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Getting better

I read an article recently about Cognitive Behavioural Therapy and its “evidence base”. The term “Evidence Based” is thrown around these days as a kind of label of approval. You might think it means “proven” or that scientists have examined the therapy and found that it works – well, when they say it works they mean they found it to be statistically superior to the control group. What they don’t say is whether or not the patients actually get well. And here’s the problem with CBT – a recent review found that 75% of people with depression treated with “CBT” did not become well, even though the statistical findings applied by the researchers led them to conclude it was “effective”. Can it be called effective if it doesn’t make people well?

CBT researcher Alan Kazdin put it bluntly in the flagship journal of the American Psychological Association:

“Researchers often do not know if clients receiving an evidence-based treatment have improved in everyday life or changed in a way that makes a difference. It is possible that evidence-based treatments with effects demonstrated on arbitrary metrics do not actually help people, that is, reduce their symptoms and improve their functioning.”

It’s strange really. The second half of my career was spent working at Glasgow Homeopathic Hospital, which developed into the NHS Centre for Integrative Care. We worked exclusively with patients with long term conditions, and, for the most part, with those who had failed to find relief through the orthodox approaches of drugs and surgery….or at least, who had failed to become well again.

We used an in-house assessment tool to measure the patients’ progress. It was a simple scale, 0 to 4, where 0 represented no change, 1 a change which had not made an impact on daily living, 2 a change which had made an impact on daily living, 3 a change which had made a major impact on daily living and 4 for completely well (there was a corresponding scale 0 to negative 4 for people who got worse). The person who assessed the change was the patient. The important point about this simple measure was that it was focused on the question…..has this therapy been of value to the patient in their daily living. That’s quite a different question from what percentage of the patients had a change in their blood lipid levels, their blood pressure, or whatever.

Time and time again our reviews showed that around two thirds of the patients rated a 2, 3 or 4 – in other words, two thirds of the patients experienced a change with had impacted on their daily living.

Yet, our approach, our tools and our therapies were rated as “not evidence based”, and year, after year, the Service was cut back and cut back, whilst at the same time online cognitive therapy programmes expanded on the back of their being “evidence based” (even though most patients didn’t become well again)

It’s a great idea to look at evidence, relevant evidence, but the pioneers of EBM said the clinician should take into account the research evidence, their clinical expertise and the preferences and values of their patients. How often does that happen?

It’s long past the time we should stop rubber stamping an approval on treatments which haven’t been shown to make a difference in most patients’ lives.

Rebecca Solnit wrote, “Categories too often become where thought goes to die. That is, there’s a widespread tendency to act as if once something has been categorised, no further consideration is required. But, often, it is.”

When I read this I thought of some of the writings of the General Semanticists, especially the phrase, “Judgement stops thought”.

We humans have a tendency to privilege the work of our left cerebral hemisphere which is our powerhouse for stripping out details, generalising what it encounters and applying labels, before setting its work into categories…..neat, separate, distinct, categories.

The trouble is, once we’ve done that, and once we start putting whatever we encounter into one of those categories, we stop seeing the uniqueness of “here and now”. We stop seeing the uniqueness of this particular person. We stop seeing a person at all.

There was a strong element of this in my training at Medical School, where they taught us pathologies before they taught us about people. Teachers and students would say things like “Have you seen the hepatomegaly in Ward 2”, or “Have you listened to the heart murmur in bed 14?” I first encountered cirrhosis of the liver in pathology class. It was in a perspex box filled with formalin so the diseased liver inside wouldn’t deteriorate any further. It was a good three years later before I encountered a human being suffering from cirrhosis of the liver (in Ward 2). This kind of thinking is still pretty dominant in Clinical Medicine. When I was a visiting a relative in hospital I overheard a nurse in the corridor say to a colleague “Have you taken blood from bed six yet?” (and I thought, good luck with that, getting blood out of a bed!)

I recently read an interview with a Paris-based oncologist, who was describing how he was using “Integrative Medicine”. He said he realised that all his chemotherapy, his radiotherapy and his surgical procedures were directed at pathology, but nothing he was doing was specifically directed towards patients. So, he began to explore, learn about, and use, a variety of interventions which engaged with the individual, unique patients, to hear their stories, to understand what they were experiencing in their lives, and to support their recovery and healing. This isn’t a new idea, but it still gets reported as if it is new.

