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Where do you relax? Part 2

Posted in from the dark room, health, life, photography on May 21, 2007| 2 Comments »


I think it’s good to know where you feel most relaxed, to know what helps you to feel good about life. We all need some time for ourselves. I often tell my patients that they should schedule into their busy diaries some time for themselves – not time to catch up on chores (well, you need that too probably!), not time to spend with your loved ones (yes, you DO need that too!), but time spent alone. It can be simply an hour one day a week (that’s better than no time at all) and it shouldn’t involve anything elaborate. A walk in the park, sitting watching the world go by for a wee while, listening to music, or reading, or just noticing your environment, really whatever works for you is good.

For each of us particular environments are most relaxing. Some of us prefer the seaside. For others, its a park.

This photo is taken in Princes Street Gardens, Edinburgh – plenty of seats there!

Go on, try it. Schedule some YOU time!

 

seats in park, originally uploaded by bobsee.

 

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Where do you relax?

Posted in from the dark room, health, life, photography on May 21, 2007| 1 Comment »

We are all different and we all find different ways to relax or wind down. One of my colleagues always asks her patients to tell her what’s their idea of a great holiday. The answer can reveal a lot about a person’s coping strategies. I think it’s important to know what makes you feel good, where you feel good, when you feel good. We often get fixated on our problems and one way to not get stuck with problems is to focus on possible solutions. The solutions come from what works for us, the places, times and situations that help us to feel good.

This boat (for many people a boat is a symbol of freedom) and the blue, blue sky, at the seaside represents a way of relaxing for many people.

Where do you go to relax?

What’s your favourite holiday?

 

boat and the sky, originally uploaded by bobsee.

 

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Meaning-full Disease

Posted in books, from the consulting room, from the reading room, health on May 14, 2007| 6 Comments »

Meaning-full Disease. Brian Broom
ISBN 978-1-85575-463-8

I read a reference to Brian Broom’s work in “Why Do People Get Ill?“, and like that book, his “Meaning-full Disease” should go on every doctor and would-be doctor’s reading list – not just on their shelves, but in their active reading list. Professor Broom leads the post-graduate programme in MindBody Healthcare at Auckland University of Technology and works as a physician specialising in allergies and clinical immunology, a psychotherapist and a mindbody specialist in Christchurch. That tells you something about what you might expect from this book. His main area of interest is psychosomatic disease. This is a term which has fallen out of favour and come to mean illnesses without any associated physical disease. However, it is making a comeback thanks to work like this and Leader and Corfield‘s work amongst others. It is particularly making a comeback because of its focus on the links between the body and the mind in illnesses where there are significant pathological changes to be found.
Broom explores the truly fascinating observations that patients’ physical diseases are often best understood by uncovering the meanings that their illnesses have for them. He pleas for a more holistic, more humane practice of medicine by placing the scientific world view in its rightful place – not as the bearer of all truth, but as a subset of experience.

“the lifeworld is a rich, multidimensional, experienced reality of which the scientific world is a part-representation, a reduction, or an abstraction.”

He sets out a powerful argument for seeing both subjective and objective experience as different manifestations of an underlying unified phenomenon, referring to both phenomenologists such as Merleau-Ponty and Husserl, and Japanese writers, Yasua and Ichikowa (the latter he quotes as saying “my ‘object-body’ and my ‘subject-body’ are inseparably united in their deeper layer, and cannot be separated clearly and decisively, except through intellectual abstraction”. I particularly enjoyed his reflections on this so-called divide between objective and subjective where he says to touch your left hand with your right – as you do this you experience you left hand objectively and in the same moment subjectively your left hand feels touched. He goes on to muse about the position of hands pressed together in prayer which similarly dissolves the barriers between subjective and objective. A lovely image and a nice way to get us thinking about these two ways of experiencing the world.
There is much more to illness than the biomedical model elucidates for us. This in no way devalues the model which is still a powerful way to not only conceptualise disease but to treat it, but trying to understand a person’s whole experience by seeking what lies behind the pathology requires quite other skills which doctors are sadly not so strongly encouraged to acquire. One of the best passages in Professor Broom’s book is where he describes the process of his work moving back and forth in a consultation between the “thing of the illness and it’s meaning”. Sounds like how a consultation should be.

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What’s Wrong with Doctors?

Posted in from the consulting room, from the reading room, health on May 13, 2007| Leave a Comment »

Richard Horton has written an excellent review of “How Doctors Think” by Jerome Groopman here.

