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Archive for the ‘from the consulting room’ Category

Attending the soul

Posted in from the consulting room, from the living room, health, life, tagged , , , on January 5, 2013| 1 Comment »

There’s a chapter in James Hollis, the Jungian analyst’s book, Creating a Life, entitled, “Attending the Soul”. This particular chapter is about the practice of psychiatry and he completely nails an important point.

If we consider health, acute and chronic illness, to be a spectrum of experience, then we need to do more than control or manage disease in order to be healthy.

Here’s how James Hollis puts it….

In seeking scientific verification of success, many of these practitioners [psychiatrists] have narrowed the definitions of pathology to behavioural patterns, faulty cognitions and flawed chemistry. While it is certainly true that we are behaviours, and behaviours may be corrected, and we are cognitions which may be challenged by other cognitions, and we are chemical processes which may be compensated by other chemical processes, none of these modalities – behaviourism, cognitive restructuring and psychopharmacology – should be confused with psychotherapy.

He goes on to say that psychotherapy seeks to address the whole person, even the meaning of the person, the meaning of their suffering or even the meaning of their life.

This same point applies across the whole of Medicine. Illness may include physical pathologies which can, and may, be addressed with drugs or surgery, or it may include adaptive, or protective symptoms and behaviours which can be changed. However, if we are interested in healing, in facilitating the experience of wellbeing, resilience, and health, then we face the fact that a whole human being is more than the sum of his or her parts.

Here’s how he concludes his chapter…

To stop at behavioural change, as important as it is, or cognitive restructuring, liberating as it may be, and pharmacology, necessary as it sometimes becomes, betokens a failure of nerve and sells the soul very short indeed.

 

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The spectrum of health and illness

Posted in from the consulting room, health on January 4, 2013| 1 Comment »

To describe health as the absence of disease is inadequate and unsatisfying. We have defined diseases for the last four hundred years or so according to the presence of certain lesions, or the presence of “abnormal” readings measured by instruments of investigation. Illness is a related, but different, term from disease. It is used mainly to refer to the experience of being unwell, incorporating our concept of disease, but actually describing the subjective experience of a person. Only a person can tell you they feel nauseated, or that they have pain. Instruments won’t reveal those phenomena.

Similarly, health should be understood as a phenomenon, or an experience, in its own right. For sure, if you have either a disease or an illness, this will impact on your experience of health, but is it really such a black and white issue? I don’t think so.

Consider these three concepts as a spectrum

spectrum of health

H = health; A = acute disease; C = chronic illness

From the condition of health, we can move rapidly into the red zone as we experience an acute illness. Think of “winter vomiting”, which only this morning was reported as having affected one in every five people in Scotland this winter. Suddenly, you feel unwell, and then you start to vomit, and/or, have diarrhoea. You pretty much have to wait it out, resting, and replacing the fluid losses as best you can. Although caused by a virus, we don’t have antiviral drugs which effectively and quickly kill this particular one (and even if we did, killing the virus is only one part of becoming well). What helps?

The body heals itself. Any intervention, including rest and replacing fluids, will only help by supporting the body’s capacity to self-heal. Personally, I and my family, used homeopathic medicines in addition, to speed our recovery from this nasty acute illness.

In other acute situations, relying on the body’s self-healing is not enough. In the situation of acute heart failure, a heart attack, severe acute asthma, a diabetic crisis (hypo or “DKA”), and so on, medical treatments including drugs or surgical procedures can make the difference between living and dying during this acute event.

However, once the acute episode settles, the person may move up into the healthy blue zone of the spectrum, or may slip around into the chronic yellow one. We see this in diseases such as MS (Multiple sclerosis), where the acute episode might settle completely and the person returns to an experience of health, or it might progress into a more chronic pattern.

Similarly, someone might develop a chronic illness insidiously, without any acute episode at the outset, and they might move towards the healthy zone, or they might occasionally fall directly into the acute red zone as they experience a flare-up (as we might see with inflammatory bowel disease, for example).

Why is this spectrum helpful?

Well I think it shows that health, acute and chronic disease and illness, are different, but related phenomena. However, it also shows us that different tools are required depending on where the person is on the spectrum. There are drugs and operations which can assist in the management of problems in the acute or chronic zones, but any movement towards health always requires the good functioning of the individual’s self-healing capacity.

