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Archive for the ‘from the consulting room’ Category

I’ve got lots of photos of spider webs. When there has been a heavy dew and the sun is just up in the morning they look absolutely bejewelled. Mesmerising and gorgeous. Most webs have that classic spiral appearance with a clear centre, and strands all spreading outwards from that centre, then concentric rings of web woven around and around that centre point.

But this one is different, and maybe you’ll look at it and think it’s not as beautiful because it has neither a clear centre, nor any lovely symmetries. But this structure is one of the most fundamental shapes in Nature.

It’s a network. It’s made up of two simple components – nodes and connections. There is no single clear centre, no branching or hierarchical structure. Some nodes are multiply connected, others only connected to two other nodes.

The cells and organs of our bodies are like this – they are multiply connected and once change takes place somewhere it spreads quickly through the entire network. There is no single commanding point. This is an incredibly flexible, adaptive structure and it is exactly what every “complex adaptive system” looks like – either literally, or functionally.

I find it utterly beautiful and wondrous. I love how I can understand human biology through this lens. I love how I can understand the brain through this lens. I love how I can understand ecosystems through this lens.

Every single one of us exists within, and emerges within, these vast complex webs or networks of Life. We don’t function like machines. The connections are not linear – instead they are “non-linear” – so effects can accelerate as they cascade through the system, and changes can occur which are utterly unpredictable from the starting state.

This reminds me of the importance of seeing each of us, not as separate disconnected individuals, but instead as unique instances of change within the entire web of Life.

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Do you see the rock just beyond the harbour wall? The white foam of the sea catches your eye, doesn’t it? At first, you think it’s water splashing against the rock, because, that’s something you’ve seen many, many times before. But if you keep looking the foam disappears and you can see this –

Click on the photo to get a closer look. Can you see the gap in the rock where the white foam was? If you look very carefully you can still see some water falling down the front of the rock from that gap.

This rock has a gap in it. A long narrow gap. The waves crash against the other side of the rock, the side you can’t see from the land (the dark side of the rock??) and some of the water flows through that gap and cascades down the front.

I don’t know how this began, and I’ve no idea when it began, but it’s quite mesmerising to watch. There’s a rhythm to it, as there always is when you are watching waves breaking on a shore line.

However it began, I know that every time some water forces its way through this gap it widens it just a little bit more. I can’t help but think about that power of water and what it can teach us.

Little by little, probably imperceptibly at first, constant, repeated, pressure of the water against the rock opens, and widens, a hole right through the middle of the rock. It would be tempting to think of the rock as solid and unchanging, and the water as soft and constantly changing, but this reveals that’s not quite right. It’s true that the presence of the rock changes the shape of the water – influences the speed and direction of the waves. But the water actually constantly changes the rock.

Gentle, constant persistence.

I’ve always been a fan of that. The ability to be present, and to pay attention, to sustain that attention, is a powerful skill. I’m pretty sure that’s one of the reasons why so many patients told me the same thing – that they had just told me something they had never told another human being. It always amazed me to hear that. Sometimes it would be an important, even a key, part of their story which made it possible to make a diagnosis. Sometimes it brought about a sudden revelation which allowed the person to make sense of what they were experiencing. One small part of a life story might be like that gap in the rock and as the water of insight flowed through it, suddenly we both understood.

I suppose it’s a bit like that famous line from Leonard Cohen –

There is a crack in everything
That’s how the light gets in

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I’ve just finished reading Madeline Miller’s superb “Circe”. I can’t tell you just how much I enjoyed it. I found it a great read. I am a bit familiar with some of the Greek myths and legends, including the story of Odysseus, but this way of telling Circe’s story let’s Madeline Miller tell you some of those myths from a new perspective. I just loved it.

Last night I read a passage which made me think “Yes! I must share this!” Here it is –

When I was young, I overheard our palace surgeon. He said that the medicines he gave out were only for show. Most hurts heal by themselves, he said, if you give them time. It was the kind of secret I loved to discover, for it made me feel cynical and wise.

I have long believed exactly that. I used to say to patients something like “If you break a leg, the surgeon will apply a plaster to your leg to hold it still. The plaster doesn’t repair the fracture. It just holds the ends together while your body gets on with doing what it does – healing – or, in this case, repairing the fracture.” Or I’d tell someone “This antibiotic isn’t going to cure your bladder infection. What antibiotics do is to kill bugs. That’s a good thing. But your bladder wall is all inflamed because of the infection, and it’s that inflammation which is causing your symptoms. The antibiotic will have no direct effect on your inflammation. But it will reduce the number of harmful bugs in your bladder to allow your body to get on with doing what it does – healing.”

