a synchronize our movement of our hands to our mouth with a coffee cup or listen to some music together, tap our feet together. And that's a kind of therapeutic. So are we all kind of doing this on and off all the time? They're my thoughts or questions. Yes, George. Yeah, Zoe, then George. Yeah, no, I just wanted to say yes with the co-regulation. I think that we kind of not always, but I think we do add an element to trying to suggest that we'd like to say that we in part help co-regulation and co- as a practitioner to achieve sort of recovery and reduce pain and, and how we, I think we all want to say that we help in that process and that we help regulate their sort of disruptive pattern, whether that's inflammation, whether that's pain, whatever sort of metrics that you want to rate your, your treatment by, or whatever your treatment goals are that you're sort of working towards, I think we all want to say that we sort of help regulate what, which ways we regulate in terms of whether our sort of, we actually change their, their heart rate or things like that. We haven't got sort of, we're not always so specific about, oh, we don't have the research to kind of show that, but we, I think, certainly there is elements of sort of sympathetic, empathic things that we do, as well as sort of the intent to co-regulate, even if we don't sort of empirically do it, or achieve it, whether just that reassurance that we're attempting to help regulate their, their pain, I think is sort of the intention that, that I hope the other practitioner and giving off to my patient, and I'll let George speak. I think, you know, if we, you know, if you come from a manual therapy background, a touch-based, hands-on approach, one could argue or old school kind of believes in the profession, who's in our jobs too, would argue that actually how you achieve that co-regulation, you know, autonomic nervous system, sympathetic, heart sympathetic, is primarily through the use of techniques, you know, use a technique in a particular part of the body, and this affects, you know, the heart sympathetic part and so on, okay, the vaguest nerve and all that stuff, that sort of implies there is a tool by which you can apply that stuff, treat that particular bit and by miracle, you know, immodulate everything. I used to be there, no longer there because, you know, the evidence isn't strong enough to actually support those clients. On the other hand, if we add another element, which is the element, you know, the synchrony, and the synchrony here goes beyond just that sort of passive, practitioner-led type of intervention into something that implies communication, implies alignment, you know, attuning to the, to the environment and the environment there is the practitioner as well, so the other person in the room, the guy that is facilitating the process, so sort of takes us, I think, away from this idea that, you know, it's everything is about touches, everything is about the manual stuff and so on, but it becomes a kind of a multi-pronged approach where touch matters, but communication matters as much as touch, and it's not a technique X, Y, or Z, but it's actually the whole package of care that's likely to enable us to get there. So, you know, is it similar, you know, and I kind of, you know, I like your analogy to sort of, you know, tough day and so on, you go out, you need to see your friends, you need to synchronize in a different environment because ultimately people, you know, will talk to each other and correlate each other even in terms of reducing all of static loads over a tough week and so on. There are kind of things that, that are similar to what happens in the clinical setting. One of them, we're probably thinking about reward systems as well, you know, there's a, there's a sort of a participation in something that is likely to, even if uncomfortable, is led, is going to lead to some improvement. It kind of, you know, maybe, maybe there's some dopamine stuff, there maybe there is a reward pathways that are kind of involved in the whole thing, like having a drink and the same, having a therapeutic intervention that ultimately is going to get me to a better state. I think, you know, it's very, very analogous to moving away from the free energy principle and to an area that is kind of works alongside that in activism, the concept of sense making, you know. So the kind of, and what inactivists would argue, participate in sense making. So synchrony could be, and also look from that, from that lens, from that perspective. Whereas if two people or more than two people, either in a group, you know, having a drink and all kind of helping each other, because I listen, or in a therapeutic setting, that's sort of participate in sense making, minimizing free energy or to poises for the, the kind of the inactivists. It's actually, I think, you know, we, we, we sort of looking at the same phenomena, maybe with different language, but arguably the same kind of phenomena. So you say, I think it's that package that probably helps core regulation rather than just one, one intervention. Thank you. Lou, welcome. Do you want to add anything or ask anything? Not right off the bat. Just hi. It's nice to be here with you guys. I'm sorry I missed last week, and I've really enjoyed the discussions with the papers so far. And I'll jump in in a little bit. I think you guys were being grossed in a, in a good conversation. So okay, awesome. So the dopamine angle and a few other things, let's, we'll return to, but we were talking about minimizing free energy. And I wanted to show a few images from the textbook because even those who have seen free energy come up in a lot of different settings, sometimes returning to the basics is a generator that helps us take it in many other ways. And for those who are maybe focused more on the clinical setting or have more of that background, this can provide a little, you know, other tissues around the connective tissue. Free energy is being used like a connective tissue here. It's bridging a lot of different ideas. It's helping us connect different sensory modalities and therapeutic modalities. So just a few cool images from the Active Inference textbook. So here is figure 2.3. And it's the action perception loop. And the two ways that discrepancies related to predictions or expectations, the two ways that discrepancies about observations can be reduced just qualitatively is through changing belief and changing action. And it's some blend of those two that individual entities are engaged in in this action perception loop. And then when we're specifically talking about free energy, there's some type of equation. This is like a simple form of it that is going to make that discrepancy minimization tractable and possible to calculate for at least us doing statistics from outside the system, if not for the system itself to do. And what is the real sort of hidden goal is this minimization of true surprise, but the minimization of true surprise is intractable or inaccessible. And so free energy serves as like this upper bound, whereas if we can reduce this upper bound, we're getting implicitly closer to this asymptotic reduction of some of surprise. So who is doing this reduction of surprise? That relates to the entity question. What is the question? What is the entity that's actually doing free energy minimization? And so what are the entities that we're talking about here? What does it mean to minimize free energy? And when is it? And I liked how earlier it was brought up when sometimes where that free energy minimization was going with the flow and then sometimes when there was a flow disrupt. So what is free energy minimization and what are the entities? And how are we modeling that in and then anyone else? Thanks. Yeah, that question of what are the entities and linking it back to George's point about sense making and inactivism. So in the paper, there was some really interesting stuff on the realising that we're all alike in the therapeutic alliance. And relating