JOURNAL OF holistic healthcare Contents

ISSN 1743-9493 Editorial ...... 2

Published by Update ...... 3 British Holistic Medical Association Being holistic West Barn, Chewton Keynsham The new focus of the BHMA ...... 4 BRISTOL BS31 2SR Email: [email protected] William House www.bhma.org Food as medicine: the anti-inflammatory diet ...... 8 Andrew T Weil Reg. Charity No. 289459 The change journey ...... 13 Editor-in-chief Chris Johnstone David Peters [email protected] Reflections on motherhood as a G P: Empathy in action! ...... 16 Gillian Myers Editorial Board Dr William House (Chair), Connecting citizens and services in new and Professor David Peters, meaningful relationships to transform healthcare ...... 20 Peter Donebauer, Dr Thuli Alyson McGregor Whitehouse, Dr Antonia Wrigley Closing the compassion gap in health and social care ...... 25 Editor Andy Bradley Edwina Rowling [email protected] Medicine as if people matter – integration rather than breakdown ...... 29 Advertising Rates Michael Dixon 1/4 page £130; 1/2 page £210; full page £400; loose inserts £140. The Lambeth GP Food Co-op: Rates are exclusive of origination An emerging model of community co-operation ...... 32 where applicable. To advertise Ed Rosen email [email protected] A conversation with David Reilly Products and services offered by Director of The WEL Project ...... 35 advertisers in these pages are not David Reilly and David Peters necessarily endorsed by the BHMA. A meaningful encounter ...... 40 Design Justin Haroun [email protected] Neural networking, confabulation and subtle information ...... 43 Printing William Bloom Spinnaker Press The juggler – being wise in the modern NHS ...... 46 William House

William House ...... 50

Research ...... 51

Reviews ...... 52

Unless otherwise stated, material is copyright BHMA and reproduction for educational, non-profit purposes is welcomed. However we do ask that you credit the journal. With this exception n o part of this publication may be reproduced in any form or by any other means – graphically, electronically, or mechanically, including photocopying, recording, taping or informa tion storage and retrieval systems – without the prior written permission from the British Holistic Medical Association. Every effort is made to ensure the accuracy of material published in the Journal of Holistic Healthcare . However, the publishers will not be liable for any inaccuracies. The Volume 13 G Issue 1 G Spring 2016 views expressed by contributors are not necessarily those of the editor or publisher. 1 David Peters Editorial Editor

If we want whole person care, let’s start their careers outside the NHS as a result of the treat doctors as whole people government’s decision to impose a new junior contract. With the NHS getting ever busier it makes no sense to Too often it’s assumed – at least tacitly – that doctors are force junior doctors into longer hours for little more pay. different. Perhaps we need to believe they are inured to If the Secretary of State has bought into the delusion that the pain, embarrassment and distress they encounter; that doctors can take anything that's thrown at them, he needs they can rise above the suffering they meet every day, and to be told that this is far from the truth. For in fact keep doing it without losing warmth and empathy. This is doctors’ mental health is worse than the general a big ask, but if we expect doctors to walk this emotional population’s and their risk of suicide far higher. Though tightrope, what will they need to help them do it? Time? the mental health of new medical students is much the Yes certainly; time enough with patients to listen, reflect same as in the general population, sadly by their second and make good decisions. What else though: emotional year medics are psychologically worse off than the rest of support, a comfortable enough home life, an optimistic us, and the overall decline continues year on year. and collaborative temperament? Well, all of the above, plus We know that as doctors get more stressed, the quality – and this is crucial – a sense of being valued. Because of care they provide deteriorates, yet half of practicing being valued is a big issue for doctors. doctors say they feel burned out – unable to empathise with patients, potentially error-prone, and often with life Doctors’ resilience – a question of balance problems outside work. At a time when many older doctors are retiring early, why is the government hell bent • overloaded • job-related gratifications on making our new doctors feel even more undervalued • lack control from positive patient and taken for granted, and less likely to stay in medicine? • work is no longer rewarding interactions The British Medical Association says many GP surgeries, • a breakdown in the • leisure-time activities; struggling to fill staff vacancies are already at ‘breaking time-out work-community point’. This situation is set to get worse, especially in • feeling unfairly treated • self-demarcation; limitation of working hours; time primary care: 69% of GP trainees are women and in • dealing with conflicting England there are now more female than male GPs. Yet an values management • continuous professional official report admits this contract will have an ‘indirect DRAINERS development Maslach, Schaufeli, Leiter 2001 adverse effect on women’.* This is particularly bad news • acceptance of professional as female doctors are already twice as prone to depression and personal boundaries as their male colleagues – and even more so if they have • a focus on positive aspects children (Hsu and Marshall, 1987), and four times more of work likely than their female patients to take their own lives. • personal reflexivity With the popularity of general practice as a chosen DRIVERS Zwack J, Schweitzer J 2013 medical career in serious decline, a perfect storm is surely brewing. There is no time to waste. Something is very Does that mean the medical pay packet ought to be high wrong with the way we educate our young doctors and fail value too? George Bernard Shaw said ‘…every man is the to look after them. Medical schools must take a long hard worse for being poor; and the doctor is a specially look at how they teach, and start creating a more dangerous man when poor’. Poor and, he might have emotionally intelligent curriculum. And, if NHS staff are to added, tired. Though our target-driven NHS has come maintain their amazing resilience in the face of austerity up with some perverse incentives, at least NHS doctors’ and ever-growing demands, we must as its citizen-owners judgements are not distorted by the need to chase press for a more human-scale and holistic NHS. personal profit. Still, no one can say that after five years of *www.bma.org.uk/news-views-analysis/news/2016/april/ demanding training junior doctors are overpaid, especially contract-will-have-adverse-effect-on-women. with five years’ university fees to settle up. A first year Hsu K, Marshall V (1987). Prevalence of depression and distress in a junior doctor’s basic salary is only £22,636 – about the large sample of Canadian residents, interns, and fellows. American same as a new school teacher’s. No wonder, fearing that Journal of Psychiatry 144 pp 1561–1566. the new contract will cut their pay by up to 40%, and force Maslach C, Schaufeli WB, Leiter MP (2001) Job burnout. Annual them to work more antisocial shifts, they are up in arms. Review of Psychology 52 pp 397–422. And for medical students in England the future looks Zwack J, Schweitzer J (2013) If every fifth physician is affected by bleak. A 2016 BMA survey (15,247 students) found that burnout, what about the other four? Resilience strategies of 74% of those responding said they were more likely to experienced physicians. Acad Med 88 pp 382–389.

2 © Journal of holistic healthcare G Volume 13 Issue 1 Spring 2016 UPDATE

Food. The forgotten medicine Earth saw ‘explosive’ annual growth in carbon dioxide in 2015 A unique meeting co-organised by former BHMA trustee Dr Catherine Zollman for the College of Medicine and The Earth saw its largest annual spike in atmospheric supported by the BHMA will take place on 9 June 2016 at carbon dioxide concentrations on record in 2015, the Royal Society of Medicine. Amazingly, this is the first according to new data released by the National Oceanic conference in the UK on health and food and headlining and Atmospheric Administration (NOAA). The increase is the event will be Dr Andrew Weil who is making a rare significant because it demonstrates the continued march appearance in the UK. The conference will include a very toward higher levels of global warming pollutants in the healthy lunch and cooking demonstrations, along with a atmosphere. Those increasingly higher levels are helping bit of physical activity and laughter to keep the circulation to destabilise parts of Antarctica and Greenland, raise sea going facilitated by Dr Phil Hammond (aka Trust Me I’m levels around the world, and cause more frequent and a Doctor – next stop the Edinburgh Fringe) and all those intense heat waves in many regions. It is a sobering attending are invited to a VIP drinks reception at the end. milestone too, since countries are working more diligently Book your place asap as they are selling like hot than ever to cut emissions of planet-warming greenhouse (wholemeal, low sugar) cakes. gases, but the atmosphere is not yet seeing the results. www.collegeofmedicine.org.uk/events/#!event/2016/6/8/food-8211- According to NOAA, carbon dioxide measurements taken the-forgotten-medicine at the Mauna Loa Observatory in Hawaii show that carbon dioxide concentrations jumped by 3.05 parts per million Lifestyle medicine workshop for GPs (ppm) during 2015, the largest year-to-year increase in 56 years of research. Data stretching back at least 800,000 Pioneering NHS GP Rob Lawson and the UK SMA Contact years shows that carbon dioxide levels are now higher Group are hosting this event. Dr Lawson organises shared than at any other time in human history. medical appointments (SMA) where several patients meet for 90 minutes with a team of healthcare professionals Hundreds of UK churches set to from different professions. Perhaps as much as 80% of chronic diseases are lifestyle-related, so a paradigm shift in go green medical practice is overdue. The aim of the model is to empower and educate patients for self-management. He More than 400 churches in the UK plan to switch to clean has found that SMAs increase patient and clinician energy providers for their light and heat, shifting spending satisfaction, while reducing waiting times and return rates. of £1 million to renewables from fossil fuels, two Christian Interested parties (potential champions of SMAs) can charities said in March. The move is part of the Big contact him at [email protected]. Church Switch, an initiative launched in February by www.rcgp.org.uk/clinical-and-research/bright-ideas/shared-medical- charities Christian Aid and Tearfund, which urged UK appointments-in-the-uk-dr-rob-lawson.aspx churches and households to use clean sources of energy instead of carbon-emitting fossil fuels. Climate change and public health Solar powered street lights could The Global Climate and Health Alliance (GCHA) and the play a key role in tackling Britain’s NCD (non-communicable diseases) Alliance have jointly energy crisis published a report focusing on the opportunities for smarter policy responses to several major public health Two streetlamps soon to be erected near the House of and sustainability challenges facing us over the coming Commons could, according to their manufacturer, play a decades. major role in tackling Britain’s energy crisis. Monopoles NCDs and Climate Change: Shared Opportunities convert sunlight to streetlight via photovoltaic (PV) panels. for Action (www.climateandhealthalliance.org/news/joint- The energy they generate can then be stored in a battery gcha-ncd-alliance-report-published) looks at the evidence and used during the night to power the lamps. Apparently surrounding key opportunities to improve public health they can generate enough energy to light themselves, while tackling climate change. Through a synthesis of and may even create a surplus for the National Grid. It is available evidence and spotlights on relevant case studies estimated that there are about 5.6 million streets lights in from around the world, it highlights important synergies the UK. between these agendas in the areas of energy, transport, air pollution and food and agriculture and looks at what policy steps are needed now to make these opportunities a reality.