The main point he makes is that doctors make mistakes primarily because of failures in the ways they think.

Good doctoring is about listening and observing,
establishing a trusting environment for the patient, displaying
authentic empathy, and using one’s skills and knowledge to deliver
superb care. But a neglected aspect of this professionalism is getting
doctors to think about their own thinking. Only by doing so are doctors
likely to reduce the number of errors they make. What should they do?

Here’s a summary of his recommendations in answer to that question –

  • Encourage patients to tell and retell their stories. “a critical element of any mutually respectful therapeutic partnership
    that the doctor acknowledges the patient’s version of the truth of his
    or her story.”
  • Slow down. “The more time a doctor takes, the fewer cognitive errors he will make”
  • Once a decision is made, always retain an element of doubt.

None of these recommendations is in tune with current medical thinking. Doctors are encouraged to make diagnoses on the basis of the results of investigations. The art of listening to a patient’s story to make a good diagnosis even before a physical examination and any tests are run has receded as doctors are increasingly encouraged to treat patients according to protocols and guidelines created on the basis of statistical analyses of what’s measurable (stories are dismissed as anecdotes and unreliable subjectivity). Rather than slow down, health authorities around the world push doctors to see more and more patients more and more quickly. And doubt? Still, young doctors are encouraged to be certain and to believe in the rightness of their decisions. Retaining a healthy amount of doubt would make doctors more humble and more able to recognise when they are not getting it right after all.

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3 Ways to know if you are healthy

Posted in from the consulting room, health on May 13, 2007| Leave a Comment »

A healthy being has certain qualities or characteristics. Health is much more than the absence of disease. Health is a positive phenomenon in its own right. How can you know if you are healthy? And how can you increase your health?

Adaptation. How are you coping with change? Nothing stays the same. No two days are the same. Sometimes we feel stuck but always our bodies, our minds and the environments in which we live are changing. Change is the reality of life. When we are healthy we cope with change. We adapt. I was once invited to teach in Santa Fe, and flew to Albuquerue from Edinburgh arriving late at night. My host, a doctor colleague, picked me up and took me to his house about 10pm. I went to bed and fell asleep only to wake about 4 hours later gasping for breath. Alarmed I wakened my host saying “I think I’ve developed asthma!”. “Don’t be silly,” he said, “We’re 7,000 feet up here. You’ve come from sea level. It’s the altitude.” By the next afternoon I was breathing completely normally. I had adapted. A healthy organsim adapts. Whether the changes in your life are physical, emotional or social, coping is a fundamental part of health.
Creativity. Human beings don’t just cope by maintaining some kind of status quo however. We continuously grow and develop. Physically and psychologically. Creativity is the ability to both express yourself and to make something new. In biological terms we use the word “emergence”. This is the word coined to capture the idea that things change in a growing system so that new behaviours and new phenomena appear (usually unexpectedly). The abilities to solve problems with new solutions, to express ourselves and to continuously make our lives new is also a fundamental part of health. An organism that is not growing and developing is dying. Think of your house plants for example!
Engagement. “No man is an island.” We all exist within multiple environments – geographical, social, cultural and so on. It is actually impossible to consider someone fully without situating them in the world. In fact, there is a kind of paradox at the heart of all our lives. We need to be separate, unique (we even have a whole immune system dedicated to recognising what is not us and keeping it out!), but we also need to be connected, to love and be loved, to share. Depression is a real black hole. It sucks everything of life inwards and cuts us off from others and from the world. A healthy person is engaged with the world, interacting, loving and being loved.

So, there’s my three criteria. If you want to know how healthy you are check yourself out against them. How are you coping? How are you growing? and How are you connecting?

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4 Questions every doctor should ask

Posted in from the consulting room, health on May 13, 2007| 1 Comment »

When you feel ill, you want to try and figure out what’s going on. If it’s not something simple and obvious then you might need to go and consult a doctor. It’s likely the doctor will ask some questions. These questions are not random. The doctor has been trained to ask them. In fact, the doctor will have a lot more questions in his or her head than the ones you are actually asked. It’s these “back questions” that interest me. The ones running continuously through the doctor’s mind which form the basis of the whole consultation.
Doctors are trained to think about illness in a particular way. The thinking model is known as the “biomedical model”. The biomedical “back question” is this –

“What is the diagnosis?”