that back to sense making, thinking that therapeutically or in a manual therapy or meeting friends, there's the outcome might be, oh, I'm not a weirdo. I haven't done anything wrong. Everything's okay again. I'm relaxed and that's therapeutic. So I'm amongst people who are very much alike me. And that's the sense making. There's the pattern recognition. I'm a valuable member of my tribe, however you want to describe it. And then I think we're never completely identical. Or are we? I don't know. So the proposal in the paper is that that's the ultimate realisation that we're all alike. And I can kind of see that that's a kind of relieving thing to realise. But, you know, we're similar but we're in my I'm similar to my pet dog in that I've got eyes and I breathe and my heart beats and I can synchronise in some ways with that. And it feels nice, but my dog can't help me do my accounts, for example. So yes, this aliveness and how does that fit into sense making? Thanks, Blue. So as I've been reading the textbook, I've been thinking a lot about the hidden states. And it's interesting to think about that in terms of using touch to kind of resolve uncertainty about the hidden states. Because while a state might be hidden to the patient, right, when you present with some like I've got a pain in my shoulder or something like that. It might be easy for the therapist to say, Oh, that's this, this, and I push here and tweak this, and then it's better. But like so it might be hidden to the patient but not hidden to the doctor or hidden to the doctor and the patient or hidden to the patient but not the doctor or the doctor but not the patient. So it might be like all of these things. And so it's like working together this kind of synchrony to resolve uncertainty about about a hidden state. And I've thought a lot about like, who's making the observation? And who's who's doing the state observing? And who is the state hidden to and and it brings back what the paper that you guys mentioned in the dot zero, the communication as active inference, because it really is like a bi-directional, harmonious kind of thing happening, right? Awesome. Thanks. Yes. George? Yeah. So actually starting with the hidden states, who's observing, who's been observed? I think, you know, the free energy model or picture, the typical representation with the two agents and or one agent in the world and internal states, external states and so on. So if we have the two agents, you know, there's something in the middle, that clearly is the ground where we kind of try to achieve some form of alignment. And then that sort of implies the reading of someone else's internal state. I think, you know, that who makes the observation is who's been observed and so on. I think again, it is the bird song is a given take because there are clearly situations where you may be telling your patient that actually is nothing to worry about. For example, where you're not particularly sure about what's going on and the patient can clearly read in your body language that, no, it's hiding something from me, right? It's something there that doesn't feel right. And actually, there's an interesting phenomena, for example, with chronic conditions, which is the concept of cognitive immunization, where it's very common these days for, you know, patient goes and sees a practitioner has read, has consulted with Dr. Google to start. Dr. Google said, you know, could be X, Y and Z. Typically, the worst case scenario goes and sees doctor number one, doctor number one says, Yeah, you know what, you know, it's nothing to worry about. There's nothing wrong with you. Patient has got fine kind of saying, All right, I don't trust you kind of thing. Then goes and sees practitioner number two that comes with a different story. And yeah, okay, maybe you forget about if forgotten about something goes to practitioner number three and so on, and gets through a process where authors argue that it's a kind of, you know, the system becomes cognitively immune to any new explanations because the expectation is surely there's something wrong with me. So clearly in those conditions, you know, if we take from this lens, one could argue, yeah, as a patient, I'm observing you, I'm kind of reading your internal states, which is, I don't trust you kind of thing, because you're actually telling me something, but actually, something that potentially you don't believe either. Okay. Or, you know, this thing about let's do cognitive reassurance because most nonspecific back pain or neck pain, you know, one cannot say that's clearly a particular tissue responsible for the pain, the symptoms and so on. So you say, Okay, you know, there's nothing serious with you. So what's wrong with me? You know, clearly you can't tell the patient, you've got nonspecific back pain because for the patient that means you haven't got a clue about what's wrong with me or you're implying that something upstairs in my head, I'm making it up. So patients observe us for sure. And they know when we kind of are confident and so on. And when we, we're not so confident, and maybe we're not entirely sure if that's the whole thing is going to happen. In the same way, we observe patients. We start observing them, you know, when they come through the door, when you first greet them and so on. How are you doing before COVID times, you know, shaking hands and so on were a pretty good first kind of getting into someone else's internal state because just the, you know, the handshake, the quality of the amount of pressure, the confidence and so on. In a lot of, you know, there were cases say this person is anxious, this person is down, is depressed and so on. And you could get that down to, you know, when you do clinical examination, you touch, you observe, you feel, you palpate and so on. So that implies that there's a lot of unconscious stuff that it's, you know, it's process comes through, arrives through our our sensory, our sensorian and, you know, we made something out of it. So I think that that's what we kind of, you know, one of the things we try to explore through this stuff about, you know, try to understand someone else's internal state, you know, predicting a little bit of their mental state. And that's where synchrony and that's where alignment kind of plays that important role because, you know, it's no alignment. I can't clearly guess what's wrong going on. The stuff about what you, Ian, what you mentioned about sense making and so on. Sense making is quite an interesting thing. And you said, okay, you know, we're not like, you know, a patient is a patient and the practitioner is a practitioner, you know, there is that power differential as well, you know, there's the doctor, there's the patient when one is an expert and when the other is an expert and things alternate. The whole thing about sense making and actually minimization of free energy and so on. Sense making is quite an interesting thing to when we look at some clinical conditions and there's some beautiful stuff written about, for example, mental health and inactive approaches and looking at, for example, depression as a disorder of sense making, for example. And you see that sometimes with patients with chronic musculoskeletal problems, they also have, you know, a comorbidity, they have depression. What came first, the depression of the back or the back pain. One could argue that if I suffer from chronic back pain, and I can't get out of the house, I can't see my friends, I can't walk my dog, I can't play with my children and so on. The world stops kind of making sense, right? You know, I don't go out because outside is a cruel world and it's kind of full of, you know, dangers and so on. So I stay in a safe environment, which is my home watching telling a kind of, you know, complaining about myself to myself. Okay. And I become depressed because I'm stuck. So the therapeutic encounter, that sort of a nice ecological niche in a sense creates opportunity for sense making to understand where those patterns, for