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Archive for the ‘from the consulting room’ Category

I am he as you as you are he as you are me and we are all together.

We’re still in the midst of a highly atomistic society, as Mary Midgley describes so clearly in books like “Science and Poetry” and “The Myths We Live By”. The thrust of human thought has been to separate, divide and reduce. Consequently there’s a popular conception that we are all separate – that there is a “me” inside my head. We have a sense that each of us are as separate as billiard balls. We might bump into each other, impact on each other, but we don’t spill over into each other.

But it’s all changing. There’s a new paradigm, a new way of thinking on the block, and it’s gaining ground fast.

That new paradigm is the irreducibility of reality, the importance of understanding connections, interactions, complexity. There’s a shift in focus from separate entities to between-ness.

“The Empathic Brain” by Christian Keysers [1932594515] gives an interesting insight into how the discovery of mirror neurons has shown us just how wrong the idea of completely separate, skull-bound minds is. Keysers is one of the pioneer researchers working on the discovery and understanding of mirror neurons.

Here are just two points from his book which might change the way you think about the mind, the self and your relationships.

Firstly, Keysers and others have shown that mirror neurons are involved in producing a phenomenon where the pre-motor strip in our brain becomes active in specific ways. When we see someone carrying out an action, our brain prepares to make our bodies carry out the same action. This might even follow through into the action itself. Have you ever noticed how two people well connected in conversation often mirror each others postures or body movements? Little things like touching one ear, or scratching their nose, where one person does it, and the other immediately mimics the same action. If you ask the people concerned about it, it’s likely they’re not even aware that it’s happening. It’s not that the one thinks “Oh she’s scratching the tip of her nose, I think I’ll scratch mine”!

Secondly, an area of the brain known as the “insula” becomes activated when we empathically respond to another’s emotion. This explains why some people can become quite overwhelmed by another’s emotion. In fact we’re not all the same in this regard. The insula of the most highly empathic people becomes much more active than that of the less  empathic. Again this isn’t something we consciously, rationally choose. The activation of the insula by others’ emotions doesn’t seem to be under our control.

Here are a couple of passages from “The Empathic Brain” –

Imagining actions also increases brain activity in the premotor regions involved in executing similar actions……Thus, during both observation and imagination, our brain uses the premotor cortex to mentally re-enact an action without actually moving the body.

 

If we interpret the actions of other individuals through our own motor programs, our own motor programs will have a very strong impact on our perception of other individuals.

 

Empathic people activate their insula very strongly and may be overwhelmed by the vicarious emotions that movies trigger in them. Other people activate their insula only weakly, needing much stronger stimuli to trigger their own feelings.

 

Through shared circuits, the people around us, their actions and their emotions, permeate into many areas of our brain that were formerly the safe harbours of our identity: our motor system and our feelings. The border between individuals becomes permeable, and the social world and the private world intermix. Emotions and actions are contagious. Invisible strings of shared circuits tie our minds together, creating the fabric of an organic system that goes beyond the individual.

The concepts of the mind as embodied and extended  seem very helpful to me. This work on mirror neurons, interestingly, touches on both of these.

 

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A study by Platform 51 claims that one in three women in the UK taken antidepressants in their lifetime. A quarter of those have taken them for over ten years.

Whatever the actual figures, clearly antidepressants are being prescribed for an awful lot of people. Are all those people suffering from a disease called depression? And do the drugs cure them? Dr Clare Gerada seems to think its not a problem and certainly seems to believe the drugs not only work, but they “save lives”.

But doctors’ leaders dismissed the poll as “alarmist”. Dr Clare Gerada, chairman of the Royal College of GPs, said the drugs were a vital treatment. “Antidepressants save lives. In the past GPs have been criticised for being cautious about prescribing them and not prescribing them for long enough or in a high enough dose,” she said.

Maybe I should send Dr Gerada a copy of Irving Kirsch’s excellent summary of the evidence base for antidepressants. I think he makes it very clear that the issue of antidepressant prescribing is a complex one, and that while there is evidence the drugs do help people with the most severe forms of depression, there isn’t the same evidence they help people with mild or moderate depression (that’s most people).

