Heroes Not Zombies

Mindfulness has become very popular, especially in America, where it has been pioneered by Jon Kabat-Zinn and others, but also in Europe. The French term for mindfulness is “en pleine conscience” – which more literally translates as “in full consciousness”.
I think it’s become so popular because it’s so helpful, particularly in the field of mental health where it has been developed through “Mindfulness Based Cognitive Therapy” (MBCT) to treat depression, and through “Mindfulness Based Stress Reduction” (MBSR), which does what it says on the tin.
But it’s more than a psychological tool for easing mental disturbances. It’s been found to influence the patterns of neurones and their connections (synapses) in the brain. Yes, it seems to actually have an influence on not just the function, but the shape, of the brain. This takes it into a realm beyond that of a therapy for diseases. As it develops the brain, so it can expand the mind. In other words it seems to have the potential to aid creativity, the growth of emotional intelligence and to increase resilience.

Freedom vs control
All through my working life as a doctor I was keen on therapies which did more than merely reduce suffering. A treatment which simply suppressed symptoms or kept a disease process under control, while potentially valuable (because who wants more symptoms and more disease?) was never that satisfying to me. I was always way more impressed with a therapy which enabled people to deepen their understanding of themselves and their lives, and free them up to grow and develop, to make life changing decisions, and, in so doing, to transform at least some of the underlying factors which caused their illnesses.
Mindfulness meditation is one such therapy. But then so are the exercises which enhance cardiac coherence, like “Heartmath”. And so are other meditation practices, whether they be “Vipassana meditation”, “transcendental meditation”, guided visualisation or “compassion meditation”.

Paying attention and non-judgement
As best I understand it, there are two fundamental tenets of mindfulness –

• Paying attention
• Non-judging

I would claim that these were the key tools of successful medical practice long before “mindfulness” became so popular in the West.
The absolute best I could ever do for any patient required that I paid attention to them, giving them my full focus, living together in the present time and place of the consultation. And that I listened with a determination to do two things – to understand them (through empathy), and to help them. I often thought that these were exactly the reasons why people came to consult me – to be understood, so that they could understand what was happening in their lives, and their bodies; and, to be helped, because they’d reached a place where they couldn’t solve their difficulties alone.
The non-judging part was equally crucial, because it’s one thing to pay attention, but if you judge what you hear it’s very hard to hear clearly. Judgement stops thought, as Hayakawa, the “general semanticist”, wrote in “Language in Thought and Action”

“A judgement is a conclusion……The premature judgement…often prevents us from seeing what is directly in front of us”

Diagnosis
Of course a diagnosis is a kind of judgement. It’s a summing up of the patient’s story, their symptoms and their signs. Diagnosis surely is the key to successful treatment. If you don’t know what you are treating, how can you offer the best treatment? So, I wasn’t against judgement as such, just “premature judgement”. In other words, trying to avoid reaching a diagnosis before I’ve paid sufficient attention.

Always more to discover
Ah, yes, I’m sure you’re thinking….so what is “premature” and what is “sufficient”?
And those are great questions. The answers to which are always “time will tell”. You can never be 100% in any particular moment that you’ve grasped the full story, that you’ve completely understood. In fact, it was quite common that patients would tell me towards the end of the consultation that they’d never told anyone the things they had just told me. But I’d respond to that by saying I don’t think anyone can be fully understood. In fact I think we each spend a lifetime trying to better understand ourselves and I’m not sure any of us reach a final, full point of understanding. There will always be more to discover.

“There will always be more to discover”

would be one of my mottos.