© Journal of holistic healthcare G Volume 13 Issue 1 Spring 2016 3 Being holistic The new focus of the BHMA

William House points away from the mechanistic and towards a much more complex reality; that: Chair, BHMA trustees ‘… the human being is a multidimensional being, possessing body, mind and spirit all inextricably This issue of the Journal of Holistic Healthcare is connected…[extending to] an interconnectedness devoted to a series of articles, each one about a different between human beings and their environment quality of the holistic practitioner. There are 12 of these which includes other human beings.’ qualities, including holistic itself, and we describe these as the dimensions of holistic practice. Of course, these are Pietroni also drew in the experimental literature of TS Eliot also the qualities to which we would all aspire. and James Joyce, the revolutionary new abstracted visual art The publication of this issue coincides with the launch of late Picasso and the beginnings of Eastern philosophy’s of a major new feature on the BHMA website that begins influence in the West – explored by The Beatles and to explore these qualities. This constitutes an important others. He advocated many options in healthcare that are change in direction for the BHMA. We are moving away only now becoming popular, such as regular exercise, from a focus on the knowledge that underpins the care of meditation, breathing and relaxation, and patient the sick, and towards a better understanding of those who empowerment. care for the sick – their ways of being and doing. By this Sadly, since those heady days, in many ways the means we may be able to reveal the true needs of the sick, problems are worse. So what happened? At about the time and of all of us, in the mirror of those who care. the BHMA was launched (the early 1980s), the evidence based medicine (EBM) movement had its own beginnings. Why is the BHMA changing? This was an attempt to ensure that treatments came with evidence of effectiveness and safety. However, the Answering this question requires knowledge of what has research needed to generate this evidence became gone before. In the early 1980s the BHMA was launched increasingly expensive and large-scale. As it gradually grew by a small group of visionary doctors who worried about in size and influence what constituted ‘evidence’ became a the fast-growing medical science and technology industry largely positivistic programme: only the linear, cause-and- that was already creating a dangerous imbalance in effect of hard Newtonian science, linked to strict statistical healthcare. They believed the time had come to… techniques, was acceptable. Whether this shift was ‘…replace our attempts at objectivity in the influenced by the increasing public popularity of the quest for further knowledge with one where the humanistic/holistic healthcare movement threatening emphasis is not on subjectivity but on authenticity. the vested interests of the academic medical research We should replace our mechanistic approach to establishment and pharmaceutical industries, it is not for the study of health and disease with a humanistic me to say, but from EBM’s very sensible beginnings it had one where aspects of human nature such as turned into a Frankenstein monster. It has enabled much caring, sharing, loving, touching, hoping and ‘evidence-based treatment’ that is actually unnecessary or hugging play as important a part in our harmful (more below). ‘Unproven therapies’ became targets endeavours to help the sick as the study of alpha for opprobrium, even vilification in the case of homeo - feto-protein and T-suppressor cells. We should pathy. Complementary and alternative medicine (CAM) replace the reductionistic approach to the care was walled off indiscriminately and the BHMA found itself of the sick with a holistic one.’ sequestrated on the wrong side of the wall. It became the Patrick Pietroni ghost in the machine. The public, however, continue to look for care and attention wherever they can find it. Most The quote comes from the first article in the first edition people are oblivious to the mainstream’s indiscriminate of what later became the Journal of Holistic Healthcare . marginalisation of the immeasurable. They notice only the It was published exactly 32 years ago. The long and lack of care, the lack of the human touch. Our challenge is beautifully written article reminds us that the cutting to exploit the wonders of bioscience without sacrificing edge of basic science discovery (quantum mechanics, the wider and deeper needs of humanity. EBM must be holograms, psychoneuroimmunology, complexity) actually tempered.

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The political angle is most needed. Complementary and alternative practice is already invigorating healthcare in its own way, though in In Dr Iona Heath’s moving essay, Love’s Labours Lost , most situations these approaches are unavailable to the she describes the change in the political economy of the poor. UK starting with the Thatcher government (1979–1990) and continuing with John Major and later Tony Blair. This was a change from the post-second world war ethos of Reclaiming the word, holistic inclusiveness, social solidarity, reciprocity and public To many people in the present day, holistic in a healthcare service towards an increasingly competitive market context is something to do with natural therapies and economy based on consumer consumption. This change even beauty products. This is a misuse of the word. If ushers in a loss of trust and erosion of generosity which there were an alternative English word that has not shifted suits a consumer society, but damages public service. its popular meaning, we would use it; but there is no such These consumerist changes were, of course, mirrored in word. For us, being holistic is about how we understand the NHS – the last major bastion of post-war welfare the world and our place in it. This understanding will provision. They were finally enshrined in law with the determine our relationship with everything and everyone 2012 Health and Social Care Act. This makes it easier for we identify as ‘not us’. In turn, this will reflect back upon NHS services to be provided by for-profit organisations. If us with an impact on our day-to-day life. Holistic cannot the Transatlantic Trade and Investment Partnership (TTIP) be defined without reducing its power of meaning. There is applied across Europe, these changes favouring multi - are other words like this; for instance love . Both holistic national corporations may become difficult to reverse. and love denote a powerful sense of connection and Alongside the supremacy of the market is the new role of perhaps belonging to, even ‘being part of’. Few human the NHS and the medical research industry as major beings can thrive without ‘being part of’. drivers for the economy. In healthcare we need to reclaim our own English language word, holistic , because its meaning is so central Why now? to being human. Other (perhaps all) languages have words that mean something similar to the original There is now public and professional unrest with the meaning of holistic . For instance, German has gestalt , present system. This gives us a potential constituency of and Southern African speakers have ubuntu. supporters for change. But to climb out from our closet We are left with a crisis in our shared humanity. behind the wall, we need a message of hope for the many Canadian writer and academic Michael Ignatieff, in his who have received poor or unfeeling medical care, and for 1984 book The Needs of Strangers , points to the crucial those many practitioners who are disillusioned with the role of language (p.138): ‘Needs which lack a language ways of working imposed on them in the NHS. While adequate to their expression do not simply pass out of wonderful work is still being done by those who manage speech: they may cease to be felt….Of all the needs I have to defy the system, there is widespread and deep mentioned the one which raises this problem of the unhappiness with contemporary healthcare. In recent adequacy of language in its acutest form is the need for years, this has been manifest in public outcries over cruel fraternity, social solidarity, for civic belonging.’ And the and degrading care of older people in hospitals and care politicians pretend to wonder why the people do not homes; in poor and degrading treatment in mental engage with the public democratic institutions! The health facilities; in never seeing the same doctor; and in result is social fragmentation, dependency and socially becoming lost in impersonal bureaucratic systems. Over determined illness, particularly addiction in all its forms. the last 2–3 years a large and growing medical grass roots We in the BHMA have looked for a way of exploiting the movement has come together against overdiagnosis and wonders of bio-science with the right hand, without overtreatment. This amounts to medicalisation of life’s sacrificing the holistic approach assigned to the left hand. travails under the guise of EBM. The current junior doctors’ industrial dispute, though ostensibly about pay and hours of work, is fuelled by the mutation of The response professional practice into a managerial process heavily The real voyage of discovery consists not in moulded by political imperative. The resulting role seeking new landscapes but in having new eyes. ambiguity and relentless pressure are highly stressful. Marcel Proust Finally, the perennial problem of waiting lists – the inability So we build our strategy for transformation, not on of the NHS to meet demand and the stress that this competing scientific claims, not with arguments about creates – is to a large degree ‘failure demand’. This means which therapy, or what research evidence, but on demand for care arising from previous failure to recognise language and the qualities of the human . Together and respond to the underlying problems, especially at a these qualities become the dimensions of being holistic social and economic level. The roots of illness are in in your understanding of one another, the world around society. you, and in the case of practitioners, your practice. We use It is clear to us that the BHMA must focus on the NHS the qualities of the human as a way into the complexity. and on the roots of illness. It is here that the holistic vision

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Here are the twelve dimensions: Humans have a peculiar need to find meaning in all this. Meaning is the tenuous, evanescent light that draws balanced, community-minded, compassionate, connected, empowered, integrated, intuitive, us onward in the story of our lives; the light that if we look meaningful,resilient, self-caring, wise, holistic too hard or try to analyse, is liable to go out. These are all natural human qualities. We all have the There is a light in my heart but when I try to look at it with my intellect, it goes out. potential for each, but none will be equally good at all. Friedrich Jacobi This is not about being perfect, there is no perfect in humanity. Or it is the ship’s lantern in the stormy sea that buffets us. We are grateful when it flickers on and saves us from Out of the crooked timber of humanity, no straight thing was ever made. darkness. We search for a medicine of meaning. Immanuel Kant Our shifting world, unknowable entirely, floating in unimaginable space, gives glimpses of itself as much to So we must forgive ourselves and others for being crooked. our intuitive sense as to our analytic mind. Our meaning We must be compassionate . Every generation has its must come from integrating these glimpses and making challenges in this respect. Ours, here, is to cope with the sense as best we can, often by a story. This will mean living manifold effects of science and technology, of harnessing with uncertainty but looking for balance , coherence and the power of the natural world in ways that are wise , resonance in a life of enquiry. where in foolish hands, great damage might be caused. Perhaps being connected is the most essential of A virtuous, ordinary life, striving for wisdom but our natural human qualities. But so often we are lonely. never far from folly, is achievement enough. This may be from being alone, but more often it is our Michel de Montaigne difficulty in making meaningful connection with another sentient being. What is most vulnerable and must be protected is like a seed in the breeze, fragile and transient but full of Loneliness does not come from having no people promise. The essence of this fragility and of human around you, but from being unable to communicate knowing is predominantly about ourselves. Without being the things that seem important to you. self-knowing and self-caring we have little hope of caring Carl Jung for others and the world. Much of this is about feeling part So much of the modern doctor’s time is taken up with of something much bigger than us. If we can achieve this, patients whose problems can be reframed as loneliness of then caring for ourselves, for others and for our wonderful the soul – of the inner being – manifest in diverse ways, planet will come to us naturally. This is community . from serious physical illness to unhappiness and lack of [People] are free when they belong to a living, fulfillment. Perhaps this is the malady of our times. Of organic, believing community, active in fulfilling course, with a holistic view, we know that this loneliness some unfulfilled, perhaps unrealised purpose. of the soul goes deeper. Here is Jung again. DH Lawrence If things go wrong in the world, this is because So to be free, we must belong; and to belong is to be something is wrong with the individual, because empowered . something is wrong with me. Therefore, if I am sensible, I shall put myself right first. There is no more powerful way to initiate Carl Jung significant change than to convene a conversation. When a community of people discovers that they This is an echo of John Donne’s famous lines, their fame share a concern, change begins. There is no power perhaps residing in their truth, their resonance with the equal to a community discovering what it cares depth of the human soul. That we do not, for the most about. part, practise this wisdom is another demonstration of our Margaret Wheatley crooked timber, yet it contains the promise of better times for mankind. Before we can start building these better Here also is the importance of being resilient . There is times, we must first have the new eyes recommended by no perfect because the energy of the world derives from Proust and which are promised to those with holistic vision. change, from tension between opposites. All is change, like the leaf in a tumbling stream, fragility riding the waves No man is an island entire of itself; …any man’s of power; once beautiful, now buffeted about on an death diminishes me, because I am involved in invisible shifting film of surface tension, buoyed up by air, mankind. And therefore never send to know for held down by gravity. Change and agility gives us both whom the bell tolls; it tolls for thee. resilience and sustainability. Just try riding a bicycle John Donne without moving the handlebars! Change also gives us stories, perhaps the most potent way of grasping our evolving reality.