Does that seem unnecessarily pedantic? I don’t think so. I think it reinforces the patient’s belief that their body can self-heal – which is exactly what all “Complex Adaptive Systems” do – all living creatures have these abilities to self-regulate, self-defend, and self-repair. It’s what they do.

That’s the wisdom part.

But in Circe’s telling this knowledge also brings a certain cynicism, and for me, that’s always been about the place of drugs in health care. There isn’t a drug on the market which is designed to directly promote and/or stimulate self-healing and self-repair. Each drug attempts to redress an imbalance, or to suppress some symptoms or pathologies. The business of the body doing what the body does – self-healing and self-repair is left to be a hopeful sort of side-benefit at best.

There are ways to work more in harmony with the body’s natural powers, but, in my opinion, those ways aren’t taken seriously enough. Targeting pathology/disease and/or symptoms remains the dominant model. But I do dream of a time when the balance tips towards targeting health/healing and/or powers of self-repair, and self-healing. The present types of drugs and treatments will then be seen as the potentially useful adjuvants that they really can be. They will no longer be seen as enough by themselves.

Oh, by the way, “Circe” isn’t a book about health or disease. It’s a telling of some of the Greek myths. It’s just that passage really resonated with me so I thought I’d share it. And, on reflection, don’t those myths have something to tell us about disease and illness, and how we cope, heal and grow?

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I’m convinced the images we encounter daily influence what we feel, what we think and how we behave. In fact, I don’t just mean images such as artworks, adverts or photos. I mean how things look – including the shapes and sizes of buildings, the presence of trees, flowers and bushes, the colours of walls, the landscape or the cityscape, depending on where we live, and the decor, light and shapes of the rooms we live in, as well as the objects which surround us.

All of these images influence us deeply, and, largely unconsciously, creating moods, emotions and feelings which stimulate or inhibit well-being, and which change the course of our lives.

One dramatic example of that is in hospital design. There is a lot of research about this, but, to give one example, it was found that patients who had a view of nature from their hospital bed recovered more quickly, needed less painkillers, and had less complications than those who only had a view of a wall.

Of course the advertising industry is well aware of the power of the image. These days there is even a specialist area of knowledge and advised described as “neuro-marketing” which seeks to employ the findings from neuroscience to persuade customers to buy certain products. These things work at the level of image, sound and smell. Mostly, they work unconsciously.

So, I think it’s good to notice our here and now, our everyday reality. I think it’s good to be aware of the images we absorb as we work, play and relax in our home and shared environments.

Taking photos is a good way to become aware. When you look around, or go out somewhere with a conscious intention of photographing what you notice, then your awareness is automatically heightened. These days most of us have smartphones which are more than ably equipped to take photos. You don’t have to have a fancy camera.

These two photos I’m sharing today are of street art I noticed as I walked around the streets of Salamanca one day last year. The image on the left is like a work of modern art. It looks a bit “Miro” to me! What I really notice about it is how the artist has used the walled off entrance as a frame, using the concrete filling the space as a canvas, but, he or she hasn’t stopped there. They’ve spread their artwork beyond the bounds of that frame….reaching out to cover the left hand pillar. I like that. I like how it demonstrates how creativity can be opportunistic, inspired by what is already there (the walled-in entrance way), and how that inspiration can come from the most unlikely places. Would you have thought that entrance way represented a canvas? I like how the artist isn’t bound by that either. How they kept creating outside of the frame – thinking and creating “outside of the box”. This work inspires me to be creative, to see opportunities for creative work, and to refuse to be constrained by other people’s frames.

The second photo shows the power of stencil. I mean just look at this person holding their head. Are they in despair, or are they trying to figure something out? I can see both. So it’s an image of hopelessness which reflects something we all feel from time to time, but, instantly, it’s also an image of someone thinking, someone deep in thought, trying to come up with a solution. At least, that’s what I see there. How about you?

I know, with every interpretation we bring our own standpoint, our own sets of values and beliefs, our own moods and preoccupations. But that’s one of the great things about art, isn’t it? It isn’t just the power of the work to convey “percept and affect” (as Deleuze would say). It offers us the chance to wake up and change by engaging with it. And even if we don’t wake it, it influences us without us realising. It interacts with us, and we interact with it. It’s a relationship.

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The Boston Ivy plant which grew over the entire enormous ancient wall which ran along one side of my garden has continued to thrive even though the wall fell down dramatically just before Christmas almost a whole year ago. In that time the stones have been left where they fell and what was left of the vine continued to grow and, even, thrive.