The ongoing relationship
Even when I’d made a diagnosis and initiated a treatment, it was important to follow through and follow up. To meet the patient again after an interval and to begin the loop of the spiral – to pay attention and to listen without judging. Failure to do that meant I’d potentially mis-judge how helpful the treatment was for this individual, and would deny me the opportunities to understand them even better.
It wasn’t unusual to hear a story from a patient which transformed my understanding of them, a story told by them several years into our therapeutic relationship. People who had told me several times things they said they’d never revealed to anyone else, could, after many, many consultations, tell me something of fundamental significance which they’d never even hinted at before. That kept me humble and reminded me of my motto “There’s always more to discover”.
I should just add here that my experience of sharing work with colleagues showed me time and time again that I could never say I was always the best person for the patient to work with. Other colleagues would discover things I’d never discovered, just as I’d discover things they’d never discovered. “There will always be more to discover” reminded me to be humble. I should never claim that I was “The One” who “knew best”.

Personalised Medicine
I think it’s those last two points which are forgotten about by some of the adherents of “Evidence Based Medicine”. The only way to know if a treatment is effective for this individual is to continue to pay attention, non-judgementally, to them. The Randomised Controlled Trials, and met-analyses, might help you to select a treatment but the proof is always in the experiencing, the personal experiencing. Only this patient can tell you whether or not their pain is improved, they are sleeping better, they feel less depressed, they can move more easily, or whatever. Only the changes in your measurements of this individual’s body can reveal the success or otherwise of this treatment. The truth is revealed in the follow up.

Personal benefits of medical practice
Finally, I think the work of a GP is a kind of mindfulness training in itself. When consulting at a rate of about ten or fifteen minute intervals you encounter a lot of different people in one day. For each and every one of them you have to be fully present and give them your complete attention. The moment they walk out of the door, and the next patient walks in, you have to stop thinking about them and switch your attention to the person right here, right now. It’s a continuous practice of attending, letting go, and attending again. It’s also a great non-judgement training. Again and again you seek to avoid rushing to conclusions, and again and again, you have to be prepared to drop your diagnosis because now you see there is a better one.
I felt blessed in many ways working as a doctor. Paying attention and listening without judging allowed me to reach levels of understanding with others which felt like a privilege. And, maybe it helped my brain while I was at it! I’d like to think so.

“En colère!”