6 © Journal of holistic healthcare G Volume 13 Issue 1 Spring 2016 © Journal of holistic healthcare G Volume 13 Issue 1 Spring 2016 7 SELF-CARING Food as medicine: the anti-inflammatory diet

Andrew T Weil MD

I am a physician, author, expert on medical botany, mind–body interactions, and alternative medicine. For many years I have practiced and taught integrative medicine, which I believe to be the future of health care. I am founder and director of the University of Arizona Center for Integrative Medicine, a centre of excellence that has graduated over 1,300 physicians from intensive two-year fellowship training. Our curriculum in integrative medicine is now a required, accredited part of residency training in 60 residency programmes throughout the US. I have written 14 books, most of them about health, that are intended to help people become more self-reliant in matters of health and more confident in the body’s innate capacity for healing.

Introduction high-carbohydrate diets promote health, not nutritional fads. This is activation of the inflammasome, and the Anti-Inflammatory Diet (AID). The It is widely agreed that chronic, low- fructose is a particular trigger for AID is best considered the nutritional grade inflammation is the root cause inflammation in the liver. 25, 26 component of an overall healthy of many serious illnesses, ranging from Intermittent fasting and other forms lifestyle programme. It builds on 1–3 4–9 heart disease to some cancers of caloric restriction inhibit inflamma - traditional Mediterranean and 10 –12 to depression, and neuro - some activation, 27 as does curcumin, Japanese eating patterns, whose anti- degenerative conditions including the most active component of inflammatory and health-promoting 13 –15 Alzheimer’s and Parkinson’s turmeric. 28 Food choices are effects are well-established, 29 –34 16, 17 diseases. The pathogenesis of particularly important because we especially with regard to primary and these diverse illnesses may have a have – at least potentially – control secondary prevention of cardio - common root in activation of the over them. vascular disease. 35 –38 inflammasome, the intracellular, There is no debate regarding multiprotein complexes that are the unhealthy nature of the typical 18 Caloric intake central to innate immunity. When Western diet, yet agreement on what activated, these molecular structures constitutes a healthy diet remains A balanced anti-inflammatory diet release cytokines that mediate the surprisingly elusive. Contradictory should include a reasonable number inflammatory response. In its place, messages about diet are pervasive, of calories to replace those lost in inflammation is the cornerstone of the creating confusion and anxiety among everyday life, as well as the right mix body’s healing system, bringing added patients. Healthcare professionals are of healthy fats, carbohydrates and nourishment and immune activity to a usually of little help because their proteins to meet the body’s nutritional site of infection or injury. But when training in nutrition is inadequate. needs. Each of the macronutrients inflammation persists beyond what is Learning how specific foods influence affects the body’s inflammatory status necessary for defense or repair or the inflammatory process is one of the in unique ways. Caloric intake should serves no purpose, it damages healthy best strategies to reduce overall disease range between 2000–3000 calories a tissues and illness may ensue. risk and promote optimum health. day for most people, with 30% coming Lifestyle factors such as psycho - This article briefly outlines a from fat, 20–30% from protein, and 19 20, 21 social stress, lack of exercise. practical approach to dietary 40–50% from carbohydrates. 22, and toxic environmental exposures modification that reduces the likeli - 24 can all contribute to excessive hood of chronic inflammation while Macronutrients inflammation, but diet is a major emphasising variety, freshness, and influence. Research is beginning to pleasure from food. The discussion Fats demonstrate that certain dietary concentrates on key areas of consensus Conventional medical wisdom patterns and specific foods can impact emerging from studies of diet and the inflammasome. For example, suggests cutting back on saturated fat

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intake as well as the total amount of fat eaten, but this is The body synthesises prostaglandins and leukotrienes only part of the story. Although evidence for the health from essential polyunsaturated fatty acids (those that must risks of saturated fat has been strong, new data has called be obtained from food). Humans require regular intake some long-held beliefs into question. 39 –41 Evidence for of both omega-3 and omega-6 essential fatty acids for the health risks of total fat consumption is much less optimum health. These differ in their chemical structure convincing. Chronic, low-grade inflammation can best be and their actions within the body. In general, hormones controlled from a dietary perspective by increasing the synthesised from omega-6 substrates upregulate intake of anti-inflammatory fats while reducing or avoiding inflammation, blood clotting, and cell proliferation. Those ingestion of fats known to promote inflammation. made from omega-3s have opposite effects. Omega-6s are The principal natural sources of saturated fat are beef, widely available in seeds and the oils extracted from them pork, lamb, unskinned chicken, duck, whole milk, products and also build up in the fat of the grain-fed animals we made from whole milk, and processed foods made with eat. Unfortunately, the starting materials for the anti- tropical oils (coconut and palm). The easiest to way to cut inflammatory pathway, the omega-3s, are mainly found in down on dietary saturated fat, as well as caloric intake (fat oily fish and are harder to come by. The two omega-3 fatty has almost twice as many calories per gram as protein and acids critical to human health are eicosapentaenoic acid carbohydrate), is to lessen reliance on animal foods. Note (EPA) and docosahexaenoic (DHA). that saturated fats are not equal with regard to cardio - The ratio of omega-6 to omega-3 fatty acids in the vascular risk. It may be that fat in meat (beef especially) diet is important for regulating the production of pro- is particularly atherogenic, while dairy fat is least harmful inflammatory and anti-inflammatory compounds in the and possibly beneficial. 42 body. 50 Experts believe that ratio was about equal in the Although polyunsaturated cooking oils (corn, soy, distant past. Today, most people in industrialised Western sesame, sunflower, cottonseed, and safflower) lower LDL countries consume far more omega-6s than omega-3s. cholesterol and have been promoted for cardiovascular Reasons for this change include the flooding of today’s health, they are chemically unstable and readily react with diet with refined vegetable oils (especially soy oil), oxygen, particularly in the presence of light and heat, fattening food animals (especially cows) on grain, resulting in toxic compounds that can damage DNA and increased consumption of meat relative to fish, and cell membranes and promote inflammation. It is best to decreased consumption of greens and other vegetable reduce consumption of polyunsaturated oils in favor of sources of omega-3s. Almost all snack foods (chips, monounsaturated ones, although high-oleic versions of crackers, cookies, and candy) and fast foods are high in sunflower and safflower oil are closer in composition to omega-6 fatty acids and devoid of omega-3s. This olive oil and are acceptable options. imbalance is a major driver of unhealthy inflammation. When unsaturated fatty acids are heated or treated Oily fish from cold northern waters are the best with chemical solvents and bleaches, they tend to deform, omega-3 food source, as they concentrate EPA and DHA going from their natural curved shape (cis-configuration) in fat. Good options include sardines, herring, mackerel, to an unnatural jointed shape (trans-configuration). The and wild salmon. Flax and hemp seeds are also high in body builds cell membranes out of cis-fatty acids and also omega-3s, as is the wild green, purslane, but they provide uses them in synthetic pathways for regulatory compounds a precursor compound (ALA, alpha-linolenic acid), whose that influence inflammation and cell proliferation. Trans- conversion to EPA and DHA is inefficient, especially in the fatty acids, or TFAs, are widely regarded as toxic and context of high intake of omega-6s. Coldwater fish should pro-inflammatory. 43 –45 They can be removed from the diet be eaten 2 to 3 times a week to help keep inflammation in by excluding all margarines, solid vegetable shortening check. Fish oil supplements are available for those who do and products made with them, as well as all products not enjoy eating fish, but they may not provide the same listing ‘partially hydrogenated’ oil of any kind on the label health benefits. 51 and by avoiding most fried foods. It has been estimated that banning trans-fats could prevent 20,000 heart attacks Protein 46 and 7,000 deaths a year in the United States alone. The majority of people living in industrialised nations Vegetable oils that are predominantly monounsaturated consume more protein than they need, which may be include olive, canola, peanut, and avocado oils. They may unhealthy, and the kinds of protein they eat may not be offer significant health benefits, especially in the case of optimal. A remarkably small amount of protein is required olive oil, a prominent component of the Mediterranean to satisfy the minimal requirements of the average adult – diet. Extra-virgin olive oil is high in oleic acid and poly - perhaps two ounces of a protein food each day. One meal phenols with significant anti-inflammatory and antioxidant a day – organised around a main course of meat, chicken, 47, 48 properties. High-quality extra-virgin olive oil also fish, eggs or vegetable protein – is probably sufficient. contains a natural anti-inflammatory agent, oleocanthal, When more protein is ingested than the body requires, 49 with activity comparable to that of ibuprofen. it is used as an energy source. Protein digestion and One of the most important dietary recommendations metabolism is inefficient, however, requiring more energy that doctors can make to their patients is to use extra- than the digestion and metabolism of fats and carbohy - virgin olive oil as the main fat in food preparation. drates. In addition, protein is not a ‘clean’ fuel source.