This is an amazing plant which goes through extremely distinct phases. There are little beak-like buds on the ends of the woody stems which open up in the Spring. The glorious green leaves which unfurl are so dense that many birds make their nests in them and in the Summer the whole plant buzzes loudly to the sound of thousands of bees collecting pollen. It produces seeds which pop out of their shells once the Sun passes towards the Western horizon beyond the wall each day, and they cascade down in the millions, sounding for all the world like a fountain. The first time I heard it I actually went looking for the water pouring down the wall, but, of course, there was none. Then in the autumn the leaves turn yellows, golds and reds, then fall off, revealing foot long bright yellow stalks, one for each leaf. These fall next. As each layer is shed other structures and colours appear….dark purple berries, and bright red stalks.

This photo, which I took a couple of days ago, shows the pattern of red stalks, now that the berries and leaves have now gone. This is a distinctive form – I recognise it from my days of anatomy study at university. The human body uses this form a lot….this structure of ever branching pathways, from large trunks to a myriad of small stalks. You can see that in our lungs. Air passes down from our noses and mouths via the trachea which branches into two – one for each lung. Then in each lung there are many further branchings, creating ever smaller, narrower passageways until finally they end in little swellings like bunches of grapes – the alveoli. You can look at how blood circulates around our bodies, through arteries, veins and capillaries and you see this same continuously branching structure. You can see similar pathways in our kidneys but the direction of branching seems reversed, starting with a myriad of small tubules, which collect together to form bigger ones, all of them ultimately draining into the ureters, one for each kidney – just like we see streams joining to form rivers which flow down the mountains to the sea. I could go on….you see this sort of structure everywhere in the body and you see it everywhere in plants as well.

At first glance it looks complex, but in fact it’s a pretty simple, straightforward form. It looks like there is more of it than necessary….wouldn’t it be better to channel all the flows down major routes instead? After all when you fall your SatNav doesn’t it tell you the quickest way to get from A to B is to avoid all the small, branching, “side” roads?

But Nature knows better. Not only does this pattern allow for the greatest interaction of, say, the plant, or the human, with the air, by creating the greatest surface area contained within a relatively compact space, but it is incredibly resilient, robust and flexible. If the flow were to be obstructed in one small section, it would soon be re-established, or increased through the myriad of other passageways.

This is what is called “redundancy” and Nature loves “redundancy” – it’s the opposite of modern management systems of “efficiency”. The idea is to always have more options, more resources, than you think you need. We design aircraft this way – they have so many backup systems, so much “redundancy”, more engines than it needs to fly, so that even if there is a failure, other systems and resources will immediately kick in so that the plane continues to fly – planes aren’t “resilient” – they aren’t designed to recover quickly from damage – they are “robust” – they are designed not to fail in the first place.

If there is one thing this pandemic has revealed, it’s the wisdom of Nature and natural systems. We have pared back our Health Services and Care Services to the bone. We have closed hospitals, beds and facilities, and failed to employ enough staff to deal with any more than the basic needs of the population – and even that not very well.

Surely it’s time to resource these services much much better. We need vastly more trained doctors, nurses and other staff. We need more facilities, more equipment and more flexible to systems. We need different, diversified, localised and devolved structures of power and organisation.

That’s the way Nature works. That’s the way the human body works. Why not design our organisations and societies on the same principles?

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Picking up on yesterday’s post about threads and weaving life stories, I thought I’d share this photo I took in an old weaving factory in Aubusson. Isn’t this a fabulous stock of yarns? Look at the colours!

Probably because I was thinking about the metaphor of threads and weaving in the way we create our reality through our stories, I looked at this image again today and thought “Well, that’s what they have to work with. That store of colours and shades” So what if we think about how that idea might apply to how we create our daily experiences?

What is there in your palette? What can you select to weave together to create your unique, singular experience of today?

What if these yarns are like beliefs, ideas, thoughts and emotions? Which ones do we have to draw on, and which do we keep going back to, perhaps over-using, when we could be shifting our attention and using a different section of the palette if we want today to be really different?

I remember reading about a theory, which seemed to be validated by studies and observations, that when a baby is born, at the moment when the umbilical cord is cut, they experience their first existential threat. In those first few seconds if the baby doesn’t take their first breath, they won’t live. Perhaps, in those few seconds, the baby experiences certain strong emotions. We don’t have access to those memories because in our early years, our consciousness and memory functions haven’t formed to allow us to access them, but that doesn’t mean to say they aren’t happening, all the same. After all, most emotions occur below the level of consciousness, and becoming aware of them takes time, attention and practice.