There is a vast over-prescribing of antidepressants. Wouldn’t it be better to construct a health service around good mental health rather than around the prescribing of drugs? Wouldn’t that be more likely to both reduce suffering and to increase resilience and well-being?

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The excellent Daran Leader, who wrote “Why Do People Get Ill?”, has written in the Guardian about the current state of Mental Health Services. Many of his points and conclusions are applicable across the board into the whole of the Health Service, not just “Mental Health”.

Mental health services become like a garage where people are fixed and put back on the road, rather than subjects to be listened to. But once we start listening we might well question our beliefs and prejudices about normality. As old psychiatry recognised, many of the phenomena that are seen to define mental illness are in fact efforts to battle against it. A delusion, for instance, may provide a meaning to one’s world, and to try to remove it may deprive the person of a crucial resource.

Listening is a crucial part of health care, which is sadly, all too frequently absent. The “restitution narrative” of quick fix, sort out the broken or troublesome part, reigns supreme. Yet illness remains an intensively personal, subjective experience, different in every circumstance, and understood only in terms of the patient’s values and beliefs.

Bhugra is right that more therapy must become available, but there must be diversity. At present therapies that mimic drugs in their aims clear the field: promising swift outcomes, localised intervention and precise targets, they use the very language of drugs. Yet they all too often buy into a discourse of normality and rehabilitation that ignores the specificity of the patient – and their ways of making sense of their situation. Mental health services need to learn more from patients, questioning the values of efficiency and autonomy fetishised by contemporary society.

Trying to fit individuals into protocols created around cohorts and averages reduces the subject to an object. We need diversity in health care, because, really, one size does not fit all.

Daran rightly highlights how the drug model is sweeping the field of alternative approaches to therapy and care, no doubt because of the vast marketing resources poured into the promotion of drugs and the manipulation of the “evidence base”. But Medicine should never have been reduced the prescribing of drugs, or to treatments which can demonstrate their drug-like abilities.

We’ve lost our way.

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A pretty extensive review of research which has looked at empathy in medical students and young doctors concludes that

empathy declines during medical school and residency compromises striving toward professionalism and may threaten health care quality. Theory-based investigations of the factors that contribute to empathy decline among trainees and improvement of the validity of self-assessment methods are necessary for further research.

(How often do you read a paper by researchers which doesn’t conclude that there should be more research!). This is a sad, but also dangerous finding. Sad because there’s something desperately wrong with medical education and training if empathy declines as a result of it, and dangerous because without empathy “quality”, and I’d argue, “safety” are under threat.

Meanwhile, Vaughn Bell, across on the Mindhacks blog doesn’t only highlight this study under a title of “Is medical school an empathotoxin?”, but he has a useful collection of links to other research which shows the importance of empathy in medical practice.

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passing the light

June is the month of the light. Next week in Scotland, it’s midsummer’s day – the shortest day of the year (you’d never know we’re in the middle of summer, given all the rain and wind we’ve had!). So, I’ve been thinking again about light.

Candle light in particular reminds us how sharing light increases it. Have you ever lit one candle from another? When you do, the first candle doesn’t get any dimmer. By lighting one candle from another, you end up with more light.

I wonder what kind of light I bring into this world? You might like to wonder about what you pass on to others too, because, although we might not physically pass light to each other, we certainly pass our emotions, our attitudes, our way of being onto to those around us and spread them the way that light can spread.

Around the turn of the year, when I was thinking about my Life (with a capital “L”), I played with this idea of light and I thought, actually, what I try to do, as a doctor, can be captured in three verbs about light.

Firstly, I try to lighten others’ loads. I try to ease their suffering. If I didn’t achieve at least that, I’d not be much of a doctor. I hope that everyone I see has their life, or the burdens in their life, lightened a bit as a result of my care.