The tendency to label and categorise seems to be on the rise. “Asylum seekers” become “illegal immigrants” become “immigrants” who should be denied the rights and privileges of those whose ancestors arrived in the country before them. In the apparently increasingly divided USA, billionaires, politicians, and evangelicals, talk about “Good vs Evil”. The President frequently applies the label “hard Left” to anyone who disagrees with his policies. Derogatory labels like “libtard” are thrown around. People are accused of being “woke”, although it seems nigh impossible to get anyone who uses that term to describe exactly what it means…..and so on. All of these terms, all of this way of thinking, tends to dehumanise….and that makes it easier to hate, easier to be cruel, easier to make life difficult for whoever is being targeted.

What’s the way out of this?

I suspect it will involve using our whole brain instead of only half of it.

The right hemisphere helps us to appreciate the whole, helps us to see connections and contexts. Looking for connections and contexts is a great way to punch holes in the labelled boxes. It’s a great way to make impermeable categories, leaky and permeable.

The reality is we are not all separate, living in entirely different boxes. We are unique, and that uniqueness arises from our individual complex web of connections and relationships. When we start to look for connections, we see the ways out of the separated boxes. We start to see humans again.

But it isn’t just uniqueness which emerges from these connections and relationships, it’s a discovery of what we have in common, of what we share. It’s a realisation that our similarities matter just as much as our differences, and, luckily, our brains have evolved to be able to handle such paradoxes magnificently…if only we would resort to using our whole brains and not stopping thought at labels and categories.

Awe and reverence

“Wonder is not simply curiosity. Curiosity is wonder without awe and reverence. It has lost the wider context.” according to the philosopher, Mary Midgley.

I love the French phrase, “L’émerveillement du quotidien” which translates as “the wonder of the everyday. “emerveillement” isn’t limited to “wonder”, though, it includes awe and amazement. Midgley knew that wonder included these elements of awe and reverence. Like Mary Oliver, she knew that when we pay loving attention we gain a both deeper and wider experience of what we are paying attention to than when we are merely curious.

There’s a view that “objectivity” involves “detachment”, keeping yourself somehow at a distance from whatever you are paying attention to. That might have its place but it’s not how I want to live my life, and it’s not how I related to the patients who consulted me.

I want to be engaged, involved, to pay empathetic attention, and, so to do more than understand…rather to wonder – with awe, with reverence, with love for this beautiful planet and the abundant Life which thrives here in it’s infinitely diverse forms.

There’s a key to this in the last sentence of that quotation “It has lost the wider context”. As wonder replaces curiosity we see this “wider context”, we experience both what we are paying attention to and the connections which inextricably embed this uniqueness in the greater whole.

When I wonder with the curious Robin who pops down beside me to see what I’m having for lunch, who comes to see what I’m digging for, who flies down behind me to see what’s in the boot of my car when I return home from the market, then I am aware, not only of this one particular Robin, but of birds, their relationship to we humans, of the amazing expressions of Life on this planet, and even of how this tiny world is spinning in an enormous galaxy in a vast universe.

The wonder takes me from the particulars of here and now out towards the virtually unimaginable infinity and eternity of the universe. All without detaching, but, rather, by engaging, and in bringing the contexts to mind, I go deeper.

I’m not just curious about other human beings, I frequently wonder about them….with awe and reverence, with “emerveillement”.

The poet, Mary Oliver, wrote “Real attention needs empathy; attention without feeling is just a report.”

When I walked into this church in Palermo, I quickly experienced one of those moments of awe. Churches can leave me cold, and some, with their images of saints being tortured to death cruelly, I find quite off-putting. Maybe that’s just me, or maybe it’s because I brought up in the Church of Scotland, which stripped its churches pretty bare of most art.

However, the thing that really caught my attention in this particular church was that shaft of light, pouring down through the upper window, a bright sunbeam illuminating some of the space inside the church, before finally resting on some of the pews. Of course, my attention didn’t stay long on the pews, because the shaft of light pulled my gaze upwards towards the ceiling. What a ceiling, covered with art.

I was stirred by this sight, and moved, feeling a sense of being connected to something greater than me, but also feeling a sense of connection to the thousands of others who must have spent time in this church, gazing, praying, listening to sermons, singing hymns, deepening their sense of connection with each other, and with God.