By diagnosis, we mean, what is this disease? Of course, there are other “back questions” which become more important once the diagnosis is made – “What action do I need to take?” and “What’s the prognosis?” for example. However, those questions are completely dependent on the answer to “what is the diagnosis?”. In the biomedical model, the diagnosis is the identification and naming of the disease. Once that’s done, the treatments are applied with expectations wholly informed by the doctor’s understanding of disease.
But disease is only part of the problem. You don’t feel diseased, you feel ill. Illness involves both the disease and the person who has the disease. Illness is the whole experience of your suffering. We are not machines and no two of us are identical. If a doctor wants to more effectively treat a patient they should use a different model from the “biomedical” one. They need a model which helps them understand the person who has the disease. This other model has been given many names but let’s use the one “holistic”. To understand the whole of a person’s illness the doctor needs to have different “back questions”.
I think to do this a doctor needs to use these four key “back questions”

  1. “What’s this person’s experience?” – the doctor needs to hear your story including a good clear description of what you are feeling, what sensations you have been experiencing, when you’ve had these sensations and in what circumstances. Your experience of illness is subjective. Nobody else can experience the pain, or nausea, or breathlessness, or distress, or whatever it is that you are experiencing. The doctor can only try to understand what your subjective experience is by enabling you to tell your story.
  2. “What kind of world does this person live in?” – we all experience the world differently. We pay attention to different aspects of life and we are affected differently by them. To understand who the person is who has this illness, the doctor needs to know what you are affected by, what’s important to you and how you experience the world.
  3. “How does this person cope?” – we all have different coping strategies. Some cope by retreating, hiding away, shutting down, whilst others cope by crying for help, needing company and support. There are many other patterns but if the doctor is going to figure out how best to help you he or she needs to find the treatments that will work best with your particular coping strategies.
  4. “What sense does this person make of this?” – we are meaning-seeking creatures. We always want to make sense of our lives. Why has this happened to me? Have I done something wrong? Is it because of my diet, or a bug that’s infected me, or my genes, or is it God punishing me? The sense we make of our illness may not only influence our chances of recovery but can actually determine the prognosis.

If these four “back questions” continuously run through the doctor’s mind, the question “what is the diagnosis?” will fall into place, not as THE important question, but as AN important question. The disease can still be named, but it will now be understood within the context of the person who has the disease. Only then will this individual, will YOU, get the most appropriate help to restore your health.

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How objective is objective?

Posted in from the consulting room, health, narrative on April 22, 2007| 4 Comments »

Patients’ stories are often dismissed by doctors as being too subjective to be of value. Objective information is rated more highly. In fact the dominant paradigm of the biomedical model is “evidence-based medicine” where a hierarchy of value has been created which emphasises the findings from research trials conducted on groups of patients over the individual stories of doctors and patients. Let’s understand and maybe challenge this hierarchy.
By subjective we usually mean a person’s unique experience. No two people can have identical experiences because no two people are identical. The dismissal of a patient’s story is the dismissal of personal experience.
We tend to think of objectivity as being outside ourselves, as being a phenomenon which is free from individual prejudice, as if it is unfiltered or pure. However, objectivity is actually just a consensus of personal, subjective views.
Take a look around your room now. What do you see? A computer probably! Maybe you can see a chair. Let’s just focus on the chair for a moment. This experience you are having right now of seeing that chair is subjective. It is YOU who is seeing the chair. But if everyone who comes into your room can also see that chair then seeing that chair becomes objective. The observation becomes more reliable in the sense that you could say to a perfect stranger “Come into my room and tell me what you can see” and, amongst other things, the stranger will report seeing that chair.
But subjectivity and objectivity are not mutually exclusive, either/or, categories. There’s a range or degrees of objectivity. For example, what colour is that chair in your room? The answer to that question will vary. Not everyone will agree about the colour of an object because colour sensation is a highly subjective phenomenon. Let’s push this one step further. Is it a comfortable chair? Well, now the consensus will become seriously shaky. You cannot be sure that a stranger coming into your room will describe that chair as comfortable.
The greater the consensus of experience, the more we are likely to call it objective, because we know that there will be a high probability that almost everyone will concur.
However, what matters to me if I have a pain is my experience of the pain. Nobody else can experience my pain. The concept of objectivity becomes irrelevant. If I take a painkiller, only I can tell you if it is working for me. No doctor or scientist knows better than you do about your pain. So claims that only treatments which are “evidence based” ie which work for many other people should be offered to patients are not supportable. Clinical trials (group experiments) reveal useful information about possibilities and even probabilities but they should never be treated as the last word on something. “Evidence” is never complete. However, although a majority of people may claim relief of their symptoms from a particular treatment, we can never guarantee that that treatment will work for this particular patient. Some people will only respond to a totally different treatment, possibly one which has never been shown to help the majority of patients. We should never prevent patients from having the treatment that works for them just because that treatment hasn’t helped most other patients.
How many patients should get relief from a drug before we can claim this drug is “evidence based”? Well,
However, as Dr Roses of Glaxo SmithKline, specialist in pharmacogenomics at Glaxo SmithKline famously said,