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Fats and carbohydrates burn to carbon dioxide and water, inflammation and risk of cardiovascular disease. 56, 57 but protein metabolism leaves toxic nitrogenous residues Overall, it is a good idea to reduce consumption of meat that must be processed by the liver and kidneys. in favour of vegetable protein. The animal foods that most people rely on for protein are high in saturated fat. Being high on the food chain, Carbohydrates they are more likely to accumulate environmental toxins, It is important to learn the difference between quickly and, unless raised organically, carry residues of growth- digested and slowly digested carbohydrate foods. That promoting hormones, antibiotics, and other chemicals difference is measured on the glycemic index (GI) scale. 58 used by commercial farmers. ‘White’ meat is no better High-GI carbohydrates raise blood sugar quickly and than red meat in this regard, except that veal has less fat significantly. Another measure, glycemic load (GL), factors than beef, and pork fat (lard) appears to be less athero - in the actual amount of carbohydrate consumed in a genic. Regularly eating processed meats, such as bacon, portion of a specific food. Rapidly digested, high GI/GL lunchmeats, and cured sausages, is associated with foods are often highly processed and of low quality, such 52, 53 increased risks of cancer and all-cause mortality. as fast foods, breads and other products made with flour; Chicken offers at least one significant advantage: its fat is snack foods; and sweetened beverages. Eaten regularly, external to muscle tissue and can be removed with the these contribute to insulin resistance, dysregulate blood skin. Otherwise, chicken and other poultry present the sugar, and promote inflammation by favouring glycation same toxic hazards as the flesh of cows, sheep, and pigs. reactions between blood sugar and proteins that result in As noted earlier, scale fish are a good source of protein pro-inflammatory end products. 59 –62 Replacing foods and omega-3 fats, but exposure to chemicals and pollutants made with flour with whole grains markedly reduces that contaminate lakes, rivers and oceans makes larger, markers of inflammation. more carnivorous, and coastal fish less desirable as food. High intake of vegetables and fruits has repeatedly Swordfish, marlin, tilefish and shark, for example, are been shown to reduce pro-inflammatory changes and to likely to contain high levels of mercury, PCBs, and other offer significant protection against cancer, 63 heart disease, 54 toxins. Unless they are raised carefully, farmed fish may and other serious ailments. 64 Vegetables are low in calories not be as beneficial to health as their wilder counterparts and high in micronutrients such as antioxidant vitamins (farmed salmon have lower amounts of omega-3s) and and minerals and protective phytochemicals. Brightly may contain residues of drugs used in commercial fish colored produce of all hues, from leafy greens to carrots farms. Even with these drawbacks, fish remains a good to berries, is rich in anti-inflammatory carotenoids, protein source. Shellfish are also good, but select molluscs flavonoids, and anthocyanins. Fresh and frozen vegetables carefully to avoid those that might be high in toxic and fruits likely provide more health benefits than canned contaminants. or dried versions, and organic varieties have lesser Milk products tend to be high in saturated fat, unless amounts of agrichemical residues than conventionally they are made from skimmed or low-fat milk (which might grown produce. 65 55 not be as healthy as whole milk ). Many people cannot Vegetables and fruits, together with whole grains and digest the sugar (lactose) in cow’s milk products, and nuts, represent the primary source of dietary fibre. many more experience immune system irritation from one Adequate fibre intake helps reduce serum cholesterol of its proteins (casein). Cow’s milk in all forms can be levels, promotes digestive health, and reduces chronic especially problematic for people with gastrointestinal and inflammation, in part by decreasing lipid peroxidation. 66 –69 atopic disorders and autoimmunity. Whole eggs in moder - Whole grains, such as rice, barley, quinoa, millet and wheat ation are good additions to the diet; the whites are an berries, also support a desirable gut microbiome that excellent source of protein. Eggs fortified with omega-3s reduces inflammation both locally and systemically. 70 are now widely available. Vegetable protein sources include beans and other legumes such as lentils and peas, grains, and some nuts. Additional considerations An important difference between animal and vegetable Dark chocolate (more than 70% cocoa) and red wine protein sources is that the latter are less concentrated. For contain polyphenols, compounds that reduce inflammation example, the protein in beans is diluted by edible starch and provide antioxidant protection. 71, 72 Both are best and indigestible fibre, so that a greater weight of beans consumed in moderation. Tea, especially green tea, also must be eaten to get the equivalent protein derived from a contains polyphenols and together with clean water similar portion of animal food. Vegetable protein has fewer should be the beverage of choice. 73 Turmeric (Curcuma toxic contaminants and a healthier fat profile, as well as longa) is the most powerful natural anti-inflammatory beneficial phytonutrients. Soybeans contain more protein agent. 74 Along with its botanical relative, ginger (Zingiber than other beans, along with significant amounts of officinale), 75 it and other spices and herbs should be polyunsaturated fat and phytoestrogens that may offer consumed frequently. Adding turmeric and ginger to protection against hormonally-driven cancers in both favored recipes may increase both enjoyment and the women and men. Eating a small handful of nuts most health benefits of meals. days of the week has a markedly beneficial effect on

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Bottom line 12 Howren MB, Lamkin DM, Suls J (2009) Associations of depression with C-reactive protein, IL-1, and IL-6: a meta-analysis. Psychosom Healthcare professionals should be able to inform patients Med 71 pp171–86. about an evidence-based dietary programme that helps 13 Xu G, Zhou Z, Zhu W, et al (2009) Plasma C-reactive protein is mitigate inappropriate inflammation while not skimping related to cognitive deterioration and dementia in patients with mild cognitive impairment. J Neurol Sci 284 pp 77–80. on taste. Key directives of the AID are: 14 McCaulley ME, Grush KA (2015) Alzheimer’s disease: exploring • eat the amount of calories needed to maintain the role of inflammation and implications for treatment. Int J normal weight Alzheimers Dis Nov 17. doi: 10.1155/2015/515248. 15 Zotova E, Nicoll JA, Kalaria R, et al (2010) Inflammation in • keep saturated fat intake moderate by eating fewer Alzheimer’s disease: relevance to pathogenesis and therapy. foods of animal origin Alzheimers Res Ther 22 (2) pp1. • avoid trans fats by eschewing margarine, vegetable 16 Wang Q, Liu Y, Zhou J (2015) Neuroinflammation in Parkinson’s shortening, foods that contain partially hydrogenated disease and its potential as therapeutic target. Transl Neurodegener 4(1) pp 1. oils, and most fried foods 17 Herrera AJ, Espinosa-Oliva AM, Carrillo-Jimenez A, et al (2015) • primarily use high-quality extra-virgin olive oil in the Relevance of chronic stress and the two faces of microglia in kitchen; do not cook with polyunsaturated vegetable Parkinson’s disease. Front Cell Neurosci 9. oils 18 Mehal WZ (2015) Cells on fire. Sci Am 6 pp 44–49. • eat oily, cold-water fish 2 to 3 times a week for their 19 Rohleder N (2014) Stimulation of systemic low-grade inflammation by psychosocial stress. Psychosom Med 76 pp181–189. omega-3 fatty acids 20 Apostolopoulos V, Borkoles E, Polman R, et al (2014) Physical and • replace animal protein with fish and vegetable protein immunological aspects of exercise in chronic diseases. • eat a variety of brightly colored vegetables and fruits Immunotherapy 6 pp 1145–1157. every day, choosing organically grown produce when 21 Gratas-Delamarche A, Derbré F, Vincent S, et al (2014) Physical inactivity, insulin resistance, and the oxidative-inflammatory loop. possible Free Radic Res 48 pp 93–108. • eat more whole grains and products made from them 22 Møller P, Danielsen PH, Karottki DG, et al (2014 ) Oxidative stress • flavour foods with a variety of herbs and spices, and inflammation generated DNA damage by exposure to air pollution particles. Mutat Res Rev Mutat Re. 762 pp133–66. especially turmeric and ginger 23 Guarnieri M, Balmes JR (2014) Outdoor pollution and asthma. • include tea, dark chocolate, and red wine (in The Lancet 383 pp1581–1592. moderation) in the diet. 24 Barua RS, Sharma M, Dileepan KN (2015) Cigarette smoke amplifies inflammatory response and atherosclerosis progression 1 Briasoulis A, Androulakis E, Christophides T, et al (2016) The role through activation of the H1R-TLR2/4-COX2 axis. Front Immunol of inflammation and cell death in the pathogenesis, progression 6 pp 572. and treatment of heart failure. Heart Fail Rev , Feb 12 (Epub ahead 25 Li X, Lian F, Liu C, et al (2015) Isocaloric pair-fed high-carbohydrate of print). diet induced more hepatic steatosis and inflammation than high- 2 Ross R (1999) Atherosclerosis – an inflammatory disease. N Engl fat diet mediated by miR-34a/SIRT1 axis in mice. Sci Rep 5 J Med , 340 pp115–126. pp 16774. 3 Tuttolomondo A, Di Raimondo D, Pecoraro R, et al (2012) 26 Zhang X, Zhang JH, Chen XY, et al (2015) Reactive oxygen species- Atherosclerosis as an inflammatory disease. Curr Pharm Des 18 induced TXNIP drives fructose-mediated hepatic inflammation pp 4266–4288. and lipid accumulation through NLRP3 inflammasome activation. Antiox Redox Signal 22(10) pp 848–70. 4 Balkwill F, Mantovani A (2001) Inflammation and cancer: back to Virchow? The Lancet 357(9255) pp 539–545. 27 Vandanmagsar B, Youm YH, Ravussin A, et al (2011) The NLRP3 inflammasome instigates obesity-induced inflammation and insulin 5 Moore MM, Chua W, Charles KA, et al (2010) Inflammation and resistance. Nat Med (2) pp 179–88. cancer: causes and consequences. Clin Pharmacol Ther 87(4) pp 504–508. 28 Gong Z, Zhou, J, Li, H, et al (2015)Curcumin suppresses NLRP3 inflammasome activation and protects against LPS-induced septic 6 Allin KH, Bojesen SE, Nordestgaard BG (2009) Baseline C–reactive shock. Mol Nutr Food Res 59(11) pp 2132–42. protein is associated with incident cancer and survival in patients with cancer. J Clin Oncol 27 pp 2217–2224. 29 The Mediterranean diet: insights from the PREDIMED study. Prog Cardiovasc Dis 2015, 58, pp 50–60. 7 Guo YZ, Pan L, Du CJ, et al (2013) Association between C-reactive protein and risk of cancer: a meta-analysis of prospective cohort 30 Caretto A, Lagattolia V (2015) Non-communicable diseases and studies. APJCP 14 pp 243–248. adherence to Mediterranean diet. Endocr Metab Immune Disord Drug Targets 15 pp 10–17. 8 Lasry A, Zinger A, Ben-Neriah Y (2016) Inflammatory networks underlying colorectal cancer. Nat Immunol 17 pp 230–240. 31 Casas R, Sacanella E, Estruch R (2014) The immune protective effect of the Mediterranean diet against chronic low-grade 9 Khandekar MJ, Cohen P, Spiegelman BM (2011) Molecular inflammatory diseases. Endocr Metab Immune Disord Drug mechanisms of cancer development in obesity. Nat Rev Cancer 11 Targets 14 pp 245–254. pp 886–95. 32 Mori M, Masumori N, Fukuta F, et al (2009) Traditional Japanese 10 Kohler O, Benros ME, Nordentoft M, et al (2014) Effect of diet and prostate cancer. Mol Nutr Food Res 53 pp191–200. anti-inflammatory treatment on depression, depressive symptoms, and adverse effects. A systematic review and meta-analysis of 33 Kanai T, Matsuoka K, Naganuma M, et al (2014) Diet, microbiota, randomized controlled trials. JAMA Psychiatr 71 pp 1381–1391. and inflammatory bowel disease: lessons from Japanese foods. Korean J Intern Med 29 pp 409–415. 11 Jokela M, Virtanen M, Batty D, et al (2016) Inflammation and specific symptoms of depression. JAMA Psychiatr 73 pp 87–8. 34 Pallauf K, Giller K, Huebbe P, et al (2013) Nutrition and healthy ageing: calorie-restriction or polyphenol-rich ‘MediterrAsian’ diet? Oxid Med Cell Long 707421.

