Archive for the ‘from the consulting room’ Category

At the port in Marseilles there is a hug mirrored roof over an open area. It provides people with some shade, but also attracts people to gather underneath it and look up – to see the world upside down.

Looking at the world upside down can be very revealing.

Think about this current pandemic. We are told there is this COVID-19 virus sweeping across the surface of the Earth, seeking out victims to slaughter. Several governments have used war metaphors accusing the virus of being an invisible, cunning and evil enemy. The answer, if this is your perspective, is to “beat” the virus, to “crush” it, “flatten” it, or “eliminate” it.

In the absence of treatments which kill the virus, the authorities pin their hopes on better defence – by which they mean immunisation – a mass vaccination programme to increase each individual’s ability to “resist” infection by this particular virus.

But, what if we turn our view upside down? What if we look at ourselves instead of the virus? Who gets sick when they catch this virus? Mainly the elderly, those with ongoing chronic health problems, the poor, and ethnic minorities. Why can’t either Public Health or the hospital services prevent the deaths of tens of thousands? (I mean reduce the number of actual deaths, not save the lives of an imaginary number who haven’t got sick)

What if we addressed these problems by making them the central target of our efforts? That would need our societies to deal with inequality, poor and overcrowded housing, poverty, low waged precarious contract work, racism and discrimination, under-resourced health and social care. We would need to invest in the creation of resilient well-resourced Public Health services including laboratory testing, contact tracing and the supply of safe place, supported isolation of the infected. We would need to invest in the resources of the clinical health services to have enough beds, nurses, doctors, equipment and personal protection for staff. We would need to address under-staffing in the health and care sectors so that too few workers didn’t have to look after too many people in too many different locations, so spreading the virus.

In other words, if we look at this pandemic from an upside down view, we might avoid future pandemics by creating healthier, more resilient, stronger societies…..no matter what the next virus is.

OK, I’m sure you’ll be thinking “but we need to treat all the sick, kill the virus which is overwhelming them, and reduce the current spread through hygiene and distancing measures”. All probably true. But none of those measures are enough. Remember my favourite phrase?

“And not or”.

We need to do both. Treat the sick, try to reduce the spread of the virus through the community, AND deal with the problems in society and the economy which have made us this vulnerable in the first place.

Sometimes it helps to add the upside down view.

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There is always another way.

I don’t believe people who say there is only way to do something. There are always other options, other choices to make, all dependent on our preferences, values, beliefs and particular circumstances.

Margaret Thatcher famously said “There is no alternative” – which was shortened to “TINA”. It wasn’t true then, and it’s never been true since.

I’m suspicious of algorithms and protocols because they tend to marshall everyone down the same pathway in order to produce the exact same outcome. But we are all different, and we are all living our every day lives, moment by unique moment, in each of our individual and particular circumstances. The more generally “TINA” is applied, the more inappropriate it is.

It’s been frustrating to hear politicians say they have been “following the science” all the time during this pandemic and that they have “taken the right steps at the right time”.

There is no “the science”.

Science is a methodology. It’s a way of considering the world, of exploring and attempting to understand it. The scientific method doesn’t produce end points. “IT’ is never finished. There is always more to discover, more to learn. Science is about doubt, not certainty. The findings and analyses of scientists can increase our understanding but they will never be set in stone, fixed for all time.

There are no “right” steps to take at “the right time”. There are just the steps we choose to take, in good faith, or carelessly. There are just the steps we choose to take now. They say hindsight has “twenty twenty vision” (or will we say in the future “2020 vision”?) but that’s not true either. Things just look different when we look back. Looking back is just a change of perspective. Not a perspective we had at the time.

Here’s the same passageway, viewed from the other side – looking back to the way we came, where the first one was looking forward to the way we were going.

Change the perspective, change the understanding, change the options.

There is always another way.

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This is a photo I shared with many patients and students over the course of my career. I saw this rock, a long, long time ago, just down from a waterfall in woods in the Scottish Highlands.

How did this rock come to have such a shape? It’s as if it had been struck by a Viking axe! What’s even more interesting is that it will never “heal”. That cleft, that wedge in the body of the rock, will never disappear.

It’s pretty common to think of healing as the complete resolution of something. We think of a cut, or a broken bone, and imagine that once it has healed, the skin or bone will return to how it had been before, forgetting somehow that all injuries leave scars. We think of infections as “self-limiting” – that is, once they have gone, they are gone. The body returns to some prior condition. We talk of “defeating disease” and use a lot of war imagery to suggest we can remove it (whatever “it” is) from our bodies, “defeat it”, and then it will be gone…for good. Job done.

But Life isn’t like that.

And neither is healing.

We don’t go backwards. Injuries, infections, traumas and diseases of all kinds change us. Even when we make a “complete recovery”, our lives have now changed. Something is altered….in the body and in the psyche. Whatever we encounter, whatever we have to “deal with”, becomes part of our story. Every event, every experience, changes our lives forever.

So, what are we to do with these wounds?

It would be nice if we could just ignore them. And in many situations they are minor enough for that to be a reasonable strategy. But the bigger impacts can’t be ignored, they can only be denied. That’s never a great strategy.