“The vast majority of drugs – more than 90 per cent – only work in 30 or 50 per cent of the people,” Dr Roses said. “I wouldn’t say that most drugs don’t work. I would say that most drugs work in 30 to 50 per cent of people. Drugs out there on the market work, but they don’t work in everybody.”

That’s a minority then. This falls far short of objectivity as consensus. Why is that? Because what matters is not just what most people experience but, when it comes to your health, your illness, it’s your story that matters. A doctor can, and should, tell you that a particular treatment has been shown to help a certain percentage of patients but you will decide which treatment to continue with solely on the basis of your unique personal experience. It’s your story, your feelings, your sensations that matter most when it comes to your health.

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Stick or twist? Attractors and bifurcators

Posted in creativity, from the living room, health, life on April 15, 2007| Leave a Comment »

There are a number of qualities in complex systems. Let’s have a look at a couple of them and see how they can help us to understand why sometimes we get stuck and why on other occasions we when we get through a certain difficult experience we feel that not only life, but we ourselves, have changed irrevocably.

Attractors

One quality is that of an “attractor”. The one attractor you’ll know something about is the kind that makes “Black Holes” – those whirlpools in space that suck everything, even light, deep into their swirling vortices. There are three kinds of attractor.

  1. Point attractors – these pull everything towards a single point.
  2. Loop attractors – these have two centres close together and anything which comes close gets swept back and forward between the two centres, flip-flopping between two alternating states.
  3. Chaos attractors – a focus of chaos, with everthing that comes near being pulled into a chaotic system.

What can these phenomena teach us about life? Well, a point attractor is the kind of thing that traps us. It might be a wound, a hurt, a bad experience. Or it might be a habit or stuck way of thinking. These are the well-worn paths that always, inevitably, end up at the same destination, producing the same outcome. It’s hard to move on, to grow or to develop when you keep going back or holding on to the same old thing. Point attractors are about stuckness. They produce routines that become ruts.

Loop attractors are those alternating states we often experience – a cycling back and forward between emotional highs and lows, between frantic activity and depression, between fear and anger. There is more variety in a loop than in a point, but they both entrap.

Chaos attractors are the most confusing of all. They hardly seem recognisable. They have no pattern, no rhythm and no predicability. Their only inevitably is chaos. These are the states we often find ourselves in when we are overwhelmed by something – bad news, loss, terror, grief. Like the points and the loops, the chaos attractors trap. At least points and loops have the comfort of the familiar, and, to some extent, the predictable. Chaos states are very hard to experience and can’t be sustained for long.

How can we break free of the pull of an attractor?

  1. Imagination. Developing your powers of imagination generates the potential for change and for movement. Without imagination it can be hard to believe that there is any possibility of breaking free from the entrapment of an attractor.
  2. Will. Determination and motivation. It’s one thing to imagine how life could be different but it takes a strong desire and determination to change to break free of the attractor.
  3. Relationships. Sometimes it takes an external influence to make the difference. This is where other people can make such a difference. It can be the attention, the love and the care of another which helps us to break free from our stuckness, our habits and ruts.
  4. Changes in circumstances. We all exist in constant interaction with our environments. As the environments change so do we. Changes in circumstances like new relationships, the ending of relationships (whether through break-up or death), loss of employment, new employment, moving house, and so on, can all exert huge power to knock us out of the old patterns and stuck places. This is why sometimes painful events can result in significant gains.

Bifurcators

Bifurcators are like crossroads. They are points where things change. With a bifurcator you usually have two possibilities – growing or shrinking. At a bifurcator the system changes and either develops, changes and grows stronger or more resilient, or it declines, shrinking or disintegrating, becoming weaker. The key thing about a bifurcator is that life is not going to be the same again. A good example is pregnancy. Once pregnant, a woman’s life will never be the same. She can never again have never been pregnant. Either the baby will grow and thrive and the woman will become a mother (and how different does THAT make a life!) or the pregnancy will not progress and the woman will experience an abortion, a miscarriage or a stillbirth. In none of these circumstances will she ever be the same again. Often there are no choices possible. Life develops one way, or it develops another. However, in many situations a bifurcator is all about making a choice. The challenges which come our way for example can be accepted or rejected. Accepting a challenge brings the potential for growth. Rejecting a challenge can leave you stuck in the arms of an attractor!