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35 Widmer RJ, Flammer AJ, Lerman LO, et al (2015) The 56 Ros E (2015) Nuts and CVD. Br J Nutr 113 Suppl 2 S111–120. Mediterranean diet, its components, and cardiovascular disease. 57 Urpi-Sarda M, Casas R, Chiva-Blanch G, et al (2012) Virgin olive Am J Med 128 pp 229–238. oil and nuts as key foods of the Mediterranean diet effects on 36 de Lorgeril M, Salen P, Martin JL, et al (1999) Mediterranean diet, inflammatory markers related to atherosclerosis. Pharmacol Res traditional risk factors, and the rate of cardiovascular complications 65 pp 577–583. after myocardial infarction: final report of the Lyon Diet Heart 58 Jenkins DJ, Wolever TM, Taylor RH, et al (1981) Glycemic index of Study. Circulation 99(6) pp 779–785. foods: a physiological basis for carbohydrate exchange. Am J Clin 37 Estruch R, Ros E, Salas-Salvado J, et al (2013) Primary prevention Nutr 34(3 pp 362–366. of cardiovascular disease with Mediterranean diet. N Engl J Med 59 Ma XY, Liu JP, Song ZY (2012) Glycemic load, glycemic index and 368 pp 1279–1290. risk of cardiovascular diseases: meta-analyses of prospective 38 GISSI Investigators: Dietary supplementation with n-3 poly- studies. Atherosclerosis 223(2) pp 491–496. unsaturated fatty acids and vitamin E after myocardial infarction: 60 Jakobsen MU, Dethlefsen C, Joensen AM, et al (2010) Intake of results of the GISSI-Prevenzione trial. Gruppo Italiano per lo carbohydrates compared with intake of saturated fatty acids and Studio della Sopravvivenza nell’Infarto miocardico. The Lancet risk of myocardial infarction: importance of the glycemic index. 1999, 354 pp 447–455. Am J Clin Nutr 91pp PP 1764–1768. 39 Siri-Tarino PW, Sun Q, Hu FB, Krauss RM (2010) Meta-analysis of 61 Rossi M, Turati F, Lagiou P, et al (2013) Mediterranean diet and prospective cohort studies evaluating the association of saturated glycaemic load in relation to incidence of type 2 diabetes: results fat with cardiovascular disease. Am J Clin Nutr 91(3) pp 535–546. from the Greek cohort of the population based European 40 Lawrence GD (2013)Dietary fats and health dietary Prospective Investigation into Cancer and Nutrition (EPIC). recommendations in the context of scientific evidence. Adv Nutr Diabetologia 56 pp 2405–2413. (Bethesda, Md) 4 pp 294–302. 62 Sharma C, Kaur A, Thind SS, et al (2015) Advanced glycation 41 Malhotra A (2013) Saturated fat is not the major issue. BMJ 347. end-products (AGEs): an emerging concern for processed food 42 Fardet A, Boirie Y (2014) Associations between food and beverage industries. J Food Sci Technol 52 pp 7561–7576. groups and major diet-related chronic diseases: an exhaustive 63 Turati F, Rossi M, Pelucchi C, et al (2015) fruit and vegetables and review of pooled/meta-analyses and systemic reviews. Nutr Rev 72 cancer risk: a review of southern European studies. Br J Nutr 113 pp 741–762. Suppl 2 S102–110. 43 Mozaffarian D, Katan MB, Ascherio A, et al (2006) Trans fatty acids 64 Wang X, Ouyang Y, Liu J, et al (2014) Fruit and vegetable and cardiovascular disease. N Engl J Med 354 pp 1601–1613. consumption and mortality from all causes, cardiovascular disease, 44 de Souza RJ, Mente A, Maroleanu A, et al (2015) Intake of and cancer: systematic review and dose-response meta-analysis of saturated and trans unsaturated fatty acids and risk of all cause prospective cohort studies. 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12 © Journal of holistic healthcare G Volume 13 Issue 1 Spring 2016 EMPOWERED The change journey

Chris Johnstone Director, CollegeofWellbeing.Com

Decades ago, I went to an empowerment workshop that changed my life. It taught me to question the inner voice saying ‘there’s nothing I can do’. I discovered instead ‘the journey approach to change’, which I later described in my first book Find Your Power (2010). Working initially as a GP, then in addictions recovery and mental health, and now as an author, trainer and coach, I see empowerment as the central thread of what I’ve done and do. I am grateful to the many guides I’ve followed, particularly Patrick Pietroni, Joanna Macy and Martin Seligman.

Introduction Annie’s story – Figure 1: Which square is Our sense of what we can or cannot empowered actions for the root cause of the circle? do doesn’t only depend on what’s positive mental health physically possible. It is also shaped by The way we deal with depression is the degree to which we’re empow - powerfully influenced by our beliefs ered. When looking at 21st century about its cause. If we link low mood healthcare challenges such as, for to a chemical imbalance in the brain, example, depression, smoking and then antidepressants like the selective the impact of social or environmental serotonin reuptake inhibitors (SSRIs), conditions, are we missing an of which Prozac is an example, might opportunity by not paying more seem a logical choice. Viewing attention to what helps people depression instead as a consequence become empowered to change? This of childhood trauma, faulty cognitions article explores insights and practices or social isolation each lead to that might help. The three Ps different responses. A shift in thinking that helps us Trying to reduce a complex Three people sit in a room. Annie become more empowered is to problem to an underlying root cause feels miserable and wants to be abandon the search for the root cause can be misleading though. For happier. Dan smokes and would and to instead work on tackling a prefer not to. Jamie is concerned example, looking at Figure 1, which range of contributing causes. Like the about climate change. When they square causes the circle? squares acting together to form the speak, it becomes clear how much As single cause solutions tend they have in common. to leave other Annie: ‘I hate feeling like this, but I contributing factors Figure 2: The 3 Ps are three types of suffer from depression and unaddressed, they contributing cause there’s not much I can do.’ are less likely to succeed. People can Dan: ‘I’ve tried giving up smoking Precipitating causes Perpetuating causes loads of times but I haven’t be left feeling (trigger factors) (maintaining factors) got the willpower.’ defeated when the Jamie: ‘Climate change is too big a proposed solution problem, I can’t make any doesn’t remove difference.’ their problem. I’ve often heard people What connects mood change, behaviour change and world change say ‘I tried antide - here is a shared experience of pressants and powerlessness. Annie, Dan and Jamie therapy, but they all want something they believe is didn’t work for me, beyond their reach. so there’s nothing I can do’.

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circle, three types of cause play a role in depression. We can call these the three Ps (see Figure 2). The first P refers to predisposing causes – these are the risk factors in someone’s background or history that increase their chances of getting depressed. Included here are family history, genetic factors and early childhood experience, societal factors such as economic inequality and unemployment, and also current personal factors such as lack of exercise, friends or sleep. The second P is for precipitating causes – these are the trigger factors that tip someone over the edge. Losing your job, a relationship break-up, a period of increased stress or illness can be trigger factors that precipitate depression. The final P refers to perpetuating causes – the things that keep a problem going or make it worse once it has started. These factors can set in motion vicious cycles of self-amplifying loops. For example, while heavy drinking might offer relief from low mood in the short term, in the longer term it causes the problem to return with interest. Figure 3: The boat and water level The more someone drinks, the more depressed they become; the more depressed they become, the more they • Resources refer to whatever we turn to for may drink. nourishment, guidance, inspiration and support. This What floats your boat? includes, for example, people who help us, services we use, special places where we feel safe and self-help Over 30 years ago I went to a lecture by holistic health - books. care pioneer Patrick Pietroni where I learned about an • Insights are the guiding ideas, wisdom or perspectives empowerment tool for mapping contributing factors. we find useful. The idea of the 3 Ps is an insight that Patrick pictured health as similar to rowing in a boat, with helps us recognise potential points of action to protect illness represented by a crash into a rock. Doctors and our mood. Using the water level mapping tool is a other health professionals, like geologists, know lots about strategy based on applying this insight. the rocks and have useful interventions for dealing with them. But rocks are only part of the story. Also important I use the letters SSRI here as a reminder that our is our water level, which represents our background level resilience toolkit of Strategies, Strengths, Resources and of resilience and wellbeing. When we’re at a low ebb, our Insights acts as a natural antidepressant (see Figure 4). water level depleted, we’re more likely to crash (see My motto here is that the natural antidepressant is Figure 3). something you do . Each day we can ask ourselves ‘Have I When looking at emotional health, the rock might be taken my natural antidepressants today?’ What we take are depression or anxiety. The mapping tool involves first steps to promote wellbeing and protect our mood. We drawing a horizontal line to represent our water level, don’t need to be depressed to benefit from this approach then considering contributing causes that might be pushing this down, drawing these in as downward arrows. Finally, consider what protective or helping factors we can bring in or strengthen to push the water level up, drawing these in as upward arrows. A resilience toolkit In the resilience courses I run, I ask people to consider four groups of upward arrows – strategies, strengths, resources and insights. • Strategies are things we can do to promote resilience and wellbeing – such as, for example, taking regular exercise, practicing mindfulness, spending time with friends or paying attention to our diet. • Strengths are the inner qualities we draw upon that help us get through challenging times. Included here, for example, are patience, determination, courage, Figure 4: The resilience toolkit of self-help sense of humour and ability to communicate. SSRIs

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– prevention is better than cure and raising the water level Jamie’s story – empowered actions of our wellbeing leaves us feeling better too. for ecological wellbeing By developing and applying the upward arrow actions that protect our mental health, we counter the About a decade ago, the Mental Health Foundation disempowered state that says ‘there’s not much I can do’. published a survey exploring people’s emotional responses to concerns about world issues (BBC, 2007). Dan’s story – empowered actions The commonest response (in 56% of those surveyed) was powerlessness. I am so glad I worked for many years in for health-related behaviour change the addictions field, because I often saw something When working in the addictions field, I developed an happen that is deeply relevant here. I saw people move entire relapse prevention programme based on the boat both into and out of the experience of powerlessness. and water level metaphor. In this case, rowing in the boat Powerlessness doesn’t have to be permanent state – meant making progress in recovery; a graphic image for there are learnable pathways that help us become more relapse was crashing into a rock. empowered (Johnstone, 2010) One of the first challenges of recovery is to make up A key factor is our response when we hit a block. One your mind – do you want to crash or not? ‘Want’ is a approach is to take our experience of defeat as proof that complex thing here, as we often want more than one we’re not able to solve the problem – and so to give up. thing at the same time. For a recovering addict, part of Another approach is to accept that we’re not able to solve them may deeply want recovery while another part the problem yet. That word yet invites the possibility that hankers for a return to old ways. An important discovery we might find a way, opening up what I call ‘the journey for me was motivational interviewing, as this approach approach to change’. Psychologists describe this as ‘the helps people become clearer about what they really want. growth mind-set’, as it involves seeing our ability to Working with and through ambivalence is empowering address issues as not fixed but growable. This approach because it facilitates movement towards a stronger place tells a different story about failure and frustration, seeing of commitment. them as just part of a journey of finding a way forward. A key idea of motivational interviewing is that we Research shows, for example, that training failing students become more motivated when we hear ourselves give in the growth mind-set can lead to dramatic break - voice to the motives that move us. A phrase for this is throughs in their academic success (see Carol Dweck’s ‘eliciting change-talk’, and the role of the interviewer is to TED talk The Power of Yet at www.youtube.com/watch?v= be so interested in the deeper pushes and pulls of the J-swZaKN2Ic) person they’re listening to that they draw out the ‘change So how does this relate to Jamie feeling powerless talk’ that motivates them. about climate change? When you add ‘yet’ to the end of You can elicit change-talk from yourself by asking what the sentence ‘I can’t make any difference’, you’re more you want. I like to use open sentences as a device here, likely to consider how you might find a way. This starts where I give myself the start of a sentence, and then see you on a journey of looking for what might help. what words seem to naturally follow this. I can use the When working with people who are struggling with same open sentence starting point several times, seeing depression, addiction or their concerns about the world, how I feel each time about what I say. To experience how a perspective I’ve found helpful is to recognise that this works, try these open sentences, and notice how you whatever situation we face, there are always different feel about the words that emerge. ways it can go. The choices we make act like votes that ‘I’d really love it if…’ influence the outcome. Empowerment training teaches us ‘What matters most to me is…’ to get better at recognising choice-points where steps we ‘Something I’d like to move forward with at the take can make the future we’d prefer more likely to occur. moment is…’ Being empowered involves not only recognising those What these sentences draw out is motivational steps, but also taking them. Being empowered, like the information. They tell us what’s attractive, what’s natural antidepressant, is something that we do. important and what we’re committed to. Finding our BBC news (2007) World troubles affect parenthood , 8 Oct. Available at: sense of direction is an important part of the http://news.bbc.co.uk/1/hi/uk/7033102.stm (accessed 24 February empowerment journey. However strengthening our will 2016). like this is really just the start. We also need to see a way Johnstone C (2010) (2nd ed) Find your power – a toolkit for to move forward with the purposes that call us most resilience and positive change. East Meon: Permanent Publications. strongly. We can run aground if we bump into obstacles or difficulties that seem to block our way. That often Acknowledgement happens, for example, when people face concerns about the world. Thanks to Dave Baines and Carlotta Cataldi for illustrations.