So, for me, my attention, this time, was grabbed by the sunbeam, then, over the next few seconds, that light set fire to my sense of awe, and to deep feelings of empathy…..for fellow human beings, for the other creatures, as dependent as me for the sunlight in order to live, and for this entire, beautiful, astonishing little planet.

I pray we learn to treat her better, this Mother Earth. I pray we learn to treat our fellow, incredibly different species of Life, with whom we share this planet. I pray we learn to treat each other with more kindness, compassion and love.

This is one of the most extraordinary trees I’ve encountered. The one on the left seems to have reached out to the one on the right, then the two trees have merged to continue upwards together as one trunk. I don’t know how they did this. It’s like grafting but as best I can tell this wasn’t a forest where there was active grafting happening. I’m pretty sure they’ve managed this all by themselves.

This image is one of my favourites and it always makes me think about the importance of connections. There really isn’t any species of life where each organism exists all by itself, disconnected, as it were, from its fellows, from other creatures, and from its environment. We can only imagine that an organism could exist completely separately if we think of it as a fixed, bounded object. But, in reality, there are no fixed, bounded objects.

As we zoom in and in to look deeper and deeper into any organism, or so-called “object”, we get down to the atoms we all learned about at school. But twentieth century physics has enabled us to look inside those, previously imagined, “fixed” objects, and we’ve discovered that there is no final, fixed material in there. Rather, even atoms are interactions between flows of energy and information, sparkling briefly in and out of existence. They aren’t fixed. They aren’t separate.

Human beings have evolved to have the longest period of dependency for their young. It takes years and years for babies to learn enough to be able to survive….I was going to say, “by themselves”, but, actually we never live “by ourselves”……..independently. So we have evolved superbly social capabilities. It has been argued that we are, in fact, THE most social of all animals.

Yet we swallow the myth of the “Self made man”, of the “hero”, or “genius”, who has somehow come to be all by themselves, without the help and support over their years, of others. It’s a nonsense. The narcissistic, massively egotistical politicians we see today are totally deluded. They only have what they have because of others, because of their connections. Same goes for the tech billionaires. They didn’t create money from nowhere, they grabbed it from others. They didn’t invent and build the technologies they own all by themselves, they profited from the skills and work of many others.

Maybe we need to follow connections a bit more carefully in order to realise just how co-dependent everyone really is.

Finally, let me zoom out a bit and consider nation states. These are inventions. They didn’t drop down onto Earth from the sky, fully formed. Some human beings, some time in the past, staked out the borders and said everything inside these lines is “mine” or “ours”, then fought off any attempts by their neighbours to live on any of that land. Those borders around the nation states are way more permeable than the politicians would like you to believe. The entire planet has one water cycle. You can’t keep separate what flows into one ocean from another. You can’t keep what flows into an ocean separate from the sky, the rivers and the lakes. Same with air. We have one atmosphere around the entire planet. You can’t stop radiation from a disaster like Chernobyl or Three Mile Island spreading freely across “borders”. Same goes for most species in the world – for bacteria, viruses (remember Covid??), insects, birds, plants and many mammals. As each species is lost through loss of habitats, connections are broken, and we are all diminished. We humans are one species. It doesn’t matter which part of the map someone has drawn is where we were born, or where we live now. Our fellow humans aren’t only those in our village, our city, or even our nation state. We are inextricably connected to them all. We are inextricably connected to the entire planet.

When we bought our house here in the Charente Maritime about four years ago the garden had been pretty much neglected for a long, long time. The house had previously been someone’s holiday house and, as if often the case, when you come on your holiday you don’t want to spend the time doing house and garden maintenance.

One result of that is that pretty much everything growing in the garden had arrived here by itself.

We spend a lot of time in the garden and have reclaimed the impenetrable area we call our forest (honestly, it’s way too small to be a forest but it has the feel of one)

I love the discoveries we make. We’ve found many plants and trees which have been thriving here for years, but it’s still an actively serendipitous garden. New plants appear every year. Here are a couple of the more recent ones…

This is Russian Sage (thank goodness for smartphone abilities to recognise plants), which has popped up in a gravel area.

And this Pokeweed, a plant I know from homeopathy, but which I’d never seen in real life until it started growing in front of the wall. It grows really tall and has spectacular leaves, flowers, stems and berries!