But that’s not enough for me. I don’t want patients to come back and just say they feel a little lighter. I want their lives to be brighter. By that I mean I hope their days become better days, more fulfilling, more colourful, brighter days. I hope for others, and I hope for me, that life becomes brighter, and by that, I really mean an increase in that “emerveillement du quotidien“.

But even that’s not enough for me. I hope, at best, to enlighten, to show new possibilities, to support and stimulate new growth. I just love when I hear that a patient’s life has become lighter, brighter and, yes, transformed – that they’re experiencing a personal enlightenment.

If you think about light this month, why not think of it as a metaphor, as well as a physical phenomenon? What metaphors of light seem most relevant in your life?

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In a consultation recently, the question of what makes an experience or a relationship meaningful came up. Whether or not something feels meaningful is something we seem to know intuitively. We don’t usually sit down, consider the details, weigh them up, then reach a calculated conclusion. But what makes an experience or a relationship a “meaningful” one?

I think there are at least two dimensions to this.

How does this experience, or relationship, fit in to my story?

A story, or a narrative, has a beginning, a middle and an end (actually, I’m increasingly doubtful about this concept of an “end”!). Let’s say then, that in constructing the story of my life, I consider the present as it emerges from the past and lies in the context of the possible futures. We do create a sense of who we are by telling ourselves and others a story – the story of my life. This is one of the two dimensions of meaning. How does this experience fit into my story? Is it strongly embedded? Is it complexly and multiply connected? How does it relate to all that has gone before, and how might it influence the scope of the possible futures? We tend to feel something is “meaningful” when we can make sense of it within our story, and when it is deeply connected to so much of our story.

Secondly, we tend to feel something is meaningful when it makes a big impact. This feels like a second dimension of meaning. The power, the strength, the depth even, of the impact. You could say this is “significance” or you could simply call it “impact”. Of course, it’s likely that the strength of an impact will have an influence on the extent to which it becomes an important part of our story.

Maybe the less meaningful experiences, are covered by a line, or a few words in our story. A paragraph at most. And maybe the more meaningful ones gain an entire chapter, or even volume, of their own?

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I recently came across this summary of Victoria Satir‘s approach to health and personal growth….

The Five Freedoms – Using Our Senses—Virginia Satir
Satir keenly observed that many adults learned to deny certain senses from childhood, that is, to deny what they hear, see, taste, smell and touch/feel.
The Five Freedoms are:
The freedom to see and hear what is here, instead of what “should” be, was, or will be.
The freedom to say what you feel and think, instead of what you “should” feel and think.
The freedom to feel what you feel, instead of what you “ought” to feel.
The freedom to ask for what you want, instead of always waiting for permission.
The freedom to take risks on you own behalf, instead of choosing to be only “secure”.

 

Satir’s Therapeutic Beliefs and Assumptions
Satir’s therapeutic model rested on the following assumptions, that:
The major goal in life is to become own choice makers, agents and architects of our life and relationships
All human beings at heart are beings of love and intelligence who seek to grow, express their creativity, intelligence, and basic goodness; need to be validated, connect, and find own inner treasure.
We are all manifestations of the same life energy and intelligence.
Change is possible. Believe it.
We cannot change past events, only the effects they have on us today.
Appreciating and accepting the past increases our ability to manage present
The most challenging tasks in life are relational. Simultaneously, relational tasks are the only avenue for growth. All challenges in life are relational.
We have choices, disempowering and empowering ones, especially in terms of responding to stress.
All efforts to produce change need to focus on health and possibilities (not pathology).
.People connect on similarities and grow on resolving differences.
Most people choose familiarity over comfort, especially in times of stress.
No task in life is more difficult as the role of parent. Parents do the best they can do given time the resources they “see” available to them at any given time.
Next to our role as parents, no task in life is more challenging. We all have the internal resources we need to access successfully and to grow.
Parents often repeat own familiar patterns, even if dysfunctional.

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A recent paper in the BMJ has argued that we should focus on the concept of “value” when making decisions about health care and health care spending.

“Value” is a simple concept to describe: useful outcomes divided by the cost of achieving those outcomes

This paper makes a couple of interesting points – not least that “useful outcomes” must be outcomes which are useful to the patient.