example, rigid behavior, rigid thinking that actually by understanding, by interacting can potentially start sort of taking the patient in a particular direction, which is the sort of, you know, this kind of road to recovery. And one, you know, one could argue that if someone starts feeling kind of bettering themselves, symptoms reduce a little bit, can start doing a little bit more, can start again engaging with the world, maybe the other stuff about feeling miserable would get better as well. And I think that's, that's sometimes what we see in Moscow's political care is this stuff, you know, we don't treat mental health conditions, and I don't think we should make those claims because they're clearly, you know, boundaries and competences and so on. But, but, you know, the patient that has got, for example, a chronic muscle skeletal problem and gets better and gets an impact, you know, that impacts changes their quality of life, changes their ability to, you know, become an agent again, because pain, they lost their agency because of pain. I think that's where the kind of the beauty of this understanding this stuff kind of comes is, you know, you can impact on some, you know, on different levels of the person, of the self, that is clearly not just that embodied self, that body, but it's beyond that embodied self is the sort of, you know, this multi-dimensional kind of what is to be a person kind of thing, right? So, and I think at times it's about kind of reading the others, you know, understanding the other guy's internal state is about sort of doing the right thing at the right time, because I know there's, there's a queue that tells me maybe I, if I do this stuff, this could be really, you know, one way of getting in surprising the system in a very positive way. Okay, so I've just been pontificating, so. Zoe? Yes. Yeah, I think, oh gosh, let me take my hand down. Okay, yeah, I think similar to what George said on sort of it's a bird song, I think there's different aspects where, you know, yes, generally on the the technical, the physiology or the anatomy side, then the practitioner is always obviously more the expert. But I think there's certain things where maybe you're looking at a patient or you're, you know, still trying to examine them and the the patient is still going to be the expert in their pain. And so you might be tossing and turning between a few diagnoses, say, and then the patient suddenly comes up with like, oh yeah, by the way. And then what you were thinking completely goes out. So I think you completely read them. There's always going to be sort of hidden states that you don't know about. And then you kind of have to, you're always on the lookout in case the situation is changing or maybe they don't want to tell you exactly what it is. And you're not, you think something's missing that intuition, that maybe there's an element of this that you're not, that you're not getting or suddenly they got worse and you're wondering well, what happened, like what changed, what was what goes on. And then you find out that, you know, their child's been really sick or something or the work's been really stressful or something else has happened, excluding that they haven't said that you kind of pick up on. So I think there's, there's that where you kind of you're inferring what that other person means. And there's definitely, you know, you're watching them, they're watching you. And you're kind of still deciding what's going to happen based on the sort of what you think's going on and that and throughout treatment, you know, there's no set treatment for certain things as well, like whether it's exercises or touch, you have to adapt based on what you're feeling. And similarly to what you put it up before the sort of synchrony and whether it's exact or not, well, it sort of also depends on the stimulus. There's a lot of research that there was one paper that was about a film, and they got two separate people to watch the same film by themselves at separate times. But in certain parts of the film, their heart rate was exactly the same. Their heart rate went up when, you know, the fight scene happened, and then their heart rate went down the same. And actually, you know, the difference was they were in sync, even though they were nowhere near each other, couldn't see each other, didn't know what that person was doing, they're probably doing completely different things. But the stimulus dictated the synchrony. So I think that's an interesting thing to consider as well, that the synchrony might be from a stimulus that's happening during the treatment, whether it's touch, whether it's something else, but we focused on touch. But yeah, whether you synchronize just based on what you're in that moment. But actually, you know, it's completely different otherwise. So yeah, just wanted to point that out. Thanks. That reminds me a lot of this direct interfacing mechanism of synchrony, which might be via like auditory communication, touch, and so on. And then there's this more stigmergy based niche modification, construction of a niche, like a corn maze where everybody walking through it is having a shared experience. Or like you said, with two people watching the same film, it's like, there's some similarity in their niche. And so there's a resulting synchronization without direct interfacing, because they're interacting in a shared there's something shared about their niche, either two people going through the same niche at different moments, patients coming through a space, or there's people that are in separate physical spaces, but the niche has some similarity. And I'm sure there's a lot of other examples like that. Ian, and then I have that image up if you want to describe what you wanted to share there. Thanks, Daniel. Yeah, we'll we'll describe that in a moment. But as conversation about films, I'm just thinking that Hollywood and filmmakers are actually masters of inducing synchrony, really, you know, they've got the birdsong. So they've got the the beautiful music or the dramatic music, or whatever, got the imagery, the words, the the composition of the images to hopefully not obviously not everyone will have the same experience of a film, but they hope that their sad film will induce some synchrony amongst the viewers in terms of the response in their body, or a happy film will induce some kind of rhythmic laughter. So I'm thinking about some work I've heard of recently of John Vivecchi looking at emotional goosebumps. And how this links to he thinks it's the process of temperature regulation is being exacted up into some kind of relevant or bringing things salient to us through goosebumps. And there's an opportunity there to kind of open up cognitively and explore some other ideas that maybe the person wasn't able to before. And you can think, okay, that music gave me goosebumps and I had all these ideas. So yeah, there's just a few things as we were talking there that I was thinking about. But this diagram was George, as you were talking about the kind of how you know, the complex things that might be at play with in a patient that this was done by MIT, I only found out about it a few days ago, it was 2015. But all of these different factors that might lead someone into a kind of vicious cycle of depression. And, you know, we've got things like cortisol or unbridled inflammation at the top there. But then you've also got, as you said, George, the physical inactivity and how this you've got all these different looping, perception, action cycles here that are creating this sort of downward spiral. And, you know, therapeutically, I guess what we're trying to do is create an upward opening, trying to get an access point. And, you know, Zoe, you said you might have to try lots of things, might have to try looking try one of these loops. And if that doesn't work, okay, try a different loop to open up this sort of thing that's tightening and maybe open it up either physically or perceptually. Yeah, thank you. This is like very much showing that