© Journal of holistic healthcare G Volume 13 Issue 1 Spring 2016 15 BALANCED Reflections on mothe rhood as a GP: Empathy in action!

Gillian Myers GP

I am a GP and mother which I find occupies more than 100% of my time! My interests include self care, medical complexity and the anthropological role of the doctor.

Introduction Embarking on motherhood is a a safe place and walk away rule’. The real leveler – I know many doctor- transference of being unable to satisfy Experiencing motherhood directly has mums who have really struggled with their unmet need can be hugely helped me complete another few such a change in pace and self- intense. It is small wonder that some sections of the jigsaw puzzle of the perceived success. At the same time, I are driven to respond to this with human condition and in this way has have met mums who were described shaking, or similar. made me a better GP, I hope. as so-called ‘teenage pregnancies’ who Personally, I have found the most thrive. There are so many different Early experiences of efficacious doctors have been those factors – often amounting to how who can think in a joined up way, isolated that woman is in going about motherhood listen to all my concerns, compute her task. At the end, we are all women Motherhood is grounding no matter them and repackage them in a way with a brand new role and job who you are at the start. I felt so ill which means I can move forward. description and it doesn’t take long for with nausea and vomiting, with Personal experiences enable us to do us to understand that no matter how anaemia (from a previous miscarriage) this better. hard we try there will be successes and yet work goes on. An ENT consultant I can reflect as a GP only on my failures every day. The best laid plans I was working for helpfully reminded own personal experiences of mother - of mice and men are frequently me as a trainee when I struggled with hood. Motherhood is such a narrative thwarted by a small being designed nausea and vomiting that, ‘pregnancy experience. Its uniqueness for every to push your boundaries while is not an illness’. The archaic mum and family requires specific simultaneously triggering sheer hierarchical structure that remains in validation even though there are devotion and sheer frustration. some surgical cultures stopped me almost always common themes, such Working harder at it, pouring more telling him how it really is. I cried as tiredness. and more of ourselves in as we so when I heard a brilliant BBC Radio If I had to summarise the often do in medicine, so often makes Woman’s Hour report on this topic. experience of motherhood as a GP everything worse! It is a very good Past unhelpful attitudes to pregnancy- into one word it would be humility, lesson in why self-care and accepting related symptoms in part led me to although as I write, I can hear my what is good enough is so important delay seeking medical advice for husband laughing! I think he’d say I as a mum and a GP. One thing I try to severe bleeding. I also knew from my wasn’t particularly humble, bossing say to all mums is that in times of first labour how much illness comes him around, exercising my leadership great distress or challenge, remember with a hospital admission – it truly is a skills at home. the ‘put them down for five minutes in place to ‘save a life’ or die when every

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other option fails. I cannot imagine a less holistic healing ripples this creates. For example, an eight-year-old environment than an acute hospitaI ward. Every effort presented to me with ‘travel sickness’ that wouldn’t should be made to provide a better healing environment, respond to tablets. She came with her devoted but as well as one more conducive to sleep. In my case the perplexed grandparents. It transpired that the child had stress of being an inpatient pushed my blood pressure up lost her mum when she was eight months old. She also – which led to four-hourly medication to control it. had anxiety and school difficulties, in spite of the amazing Like many other doctor mums I know, I had brutal efforts of the grandparents. Nobody else in the family, childbirth experiences. I inwardly smirked at my fellow including her father, was able to bear her resemblance to NCT group members’ plans for home births. ‘Ha’ I her dead mother. I cried and cried to myself when that thought, ‘they’ll learn…’ and then balked when they all got consultation had finished, faithfully fixing myself a tea no away with it and I was the one with all the interventions matter how late I was running. and hospital nightmares! Maybe it has something to do Ultimately, motherhood re-sensitises us. Perhaps this with being older. is a combination of the labour, the ‘hormones’, the time I have found that nothing helps me validate my away from workplace pressures, the role as an empathiser, patients’ concerns as much as having had similar advocate and problem-solver for a small, adorable, experiences myself. After horrendous labours which have dependent non-formed-word communicator. Being a been the biggest reminders to my psyche that we are doctor needs objectivity and calm. Overreacting indeed physical animals born of the earth, I experienced emotionally to every human sadness would make it two long hospital admissions, in maternity wards and in difficult to complete medical training, let alone make it the children’s hospital, that really taught me what it’s like through a morning surgery. Having some time off being a to be a patient or a patient’s parent. After I presented my doctor but occupying another 24-hour caring role, often sick neonate, including test results, in what I thought was as a patient or mother of a patient, has definitely increased a very concise summary to the ward round, a nurse took my empathy for all of those forming part of a family – by me aside and told me to ‘just be his mum…’ As if I can about a trillion billion, as my four-year-old would say! shut down my ‘medical brain’ on command. And yet I I have an increased love for the six-week newborn knew she was trying to help me. But it was still true that checks. What a privilege to interact with a (mostly) well no one had chased the group B strep swabs taken at a brand-new human! A chance to formally welcome them to different hospital! the human race on behalf of our profession. What a great perk of the job! It would be greatly missed were it to be What being a GP brings to sub-contracted out as not cost-effective! I always remember my sister-in-law saying after my first son was born: ‘Well motherhood done you two. What a great job you are doing – he’s After such epic early motherhood experiences I have been thriving.’ The relief and pleasure I see in parents when I glad that being a GP helps with being a mum: I already repeat this comment in consultations means I consider knew how to tell if a newborn is breathing and didn’t saying this to every new mum I see. I find they often say, spend hours watching them or holding a mirror to their ‘Really? You think so? I’m not so sure, thank you’ and I mouth. Being awake all night was not a brand new hope it increases their confidence and nurtures trust in experience and therefore much less traumatic. I had their own instincts – they are truly the world’s expert in already started to nurture my own resilience in the face of the care of that other human. A lack of response to this multi-factorial adversity. I knew what constituted a real praise would mean I’ve totally misjudged my crisis rather than what just felt like one. The well-practised communication (it’s not yet happened but I’m sure it communication skills are invaluable at home, for example will one day) or would raise a suspicion that there is ‘echoing’ works very well with a child (when I am very something else going on: perhaps they live with grandma busy multi-tasking and I don’t know what my four-year-old who is doing everything or mum is indeed struggling. is talking about). Advancing my empathy skills… What being a mum brings to As I write this my four-month-old is suffering with croup being a GP and this has made this writing process so very much My mother-in-law says children are sent to teach us harder. The first time my eldest son had bronchiolitis, patience. They teach us so much. I barely need to say that aged 14 weeks, I would have cut my own arm off if it being a mum helps with being a GP. For instance, would have stopped him suffering. Experiencing mother - empathy; and the ability to give pragmatic rather than hood is like experiencing a physiological and therefore guideline/textbook/default risk-averse advice; meaningful very tangible definition of empathy; after all my heart and validation of exhaustion as well as the far-reaching respiratory rate are directly linked to that of my baby’s. I consequences of family breakdown. Being a mum has also used to claim that the reason my first son didn’t cry much led directly to a more comprehensive appreciation of the when he had his immunisations was that I was able to stay consequences of the loss of a mum to families and the so calm because I was so pleased for him to be receiving

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one of the best achievements of modern medicine. I just a virus’ or ‘it’s nothing’. We can’t always get it right, as would think of the many children in the developing world a colleague told me once. who don’t have this opportunity to help them to simply survive. Of course, I was proved wrong with my second …increases understanding of son and learnt that perhaps it may have been partly their personalities after all, another humbling experience! But I social context have countless times felt their reaction to my conscious Motherhood has shown me that community and social calm breathing or relaxation – the origin of transference. context are everything. I have a new respect for single I am also experiencing a profoundly increased parents or anyone where this is made harder. Motherhood empathy for children in general, especially growing up in in my amazingly supportive community is clearly a very a world that it so IT heavy. Our civilisation is experiencing different experience. Strangers’ smiles and the trusting of exponential social change; parents’ experiences now differ other mums or dads in cafés while I pop to the loo, greatly from that of their child’s. Every generation reminds me motherhood is not a lone task. It was never experiences social change but I don't believe it has meant to be mum and baby in a room together all day, previously moved at this rate. Imagine going home from with the odd walk round the park to kill time until dad school and not being able to escape the social clutches of gets home from work. The group helps to get a feel for your peers through texting or social media. Anyone can what’s normal; and the catharsis of venting normal post an unpleasant picture of you 24 hours a day, invading frustrations with our children, our partners, the house - what should be your nurturing, neutral, unconditionally work! Community helps enjoyment of life at every stage. loving home environment. I went to a colouring group ‘for all ages’ – with my four- Every day brings back long-forgotten childhood year-old son, my 18-week-old baby and my husband. The moments triggered by a simple smell or a Dick Bruna book. group leader explained about mindfulness, for instance, My husband and I call them ‘Ratatouille moments’ after how colouring-in had helped pain relief, and loneliness the excellent children’s film ‘Ratatouille’. For example, and even the symptoms of Parkinson’s disease in groups remembering how it felt to lack your own autonomy, how she had run in the past. Few drugs I know can have such it was to feel so secure in mum’s cuddles. These wide-reaching effects. ‘Ratatouille moments’ have really helped my consultations Friends without children look sympathetically at me with children, including them as early as I can. I aim to and think it’s the end of my social life, but raising children really target their concerns and not just those of the is one of the most social things I have done! I’ve made so parents. I hope a positive experience at this stage could many new friends, not only other mums, but having affect their whole life of health-seeking behaviour: children in tow becomes a talking point – their own confidence, setting what is normal, the importance of parenting experiences, offering support and words of self-care and the sense that they are in charge of their wisdom or just delighting in the wonder of a little ones’ own health. smile.