This is one of the main things I find missing in modern health care. We attend to the lesions and dysfunctions, but we lack the technologies for directly supporting and stimulating the body’s necessary self-healing capacity.

This is the area being explored by doctors interested in “integrative medicine” ie interventions which are intended to support greater integration or coherence of the whole system.

We need research to better understand self-healing. In fact, we need to become better able to describe and understand the condition we call health. If we want to increase the health of populations we will probably find the answers, not in drugs, operations or therapies, but in creating the conditions, and supporting the contexts, for adaptation, creating and engagement – characteristics of health.

In relation to illness, however, we also need to explore interventions which are intended to be integrative by examining their impact on health, not on lesions.

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Separate and connected, the heart of opposites

Posted in from the consulting room, from the living room, health, life, personal growth on January 3, 2013| 2 Comments »

For many years when I’ve taught about the different ways in which we develop an identity I’ve described a line with two poles.

At one end is “I”, the unique, separate, different “me”. We have a whole body system, the immune system, developed to be constantly on the alert for what is not “I”, whether it be a virus, another person’s genetic material, or a chemical substance from “outside”. The immune system is primed to quickly recognise any such foreign material and isolate or remove it.

At the other end is “we”, the connected self, the “me” which is part of “we”, whether that be in relationship with another single person, or with a group.

We all need to know that we are unique, that we are different and separate from others. What can come with that however, is a sense of disconnection, or loneliness. Just as importantly we need to know that we are connected, that we belong, that we “fit in” and that we love and are loved. What can come with that can be a loss of personal identity, a feeling of just being a number within the group.

I pointed out that this line with its two poles didn’t have a point somewhere along it where everything was balanced. It doesn’t work like that. We move continuously along the line, back and forth, changing our focus, our awareness and our sense of self, but never wholly living at only one of those poles.

Then last year, I read two books which mentioned concepts which fitted right in to this simple diagram. Thomas Berry’s The Great Work, where he beautifully describes the twin polar opposites of “wildness and discipline“.

When first the solar system gathered itself together with the sun as the center surrounded by the nine fragments of matter shaped into planets, the planets that we observe in the sky each night, these were all composed of the same matter; yet Mars turned into rock so firm that nothing fluid can exist there, and Jupiter remained a fiery mass of gases so fluid that nothing firm can exist there. Only the Earth became a living planet filled with those innumerable forms of geological structure and biological expression that we observe throughout the natural world……….The excess of discipline suppressed the wildness of Mars. The excess of wildness overcame the discipline of Jupiter. Their creativity was lost by an excess of one over the other.

The greater the wildness, the greater the emphasis on “I”, on separateness. The greater the discipline, the greater the emphasis on “we”, on the bonds, the connections.

And Howard Bloom’s The Global Mind, where he picks out five characteristics of complex adaptive systems and highlights the first two as “diversity generators” and “conformity enforcers”. Diversity generators increase the wildness and the sense of “I”, whilst the conformity enforcers increase the discipline and the sense of belonging.

I now have two lists with a line connecting them, and it still didn’t look right. It wasn’t a simple spectrum for example, and it wasn’t a line where there was some balanced point half way along where we “should” be. So, I turned the horizontal line into a vertical line running between the two lists, and then I bent the line into an “S” shape. Drawing a circle right around the whole image turned it into a yin yang symbol and I thought, “Yes, that’s it” – that’s the heart of the universe.

yin yang

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Lub dub

Posted in from the consulting room, from the living room, health, life, personal growth on January 2, 2013| 1 Comment »

“lub dub, lub dub, lub dub”

That’s what I was taught to listen for when I was first shown how to use a stethoscope. This was the natural sound of the heart. It was a beautiful rhythm. I think you can’t help being impressed, or even moved by it. I remember the first time I was taught to use another, similar, but different device – the pinna. A pinna was a plastic cone which you placed on a pregnant mum’s tum to listen to the baby’s heart beat. So fast, but so amazing. Thrilling every time. But it was a kind of private thrill because nobody else could hear it. These days, we use technology to show the beating heart of the baby, or to play the fast lub dubs through speakers so everyone can hear it.

The heart beat is a constant alternation of opposite states – systole, where the heart muscle is contracted and the chambers of the heart are emptied, and asystole, where the muscle rests and the chambers fill with blood. There is a such an amazing truth in that observation.