complex causation. And so sometimes a disciplinary approach might be like, well, hippocampal volume is associated with this change. And that could absolutely be empirically true or cytokine signaling or early adverse experiences. And so part of the challenge is reassembling this complex causal network. And then even if there were some sort of causal network that could be reassembled, then how might the failure mode be similar or different from the recovery mode? Like, there are certain things that cannot be changed, like in the past. And there's other things kind of like the concept of hysteresis, where we can't just reversibly modify something. And so where are the leverage points in this diagram? And it's, yeah, George? Yeah, it's pretty complex, but yeah, very good diagram for sure. And I think there's a lot of stuff that we are talking about that's clearly there. Clearly we have modifiable and non-modifiable things. There's stuff, we can't change someone else's genetics. We can't change what happened in the past, okay? But there are modifiable things that, at least in the context of musculoskeletal care, are present. That can include beliefs, their prayers about their ideas about pain and what's wrong with them and so on, down to things that could be lifestyle. And lifestyle, it could be more movement, kind of changing the diet or whatever, stop smoking, kind of engaging in something that starts getting them kind of, you know, start getting their sense making back, okay? Through the sense, you know, the idea is actually, the other interesting thing about this stuff, you know, where are the opportunities? You know, how can we start, how can we start that process of change? A very nice model, typically aligned more with an activist approach, now sort of finding ways into pain and so on, are the ecological psychology ideas about affordances? You know, what is out there in the environment? You know, already linked, some offers to tell of the active inference, predictive processing and so on. But clearly, one can think about, you know, the world provides us with a landscape of affordances, you know, stuff that kind of are opportunities for action, which is basically what the description of an affordance is. And one that lives in a very nice environment, for example, with a beautiful park and can walk, you know, along the coastline and, you know, stress free environment and so on. Clearly, that world, it's a world for a sort of, you know, beautiful kind of lifestyle and so on, right? Whereas if one lives in an urban jungle and everybody's super stressed outside and so on, arguably that landscape kind of is much, much smaller. And you know, when we say, yeah, you know, would be good for you to start walking, for example, you know, that would be a good way of start to start managing your back pain. The patient can say, yeah, but you know, when I get out of the house, I'm struggling, I might just get run over by a car straight away. The environment outside is awful, you know, there's pollution everywhere. You know, what do you want me to do, you know, kind of a, yeah, I'm scared of going outside. So no, thank you very much. But of course, if you aren't the other side of the spectrum, you know, you can invite the person and use what's up there and start playing a little bit with those opportunities for action. I think that those are tools that if we think sometimes, you know, we can start thinking very hard about what sort of exercises should the patient do, should the person get engaged and so on. And if we think much, you know, in much simpler terms and think about, you know, what's outside, what's out there, what kind of, you know, what kind of things are already in the environment that can be used to actually promote change, you know, we would be surprised that actually just a flight of stairs would be good enough, you know, don't take the lift, take the stairs and, you know, start sort of walking a little bit back and forth, you know, from home to work and so on. Those minimal things, if the person feels like, yeah, okay, I'll have a go and I'll try that. Clearly, we are in a, in that process of, you know, change, kind of changing a little bit of their, their sort of internal states, you know, maybe that prior about, yeah, I can't move, I can't lift because, you know, it'll damage my back. In fact, when they start trusting their bodies, you know, they can do a little bit more. So, there's a kind of a, it's always hard to think about, okay, how can I change this? How can I change the generative model? And we almost think, you know, everything needs to be conscious, cognitive, and so on, when in fact, a lot of stuff happens unconsciously, right? You know, if it was always about, I'm going to think about changing, and I'm going to do this, and then the world would be much simpler, right? But, you know, we, you know, a lot of stuff is hidden anyway, and even the person is not aware of that stuff. So, but, so the change, the process, the tools, and so on, I kind of, this is a facet, you know, that goes back to that very good diagram with all these factors. And I think, as a practitioner, yes, okay, I can focus entirely on the brain, and the neuroscience of it, and become like a brain-centric approach, or I can start thinking about actually, the brain is, you know, it's the hardware kind of stuff, but there's much more in it, and much more in it, takes the person, takes the environment, takes the kind of opportunities, and so on, the stuff out there can be used. Thank you, George. Zoe? Yeah, just going off of what George said in terms of the environment around it, like when you're sort of, maybe if you're surrounded by nature, or things like that, then you might be sort of more willing, or more able to change your priors. I think it's also important to realize, especially through touch, that it's one modality, right? It's one way in which we're starting to kind of try to understand, and try to manipulate the process of sort of changing those memories, whether it's the way it's processed, or just having initially, or just trying to adapt it, and that's the touch is one way, but I think also it's interesting that it's probably more likely that we may not be able to completely change that sort of prior, but we might in that context, so we might not change the fact that it's painful to bend down, but we might be able to, through touch, and through sort of treatment, get the patient to realize, okay, well, yes, maybe bending forwards is dangerous, it is a bad thing, but if you do it in a certain way, and you look at it in this way, then actually it's not so bad, so I think it's, yeah, it's important to take the context into it, I think with this I think we might be able to, maybe not completely change the maladaptive belief, but with touch we can try to change it so that it's more context specific, rather than a general belief that isn't able to change, we might be able to change it so in certain circumstances, whether it's the way we do things or just the way that we approach things, we might be able to update it or modify it for that specific thing. I know that papers were talking about it in terms of like being scared of spiders, you know, you might still be scared of spiders, but if you know that you're scared of spiders and they've got food nearby and they're just spiders happy, then maybe, yeah, the spider is still scary, but it's not likely to kill you or something like that in this circumstance, it's not as bad as it could be and you're going to be safe from whatever sort of fear it is, so I think that's an important thing to add on from what George was saying, and I'll pass it back to George. Yes, George, and then Ian. No, it's just, you know, what's always just said, kind of, yeah, it's quite important, and through touch we can clearly get in, kind of affect, understand, and so on. I think that that's all the positive stuff about touch. There's another factor, another side of the equation, which I think, you know, as practitioners we need to