I’d only been living in France for a few weeks when I realised that almost daily there was at least one report in the news of somebody being angry. In French, they say “En colère!” Some days it would be railway workers, the next air traffic control or Air France pilots. Mostly the people in the streets with “en colère” banners were workers who were “en grève” (on strike) and there were plenty of the red flags of the main trade unions. But it wasn’t always about workers on strike demanding better pay or conditions, or objecting to reforms of employment law. Sometimes it would be a group of parents protesting about the proposed closure of a small school, or workers and patients together protesting about a proposed closure of a local hospital. Other times it would be taxi drivers who felt threatened by the rise of Uber, or farmers struggling to survive in the face of cheap imports from other EU countries and the low prices for their produce forced upon them by the big supermarket chains.
What struck me was what they all had in common. They were all making it very clear that they were angry – en colère! I don’t know if they were also scared, anxious, sad or grieving, but they were certainly angry. It began to seem that anger was a characteristic of French culture.
When I thought back to living in Scotland, I couldn’t recall ever seeing protesters with banners saying they were angry. Sure, you’d see people protesting about proposed school or hospital closures but my memory is that they mainly had slogans like “Save our….[insert school or hospital here] or “Support our….[whatever]”. Pleas for help more than expressions of anger. Not to say people weren’t angry. I’m sure many of them were. It’s just they didn’t seem to express it as much as French people seem to do.
Then at the end of 2018 the anger in France boiled over. The “gilets jaunes” movement brought hundreds of thousands of people into the streets, occupying roundabouts and autoroutes, blocking the entrances to shopping centres, ports and even borders.
As I write this we’ve just had the tenth consecutive Saturday of protests and demonstrations in several of the larger French cities. The numbers demonstrating have gradually diminished since the initial high but there are still about 100,000 people taking part. The autoroutes, ports, borders and roundabouts have been cleared by the police but now every Saturday there are demonstrations in Paris, Bordeaux, Toulouse, and several other cities. Every Saturday the demonstrations start peacefully, then by the end of the afternoon there are confrontations with the police, clouds of tear gas fill the city centres and rubber bullets are fired at the protestors. Every Saturday museums, parks and public buildings are closed, trams and buses stop running, and shops and banks pull down metal shutters or nail large sheets of plywood over their windows. Every Saturday cars are burned, windows are smashed and running battles spill through the streets surrounding the main squares.
What unleashed all this anger? Why has it suddenly reached a new peak? It seems clear that the anger didn’t just spontaneously appear at the end of 2018 but this explosion of street demonstrations and blockages was apparently sparked by a proposed increase in taxes on petrol and diesel. The government caved in pretty quickly on that one, and also responded to some other demands about workers on minimum wage and so on. But the highly de-centralised protests continued, organised by diverse local groups collaborating by using social media and the demands spiralled to upwards of forty different, even conflicting ones.
The government has now launched “Le Grand Debat”, a national consultation exercise to run from the 15th January to the 15th March. It’ll give a lot of opportunities for anyone to express their grievances, but also to put forward their own ideas about the economy, taxation, public services, the environment, even the system of democracy in France. Every single Town Hall, or “Mairie” in France has made a “Cahier des Doléances” available – which is a notebook which anyone can write in to list their personal grievances. This is an ancient tradition in France. But still the “gilets jaunes” continue to express their anger.
It’s pervasive, this anger, and it’s laced with hatred….hatred for President Macron, hatred for all politicians, for the Police and for journalists.
In the beginning of the protests, we, like probably many people in France, stopped going out. When we had to go out on an errand, or whatever, we’d take meandering country lanes and back roads to avoid the roundabouts and motorways. I haven’t visited Bordeaux for many weeks now and I certainly wouldn’t consider going there for a weekend any more. During a few days in Paris before Christmas it felt as if the “City of Light” had turned into a city of obstacles and threats. On the Saturday we were there we had to make careful plans to pass our time in the parts of the city less likely to be invaded by protestors, parts close enough to our hotel to explore on foot because many of the metro stations were closed and buses cancelled.

Emotions

I’ve never liked anger.
I don’t think I handle it well. I’d say I see it as a destructive force which leads to hatred and violence. I do my best to avoid it.
So all this got me wondering……is anger negative? Or does it have a purpose, a positive value?
That wondering has led me into a wider study of emotions. What are emotions for? What are they exactly?
Pretty quickly I stumbled across this quotation from the psychologist, Donald Calne,

“The essential difference between emotion and reason is that emotion leads to action while reason leads to conclusions”

Aha! Now, that’s interesting! Emotions lead to actions. That makes sense.

Next I came across Robert Plutchick’s “Wheel of Emotions”  which arranged eight emotions in a circle of four pairs. Eight?
Wait! I thought there were five basic emotions! Anger, Sadness, Disgust, Excitement and Joy. And I always thought that the first three of those were negative emotions, with the latter two being positive. Plutchick adds three more to these five, Fear, Surprise and Trust, and calls Excitement, Anticipation. He pairs them up as polar opposites like this – Anger and Fear; Sadness and Joy; Disgust and Trust; and Surprise and Anticipation.
I like that, but I had to take a pause. Before I looked at this any further, what were emotions anyway? Why do we experience them?
My understanding of the answers to those two questions comes from reading, over the years, some of the works of Antonio Damasio, and of Spinoza. I won’t go into any detail about their ideas here but suffice to say they’ve convinced me that emotions are whole organism adaptive strategies.
What?

“Emotions are whole organism adaptive strategies.”