Value emphasises the importance of doing whatever we do efficiently. It also highlights the importance of viewing health and disease along a continuum of prevention; of early diagnosis followed by proactive intervention in long term conditions; and of linking healthcare to social care and public health. Most of all it emphasises that what matters to patients and population is not healthcare in itself but health. Healthcare is often a means to health, but it is not the only means. This highlights the importance of establishing a quality numerator in the value equation that truly describes outcomes that matter to patients. We think that quality should encompass clinical outcomes, outcomes reported by patients, and patients’ experiences, measured along whole pathways of care.

Whilst I support this argument and particularly appreciate the emphases on patient reported outcomes and patients’ experiences (which are almost entirely neglected by RCTs based on measurement of a narrow range of biological quantities), I think there’s a crucial missing part of their proposed spectrum of “prevention; of early diagnosis followed by proactive intervention in long term conditions” – health.

If we only start by considering disease and its prevention we will be caught up in an endless pursuit of moving targets. It’s important to be able to reduce the risks of preventable diseases, and it’s also important to treat disease, acute or chronic, but we’re only going to improve the health of the population and reduce the burden of disease if we understand what “health” is, and seek to create the conditions for optimal health.

Value in health care, therefore, has to include policies and processes consciously created to support and develop health, not just to try to prevent or treat disease.

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Pharmageddon – interesting title captured on the BBC News site.

It’s been coined in relation to a veritable epidemic of addiction to prescription drugs – I’ll say that again PRESCRIPTION DRUGS.

I believe I can safely say that over 80% of the inmates in the Pike County regional detention centre are in there for something dealing with their addiction to prescription drugs,” said Dan Smoot, director of law enforcement

80%?!

the average age at which users first abuse prescription pills is 11. It’s a statistic that makes him angry. “We have basically robbed our children of a childhood.” The pill crisis, which some are calling pharmageddon, is only now receiving national attention.

There are just too many drugs being prescribed. Too many, too carelessly, and too easily. Add to this the toll from Adverse Drug Reactions, and the rapidly escalating drugs bills of all health services, and isn’t it about time we came up with a radically different health care strategy? One which emphasised health and non-pharmacological interventions as much as possible and reduced drug interventions to only where really necessary?

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Strangely, a letter to the Lancet from a group of scientists, and an early day motion in Parliament calling for more human-based as opposed to animal-based testing of drugs, has gone fairly unn0ticed in the news. If I hadn’t just stumbled onto Sky News yesterday, I think I’d have missed it entirely.

The call is based on some pretty disturbing statistics –

Adverse drug reactions have reached epidemic proportions and are increasing at twice the rate of prescriptions.The European Commission estimated in 2008 that adverse reactions kill 197 000 EU citizens annually, at a cost of €79 billion. The cost of new medicines is rising unsustainably, creating an ever-increasing burden on the National Health Service (NHS). Meanwhile, many increasingly prevalent diseases, such as Alzheimer’s disease, diabetes, many cancers, and stroke, remain without adequate treatments. The major reason for the rising cost of new drugs is the fact that more than 90% of them fail in clinical trials
In the UK alone it’s reckoned that it costs £2 billion a year to treat patients suffering from adverse drug reactions.
However, the problem isn’t just that drugs are likely to produce different effects in humans from other animals. RCTs aren’t the best way to demonstrate harms. In fact, most harms from drugs don’t become apparent until they are actually used in large numbers of human beings (think if Thalidomide for one such memorable example).
Even if we could filter out drugs which cause a lot of harm, we still need to find ways to prescribe less drugs. As Ray Moynihan pointed out in last week’s BMJ, the evidence base for drugs is terribly corrupted by drug company funded research and publications –
In our collective zeal to summarise, we have too often ignored the fact that a vast and growing proportion of those original studies are industry sponsored, which means that they tend to exaggerate benefits and play down harms. Summarising that bias doesn’t make it go away. Medicine’s prized evidence base has become debased.
Maybe it’s time we worked harder to return to “first do no harm”.

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