be aware of, which is the power of, you know, what's the hidden state and that touch can trigger, and particularly in trauma situations, memories are embodied, and when you touch someone in a particular part of the body, that might, again, bring that unconscious stuff about, for example, someone has been in the victim of sexual abuse, for example, and you could touch a person and straight away, either there's a sort of a massive response, no fight or flight, you know, what's going on here, or you might actually, if it is about this sort of hidden state, you might actually find that, you know, that touch kind of created a response that is almost like a no-go zone, and you kind of need to be aware that sometimes, you touch people that don't like being touched, okay? If someone goes to a clinician that's, you know, in an intervention, it's primarily touch-based, doesn't like being touched, he might, you know, might go well, he might synchronize extremely well, you know, kind of, they understand you, they talk, when you start, say, okay, let's have a look, let's palpate that, you can feel like there's a fight or flight kind of mode, the person goes in straight away. So I think understanding this is also quite important in understanding the limits of competence of someone, you know, in musculoskeletal care, for example, that that's an area that where probably the person needs to be referred to, someone else, an expert in the area, or maybe by getting a sense of, you know, there's a response here that's not the one I would expect to perhaps not then to open the Pandora box, oh, tell me a little bit about what's going on here, because again, you know, it's a kind of, you know, you probably triggered, you pressed on a button that, yeah, you know, keep the lid on kind of thing, don't open it, please, because so this is important, I think, both ways, it's kind of the power as a therapeutic tool, but also the power of triggering the responses that actually are quite, you know, quite important to take into account. And in fact, you know, it's, you know, the paper we got accepted yesterday, which is the continuation of this musculoskeletal care, you know, one of the reviewers actually wanted us to say, you know, there are, you know, psychologists in a psychotherapy treat people that memories are embodied, and you need to be aware of avoiding overlaps, okay. So that means don't jump into an area that you don't know about, and but be aware that sometimes, you know, you, yeah, you're getting that the responses is pretty much you're getting into someone hidden states stuff that is there, and the background, leave it alone, please. That's the way at least I see my, you know, the world around me is like, don't, don't, don't sort of start the process that you don't want to, or if you don't, if you do, then go and see someone else. Thank you, blue, and then, sorry, Ian, and then blue. Oh, it's okay, I didn't have my hand up, so over to blue, sorry. Okay, blue, go for it. So it's interesting, and I don't know if, like, in your work as an Alastair path, but like, there's many layers, like I found, like, through working emotionally, physically, on myself through my life, like, it's like feeling an onion, right? And so as you go through, it's interesting that, like, like, all this stuff resurfaces, and like, even physical trauma remains there, like you stub your pinky toe, you stub your pinky toe 25 times, 35 times, 255 times, who knows how many times, right, depends on how clumsy you are. But, but your pinky toe remembers being stubbed, like, it has maybe like a hyper response, because it's been stubbed so many times, because it's whatever, that's, it's little job in life is to be stubbed, I think. But, but, like, it's interesting that, you know, you kind of have to open it up to, to do the work, and I wonder, like, what kind of synchronous work there is, like, I mean, I know that there are some people that deal with, like, physical and emotional trauma, and I know, like, physical trauma can be a manifestation of emotional trauma, and you can have emotional trauma based on your physical trauma. So again, it's like this, like, bi-directional circular loop, and I wonder what, like, the training is in osteopathy to deal with emotional trauma that may come up, or what kind of, like, are there people that do integrative practices, like, you have to be like an osteopath, and then maybe you do your residency as a psychiatrist, or what kind of, you know, can you get it all out, like, if you have, like, some kind of linked problem that's both physical and emotional. Thank you. George, then. Okay. So the, so, so, so the model in, in terms of therapeutic alliance and synchrony and using touch, if we use to the whole world of healthcare practice, you know, could argue that, you know, in a world of psychotherapy, for example, mind, body kind of stuff, yeah, the person would be sort of equipped with the tools to explore, to enable them to open up, to start the process, and being able to deal with that. So, the paper has a, has a kind of a generic kind of model that could apply, you know, as an umbrella to a number of areas of practice. For sure, we can do that and no problem. If we think specifically about manual therapy and specifically about osteopathy, then you've got two worlds, the American world of osteopathic medicine, where osteopathic medicine is medicine. And, you know, the, they are, there are osteopaths in the, in the US, who are psychiatrists as well. And in that case, yes, that person would be ideally suited to be able to explore that, you know, to do that, to kind of start that process of care actually using both their competences as a psychiatrist and their competences as a, you know, also manual therapist as a hands-on, hands-on kind of a practitioner. In other countries, osteopaths are primarily kind of a manual therapist, if you want to call it that way, although osteopaths don't like being called manual therapists, but primarily use manual therapy, primarily in Moscow school, a little care, but, you know, other areas of practice. And we start seeing a number of practitioners going down the route of, like physiotherapists, using what is called a psychologically informed type of practice. And that typically involves some additional training in counseling or some additional training in some, you know, CVT-like kind of approaches, like, for example, something like acceptance and commitment therapy, for example. So stuff that actually combined with that with hands-on is sort of, you know, potentiates the effect of the treatment that the hands-on alone would not achieve. But when you come from the two kind of two different angles, meeting in the middle and providing a more robust package of care, you can get better results. Because, you know, the training as a pre-registration level is very basic to sort of, to enable you to recognize that there are things that are, you know, neither referral to another practitioner. Even those that practice a psychological informed type of practice, like several physiotherapists have developed a kind of a traffic light system where clearly there are stuff on the yellow that's, you know, anxieties associated with pain and so on. That's okay. You know, you can deal with that. There's some stuff kind of in the orange that you have to be a little bit careful and they clearly stuff PTSD and so on, where, you know, it's a no-go zone, you know, because, you know, you can dive in and then you don't know if you're going to come back, okay, kind of thing. So that is typically referral to another practitioner. Having said that, I think there are opportunities for collaborative work where the two together can actually provide a much better service to a person that simply relying on one practitioner that can do everything. I think that's sometimes exploring stuff through the physical body, the embodied self, opens the doors for stuff to be explored at other elements of the self, okay. When the body is a little bit more prepared to deal with