Maybe we could fill in the gap. Fill that wedge with prozac-a-filla or something like that. Would that work? Unfortunately, suppressing, and hiding the wounds tends not to work for very long. All those “anti-” medicines that we use – antibiotics, antihypertensives, antacids, anti-inflammatories, antidepressants etc combined with opiates and other sense-numbing drugs, don’t actually directly promote healing at all. They just “take the edge off” things….for a bit. You think antibiotics cure infections? I’m afraid not. They can do a very important job. They might even save your life. But what they do is kill bugs. The inflamed, swollen, and damaged tissues in your body need to heal. The antibiotics don’t do that. It’s your ability to self-repair that does. And antibiotics don’t stimulate the self-repairing functions of the body.

So what do we have to do?

Take a look at the photo again. See the river rushing by the rock? I think of the life force when I see that. The wound has become part of our internal landscape now. The illness, the experience of it, the memory of it, the impact it had on our psyches and our lives, is part of who we are now. It’s an integral part of our story. But life continues. We adapt. We find new ways to live and to thrive with this changed landscape. We evolve our inner environment.

I’m not saying we shouldn’t use our modern medicines. They can reduce our suffering and even, sometimes, save our lives. But they don’t directly help us to heal. We still need to recover, repair and adapt. How much of “Medicine” or our “Health Service” is directed towards that life-long, important issue of healing?

I hope that, whatever the answer to that question, the answer will be “a lot more in the future”.

Our lives are not going to be the same once this coronavirus pandemic is over. How are we going to heal? How are we going to adapt? How are we going to live differently?

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I took this photo at noon one January 1st.

You might think its pretty much just a photo of some grass, so, hold on, let’s look more carefully, and consider the contexts. If it was simply a photo of a patch of grass it wouldn’t be particularly interesting but what caught my eye wasn’t the grass, it was the interplay of shadow and light.

Despite it being noon, the Sun is still pretty low in the sky. Well, it’s taken in the wintertime in Scotland, so that’s normal. But, normal or not, the effect of the low sunlight streaming through the trees is spectacular. The angle of the light makes the shadows SO long and the spaces between the trees show frosted grass sparkling brightly.

I love the forms and the patterns of the shadows, the light, the frost and the grass. It takes all of them together to create the scene.

Here’s another scene –

This is a huge puddle which is there more often than it’s not in this particular field. I once saw swans swimming on it! But today, what makes this image so beautiful is the trees and their reflection. Without the trees, the clarity of the light and the stillness of the water, this just wouldn’t be the same. It has echoes of the previous photo but it’s completely different. However, both photos were taken within minutes of each other, the flooded field lying just a short walk along the road from the shadowed park.

I’m struck by how important the contexts are in these photos. If I’d “abstracted” just one element in each – a grassy patch, a section of the puddle, a single tree – I’d lose all the context. It’s the interplay of all the elements which makes these images more than the sum of their parts.

Life is like that.

When we focus too narrowly, when we consider only a part in isolation, we achieve only a partial understanding. It’s the whole experience, in all it’s contexts and environments, with the story which holds them together, and the remembered subjective experience of being there which makes them so unique, so particular to me.

So, if I am to share any of that with you, I need to show you, and tell you, at least some of the contexts. That way, you’ll come closer to experiencing what I experienced.

That was my everyday working reality. Every single patient who came to see me had a unique story to tell. If I were to understand them I had to hear their story. I had to try to have some experience of their experience, to feel what they were feeling, to know what they knew, if I was to understand, diagnose and help them.

But it’s the same for all of us. If we are to understand anyone, friend, relative, colleague, stranger, we have to hear their story, and try to experience some of their experience.

It’s always partial. It’s never fixed. It’s never completely knowable. But there’s no substitute.

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I can remember science lessons in High School where we studied waves. I thought they were fascinating. I still do. All kinds of waves. Waves in the sea

waves in a pond

the electromagnetic spectrum which includes the light and colours we can see, the radio waves we can tune into and many other varieties of invisible waves which affect us.

the waves produced by our hearts and brains which we can’t see, but we can measure and represent on charts (did you know that when your heart rhythm emits a wave pattern which can influence the heart rhythms of people who are physically close to you? 

Even the representation of waves drawn in the stones in a temple or shrine (like the one at the start of this post).

Waves change us.

Waves carry energy and information.

As energy and information reaches into our bodies and minds it changes us.

I read the other day that “influencers” are having a hard time. Bear with me, I’m 66 next month, and “social media influencers” are not my specialist subject, but as best I can tell people who make a living from advertising and marketing revenues from companies by sharing pictures and videos of themselves wearing or using those companies’ products have seen a sharp decline in their income.

Seems one of the things during this pandemic is that people are consuming less “stuff”. Well, given that around the world millions of shops are closed and production lines are at a standstill, maybe this is no surprise. But there’s another element to this story which seems to be a sort of re-evaluation that’s going on. Less people seem interested in the lives of “celebrities” (ie people who are famous for being famous) just now. Priorities and values are changing.