Beauty and utility

When I saw this window, the first thing I thought was, how beautiful. Look at the colours, the textures, the range and diversity. You can tell this is very old, and, most probably fashioned by hand. It is SO interesting. It caught my attention, stopped me, and drew me in to contemplate it for several minutes.

It doesn’t just let the light into the room, it filters and shades the light, creating what is nothing short of a dynamic artwork, changing minute by minute as the sun moves across the sky.

What it doesn’t do is let you see what is outside.

So, if you think the point of a window is to let you see what is outside, then you wouldn’t see the point of this window.

The creator of this window probably thought letting light into the room, and creating an object of true beauty while it did that, was sufficient. After all, if the main purpose was to let you see what was outside, you’d have selected plain, transparent, colourless glass, wouldn’t you?

I can’t help think, when I walk around any old town in France, that we’ve moved way, way too far down the path of mere utility. I can’t remember the last time I saw a mid 20th century tower block being blown up, and thinking, oh what a shame, what a loss…… Who mourns the passing of concrete (or, worse, “RAC”?)

There are still brilliant designers, artists and craftsmen and women. I just wish we directed more resources towards them, and less towards the get rich quick, throw up a cheap, poor quality building and pocket the profits types.

Beauty humanises.

Beauty enhances.

Beauty makes a life worth living.

One day I was walking in a forest and I came across these rocks. At least I thought they were rocks. They look more like tree trunks than rocks. They look more like water flowing in the river. They look like an elephant.

There are patterns that appear in a huge variety of forms and materials in the world. The Chinese use a concept of “Li” to describe these underlying patterns which manifest through whatever appears to our eyes.

I think when you see something like this you are instantly aware of the interconnectedness of everything. The sense of a world made up of separate objects disappears.

Since emigrating to France from Scotland I have the opportunity to eat outside A LOT more often.

Whether it’s having breakfast, a coffee, lunch, or “apero”, in my garden, or having a meal, or a drink at a cafe, bistro or restaurant « en terrasse » , the climate here just allows that to happen through most of the year.

There’s loads of advice about what constitutes “a good diet”, or “a healthy diet”, but until I came across some articles in French, I didn’t think much about the importance of the non-food aspects of “healthy eating”.

Where you eat influences your experience of eating. There’s something “extra” about being able to eat outside, whether that’s in natural surroundings, like the garden, or gazing out over the ocean or a lake, or in town, “people watching”. It adds to your enjoyment, so influences your emotions, the healthy chemicals in your blood, your heart rate, and even your immune system.

Who you share your food and drink with is important too. The « apero » is an especially social activity, often sharing a board or two of cheeses and charcuterie, accompanied by a beer or a glass of wine. It’s a family event, an event shared with neighbours and/or friends, and it’s more about the people than the food and drink.

The social aspect of eating and drinking is hugely important and takes food well beyond mere “nutrients” or “fuel”.

I love this more holistic way to think about “healthy eating”. It’s not that the food isn’t important. It is. But it’s “and not or”…..the environment and the relationships around the table are also important.

There’s something else which contributes to healthy, enjoyable eating, and that’s the power of food to evoke memories. Whether it’s Proust with his Madeleines, or the dish your mum used to make, or the meal you shared with a loved one, the particular dish can help you relive great moments, and strengthen your relationships.

If stones could speak

William Blake said we can see a world in a grain of sand, so how much world could we see in this one stone?

It was lying on a beach and from the lichen and/or seaweed growing on its surface, it’s clearly been there a long time.

And look at the layers within in the stone. Almost like the rings of a tree…laid down, accumulated, accreted, over decades, centuries even.

What’s the origin story of this one stone? How far has it traveled? How long has it lain on this particular beach?

I’m pretty sure there will be other life within the plant life there…maybe insects, bacteria, viruses….a whole ecosystem of Life.

And without trying to anthropomorphise too much, what stories could this stone tell us, if only it could? What has experienced? How has it changed in response to the events which have occurred around it within the timescale of its own existence?

And what about us?

How have events changed and shaped us? How have we cocreated our unique reality? What stories do we have to tell?

I spent my working life, one to one, with patient after patient, helping them to tell their stories, so that, together we could make sense of their experience. Time and again, they amazed me, they moved me, they intrigued me.

You can indeed see a world in a grain of sand, a whole world in one stone on the beach, a universe in the heart and mind of another.