Emotions aren’t just a class of thoughts sitting in our brains. They are patterns of change which involve every aspect of our being. That’s kind of intuitive, isn’t it? I mean, if you have a fright, or you are afraid, you feel your heart beating faster, your breathing quicken, your mouth dries up and your muscles tense. You know the emotion of fear doesn’t just live in your head. You might even know something about the changes in the nervous system, the endocrine system or the immune system which occur when we experience different emotions. I bet you’ve heard of the “fight or flight response” which activates the “autonomic nervous system”, a complex of nerves running between the brain, the heart and the rest of the body. You’ve probably even said from time to time that you have a “gut feeling” about something, or experienced some “heartache”.
The autonomic nervous system stimulates the adrenal glands which sit on top of your kidneys. These glands produce adrenaline. Other hormones provoke the release of sugar into the blood from stores in the body. The whole body is being geared up to deal with a perceived threat.
Or think of a time when you felt embarrassed. How your cheeks and neck turned bright red. Yes, I think we know that emotions are “whole organism” responses to something.
But what do we have them for? Why do we have them?
If Calne is right then they are there to make us act. Actually, and here’s a challenging thought, they are there to make us act in our own best interests. They are coping mechanisms. Or, better, “adaptive responses”.
Responses? Responses to what?
Ah, that’s where it gets even trickier. They are responses to stimuli – but we humans, with our complex brains and nervous systems, don’t just respond to stimuli in the external world. We create our own stimuli inside our heads, using our imaginations, our ideas, thoughts and memories. We have whole stories running in our brains, chains of memories, tied to certain feelings, images, thoughts. Stories which we’ve rehearsed and recalled probably hundreds of times. Small triggers, or stimuli, can set off whole cascades of linked reactions and changes based on one of these stories. So, sometimes, often I suspect, we experience a surge of emotion which no-one else can understand because there seems to be neither an external stimulus for it, or only a very feeble one. Panic attacks, temper tantrums, mood swings. All can be hard to fathom and rarely bear a simple one-to-one, linear relationship with a present circumstance or event.
Ok, so I can accept that these “whole organism changes”, these emotions, are “adaptive strategies” or responses, but then why are some negative and others are positive? What is the benefit, what is the usefulness, of the actions provoked by negative emotions?
Who wants to be disgusted, sad angry or taken unawares (surprised)?
Time to return to the Wheel.
I looked at the pairs again. Yep, I can see that sadness seems to be the opposite of joy, that trust is the opposite of disgust, and that surprise and anticipation also form a pair of opposites. But that leaves one more pair – Fear and Anger. So which is the positive one, and which is negative? It would seem that fear in negative, so that would make anger positive.
I never thought of it that way before. I didn’t see anger as a positive emotion.
When I go out in the car, I often play an audiobook while I drive. As it happens, I’m listening to Irvin Yalom’s “Becoming Myself” just now. He was describing his experience as a young doctor when he was humiliated but the surgeon who cruelly criticised his stitching skills at the end of an operation. Humiliation is still the mainstay of clinical education. All of we doctors have experienced it. In his reflections, Irvin wrote that he should have been angry and stood up for himself, but that he didn’t have “sufficient self-esteem”.
Now that’s interesting. Because I think anger often arises in situations of humiliation, or disrespect. In fact, the “gilets jaunes” movement cleverly used the device of the bright yellow, “hi vis” jacket (which every French motorist has a legal requirement to carry in their car) says “Look at me!” “Don’t ignore me!” “I’m here!” “I exist!” There’s a deep well of feelings of neglect, humiliation, powerlessness and injustice beneath this eruption of public anger.
Well, it doesn’t seem negative to say no to injustice. Or demand respect, or even attention. So maybe there is something move positive about anger than I’d thought.
But there’s still something nagging away at me here. Why have negative emotions at all?
Back to the Wheel again.
Here’s the next clever thing about the Wheel. He presents it as a colour wheel, with each of the eight main colours deepening in intensity as they move towards the centre, and fading as they move to the periphery. That gives us sixteen more emotions to consider. Eight from the intensification of the basic set, and eight from their dissipation. I like that. It makes the emotions more nuanced, more realistically dynamic. It immediately conveys a range of tones. Now the Wheel looks like a palette. A palette from which I can create a life of feelings, experiences, behaviours, thoughts and actions.