Communicating with patients… The importance of self-care has I often say that I am always at least 25% with my children finally hit home and translated whether they are physically with me or not. I used to balk into my own behaviour change… at those women who would ask me a question and then promptly not listen to the answer, as they were ‘What’s good for mum is good for baby.’ I love to say this! simultaneously distracted by their child. ‘What poor I tell my patients that when I get stressed at home, the communication’ I used to think, and now I am that whole family falls apart. I try to get across that it isn’t person. I just acknowledge it and apologise to the adult learning mandarin that’s important in baby mandarin (or concerned. I hope makes up for my deficit slightly. its equivalent), that there is no point slavishly following a I reflect on ‘safety nets’ and the double messages we Gina Ford routine, or trying for perfect attachment give our patients. Come back ‘if they have any breathing parenting, if this very process is destroying mum’s sense difficulties’ means so many things to so many people. of wellbeing. Because the little being attached to you is But being too specific doesn’t help either and may modeling on your own behaviours how to look after disempower mum from bringing a child back. I realise we himself. For me, mum and baby yoga is brilliant because it are expecting a lot from our patients, especially during this relieves my aches and pains from childcare and it releases austerity drive. Yet more self-care has to be a big part of endorphins to ease my overburdened mind. Then because the future. my baby gets a happier mummy back at the end of class, I received a meningitis awareness leaflet from my he wins too. We need to take care of our own health for heath visitor. So I read it as a mother, then I read it as a the sake of our own children that we protect in so many GP. It made me think how much judgement and intuition other ways. I am truly realising the importance of self-care goes into the assessment; how very skilled it is; how I and its positive feedback loops. This seems especially have a decade of knowledge and experience and still it’s relevant to a GP right now in today’s climate of such poor certainly not easy. And I hear the voices: the GP said ‘it’s morale.

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Learning from motherhood of a I now appreciate how regularly children appear school-age child worse at night. A simple question like, ‘how’s the sleep going in your house?’, accompanied by a knowing tone or I love my new daily ritual in the school gate community look often reveals a tirade of frustration and distress. culture. What a privilege! I don’t mind saying that my GP skills help me here too: listening, validating anxieties and Motherhood and the pitfalls of an ease with being honest to strangers. I will miss this so much when I return to work – I really feel that my young being a doctor and a parent of a August boy who started school at age four years and 14 patient days next to girls who were already five got a lot from I take my four-month-old to water babies. Wow! We these discussions. It’s back to the catharsis and knowing submerge them on their first session! I’m sure baby what’s normal and hilarious laughing as well. So I don’t aspirated water and swallowed water and air; I’m sure he always pass on my anxiety about his performance or lack will get used to it but not so sure about the story that of social skills onto my son, therefore freeing him to learn, being submerged before birth will seamlessly transition make his mistakes and me just love and support him, with to swimming! That night he develops stridor. I am gentle advice rather than over parent him and make him knackered! I wake my husband for a second opinion – feel that he has failed or is abnormal in some way. he is a hospital doctor. Conclusion: he has a chemical My favourite school gate moment was returning with tracheitis from the chlorine! Yikes! Call 111 for objective our new family member, baby Fergus, with everyone opinion has become our mantra. They send the paramedics saying ‘well done!’, and my elder son really basking in this and within a few minutes baby has dexamethasone for his praise too, running around my feet shouting, ‘hooray for croup. ‘The physician who treats himself has a fool for a mummy hooray for mummy’, with a massive smile on his patient!’ to misquote Voltaire. In our (fairly frequent) face full of joy – surely one of the best moments of my life! experience, 111, paramedics, out-of-hours practitioners At the school gate I am reminded of the role of the GP and acute paediatric services have been incredibly positive. as a Western ‘everyday anthropologist’: I am equipped with skills to read between the lines in terms of family situations and dynamics. I am armed with social experience Conclusions and have a unique frame of reference and have been told To us, family life and general practice still seem so much I am an attractive choice of confidante because I am more compatible, compared with hospital medicine that unshockable. my husband practices. However I do not think I could I’ve given lots of medical advice at the school gate as have completed my GP training without the extensive a known GP: rashes, viral illnesses, head injuries from support of my own parents and parents-in-law. toddler falls, dying parents and possible scarlet fever to Successful childcare is inherently mindful. A new baby name but a few. I am obviously very careful to not treat reminds us of the simple things that yield the greatest friends and family so mainly listen, offer very general pleasures in life. They respond to smiles, music, facial advice and in particular, signposting to appropriate expression, dancing. This makes me contemplate and services. This reminds me how complex our ‘patient reprioritise what ‘I want our family life to look like’ but pathways’ are. Why should our patients be expert in the also that I want to make more non-pharmaceutical choice of 111 versus pharmacist versus 999 versus prescriptions. I want to re-enforce, even more so than attendance at A&E? We can educate and encourage before, the positive health benefits our communities can appropriate service use but we cannot expect this. provide to counteract the all-pervasive tide of the pharmaceutical industry’s profit margins. A new understanding of what I have learned to treasure the satisfaction of ‘family doctor’ means completing a task because motherhood means never finishing anything! So much about the normal human life cycle seems to fall But still, motherhood is hard. The highs are epically into place. We have a renewed need for our parents (to high, and the lows are epically low. The tiredness I feel is whom we thought we had bid farewell in our 20s) who not just like that of a long shift. The word ‘tired’ like the are desperately needed again to coo over our offspring word ‘pain’ encompasses so many different aspects of (with such efficacy that no one else really can achieve). human experience. Tiredness of motherhood includes They also provide pragmatic childcare or financial and derealisation, fogginess of thought and chronicity like that emotional support. For example, a 3-year-old not sleeping of work, but also a ‘deep ache into my bones’, as one of is going to be the whole family’s problem. Also, I now my mother friends describes it. know the main reason mum is asking me to check her To summarise – I feel that GP-mothers have unique seemingly well viral child is not just for ‘reassurance’ insights and skills in the world of motherhood. And but because they are so tired they’ve lost objectivity, mothers have unique skills and insights to use in the perspective and confidence in their own judgements. world of general practice. Though of course, even with This is especially so if mum isn’t there at all and dad has ‘unique insights’, I still frequently get it wrong! brought them and can’t actually give us the history!

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Alyson McGregor Director of Altogether Better, an NHS After spending many years working very hard in the NHS doing the wrong things well National Network Organisation I was lucky enough to become the director of Altogether Better and became part of a network of people who helped me discover what really matters. Working alongside a group of health leaders, doctors, academics, organisational development consultants, social activists and citizens I have learned that almost everything we do depends on other people and that to succeed we need to work as peers, as equals, valuing the contribution of others and working out solutions together. This means that we need to pay attention to the relationships we have with others and to focus on our connectedness. This learning underpins not only the way we work but our whole way of being in the world. It allows us to see the world as resourceful and abundant and full of amazing possibilities.

Introduction change, and develop a more sustained ‘We have increased our patient relationship with patients, carers and list by 4,500 people, that’s a 57% The NHS is no longer sustainable in citizens. But there are few examples increase, and we have seen no its current form as it struggles with the where citizens have made a significant increase in demand for either emerging challenges of an increasing change – through participation rather primary or secondary care burden of long-term conditions and than consultation – to the way that consultations because we do health needs generated by social general practice and wider health and things differently.’ factors such as isolation. The morale social care services are designed and Mev Forbes, Managing Partner, of staff in general practice is low, as delivered. Robin Lane Medical Centre pressures in the system increase and This policy backdrop echoes This new relationship and connected - funding is unlikely to match escalating Altogether Better’s vision for an NHS ness between citizens and services demand. Equally we are not serving where citizens are recognised as part leads to the emergence of a vast range the populations needs well; people of the solution and not the problem of new offers that promote wellbeing with long-term conditions are not and where citizens gift their time, and resilience, prevent ill-health, and getting the support they need and a talents and enthusiasm to work along - treat people who struggle to live well session with the GP can’t ‘cure’ side primary care workers as equal with their long-term conditions, isolation. partners. Using a systems model of isolation and loneliness. We have In response, the NHS Five Year organisational development and an worked with GP practices and citizens Forward View (www.england.nhs.ukk/ evidenced-based health champion ourwork/futurenhs) asks us to imagine approach to citizen involvement, we new models of care and ‘a future prototyped and scaled a radical where fully engaged patients, carers system-intervention which slowly, and citizens play a greater role in gently and subversively allows the their health and health care’ . It practice and the population it serves argues that health services need to to co-evolve.

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to create a future where general practice is drawing on the and the population they serve to co-evolve, creating a assets, strengths and resourcefulness of people in their movement towards a social model of primary care which communities as well as the staff in their services, to do could in turn lead to a more sustainable primary care things differently and find new solutions to the pressing system. The evidence tells us that when this approach and overwhelming pressures faced by healthcare services. works well, it leads to an NHS where: • a new social model of care emerges within general The overwhelming case for change practice which effectively reduces demand on GPs’ time in general practice • consultations in primary and secondary care reduce The kind of data needed to provide us with the whole • a new sustainable business model for general practice picture about what patients present with in general emerges practice is not routinely collected. However, it has been • staff morale improves estimated that around 20% of patients who consult their • we learn ways to connect and work together with GP bring what is primarily a social problem. In fact the people, not do things to them or for them Low Commission (2015) reported that 15% of GP visits • people in communities connect effectively with and were for social welfare advice alone. This may well be a work alongside staff to become part of the practice huge underestimate, for many GPs anecdotally report ‘family’, thus breaking down unhelpful and outdated much higher levels of demand. Far from addressing this hierarchies need, increasing the number of appointments or • patients get what they need and not only what extending opening hours will only make things worse. professionals can offer. ‘My estimate is that 40 –55% of the patients I see Our model started to take shape in 2012 when, combining every week could be better supported by someone theoretical models of organisational development and our else, they don’t need to see someone with five evidence-based, health champion approach to citizen degrees. It’s a rotating door; they just come back engagement, we created an innovative approach to again and again. Patients need people not pills.’ ‘community centred practice’ in three GP centres. The Dr Niall Macleod GP, Exeter impact of this was encouraging enough for us to explore Dr Niall Macleod, an Exeter GP, estimates that: how to scale up the work. We then developed and spread • 10–15% of people come with minor ailments – sore this approach to more than 60 practices, in 16 clinical throat, headache, that could be sorted by a pharmacist commissioning group areas, by working nationally and or a wise granny internationally with enthusiastic practices where citizens were invited to work alongside staff. We are noticing that • 10–15% of people he sees are depressed, anxious, when the right conditions are created, practices begin to stressed, fatigued. They need a job, friends, a loving see citizens as ‘ makers and shapers ’ in the system rather partner, NOT anti-depressants or counselling than ‘users or choosers’ who pass through it. They begin • 10% are overweight and have lifestyle-related issues to understand that the community is an asset not a type 2 diabetes, hypertension, heart disease. They burden. need to lose weight, move about more, eat fresh food. NOT blood pressure tablets Failure demand is a systems concept used in • 5% are lonely and the GP is the only social contact service organisations first discovered and • 5–10% are just getting old! They have lots of problems articulated by Professor John Seddon as ‘demand and there is no cure. caused by a failure to do something or do something right for the customer’. Seddon makes For these patients to medicalise their problems is the distinction between ‘failure demand’ and inappropriate, results in over-diagnosis and is equally ‘value demand’, which is what the service exists to frustrating for both patient and GP. GP training places provide. Failure demand represents a common remain unfilled, senior GPs are retiring early and type of waste found in service organisations. insufficient numbers of junior doctors are applying to Wikipedia join general practice because of a perceived impossible We begin by finding GP practices interested in developing workload. a new model of care designed to help them deal with the And it’s not just GPs who are affected by the current rising levels of failure demand generated by patients pressures in healthcare. Healthcare professionals generally whose health and wellbeing needs can’t be met by a work tirelessly to do their best for patients in the face of clinical intervention alone. ever increasing workloads. We support these practices in finding enthusiastic people willing to gift their time to work alongside the Stumbling upon a new model of practice as volunteer practice health champions. Then we general practice guide and model a way of working together, a way of being Responding to this crisis Altogether Better developed and connected which works for citizens and for the service. spread a system intervention that has allowed GP practices

