Archive for October, 2009

BBC Radio 4 broadcast a really interesting programme this week entitled Metaphor for Healing. I don’t think you’ll be able to listen to it (unless it’s still on the BBC iPlayer) but they’ve put up a good page about it on the bbc website. There’s obviously a link between issues of metaphor and those of visualisation. In fact, in some ways metaphors are tools for visualisation aren’t they? The programme talked a bit about Jan Alcoe, who used visualisation to both cope with both her disease and her treatment. It’s not hard to think that every patient should have a session about this before undergoing chemo and radiotherapy. I’ve read a lot about visualisation in cancer settings before so although her story is a particularly impressive one, it didn’t tell me anything really new. However, the rest of the programme was about the conscious use of metaphor in consultations, and I’ve not heard that discussed so clearly before.

Dr Grahame Brown, a musculo-skeletal specialist at the Royal Orthopaedic Hospital in Birmingham, claims he is able to save hundreds of patients from the need to have spinal surgery every year simply by “reframing the negative metaphors that have been unwittingly used by their doctors that can lead to a destructive and self-fulfilling cycle”. Many of the patients he sees have been referred for surgery after becoming convinced their spine is ‘crumbling’ or that they have ‘degenerating’ disc disease, when in fact they have a prolapsed disc or other normal wear and tear that is common in most people. Yet anxious patients latch on to these suggestions and become convinced that things are only going to get worse.

Now this really is fascinating. By becoming aware of the metaphors used by the patient (typically those given to them by other doctors) which make it harder for a patient to break free from chronic pain, then giving them different metaphors, he helps them change the way they think about, perceive, and, ultimately, experience their pain. He claims that this can have such a dramatic, quick effect, that many escape not only the need for surgery, but also escape from their pain.

It’s an impressive outcome.

There is specific mention of two techniques, or approaches, based on metaphor, used by people in this programme – the Human Givens method, which is a fascinating counseling technique, and the Clean Language approach, which is based on a technique developed by a practitioner inspired by “Metaphors we live by” written by Lakoff and Johnson, one of the books which have changed the way I think about the world. Fascinating to see these ideas turn into practice.

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Look at the colour of this water. It’s an amazing colour isn’t it?

water green from reflected leaves

Why is it that colour? It’s the effect of all the leaves on the trees of the forest through which the stream is flowing. On another day, in another season, this very water (well, actually, this very stream, not this very water!), looks an entirely different colour. In fact, a few hours earlier, or a few hours later, it looks completely different.

This got me thinking. Not just thinking how beautiful it is. It is stunningly beautiful. But how change is a such a constant, and, how whatever we see is the result of many factors, and how everything needs to be understood in it’s context, and how nothing can be reduced to some simple set of data, or simple description, without, in fact, obscuring its reality.

Maybe it’s just the way my mind works, but it also got me thinking about the interactions between the environment and the elements of the environment. I’ve just taken out a subscription to a new journal titled Ecopsychology. I’ve never come across this term before, but its the area of study which looks at the interactions between behaviour and the environment. I love it when I come across these whole new fields of human exploration and knowledge.

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Greed is good?

First this week we have the vice-chairman of Goldman Sachs, Lord Griffiths,  saying

We have to accept that inequality is a way of achieving greater opportunity and prosperity for all.

No we don’t. It’s just not true. Inequality is NOT a way of making life better for ALL. The evidence actually points the other way. Inequality is a BAD way of trying to make life better, even for the privileged.

Then the Duke of York chips in to defend the bonuses –

I don’t want to demonise the banking and financial sector. Bonuses, in the scheme of things, are minute. They are easy to target. A number will have abused their privilege of a bonus, so get rid of the excesses, but don’t throw the baby out with the bath water.

Have these guys never read the research on the effects of inequality? Take a look at just two books – The Impact of Inequality, and The Spirit Level, and make up your own mind. Or go to The Equality Trust and read more.

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I took a walk at the weekend. Up through the Birks of Aberfeldy. Robert Burns wrote a poem about this place. Here he is –

Burns writing The Birks

He wrote well before me, in an earlier time and an earlier season.