So, what emotions might a baby experience in the midst of this first existential crisis? The theory proposes three – fear, anger or separation anxiety. Makes sense to me. So, the idea is that maybe which of the three dominates is genetically determined, but, whether it is or not, that particular pattern of those three emotions sets itself up as a core as we continue through life and try to make sense of our experiences.

So, some people have fear at the core, and that’s the main colour they use in their daily palette. For others, it is anger, and for yet others it is separation anxiety. You can try this for yourself. See if you can think back to your very earliest memory. Preferably one form before the age of five, from before you started school. When you recall that event, what emotions do you associate with it? Is it fear, anger or separation anxiety? I found with patients that some would identify one of these very clearly, some would identify a mix, or find more than one strong early memory, each with a different dominant emotion. Others would find none. They either couldn’t access any early memories at all, or they wouldn’t be able to say which emotions they associated with any they could remember.

For people who can find one, it is interesting to then follow that thread through life. To what extent does that emotion seem a foundation to other significant life events? Remember that with each emotion, we might suppress it, express it, or deal with in some hybrid way. So, if it is fear, then both fear and courage might appear. If it’s anger, both temper and avoidance of conflict might appear. And so on…..

Well, that’s one way to start to think about what palette you have, and what section of the palette you draw upon most frequently to create your daily reality.

You can also become aware of your dominant emotions, thoughts and beliefs by journaling….for example by doing “morning pages”. In fact, there are many ways to become aware of our habitual patterns of emotion, thought and belief.

I think it’s good to explore this, but we can take it a stage further by deliberately choosing certain part of the palette, or even adding new sections. We can decide we want to colour each day with more joy, more wonder, more love. We can decide we want to see each day through more half full glasses than half empty ones. We can do that with affirmations, with visualisations, with making more conscious choices about where to focus our attention, our time and our energies.

But all that is maybe for another day. Today, I’m just suggesting an exercise in awareness. Can you become more aware of what your personal palette looks like? Can you become more aware of which sections of that palette you keep going back to again, and again, and again? Finally, which underused sections of your palette would you like to pay more attention to? Or as you look at the vast range available, which colours of yarn would you like to add now?

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I love stories. I always looked forward to hearing the stories patients would tell me, and I’m sure a significant part of my work was to be an active co-creator of stories. It would be common for a patient to sit down next to me for the first time, and I’d begin “Tell me your story”. Quite often that opening would be met with surprise or even some puzzlement, but I’d just stay quiet, maintain eye contact, and show I was waiting with undivided attention. Sometimes people would ask “Where will I start? How I am now, or what went wrong first?” I’d suggest there wasn’t a right or wrong place to start so just choose to start wherever they like.

The first part of the story would be up to the patient, but then I’d ask certain questions to explore particular aspects of the story, or to open up other areas which hadn’t been covered. So, together, we’d enable the telling of a unique story, a life story, with a certain focus – health and disease. Because, I am a doctor after all.

Now when I see this photo of threads beginning to be woven into a tapestry I think that rather than “focus” in that last paragraph, maybe I’d be better using the word “thread”. Because often the life story of health and disease is a story which needs unravelled, untangled, to identify the important threads, colours, textures, and images, or the important events, themes, experiences and patterns.

Maybe, in fact, the life story of health and disease is just one of the tapestries we create from all the threads and colours which allow us to create and experience our one, unique, and singular life.

So, threads, tapestries and images turn out to be as important for me as stories.

Where do the threads come from? The ones we weave into our personal experience? Some come from our genes. There are threads of lineage which run through each of us. Some come from our birth experience, and our response in those first few seconds to the cutting of the umbilical cord. Others come from our experiences, from the events of our lives and both our reactions and responses to those events. Yet others come from our relationships and from the physical environments in which we live.

Then there are other kinds of threads which we pick up and make our own. The threads of myths and legends. The threads of other peoples’ stories, beliefs and values. The threads of culture, music and art. In other words, the threads of our collective imagination.

Finally, as well as threads, the weaver has to have some idea of what they want to create. They have to have a vision, have imagination, maybe even have a pattern or a plan to follow.

I wonder what threads you can find in your life. I wonder what visions, thought patterns, feeling patterns, behaviours and influences create what you do with those threads…..

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How much do you think love motivates you to do what you do, to say what you say, to think what you think?

Are there serious arguments against making love our priority, our touchstone, our foundation, our core?

What couldn’t be improved by bringing a loving attitude to bear?

I think good health care requires love….love in the form of caring about, caring for, and wanting the best for, every patient. Love in the form of non-judgemental listening and attending. Love in the form of respect for the unique individual. Love which values personal relationships above techniques, tools and processes.