stuff and people maybe are prepared to talk, sometimes you see that in cases of childhood abuse and so on, you know, kind of had some, some stuff that felt good, some hands-on work, even the massage and the person felt a bit more confident in themselves and they were prepared and let's have a chat. They were not prepared to sort of go to talking therapy straight away because there was too much going on in their kind of embodied self. The sirens go off when certain things happen. Yeah, so just sort of picking up on the points from George and the question from Blue really totally agree that it's, you know, not the job of an untrained manual therapist to kind of aim to open a kind of worms of something that, you know, especially if it's not five minutes before the end of a session and then you kind of say, okay, I want to, you know, see you later, see you next week and I've got another client now and, you know, that's not definitely not a good idea. However, as you said, George, sometimes people will come and they'll want to offer things and they'll want to talk about stuff. And what I was thinking about, Blue, as you were asking about sort of the different combinations of approaches, I don't know if George and Zoe or any of you are familiar with David Baccelli's work on TRE trauma release or tension release exercises. So what, you know, he doesn't really go into the story. So it's not kind of psychoanalytical or unraveling the stories of people's past, but he has a methods for inducing kind of what I think is myofascial and what it looks like myofascial unwinding. So sometimes it's tremoring. And so it's sort of, I don't think he necessarily uses touch in the beginning, but it's, I guess what I'm thinking is that there are ways that if, you know, the ways of offering clients opportunities to unravel the bodily trapped or the stuff that's held in the body that where they don't have to verbalize it if they don't want to. But the inroad is to induce some kind of letting go, which maybe is what all therapy is about to a greater or lesser degree. But his, you know, his examples are quite dramatic. You know, people will be making big movements that seemingly are uncontrolled. But if you ask them to stop at any time, they can stop. They can bring it into voluntary. But there seems to be a really big updating of some generative model through this process. Yeah, they're my thoughts. Thank you. I'm going to return to our previous complex causation network. Now it's smaller because we're abstracting away from the details and think about like, what are some active inference questions that come to mind? And how can we look at this differently than, for example, just a structural equation model that's fit from many empirical studies. And so here's figure 4.3 from the textbook. And this is a partially observable Markov decision process. And it's come up in other papers and live streams. So we won't go into too much details. But the kinds of things that we might want to ask are like, what variables are latent states or observable in general, and then in the specific case, for example, maybe there's a total absolutely perfect association between hippocampus volume and some other clinical outcome. And so hippocampus volume conceptually is observable, it could be observed. But in that exact patient's case, it may not be an observable in that relationship. So variables can be observable in one context and latent in another context. So that might speak to evidence-based grounding where like, okay, we don't know what somebody's blood level of this is. What's the most informative thing to do? Maybe we can measure it. And then that ties their measurements into other observables. So that's one question, what are observables and what are latent variables? What variables do we have causal influence on? What affordances exist that might have intervening influence on some unobserved state? So here's like pi, the policy selection. And then the way that the hidden state is changing through time, that's what the affordances are about influencing. The hidden state is the true temperature of the room, the thermometer is the observed value. And then taking an action like turning on the air conditioning is about intervening in the hidden state such that other observables are seen. And then we talked also about like, in what ways can we change the generative model? So here's the policy selection of the practitioner. And then in the interface, it's like it's meeting with the observations of the patient. The actions of the practitioner, what they say and what they do are received as observations. And that's kind of this dyad actinth that we've seen. So rather than the one entity navigating and sense making in the world, the joint sense making features this interface where the policy selections on one, and they're thinking through other minds, their inference on the generative model of the other is what is being intervened in. How can we change the generative model, the cognitive models? How can we change the generative process? Could there be something welcoming on the door of the room that is a modification of the niche or some other design choice that helps scaffold this therapeutic niche? And yeah, what policies can be taken from the toolkit that is afforded in that moment, based upon the training and the equipment available and so on, that influence what to result in what? And that kind of comes back to this synchrony for what question? Just achieving synchrony is like a sort of undirected hypnosis or undirected sort of, I don't know, it's just sort of like this vegetative propagation of coordination that would only coincidentally be functional. So having a functional outcome in mind, then there can be a working backwards like, well, what observations are we looking for? And then what hidden states give rise to those observations? And what policies exist that intervene in those hidden states and in the dynamics of how they change, recognizing like their complexity. So those would just be a few active inference variables and approaches that are being invoked here. Conversationally, however, the kinds of models and the empirical data to take it further are being sketched out. Well, it's going very fast. And we're in kind of the home stretch. So what would anyone like to look at or turn to? We have a few other questions that previously had been raised that we didn't perhaps get to. Some of them are written here. So anything that people see here that they're interested in or any other topic. And then also just how are we coming out of this dot too? What will be different in our action as we are engaged in this area, of course, for many different perspectives? George? I love your kind of proposal, your summary of all the, you know, those active inference questions. In fact, there's a structure for Piper in it, right? It can take us down the road even just sort of looking at some computational stuff. So creating some kind of, you know, a framework. Yeah, so I very much like it. I think there is a sort of challenge in what are the latent and observables and so on to define those kind of things that needs a little bit of thinking. We can, you know, the other stuff, you know, as you said, you know, probably, you know, working backwards would sort of becomes easier, you know, isn't it? You know, if when it kind of it is about hands-on with reassurance and, you know, and so on, if that's a sort of what's, you know, the policy and so on and what we observed, you know, back at the beginning, I think, you know, it would be fascinating. I think in terms of the bio-behavioral kind of element of synchrony, there's clearly changes in breathing, changes in probably heart rate variability and so on. That would be interesting to understand. You know, is there the sign that the system is sort of starting changing? The process, you know, it talked about the thing in the, you know, maybe something in the door of the room. A couple of years ago when I was practicing in another country, I, for quite a