I went to the Birks to find leaves. I love the colours of autumn. Come and have a look at some of the amazing golds, and reds, and silvers, and yellows, and greens, and bronzes I found…..

yellow splash

autumn bridge

higher turns first

silver forest

silver birch


But what I really like most about this time of year is how you can see change happening right before your eyes. It’s true, change is always with us. Life is dynamic. Nothing can be reduced to a fixed, final and complete understanding. There’s always more to see, more to learn. There are always new ways to explore, growth and change to pursue and enjoy.

leaves turning

red tinge

shadow leaf

There’s always wonder.

There’s always hope.

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Very berry

Look at some of the wonderful berries I spotted recently……


red  berries

white berries

pink berries

green berries going red

red berries

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Human beings are sense-making creatures. We continuously process all the information we can gather from our environments – internal and external – and try to put the information together somehow. I think we use two particular sets of skills to do this, and they’re related.

The first skill is pattern spotting.

What do we think when we look up and see this?


We pick out the colours, the shapes and the contexts of what we see, and we name it – sunlight behind oak leaves, casting overlapping shadows.

This happens so quickly and effortlessly that we don’t even pause to wonder about it. In fact, we’re seeing patterns everywhere, all the time. It’s a fundamental skill needed for understanding.

The other skill we use is storytelling, or narrative. We “join the dots”, or “put things together” by creating narratives. By creating stories we make sense of the patterns we see. Personal sense. When you look at this oak tree for example, you’ll perhaps become aware of certain feelings, and maybe those feelings related to previous experiences involving oak trees. As a species we create stories about trees, and, specifically, about oak trees, so maybe some of those stories will come to mind and your experience of looking at this tree will be enriched by that.

Well, here’s an interesting study which explores how we might enhance these core skills. The first sentence of the report caught my attention –

Reading a book by Franz Kafka –– or watching a film by director David Lynch –– could make you smarter.


Well, according to the psychologists who conducted this study –

exposure to the surrealism in, say, Kafka’s “The Country Doctor” or Lynch’s “Blue Velvet” enhances the cognitive mechanisms that oversee implicit learning functions

It appears that reading a text, or watching a movie which is challenging to understand because it doesn’t appear to make sense, enhances our skills in making sense! I suppose it’s a bit like going to the gym (I wouldn’t know….never been!) and practising using your muscles so that they then work more efficiently and with greater strength.

Well, the questions which arise about what do they mean by “smarter” are answered by the specifics of the study. What they actually showed was that after reading Kafka, or watching a David Lynch movie, a person’s ability to spot patterns was enhanced.

Interesting. Actually, I spend most of every day trying to spot patterns, listening to stories, and trying to make sense of what I’m seeing and hearing. You could say that’s my job. But how interesting, even from the perspective of training doctors. Maybe we should be encouraging doctors and medical students to encounter surrealism, to read Kafka and watch David Lynch. Maybe that would help them to become more skilled doctors. The practice of medicine isn’t all about learning facts after all.

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A study published in Science last week reports finding a high incidence of XMRV in patients with chronic fatigue. XMRV stands for “xenotropic murine leukemia virus-related” virus and is a retrovirus which seems to have jumped species from mice to men.

Dr. Mikovits and researchers from the National Cancer Institute and the Cleveland Clinic reported in Science that 68 of 101 patients with chronic fatigue syndrome, or 67 percent, were infected with XMRV, compared with only 3.7 percent of 218 healthy control subjects. Further testing after the paper was written found the virus in nearly 98 percent of about 300 patients with the syndrome, Dr. Mikovits said.

This is interesting, but the way it’s been reported is disturbing. The authors are claiming that it may be the “sole” cause of “ME”. I think that’s highly unlikely because “ME”, or “CFS”, is a poorly understood syndrome which probably encompasses a number of different aetiologies and illnesses. On the back of that, they’re predicting a bright future for the treatment of the condition using antiviral drugs and developing vaccines. Woa! Too fast! You can just hear the drug companies rubbing their hands with glee! This constant portrayal of complex illness in simplistic terms results in products being matched to diagnoses, instead of individuals being understood and enabled to experience healthy, natural recovery. (as a side note, I think you can conceptualise such complex disorders as failures of the body’s normal healing processes. Something precipitated the ill state, and for whatever reasons, the patient has developed a chronic condition of low vitality, poor resilience and ill health).