I think good education requires love…..love for children, love for knowledge, love for wisdom, love for growth, development and maturity. Actually, education isn’t something we should restrict to children, we could all do with learning all our lives. We could all benefit from life long education based on loving each person and wanting to try to help them realise their potentials.

I think good work requires love….love for craft, for skill, for quality, for service to our fellow workers, our families and our communities.

So how about a politics of love and an economics of love ….. love of Nature, of Planet Earth, of our fellow creatures, and of other people? What would that look like?

Maybe it’s time for us to be less shy about love. Maybe it’s time for us to speak up and say it’s important. More than important….essential.

Can we learn from this pandemic and move towards a society based more on creativity and care, than the present model which is based on consumption and competition? Can we move towards a society based more on qualities than on quantities, challenging the current dominance of figures, statistics and “data”, and insisting instead on loving, caring relationships, on experiences, on individual uniqueness, and on diversity?

I’d like to see that. How about you?

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This is a machine. It is manufactured by human beings. It has a number of solid, pretty unchanging parts (ok, they all gradually wear out with use), which are assembled into fixed relationships with each other by other parts…. nuts, bolts, springs, cogs and hinges.

These parts don’t grow. They don’t develop or mature. They don’t develop new ways of connecting to each other and they don’t change their function. Their relationships are linear. A always leads to B.

This machine looks a bit complicated but everything can be taken to pieces and understood. We can learn how it works and predict how it is going to work. It does what it was designed to do and if it stops doing that we can find the parts which are “defective” and replace them with new parts.

Living creatures are not like this. Human beings are not like this. We are not manufactured by human beings. Every cell, every tissue, every organ within the body changes all the time. The massive network of inter-connected feedback loops create relationships in the human body between cells, tissues and organs. These relationships are non-linear. A influences B in the presence C, D, and a host of others, whilst B, in turn influences A. These relationships are not fixed. They are not predictable.

Living creatures, like human beings, are “Complex” not “Complicated”. You can’t take them to pieces and understand the whole.

We are all “complex adaptive systems”, constantly bathed in flows of molecules, energies and information, which we transform within ourselves before contributing to their onward flow into others.

Machines can exist in isolation. Human beings cannot. We live only because we are embedded in the complex biosphere of Nature, dependent on the lives of a myriad of other forms of life, dependent on our relationships with others.

Machines are not unique. You can produce millions of identical machines. Human beings are unique. There has never been “YOU” before in the whole history of the universe, and there will never by “YOU” again, once you die.

The truth is every one of us is special, and every one of us deserves to be treated as unique. Every one of us deserves to be understood within our individual web of connections, relationships and life story.

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It strikes me there is a paradox at the heart of what it is to be human. We each have a sense of being different from other people. We experience what Freud termed “the ego”. It’s a sense of “self”, of a kind of centre of the universe from which we observe and interact with everyone and everything else. Our immune system is finely tuned to quickly recognise anything that is “not me”, to identify it as a potential threat and to mount inflammatory and/or allergic responses to contain and/or expel it. We need to know that we matter, that we have value and worth, and whilst some of that comes self-referentially as “self-belief” and “self-worth”, a lot of it comes from that other, somewhat paradoxical theme – the fact that we are social creatures.

We need to belong. Complete isolation is a punishment – we call it “solitary confinement”. We need to find common ground with others, to be accepted by a family, a group, or a community. We need to find and express what connects us to others so that we can share our experiences with them.

This paradox of separateness and belonging is never “resolved” if we see them both as opposite, unconnected poles. Although they are undoubtedly difficult to reconcile, they need to be “integrated” – in other words we need to find how we can connect them to each other in ways which will enhance and develop both.

It’s important to grow and mature as an individual. It’s important to feel free, to have personal autonomy. It’s also important to grow as communities, as a species, (if we want to evolve), and even as an integral part of all Life on Planet Earth. We share the same air, the same water, the same limited “resources”. We create waste which cannot be contained. What I do affects others. There’s no getting away from that.

If an individual takes a strong exclusive position on one of these two needs, they lose their necessary connection to the other one. That results on the one hand in selfishness and narcissism, and on the other, as auto-pilot, group-thinking, which sets them up for domination and manipulation by others.

These things make us sick. They set in train the forces of dis-ease.

To be healthy and fully human we need self-belief and self-knowledge. We need freedom and autonomy. We need to belong, to form loving, caring and mutually beneficial relationships. We need to find common ground with others. And we need to see ourselves as inseparable individuals emerging from, and embedded within, the whole – the whole species, the whole living planet, the whole universe.

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