So, here is a key difference between a hero and a zombie – heroes break free of attractors, grasp the bifurcation points and grow; zombies stay stuck at the same points, in the same loops, engulfed in the same chaos, avoiding bifurcators and preventing growth.

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A Matter of Life and Death

Posted in from the viewing room, health, movies, narrative on March 28, 2007| Leave a Comment »

A Matter of Life and Death was made in 1946. It’s a film by Powell and Pressburger. They tell the story of a pilot, Peter Carter, shot down during the Second World War. But as he falls to Earth, the angel sent to bring his soul to heaven loses him in the fog, and by the time they find him he has fallen in love so he pleads to be allowed to stay alive a while longer. A court case to decide the issue is set up in Heaven. OK, so far, you’re thinking “this is just crazy, isn’t it?” Well, it’s a much more interesting movie than just a fantasy. And here’s what makes it interesting for me – Peter’s new love, June, asks a doctor friend to see him. This doctor, Dr Frank Reeves, is a neurologist and diagnoses that the pilot is suffering from a brain lesion which is affecting his visual pathways and so causing these vivid hallucinations of angels, heaven and a court case. What Dr Reeves very cleverly realises is that Peter’s story of the court case in heaven is so coherent and convincing to him (Peter) that if the case goes against him he will die and if it goes in his favour he will live. He deliberately encourages Peter to develop a positive narrative of how the case may go while persuading a neurosurgical colleague to operate on Peter.

The operation is successful and so, of course, is the court case.

Although this movie was made way back in 1946 it is remarkably perceptive and knowing with regard to the human psyche. It shows the importance of narrative in making sense of our experiences and it shows neatly how two different narratives (the medical/neurosurgical one and the patient’s one) can intertwine, indeed, MUST intertwine to produce a successful result of a treatment. The key scene is just over an hour into the movie where Dr Reeves is explaining his diagnosis and the importance of Peter’s narrative. I especially smiled at this comment by Frank Reeves –

A weak mind isn’t strong enough to hurt itself. Stupidity has saved many a man from going mad.

This is part of his argument that this “delusion” of Peter’s is not madness but is a physical problem of the brain. He argues that the delusion has its own internal logic and that Peter has an exceptionally good imagination. This is an interesting early exploration of the relationship between psychiatric illnesses and organic brain disease. But mostly it is an interesting exploration of the importance of the patient’s narrative, not only as a key method of diagnosis (a skill I fear is being lost in Medicine today) but also as a determining factor in healing, even in tipping the balance between life and death. More than this, it makes me think about the age belief – that there is a fine line between genius and madness. However, there is no known link between IQ (one measure of “strength” of mind) and the chances of having a mental illness. But is this what Frank means by “strong” or “weak”? What IS a “strong” mind? Frank says nothing about Peter’s intelligence, what he emphasises are Peter’s imagination and his ability to be logical. Here is what he really means – a “strong” mind has at least two strong capabilities – imagination and logic. Aren’t these key tools in the creation of narratives? Aren’t the most compelling narratives the ones which have been well imagined and seem to the reader to make sense (within their own terms)?

So, what of this apparent danger in a “strong” mind? If we think of this the same way as Frank we can see that if the narrative we tell ourselves becomes dislocated from external reality but is a STRONG narrative then it becomes harmful. This is the way I understand psychosis – a psychotic state is one where the person’s beliefs, their narrative of self, is not well connected to external reality and so becomes a hindrance rather than a help in living.

What’s the lesson here? It’s good to develop a strong narrative ability (it is this, at least partially, which saves Peter’s life – OK, I know, some will argue it’s the surgeon’s skill which does it, but time and time again recovery depends on individual patient’s mental state even when the same pathology is excised by the same surgeon). The danger lies in creating stories which don’t make sense of external reality when the storyteller fails to realise that. We can protect ourselves from that by sharing our narratives to co-create with others the narratives that make sense of all our lives.

What a great movie! I haven’t even touched on the technique of this film, the use of colour and black and white, the special effects, the framing, lighting, scene setting. I should also warn you that if you are of a sensitive disposition (like me) you’ll be in tears in the first ten minutes of this movie (I was!!)

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