The second disturbing aspect of this report is how both sufferers and medical professionals have jumped on this as a possible “legitimation” of the illness. As if finding evidence of a virus now makes the disorder “real”, or “not a mental disorder”, or even illusory. OK, if this connection is established and results in sufferers being listened to, and taken seriously, then I can see that as a benefit, but why can’t they be listened to and taken seriously even without finding a virus?

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…..Royal Botanic Gardens, Edinburgh, 4th October……yes OCTOBER! What an amazing colour to stumble across in October!

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Oh how little we understand about the so-called “placebo response”. Here’s an interesting study to throw into the mix. Apparently, the actual symptoms experienced by “placebo responders” in clinical trials accurately mimic the drugs being tested. The likely ill-effects reported by those who took a placebo in a trial are likely to be just like the ill-effects experienced by those who took the active drug.
What does this mean?
Well, if it’s truly a double-blinded study, how does the volunteer know what side-effects are likely? Some commentators have dismissed this finding as down to expectations but how did the volunteers know what to expect? I think this phenomenon needs to be studied rather more closely. If the volunteers, through the process of informed consent, are being made aware of the type of drug being tested and/or the possible effects it might have, then maybe this phenomenon will manifest itself more strongly than it would in a group of volunteers who really didn’t have a clue what they were (possibly) taking. If this were the case, then the expectation explanation might hold water. But if it turned out not to be the case, then how do we explain it? Morphogenetic fields? Collective unconsciousness?
I do wish the incredible rich variety of responses of the human being to therapeutic interventions was not reduced to such simplistic notions of a “placebo” (by which the researcher means, “nothing”).
Life is more complex than that.

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Was HPV vaccination responsible for the death of that little girl in England last week? We live in a society where simplistic and judgmental conclusions seem to be both valued and common. In response to that news story you’ll have read some people argue that the vaccine isn’t safe, and others argue that it had absolutely nothing to do with the girl’s death.
Is life so simple? Can we really be so certain in relation to cause and effect? I don’t think so.
I often say to patients that when you think about chronic illness, it’s rare to be able to ascertain a single cause. In the vast majority of cases it’s far better to think about the multiplicity of factors and influences which have challenged the person, and to think about the dynamic, continually changing ways a person responds to and copes with those challenges.
For example, it appears this girl had a tumour “heavily infiltrating” her heart and one lung. It’s highly likely that such a serious pathology would be life threatening. The presence of that disease meant she was considerably more vulnerable and more fragile than other girls in her class. So did the vaccination provoke her final, fatal incident? Sadly, the truth is, we’re not clever enough to be able to know. In fact, until we stop thinking of human beings as simple machines where this leads directly to that, we’ll never be clever enough to know. We don’t have the equipment to show the complex behaviour of the whole organism. So to say that the advocates of the vaccination could “breathe a sigh of relief” was not just insensitive, it was wrong.
The fact that 1.4 million doses of this vaccine have been administered without any deaths is reassuring to everyone except Natalie Morton’s parents.
Human beings are not reducible to numbers. In yesterday’s Guardian there was a sensitive exploration of the difference between making a Public Health announcement and making a decision about a member of your own family.
Is vaccination a biological challenge? Yes, it is. If it were no challenge there would be no provocation of the immune response. Can a biological challenge be fatal? Absolutely. An anaphylactic reaction to a bee sting in a previously fit and healthy person can be fatal. Much lesser challenges can be fatal in an already vulnerable, compromised individual. Rather than dismiss the role of HPV vaccination in this tragic case, wouldn’t we be better served by improving the screening procedures before mass vaccination? Shouldn’t we make a better attempt to assess the fitness of the individual to receive this challenge?
Maybe it’s not easy to find such answers, or to live with uncertainty, but outright dismissal of risk by simplistic explanations and population-based statistics, really don’t inspire confidence.

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