However you want to look at this, the underlying reality is that we are all influencers. There is nothing I do, from the breaths I take, to the beating of my heart, to the communications I make and the behaviours I show, which doesn’t change the world. OK, yes, of course, not the whole world! Well, probably a very small part of the world actually. But collectively we are all influencers.

We send out materials, energy and information into the world constantly. Unceasingly.

What materials do you send out? What “waste” do you produce and what do you do with it?

What energy do you send out? How does that energy affect your relationships?

What information do you send out? What are your messages? How do you say them? Are they based on kindness or hate? Hope or fear? Anger or Joy?

You cannot escape being an influencer.

The question is – what waves are we making? You and I.

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There’s something of this shrub that makes me think about the human brain. The leafy cortex forming a curved border and the mesh of branches, twigs and stems which look a bit like a neural net.

Deleuze and Maturna wrote about two common models we use to organise our world view – the arboreal and the rhizomal. They described how we use the former to create tree structures everywhere…..those hierarchical constantly branching sets of binary choices. Think of a genealogy chart, and how we refer to it as a “family tree”. But think also of “organisation charts” which lay out the positions within a company, and show the power flows, with the “Chief Executive Officer” at the top. We see it in protocols, guidelines and algorithms, which proscribe the actions to take at every point to get from a starting position to an “outcome” or “goal”.

I love trees, but “arboreal” models of thought and world view make me uneasy. They are too binary for me. At every stage you can go this way or that way, and there is often an implication that there is only one way which is the right way. It assumes that the starting conditions are exactly as the author expects them to be, and the goals or outcomes which the model maker identifies are the best, or most relevant, or most “efficient” ones, so everyone should share them. Like all models the people who make them have certain values, beliefs and world views, but, rarely are those things made explicit. They are also too hierarchical for me. I’m not a fan of strongly hierarchical, centralised power structures.

On the other hand, there is something very appealing about these tree-like diagrams. I probably drew little family trees every working day. I found it helpful to chart a patient’s relationships, siblings, parents, grandparents, partners and children. They often revealed patterns which shone a light on this patient’s illness. And there is no denying the tree-like branching structures within the body – particularly in the lungs and the circulatory system, but not only there.

In Jacques Tassin’s “Pour un Ecologie du Sensible”, he uses a variety of metaphors to show how interconnected all of life is. One of his metaphors is the tree. He says all life is like an invisible tree rooted in the Earth, each branch, each leaf a living being, a part of the same tree. I like that. If each of us is a single leaf, then, obviously we are connected to every other leaf through the over all structure of the tree. I also like his reference to the roots, which we usually don’t see, because it seems very true that we are vastly interconnected in invisible ways.

The rhizome model is more like grass. There isn’t a single trunk, or root. It’s massively interconnected. It’s a “distributed network” as opposed to a “hierarchical structure”. The brain is probably more like that. Every one of our millions and millions of neurones makes up to 50,000 connections with other neurones. Trees don’t do that. I find the network model very appealing. I love the way it reveals a multiplicity of equally “good” pathways. I love how it doesn’t pre-determine either the starting points or the end points. In fact, it’s kind of impossible to see where a brain begins and ends. It’s not even fenced off in the skull!

When I look at this shrub, then, I actually see elements of both of these models – the branching tree structure, and the presence of multiple, connected pathways.

OK, maybe only up to a point, but, hey, at the end of the day, it’s a pretty appealing and inspirational shrub!

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When I looked at this image I saw an earthy path with a puddle lying on it. The puddle is beautifully blue because it is reflecting the sky above. There’s an enticingly intricate pattern of shadows on the earth, cast by the sun shining on the leaves of some trees. At the edge of the puddle the reflected green of the leaves borders the sky.

Then, I thought, hold on, there’s something odd about this. That puddle is a really, really strange shape. It’s almost a triangle. Something’s not right here.

So, I looked more carefully, and a different interpretation leapt out at me.

This isn’t an earthy path, and that isn’t a puddle.

This is a photo of a pond. The water is so clear you can see right through to the muddy floor. The shadows are cast right through the invisible water and the reflected sky is on the surface of a pond, not a puddle lying on the earth.

When I realised this I was quite surprised. No matter how hard I look I still can’t see any water lying over the earth. The reflected sky, however, reveals the water. It makes it more obvious.

This got me thinking (well, if you’ve read a few of my posts, you’ll be familiar with how my images provoke my thoughts). It got me thinking, I wonder how often I don’t see reality because I don’t look carefully enough? I wonder if taking my time allows me to notice the peculiar, and how often it’s the peculiar, the strange, the thing that doesn’t fit, which is the key to the door of perception.

There are two lessons in that thought…..slow down, and be open to what’s different, what seems peculiar.

I guess a lot of the way I engage with the world is at a superficial, faster level, with an eye open for what’s familiar, what I know already…….that way I can quickly tell myself I know what I’m looking at, and move on. I’m sure those mental behaviours are valuable, but I do think they are over-used.

That’s my lesson to myself today –

Remember to slow down and savour.


Remember to look out for what is strange, rare, or peculiar.

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