At the heart of the universe there is creation. There is a story of the universe, from The Big Bang, to the emergence of hydrogen and helium, the cycles of growth, expansion and contraction of the great billions of stars, to the creation of Planet Earth, at first lifeless, then rapidly (in universe timescales!), creating simple, single celled life forms, complex, multicellular ones, plants, creatures of the sea and the land, right up to our continually developing, evolving human race with its most peculiar characteristic of consciousness. This story is the the story of constant becoming. It’s a story of ever increasing amounts of uniqueness. The universe loves diversity. And it loves to make connections.

This is the heart of the universe. Two opposite processes, tightly bound together – diversification and integration.

We need both the diversity generators and the conformity enforcers as Howard Bloom refers to them in The Global Brain.

Can you hear it?

This constant creative heart beat?

Lub dub, lub dub.

yin yang

Right here inside you, right here and right now, in your unique and singular life, the amazing, constant rhythm of becoming…..

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Heart of the universe

Posted in from the consulting room, from the living room, health, life, perception, personal growth, science, tagged , , on January 1, 2013| Leave a Comment »

Sometimes (quite often actually), I wake up with a word or phrase in my head. This morning it was “heart of the universe”. The particular word or phrase can set off all kinds of different thoughts and where this one quickly went was “It’s 2013. It’s 40 years since I dissected a human heart. Second year, Medical School, Edinburgh University. That year we learned Anatomy and Physiology. I was amazed at the structure of the heart. It’s four chambers, the valves, the specialised heart muscle cells which each had their own rhythm, the conduction pathways from the “AV node” which carried the co-ordinating electrical beat to produce the two, opposite states of the heart – systole and asystole.

It was two years later before they told us to put on white coats, buy a good quality stethoscope, and led us on ward rounds, to stand collectively around patients’ beds, and one by one, place our shiny new stethoscopes on their chests to listen for the “lub dub” of the “normal” heart, and listen carefully for the clicks and sounds which filled the silences and revealed the disorders of the valves.

Over the years as a GP, I prescribed the drugs to slow hearts down, to regulate disordered rhythms, and to improve the blood supply to get the oxygen to the cells starved by blocked arteries and causing angina. I also found people presenting with pain, flutters and skipped beats of the heart whose investigation results showed no obvious pathologies. What were we to do with them? And where was the explanation for their symptoms? If their symptoms weren’t signposts to pathology, then what were they?

Gradually, I became aware of how we use heart in our language, as people told me about “broken hearts”, “heart ache”, “longings of the heart”, “an emptiness in my heart”, “getting to the heart of the problem”, “filling my heart with joy”. Of course, from early years I became familiar with the shape of a heart as we would draw it to communicate love. We see that shape everywhere.

three leaves

cafe love

tree

wishes

Why the heart? Why not the liver, or the pancreas, or the spleen? Why not the kidneys?

I knew there were intimate connections between the brain and the heart, mainly channeled through the “autonomic nervous system”. Then only in the last few years did I learn we’ve discovered that there is a neural network around the heart and associated with that is the production of neuropeptides (the small proteins which act on the brain) within the heart and its neural network. So, the links are more intimate than I realised, and, most importantly, more two way than I realised – the brain acts on the heart, but the heart also acts on the brain. In fact, it seems we do some of our mental processing using these neurones around the heart. (That dismissive phrase which I never liked – “it’s all in your head” – turns out to be even more stupid than I always thought it was)

And as time passed, and I experienced encounters with more patients, I began to see that sometimes (not always but often enough to always consider), there were direct links between “heart issues”, “heart language” and “heart symptoms”, irrespective of the presence or absence of pathologies.

So, here’s something to consider as you think ahead into 2013. How about building your “heart intelligence”? That’s a concept that means somewhat different things to different people, but let’s just use it as it is, without detailed definition.

Try the Heartmath technique. Sit quietly, focus on your heart area, take three deep, slow heart breaths, then recreate for yourself a heart feeling (you can find the details here). In this state of “coherence”, ask your heart a question, and wait to see what answer appears. Write it down.

What does your heart tell you about 2013?

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Out of your head…and into your other brain

Posted in from the consulting room, health, tagged , , on December 21, 2012| Leave a Comment »

Your other brain?

You probably imagine that you do all your mental work – perceiving, analysing, thinking, feeling and so on – with your brain – that organ inside your skull. However, we’ve known for some time that there are networks of neurones around the hollow organs of the body, especially around the heart and the intestines. We’ve also discovered “neurotransmitters” originating from those parts of the body. So, at very least, we are aware that there are two way connections between the heart and the brain, and the gut and the brain.