Engagement and Withdrawal vs Positive and Negative

But still it niggles at me. This idea of negative and positive emotions.
So, next, two things happen. I turn the Wheel round a bit, so that Anger is at the top, Anticipation, Joy and Trust are on the right. Disgust, Sadness and Surprise are on the left. This fits with another diagram I used to draw for patients when I was teaching the Heartmath method.

The first thing is I see the right half of the Wheel, more or less, representing engagement, and the left, withdrawal. I start on the horizontal axis in the middle and I see that joy is on the right, and its opposite, sadness, on the left. Joy engages me, it pulls me towards the object of my attention. It encourages me to be open and to make new connections, or to strengthen existing ones. Maybe even in the language of “The Little Prince”, it “tames” me. Or using the concepts of Dan Siegel’s “Mindsight”, it creates “mutually beneficial bonds” – the essence of integration.
On the other hand, sadness withdraws me. I retreat and want to be left alone. In the darkness of sadness, in the midst of the blues, it’s hard to connect, to be open, or to engage.
So, I carry this idea around the rest of the Wheel.
Disgust repels me – I spit it out, step backwards from, withdraw from whatever has disgusted me.
Surprise startles me. It makes me stop, withdraw and set myself up for a response.
Fear scares me. I remember a group of us as teenagers deciding to explore an abandoned mansion one night. It was pitch dark. Of course, we set ourselves up by sharing stories of ghosts and murderers. We completely spooked ourselves out. Then we tried to walk up through the dense. overgrown, rhododendrons, trees and bushes along a path we could hardly see an arms length in front of us, towards the abandoned building. I don’t know how it started but something triggered one of us and in an instant we were running for our lives, back down the path, away from the house. Not one of us could make it down that path. Fear makes us withdraw.
On the other hand, trust is the very essence of making a bond, of reaching out, connecting with another, and of establishing a sense of belonging.
Anticipation sets us into planning mode, as we prepare ourselves for whatever it is we think we are about to experience. We engage.
And so, here I am, back at anger. And what is anger other than another form of engagement? It drives us out of submission, out of passivity and reluctant acceptance to say “no”, “I don’t accept that” “I won’t be ignored” “I won’t be pushed around”.
As I consider the Wheel from this perspective I see there are no negatives or positives. There’s just engagement and withdrawal.
I’m not sure why, but at that point, the phenomenon of pain pops into my head. I mean, who wants pain? But pain is crucial in our lives. It’s an intense alarm signal which, at very least, says “Something is wrong!” and, usually, provokes us to take an action. Withdraw a hand from a hot plate. Make a different choice. Learn something from an experience, even.
So maybe withdrawal emotions are more like pain?
They work for us, in our best interests, to help us adapt.
I realise I’m thinking of all of this in the context of ordinary, daily, healthy life. The pathologies which arise from excesses of any of these emotions is another story. Something isn’t an adaptive response when it occurs in out of control or unbalanced ways. The inflammatory system of the body is a good example. We need it to defend ourselves against infections and to repair wounds but it becomes a destructive power when it overshoots or occurs without the presence of infection or injury. It’s therefore not a matter of saying that because emotions are “whole organism adaptive strategies” that they are a simple good. Nor are they sufficient in themselves to guide our behaviours. We gain a lot from our highly developed cerebral cortex, those two hemispheres with their large frontal lobes which give us the capacity for rational thought, will, and our ability to stand back and make active choices, amongst many other things.

An artisan of the emotions

So, there’s something to learn here. I mean for me, personally, in my own life. To learn to become aware of the emotions I’m experiencing, to learn where and when they arise, so that I can use them to my best advantage.
How do I interact with my emotional life to enhance my creativity? Can I learn to use the emotions to craft the life I want to live?
The term “artisan” is still used a lot in France. They use it for anyone who develops a particular skill, whether that be baking, wine making, or woodwork. It’s really a way of describing and respecting someone who has achieved an expertise. So, I’m wondering……how do I become an artisan of the emotions?