few months, I used to use a lot of classical music and opera and so on. And that was actually a tremendously effective way of creating an environment where the person sort of actually a form of inducing that synchrony and kind of, you know, I'm treating, I'm kind of doing this stuff. I don't need to talk that much. I'm kind of, you know, just go with the sensations, go with the music. And I felt that actually that was a very good way as a process of start changing the generative model. And so there is the stuff, as we kind of proposed on one of the recent papers, the stuff that you can implement. So if you're doing the tactile, the touch-based intervention and use forms of language sometimes to get the person to visualize what you're doing. You know, for example, I'm doing this, I'm trying to achieve that. And you think that you know that the person is even like interceptively robust enough to let you explore the inner sensations to situations as, you know, you're probably doing some work and you realize by sort of predicting their internal states that they're just focusing too much, giving too much attention to stuff, which is actually not useful where you can just say, oh, you know what? Like we said in the type, you know, I have a new dog and I kind of, where does the dog come from? But a dog in that sense is a way of sort of breaking down that attention to what he's doing to sort of say, oh, okay, so you're continuing, you know, there's still the sensory stimulation, there's still that sensory evidence arriving to the system, but actually you start changing a little bit, you know, you're flattening a little bit of the sensory state by sort of zeroing the things and then maybe those sensations that come in potentially kind of change some stuff. So yeah, I think at this level that's for sure some stuff to do. I think it's an interesting thing that actually started being explored now with Ted Cupchuk lab in Harvard around Acupuncture, which is, you know, looking at synchrony as well with hyperscanning techniques and kind of finding that actually successful in terms of the intervention is associated again with what? Synchrony. So kind of it's a body of evidence sort of building up, I think, like nice folks. One thought on the free energy minimizing and ML Dawn and several others were discussing in the chat about like our biological systems truly finding global minima and so it's a big question, but just to give one thought on it is the free energy is calculated for a given policy sequence of actions in terms of how informative that sequence of actions is expected to be and how useful that sequence of action is supposed to be expected to be. And so different action pathways are evaluated based upon their ability to produce uncertainty or provide direct value. And so if we can just maybe there's multiple things that have value in the therapeutic alliance, but one for the generative model of the practitioner might be like to reduce a number on a pain survey. That would be useful. And then there might be multiple policies and maybe adequacy is good enough. And if the pathways are to some balance or shifting balance of informative and useful, either reducing pain or helping understand how to reduce pain, then navigating and shifting policies is something that can be done adaptively. And then in contrast, the policies that might want to be disfavored would be like the ones that are adding confusion, reducing clarity of sensemaking or increasing pain. And that's not to say that there's not moments where transiently surprise does increase or pain does increase. But that is part of a policy like I'm going to touch this place. That might transiently increase pain, but that might be an informative action that in an extended timeline is part of a free energy minimizing trajectory. And so what is the horizon? And so on. George, or then anyone else? That thing, sort of modifying pain, modifying symptoms, it's quite an interesting thing because for example, at least in my profession, there's this idea that we don't treat the symptoms, we treat the cause of the problem. So pain is just a symptom, it's nothing to worry about. But from this perspective, actually changing symptoms, reducing symptoms is actually an important thing, quite an important thing, particularly if you're thinking about chronic conditions. If you start making the person start feeling a little bit better, then you probably start changing the whole process. If you don't change anything, how is the person going to engage in that if actually you can continue saying, you're moving much better, your function is so much better. But actually the person says, you know what, pain hasn't reduced at all, I'm still in agony. So I think going a little bit with small things at that level are quite important in the greatest scheme of things in terms of changing the generative model. So it is clearly a fundamental bit of the jigsaw. And it's the same, as you said, in forming, for example, this might be uncomfortable, but in fact is important in kind of achieving something. So the same way some patients tell you, it is painful, but it's a good pain. So again, what's the value of the good pain is a reward. This is a sort of anticipation that this will lead to a positive change. Thank you, Zoe. Yeah, I think George just kind of touched upon what I was going to say. Pain, you know, sometimes patients, I know I have patients that come to a session and they expect it to be painful. I mean, a lot of people expect that at some point, you know, they might get that sort of quote, good pain, where they know they almost want to feel like something's happening, and whether that feedback is kind of pain or something that's kind of reassuring. I know patients, especially with sort of osteopathic manipulative sort of treatment, they want the click. If someone manipulates them, they come in and go, oh, I just want you to click me. And, you know, the research shows that not necessarily you need that sound, but that feedback that they sort of want, they kind of want. Some people, they expect if you do a hard sort of a more firm massage, they feel like they're, I don't know, getting our money's worth or they're getting more sort of treatment than if they want. They want you to, they kind of want that feedback to say, yeah, you're in the right place. And I get that a lot. So I think pain is an interesting one. I think it just, the biosynchrony that we get and we go upon, you know, whether it is the patient's heart rate, their breathing changes, you see their facial expression changes when you're, or the muscle tightens up nearby. You kind of go on, on that. But I think it's what they expect to get from treatment. Not every patient's going to come in and go, yeah, I want to, I want to be in less pain. That might not be their ultimate goal. Obviously, they're not going to say no to it, but they might really just want to be able to pick their kid up or go to sleep with just being able to go to sleep, not being in pain or not waking up or something like that. So I think it's not, yes, we can clinically, it's not so simple as something that we can measure empirically. It might be something that's, you know, a goal. So that patient is more important than, you know, if their pain is less or if they're moving better or, oh, well, yeah, you know, if we had the technology to say, look, oh, look, your heart rate's lower, or this means that you're more efficient, you know, you're saving free energy because you're not expending ting on your pain or it, you know, you're more efficient. So it's not going to, you'll have more energy to do this now that you're doing this better. They may not care. They may just want to be able to pick their kid up and not be in pain. So I think what we're measuring, I think we'll be very individual to the patient. And it might not be something that is necessarily useful in terms of research that we can quantify. It just might be that goal that's not always sort of empirical. Thank you, Zoe. Ian. Thanks. Thanks