A recent article in New Scientist magazine described the network around the gut and named it the “Enteric Nervous System” (ENS). There are around 500,000 neurones around the gut (where there are about 85 billion in the brain). Most surprisingly, alongside the 40 or so neurotransmitters in this network, two chemicals known to affect mood and mental functions, dopamine and serotonin, are also present. In fact, it is now thought that 50% of all dopamine is produced in the brain, and 50% in the ENS. Only 5% of serotonin is produced by the brain, and 95% of it in the ENS. This is quite astonishing when you consider the roles these hormones can play in our behaviour.

The other fascinating fact the author of the New Scientist article highlights is the presence of Lewy bodies in the ENS (these are the pathological lesions seen in the brains of patients with Parkinsons Disease), and patients with Alzheimer’s have characteristic lesions on both their brain and ENS neurones. Do those “neurological” diseases begin in the brain, or in the gut?

It’s good to see scientists discovering how interlinked our bodily systems are, and how difficult it is to reduce a person to parts – even the two parts of Mind and Body. Are those parts really such separate parts of they are so connected and inter-related?

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The National Drug Service

Posted in from the consulting room, health on December 17, 2012| 1 Comment »

An ad on STV caught my eye the other day. It was a public service ad from NHS Scotland and was exhorting people to be prepared for the Christmas and New Year holidays as their GP surgeries would be closed Tuesday and Wednesday on each of the next two weeks. So, “don’t run out of your repeat prescriptions”!

And I thought, this is the big idea in health care? Make sure patients realise their doctors won’t be working for two days in a row so DON’T RUN OUT OF YOUR DRUGS.

I thought I’d pop across and see what NHS24 were saying. They have a whole section called “Be Ready for Winter”. It’s got three pieces of advice –

1. Restock your medicine cabinet

2. Order repeat prescriptions

3. Note when your GP’s surgery closes

Then, on Friday, I read an article in New Scientist, entitled “A humane solution” which was advocating more human drug trials instead of animal ones, as the animal ones don’t show the potential problems when drugs are taken by humans. But here’s the bit in the article that whacked me between the eyes….the first sentence….

Adverse drug reactions are a major cause of death, killing 197,000 people annually in the European Union and upwards of 100,000 in the US

Why do we tolerate this?

How did a “Health Service” become a “Drug Service”?

 

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Flu

Posted in from the consulting room, health on December 6, 2012| 1 Comment »

At this time of year there are queues of patients in the GPs’ surgeries standing in line waiting for flu jabs. I routinely receive emails from my employer (the NHS) exhorting me to have the flu vaccine.
I’m not joining in.
An elderly patient told me recently she attended her GP for a routine BP check from the nurse who asked her if she had been vaccinated for the flu yet. She said no, and as last year she had felt unwell for a few days afterwards, she said she would come back for it after a planned weekend break. The nurse said, nonsense, the flu jag doesn’t make you feel unwell, picked up a syringe in injected it into the patient’s arm. She was furious, and said she wasn’t well enough to enjoy her weekend away afterwards. I’m sorry, but this is no way to deliver health care.
Here’s where the story gets worse.
The Center for Infectious Disease Research and Policy in Minnesota has reviewed the evidence for the claims made about flu vaccination. What did they find?
Based on a comprehensive review of data published from 1967 to 2012, they found evidence for “consistent high-level protection is elusive,” the researchers concluded. Although vaccination was found to provide modest protection from infection in young healthy adults who rarely have complications of flu, the authors found that “evidence for protection in adults 65 years of age and older [who represent over 90% of deaths from flu] . . . is lacking.” Apparently in otherwise fit, healthy young adults flu immunisation can reduce their experience of illness by half a working day. In the elderly there is no evidence is protects them. (This study was reported in the BMJ with the headline “Belief not science is behind flu jab promotion, new report says”)
Yet, the NHS heavily pushes this immunisation.
On a related subject let’s think about Tamiflu which Roche persuaded governments around the world, including the UK, to stockpile supplies costing billions of dollars, on the basis of an evidence base which they continue to refuse to publish. In 2005, the UK agreed to buy £200 million of Tamiflu.
However, the evidence that Tamiflu would actually significantly prevent either the spread of flu, or the incidence of complications has all been based on studies carried out by Roche itself. The BMJ and the Cochrane Collaboration are leading a campaign to get Roche to release the data from their 8 out of 10 unpublished trials. In fact, the BMJ has set up a website.
When it comes to flu, the government seem prepared to promote and purchase, at huge cost, treatments with very, very sparse evidence bases.

