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Archive for March, 2011

My place of work is “The Centre for Integrative Care. Glasgow Homeopathic Hospital”. It’s an NHS hospital with a small inpatient unit, a new day service, and a very busy outpatient department. Here’s an interesting fact about our budget – over 90% of our total costs are spent on salaries. That means less than 10% is spent on drugs, equipment, maintenance etc. Over 90% is spent on people. I think that’s amazing and something to be very proud of.

Health care is about people. It’s about people who are seeking help and those who are seeking to help. It’s about care, about compassion, relationships, communication and understanding.

Our particular approaches, our integrative approaches, prioritise the human aspect of health care. I’d be worried if the greatest part of the budget was spent on technology or drugs. (I understand that this is not the same in all departments – some acute medicine and surgery has to be very high tech, and that tech is very expensive – but even where non-people costs are great, I still think it’s important to prioritise the human beings – the patients and the carers)

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What is “integrative care”?

This is a term which is being used more widely in recent months and many times it seems to be used interchangeably with “integrated care” (or “integrated medicine”), so what is it? And are they both the same thing?

From what I can see different people use these phrases different ways, so let me just explain what it means where I work. I work in the “Centre for Integrative Care. Glasgow Homeopathic Hospital”. Those are the titles fixed to the front wall of our building, and they’ve been there since this hospital was built just over a decade ago.

What we mean by “integrative care” is an intention to support and develop greater integration in a patient. If we think of health as being a state of wellbeing and good function of the whole person, we can think of such a state having certain qualities. These include all the bits working well together! We call that “coherence”, but sometimes, I think the metaphor of “flow” is a better one – it’s where not only does everything flow well, but the person has an experience of “flow” (Csikszentmihalyi).

If we think of any organism as being a “complex adaptive system” then we can conceptualise an idea of health as a state of optimal self-organisation – that’s maximal integration.

So, “integrative care” is an intention. It doesn’t specify a treatment or procedure. The question is, does this consultation, or treatment, increase integration? Does it, in other words, promote healing? You’d be surprised how little health care is directly intended to promote healing (rather, most biomedical health care is focused on “disease management”)

“Integrated care” on the other hand, tends to refer to the bringing together of “orthodox” and “alternative” treatments. The “Royal London Hospital for Integrated Medicine” is an example of that type – they seek to blend “mainstream” and “complementary” medicine. Terms such as “alternative”, “complementary”, “mainstream” and “orthodox” however, are social constructs, determined by whoever happens to be in a place of authority in a society at a particular time. “Complementary” treatments may, or may not, promote greater integration.

 

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I find something very disturbing about the Brian Cox style of science programme. He usually presents something along the lines of the current “Wonders of the Universe” (his other recent outing being the astronomy week on BBC2 where his irritation factor was doubled by the contributions of his co-presenter Dara O Briain). The subject matter should be right up my street. I’ve had a lifelong passion for the wonders of Nature and the Universe. So, what’s the problem?

Two things – a certain contempt for human knowledge and wisdom prior to the present day which feeds an arrogant implication that everyone in the entire history of mankind was thick as two short planks until our current cohort of scientists who have finally found out the truth about everything. Secondly, an apparent view that only science can reveal truth. (Consider instead Ken Wilber’s Integral model which shows that science is a way of understanding surfaces, but that we need other ways to understand the depths)

Mark Vernon nails the issue perfectly.

At the start of the second programme, Cox is filmed on the banks of a holy river amidst Hindus attending to their dead. He notes that Hinduism, along with other religions, has a story to tell about people’s origins and the meaning of their lives. Only, that story is flawed. He has a deeper story to tell. ‘The path to enlightenment is not to understand our own lives and deaths,’ he intones, ‘but to understand the lives and deaths of the stars.’ He then proceeds to describe how the elements in our bodies are made from the explosive death of stars. Which is true. Only that’s not nearly enough to deliver on the enlightenment promise at the top. That would be like saying the meaning of Michelangelo’s David can be found in the quarry where the marble came from.

Nicely put, Mark! He concludes –

Science of itself does not do the meaning part. Only a human interpretation of the science can achieve that. But to do so, the interpretation must make raids on the language of values and metaphysics. It needs the beauty of colour and the harmonies of music – qualities which, of themselves, again are unknown to physics as physics.

I think it’s a shame to hear scientists trying to present science as a kind of “the truth, the whole truth, and nothing but the truth” activity. Scientific enquiry and exploration is such a wonderful human enterprise, but it goes seriously off course when it turns into scientism.

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Lovely piece on the School of Life site considering active and passive paths to wellness. The yin yang symbol is one of the most potent symbols we have – I wear one around my neck. One aspect of the symbol is the representation of a dynamic balance of active and passive principles. Taking this idea, Jules Evans writes about a session at the School of Life where representatives of each of these models tell their stories.

The active form of well-being lies in the happiness of pursuit, striving after a goal, making things happen. Its great champion is Aristotle, who defined happiness as a vital activity of the soul. The other form of well-being is passive. It finds happiness in the renunciation of the will – not in making things happen, but in accepting things happening as they do. This is the approach of the Stoics and Epicureans, both of whom define happiness as freedom from desire, and also of the Buddhists and Taoists.