all. And yeah, just as you were saying that, you know, that Zoe, you said at the beginning, I think the intention behind it all is to help them. And I'm just thinking of a scenario or some scenarios of when, you know, agreeing on the goals is so important. So I'm thinking short-term goals and long-term goals here. So clients who are maybe endurance runners, and, you know, they want to do six ultramarathans a year and they come to you because their calves are hurting. So your immediate goal is to reduce the pain in the calves so they can make the ultramarathon at the end of the month. But then, you know, do I really, if I'm aware as a therapist that there's a link between endurance running and developing arrhythmias, heart arrhythmias, for example, and I see this person is very anxious about their goals to the point where, you know, it's almost like they need it rather than it's a pleasure as such, then, you know, if I disagree with their goal, are we, am I, you know, and saying actually maybe four ultramarathans a year would be enough for you? Am I just enabling this drive by relieving your calf pain in the short term? So, you know, agreeing, I think agreeing on those like longer, you know, more broader life goals and or referring to someone else, if I don't agree with that or just, you know, that's a more of an ethical issue. But it came to mind as we were talking there. Yeah, that reminds me of like the kind of performances that we might see in the Olympics or the medical care that might happen like on the sideline of a game where somebody has been injured, but they're going to like continue doing it almost in a way that is like rapidly degrading potentially the future weeks of their health. And then that's the ethical challenge or the decision making challenge like, is it, is it worth them to hobble across the finish line with an injury that every step is just deteriorating the injury, but then being consistent with a belief that one is a finisher or even a signal to those who are watching, there's so many complex phenomena at that level. Those are very interesting questions. Wow. So, we're towards the end here. I guess for the authors and for anyone else, we can give some of our last thoughts. What are some of your next directions for this line of research and application? Okay. So, well, first of all, as last time was a fascinating discussion. I think kind of a learning a lot from this kind of interaction for sure. Within this, we sort of got some stuff done in publishing in my school's political side of things. We have another paper to be submitted very soon the next week or so. The same topic but in pediatrics and there's the bulk of other stuff building up. I think, you know, what we want to achieve now is to start testing some of these ideas empirically using different methods from qualitative kind of phenomenological type of approaches, try to understand really what's going on to more, you know, sort of neuro bio stuff, kind of along the lines of looking at, for example, some some markers of behavioral synchrony like, for example, you know, physiological changes in both the practitioner and the patients going in mind. Some of this stuff, it is a bit more challenging to achieve because whereas, for example, in the field of psychotherapy, the person, the practitioner is typically sitting down, the guy doing manual therapy is probably, you know, he's moving around. So, therefore, the heart rate is not going to be exactly the same. But, you know, looking at what's what can be done and, you know, and some, you know, creating some some some some models as well. So, the idea around computational stuff also makes sense, you know, to test some of the ideas. This is work that is building up. So, you know, we very much look forward to kind of people getting in touch, bouncing off ideas from each other, kind of looking at how we can move forward with this. There's it's not osteopathic specific is is more than that. I think at least it can be manual therapy, you know, more broadening along those lines. You can look at sort of, you know, the role of some of this stuff in chronic condition, not just pain but, you know, other persistent physical symptoms, and so on. So, that's that's where we are. It's time now to start kind of testing some of the stuff for sure and stop writing theoretical papers. Cool. Zoe? Yeah, sort of what George said. We've got I've got we've had one paper accepted for MSK. So, hopefully that will come out for everyone to read soon. What is MSK? We've got one waiting. Care. Okay. So, for more orthopedic general, yeah, muscle and bones kind of patients. And then the pediatrics one is almost ready to submit. And then, yeah, I guess we'll be looking towards seeing where it goes and what we can sort of empirically prove from all the theories that are kind of circulating and going and going from there. But hopefully discussions like what everyone said now will give everyone more ideas to sort of where we're where we're going or where we could go and different ways to apply the principles and the frameworks that we've suggested so far. Awesome. George? Yeah, just what you know on on the pediatrics we actually have, you know, in the first lines to start exploring is is a synchrony between mother, baby and practitioner. Starting with not sure if we're gonna be we've been done, you know, we've been doing a bit of work around, you know, the effect of touch on premature babies. So, we have those collaborations with hospitals in Italy, what not enable us to do some of that stuff. But we we sort of start looking also, you know, looking at this whole concept of synchrony on a triadic kind of thing. So, the baby, the practitioner and the mother and see if actually if we find that, you know, the synchrony actually between mother and baby is a marker of, you know, for example, the baby would be, you know, some some some some markers of, you know, autonomic change, you know, changes in autonomic arousal, for example, like we observed, for example, the effect of effective touch, gentle touch on the baby. Thank you, Ian. George, just as you're saying about the challenge of a practitioner being moving whilst during the, you know, manual therapy session and sort of aware of that does lead some difficulties, especially with the PPG sort of measurement of heart rate variability. I heard just an idea I heard about, I don't know if you've come across it an easy a wearable ECG, that encourage it's aimed at increasing respiratory sinus arrhythmia, it stimulates, it vibrates and it stimulates the person catches them at the top of their outbreath. And it's designed to actually be used whilst you're walking around in everyday life. So I'm just wondering if there's an opportunity there to because it's designed to a increase RSA and B to be used whilst moving, that might be an interesting piece of kit to use. Yeah, absolutely. Cool. Blue? Or would anyone else like any comments? I just want to give a final thought. So something that I'm going to be thinking about for I don't know whoever knows how long is this idea of the emotional and physical body in terms of reference point, right? So we studied in, I think live stream 40 the FEP for generic quantum systems and it talked about how like the FEP drives entanglement. And in this way, like when there's when there's perfect learning, there's like this overlapping of the reference point. So I just wonder like how like kind of an emotional body and a physical body be driven toward a more overlapping reference frame, like when those things are so fundamentally different. So I'm going to be thinking about that. Cool. Very cool. All right. Well, thank you for this excellence.2. That concludes 44 and really appreciated the authors joining and blue. Thank you for joining Ian also for contributing so much with the dot zero. And everyone is welcome back to give us updates on their learning and application on this very important area. So thanks again, everybody. See you later. Thank you. Thank you. Goodbye. Bye. Bye.