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Life and death and choices

Posted in from the consulting room, from the reading room, health, life, tagged , on November 21, 2012| 2 Comments »

There was an amazing story recently in the NY Times about a Greek man living in the US. He was diagnosed with lung cancer in his mid 60s and given the prognosis of 9 months to live. He decided that instead expensive treatments and a costly funeral in the US, he would return to his native Greek island of Ikaria.

He moved back in with his parents and went to bed to be cared for by his wife and mother. But he started to feel strong enough to go out so reconnected with childhood friends and re-established his Sunday trips to church.

As the months passed he felt strong enough to do some gardening (a common activity on the island) and planted vegetables thinking he might not live to enjoy them, but he would enjoy growing them. Not only did he live to enjoy them but with his regular routines now of plenty of sleep, regular walks up the hill, spending time in the garden and in the evenings with his friends at the bar, and his weekly visits to the church he began to feel well enough to tackle the old, neglected family vineyard.

Three and a half decades on he is now 97, producing 400 gallons of wine a year from his vineyard and seems to be cancer free.

What can we learn from this inspirational story? Well, the author of the story in the NY Times concludes this –

If you pay careful attention to the way Ikarians have lived their lives, it appears that a dozen subtly powerful, mutually enhancing and pervasive factors are at work. It’s easy to get enough rest if no one else wakes up early and the village goes dead during afternoon naptime. It helps that the cheapest, most accessible foods are also the most healthful — and that your ancestors have spent centuries developing ways to make them taste good. It’s hard to get through the day in Ikaria without walking up 20 hills. You’re not likely to ever feel the existential pain of not belonging or even the simple stress of arriving late. Your community makes sure you’ll always have something to eat, but peer pressure will get you to contribute something too. You’re going to grow a garden, because that’s what your parents did, and that’s what your neighbors are doing. You’re less likely to be a victim of crime because everyone at once is a busybody and feels as if he’s being watched. At day’s end, you’ll share a cup of the seasonal herbal tea with your neighbor because that’s what he’s serving. Several glasses of wine may follow the tea, but you’ll drink them in the company of good friends. On Sunday, you’ll attend church, and you’ll fast before Orthodox feast days. Even if you’re antisocial, you’ll never be entirely alone. Your neighbors will cajole you out of your house for the village festival to eat your portion of goat meat

 

Those are probably reasonable conclusions but what inspires me most about this this story is the series of simple, pragmatic choices this man made. He didn’t set off to “beat cancer”, or to find the elusive magical cure. No, what he did was chose, moment by moment, day by day, to live. He might have died in his bed within days of returning to Ikaria. He would have had the death he chose, if that were the case. But he was not at any point focused on trying to determine the detailed outcomes.

Here is what inspires me about this story – at each stage he was focused on how he would live today and at no point did he think how to escape death.

Read the whole article here.

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Health in healthcare training

Posted in education, from the consulting room, from the reading room, health on November 20, 2012| 1 Comment »

I’ve long been bemused by the lack of reference to health in healthcare training. The standard clinical textbooks of Medicine not only have no chapters on health, books like Davidson, still a standard medical school text don’t even have an index entry for health.

Then the other day I stumbled on an old document from 1938 entitled “The Wheel of Health”, by G T Wrench MD. The content of the text is not what I want to mention today, but I’d like to share the following paragraphs from the author’s introduction.

Why was it that as students we were always presented with sick or convalescent people for our teaching and never with the ultrahealthy? Why were we only taught disease? Why was it presumed that we knew all about health in its fulness? The teaching was wholly one-sided. Moreover, the basis of our teaching upon disease was pathology, namely, the appearance of that which is dead from disease. We started from our knowledge of the dead, from which we interpreted the manifestations, slight or severe, of threatened death, which is disease. Through these various manifestations, which fattened our text-books, we approached health. By the time, however, we reached real health, like that of the keen times of public school, the studies were dropped. Their human representatives, the patients, were now well, and neither we nor our educators were any longer concerned with them. We made no studies of the healthy–only the sick.

 

1938! He could have written that today!

Does this not surprise you?

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