I like this idea. My daily practice of medicine is grounded on the belief that all human beings are unique and by active, non-judgmental listening, I can come to understand the particular worldviews, coping strategies and pathological changes within each patient I meet (and, of course, how these are all linked). One consequence of this approach is to realise that different people have very different approaches to wellness. And that, fundamentally, is ok. There really is no one size fits all, and there is always an alternative.

Representing the Yang school of well-being, there is the entrepreneur Robert Kelsey, full of energy, leaping from mission to mission (‘first I was a journalist, then a banker, then a writer, then an entrepreneur’), picking himself up when a mission fails, only to launch himself on another voyage……[and, on the other hand, Ed Halliwell]….tells us that he only found peace from his battle with depression when he stopped “desperately striving to change my situation. When I did, a curious thing happened: my depression lifted”. Meditation is, he says, the opposite of striving: “It’s impossible to strive to do it. The process is about sitting and observing, being in the moment, rather than striving.”

 

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strange gait

OK, I meant strange gate……

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Do you remember hearing this riddle when you were a child…..”how many sides does a bottle have?”

The answer was “two – and inside and an outside”.

Ken Wilber’s 4 quadrant map stimulates us to think about these two sides of everything – what lies on the outside, the surface, can be seen, pointed to and known – Wilber refers to this aspect as the “right hand side” (related to his diagram), or to whatever can be empirically known by just observing. And what lies inside, on the “left hand side” of his diagram, and which can only be revealed through dialogue and interpretation.

Here are a couple of paragraphs from his “A Brief History of Everything” to explain this thinking tool –

…all of the Right Hand dimensions can be accessed with this empirical gaze, this “monological” gaze, this objectifying stance, this empirical mapping – because you are only studying the exteriors, the surfaces, the aspects of holons that can be seen empirically – the Right Hand aspects, such as the brain.
But the Left Hand aspects, the interior dimensions, can only be accessed by communication and interpretation, by “dialogue” and “dialogical” approaches, which are not staring at the exteriors but sharing of interiors. Not objective but intersubjective. Not surfaces but depths.

and

[the Right Hand phenomena] all have simple location, because they are the physical-material correlates of all holons…….But….none of the Left Hand aspects have simple location. You can point to the brain, or to a rock, or to a town, but you cannot simply point to envy, or pride, or consciousness, or value, or intention, or desire. Where is desire? Point to it. You can’t really, not the way you can point to a rock, because it’s largely an interior dimension, so it doesn’t have simple location. This doesn’t mean it isn’t real! It only means it doesn’t have simple location, and therefore you can’t see it with a microscope or a telescope or any sensory-empirical device.

I find this very helpful. Health care is so dominated by this focus on exteriors, on what can be objectively described and measured, but health is such a human experience, that to ever understand it in any individual demands that you explore their interior dimension. Through dialogue. This is just as real, and, arguably, even more important, than what can be seen on the surface, or the exterior. I like this reference to simple location, because my everyday work is in dialogue, in exploring narrative, in diving into the interior…..which cannot be discovered by simple mapping or locating.

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tree fog

I probably see this tree every day. It’s just that I don’t remember ever seeing it. However, because of the fog this morning, the background which the tree usually disappears into, was faded to white and suddenly…..there’s a tree!

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Read this quote from Robert Redford today in the “i” newspaper

Storytellers broaden our minds: engage, provoke, inspire, and ultimately. connect us

Fantastic!

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jasmine tea

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Ken Wilber’s “Integral Theory” has a number of elements. The holon is one of them. Another important element is the simple, elegant and immensely useful Four Quadrants. He simply draws a cross which yields four squares, or quadrants. On the horizontal, the upper two quadrants represent a singular perspective, and the lower two, the plural perspective. On the vertical, the left hand quadrants represent the interior, and the right hand ones, the exterior.

Even more simply, you can think of the pronouns which apply to each quadrant – upper left, is singular, interior and is communicated by using “I”, whereas, upper right, is singular exterior, so is communicated using “it”. Bottom left is plural interior, communicated with “we” and bottom right, being plural exterior, communicated with “its”.

You can see that the left hand refers to subjective experience and the right to objective.

One of the things you can do with this is map other conceptual maps onto it. So, if we take Karl Popper’s “three worlds”, then top left is “subjective”, bottom left is “cultural” and the right hand side is “objective”. Habermas describes three truths – the subjective truthfulness of I, the cultural justness of we, and the objective truth of its. You can also map Kant’s three great works against this – Critique of judgement (art and self-expression), Critique of practical reason (morals or we), and Critique of pure reason (science).

Finally, you can map onto the same plan, Plato’s Beautiful, Good and True.

I’m sure you will probably be able to come up with other parallels, but why not play with this for a bit. I think you’ll agree it provides a very useful and much more holistic framework within which to understand things.

I especially like how he values ALL four quadrants, and in so doing, makes it clear that if you only come at an issue from one of the quadrants, you’re just not going to get the full picture…..puts objective science into its right place in my opinion!

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