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New service offers emerged from practices including Systems organise around a purpose, and so a way to kite flying, conversation club for non-English speakers, fundamentally change a system is to get it to identify a bipolar group, fatigue support group, cancer, chronic pain new purpose, often by formulating this as a question. The and diabetes groups, ukulele group, circle dancing for Huber definition helps us shape a new question: patients with dementia, glass painting, crochet and cross- ‘How do we support people to adapt and change in stitch. One practice became the first in the country with a the face of social, physical and emotional challenges?’ licensed bar while simultaneously reducing its primary and So health is no longer seen as the absence of disease, secondary care appointments! and the challenge is to create a system within which

people are able to adapt and change. When citizens The nature of disease has changed become part of this changing system the developmental a a work takes place in liminal space – where neither the fundamentally… we live in an age of rules norms and behaviours of the organisational world diseases which are largely social nor those of the ordinary social realm applied and would have to be suspended in order for exciting possibilities to be generated. We found that having champions as part of the practice changes the nature of the ‘practice family’ so that During liminal periods of all kinds, social both groups co-evolve to do things differently. This in turn hierarchies may be reversed or temporarily leads to benefits for patients, champions and the practice. dissolved, continuity of tradition may become What has emerged is a new collaborative community- uncertain, and future outcomes once taken centred model of general practice. for granted may be thrown into doubt. The New relationships between champions and practices dissolution of order during liminality creates become embedded and are sustainable in the long term a fluid, malleable situation that enables new without ongoing funding. As champions merge into the institutions and customs to become established. ‘practice family’ they simply become part of ‘ how we do Wikipedia things round here ’. Working in liminal space A new mind set Liminal space happens at the boundary between the The starting point for the work is the recognition that formal world of organisations and the informal life-world the NHS is now functioning within an entirely different of citizens. Inviting citizens and services to work together environment than in its formative years. The nature of towards a new system, we realised unexpectedly that a disease has changed fundamentally; our healthcare new world and a new language was being created. It imperatives are no longer driven by the need to fix became clear that working at this boundary required a infectious disease or broken bones. We live in an age of different way of seeing the world, and a new set of skills, chronic complex multi-morbid diseases which are largely norms, behaviours and language, which were all very and fundamentally social in character. Demand is different from the traditional NHS approach. provoked by either social factors, such as isolation, diet, poverty, or by an individual’s inability to adapt well to living with long- Balanced between two world views term conditions such as diabetes, asthma or dementia. These impacts are not fixable but neither do they go away. This calls for The ‘Life world’ Formal systems/institutions an adaptive response, a process of coming Practice to terms with their changed circumstances • People with myriad and • Roles, qualifications, titles unique skills, interests, Health and the need to deal with life differently. Champions • Fixed & legitimised identities These are both social processes, not ‘clini - values, beliefs, needs • Processes & structured cal’ or ‘professional’, and can be met more • Multiple and fluid interaction identities effectively with a social response rather • Protocols and pathways than a professional, clinical response. So • Human interaction • Fixed definitions the challenge for society now is to create • Flexibility, improvisation • Data systems within which people can adapt • Stories • Hierarchy, authority and change and achieve ‘health’ which is, • Relationships • Monetary economy, fixed as Huber defines it, ‘ the ability to adapt • Non-monetary, fluid ideas of currencies and and self-manage in the face of social, ideas of exchange and exchange reward physical and emotional challenges ’ • Planned order (Huber et al , 2011). • Emergent order

© Altogether Better 2015

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improvements in patients’ wellbeing and resilience and …Patients draw strength and a better understanding of how and when to use services. a a This increased resilience in turn leads to an ability to resilience from the community… adapt, cope and live well with long-term conditions. In and learn to live well or better other words, patients draw strength and resilience from the community – ‘people like me’ – and learn to live well or better, adapting to the ever-shifting challenge of health Some people (practice staff and champions) concerns that cannot be ‘fixed’ by clinicians. With over instinctively understood what the work was about. 15 million people in the UK living with one or more long- Some struggled. Those who struggled saw it as either an term condition, this work could not be more timely. extension of their employing organisation’s way of doing things or they thought it was having a new group of ‘friends’ attached to the organisation/system. Those who A new model of systems-working understood recognised that it was neither. The closest real This work is not social prescribing in the usual sense of life analogy is that of a beach, a place that is neither land shifting the burden from one professional (GP) to another nor sea and upon which human behaviour differs from (third sector providers). Nor is it for creating new referral that normally found on either. On the beach, normal rules pathways whose starting point is still the doctor’s or are suspended and we behave in very different ways for nurse’s consulting room. It is not ‘signposting’ or a means example we dress (undress) and behave in ways that of parachuting volunteers into a practice setting. It don’t happen elsewhere. Similarly, when connecting and requires both a shift of mindset and a slightly different working together in the space between the formal and way of organising. So unsurprisingly these changes don’t informal worlds, traditional language and ways of working happen without skilful support. The biggest threat to are no longer effective or appropriate. A major part of the scalability of this approach would be if system leaders, work for Altogether Better was to challenge language and GPs and practice managers failed to take the time to behaviour wherever it slipped out of the liminal space and understand what is radically (but subtly) different about back into either world, so that champions and practices our approach and so default to framing it merely as a might come up with appropriate and fit for purpose volunteer programme. language and behaviours.

‘It feels like we’re a GP practice within a larger organisation. There’s the general practice 94% of patients surveyed primary care bit which is wrapped around with a a a much bigger range of things going on.’ reported increased Dr Linda Belderson, GP, Robin Lane Medical Centre, Leeds confidence and wellbeing One of the key lessons was that champions do not receive monetary reward (formal world) but are doing what they Our evidence is growing and compelling, and our do for a purpose; and not just for pleasure. This meant approach to ‘community centred practice’ has gained that the practice needed to find different ways to value national and international recognition. Forward thinking and recognise the champions. Another theme was the practices and commissioners are pulled towards it, value of sharing tea and cake to strengthen relationships recognising it as one of the solutions to the challenges while planning new activities. However, it was equally faced by primary care teams under huge pressure. When important that the social aspect didn’t take over and stop enthusiastic practices and champions work together we effective planning from being done. To connect effectively see significant improvements in mental health and the conditions need to be created in which the champions wellbeing and overwhelming support from practice staff don’t just enjoy the experience (lifeworld) or just get the to embed and sustain the work: task done (formal world), but enjoy both the process and the end result of making a difference. • 94% of patients surveyed reported increased What grew out of this new understanding of working confidence and wellbeing in liminal space could not have been predicted. Citizens, • 94% acquired new knowledge about health and joining this work as volunteer Champions who had been wellbeing invited by their practice to work with them, drew on their • 99% reported increased involvement in social own passions, interest and resourcefulness to generate an groups and activities enormous range of groups, activities and events for the • 95% of staff surveyed recommend and want to patient list. A comprehensive evaluation, which drew on continue the work. evidence from the government’s Foresight Project and the New Economics Foundation, demonstrated that 216 different champion-led activities brought about

© Journal of holistic healthcare G Volume 13 Issue 1 Spring 2016 23 CONNECTED Connecting citizens and services in new and meaningful relationships to transform healthcare

A case story from Robin Lane Medical isolated; they have made new friendships and use services Centre, Leeds: Creating a sustainable differently’ (Mev Forbes, Managing Partner). future for general practice Evidence of improved efficiency and increased productivity: ‘We had a growing realisation that general • The practice has increased its patient list by 57% practice was unsustainable in its current format. from 8,500 to 13,000 patients without any increase in We knew that funding was going to be an issue. primary of secondary referrals and a 10% reduction We can’t just go on employing more and more in use of A&E doctors to meet more and more demands, we had to think quite radically about how to change • There is evidence of increased efficiency by dealing demand in the first place.’ with failure demand Mev Forbes, Managing Partner • Over 50 volunteer practice health champions work alongside the practice team Robin Lane now works with more than 50 enthusiastic citizens who deliver 19 different kinds of groups and • The practice has reconfigured its staff team and activities. As well as the plethora of champion-led social redesigned its offer to respond to the new challenges, groups, the practice now runs a Ukulele group, provides choosing not to appoint to a vacant salaried GP post 7 day a week breastfeeding support delivered by but instead choosing to invest in a community champions, keeps a constantly updated dynamic matron and a wellbeing co-ordinator directory of local services and resources and signposts • The practice has evolved to do things differently – its and routes people to activities in the community. identity has changed. It no longer describes itself as a Champions also support service delivery in many medical service and is rebranding as the Robin Lane different ways including for example increasing the Health and Wellbeing Centre. number of people attending Saturday flu clinic from 300 to over 800 people. Huber et al , BMJ , 2011 How should we define health. BMJ ‘The champions have enabled a lot of things to 2011;343:d4163 doi: 10.1136/bmj.d4163 The Low Commission (2015) The role of advice services in health happen which wouldn’t have been able to happen outcomes: evidence review and mapping study. Available at: otherwise’ (Linda Belderson, GP). ‘But the great story is www.lowcommission.org.uk/dyn/1435582011755/ASA-report_Web.pdf that lives have been transformed, people are no longer (accessed 12 March 2016)

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24 © Journal of holistic healthcare G Volume 13 Issue 1 Spring 2016 COMPASSIONATE Closing the compassion gap in health and social care

Andy Bradley Frameworks 4 Change

I founded Frameworks 4 Change 11 years ago as I felt so unsettled by the pervasive culture in health and social care which is driven more by the forces of competition and regulation than those of compassion and our shared humanity. Having spent part of my childhood living in a care home established by my parents (which operated as a compassionate community) I now realise I caught a glimpse of how good and kind we can be given the right conditions. We all matter and we all need to belong. We must join with each other to write a wiser, more collaborative and integrated story of health and care. This article is my attempt to summarise how our Frameworks 4 Change work developed, its impact and our direction of travel into the future.

Compassion is not something abstract. to those using these services (that will home), which was home to both my The catastrophic failings of care include most of us eventually) that family and older people living with revealed in the report on Mid Staffs they are the ones at risk of a dementia and in need of care and and the Panorama exposé of compassionate deficit. Why do we so support. Having spent 15 years shocking abuse at Winterbourne View often hear about a lack of compassion working in health and social care provoked widespread calls for NHS for patients but so little about environments in care and support and social care staff to be more compassion for the people whose job roles and then as a leader I realised compassionate. But I am convinced it is to serve them? In fact if compassion there was a gap between the culture that speaking about compassion as if can’t flow from self to self and from and practice I grew up with, and the it were some disembodied abstract others to self then it’s more like pity current pervasive culture in health commodity may do more harm than than compassion. In such a deficit and social care. good. For if those calling for a model as this, where there can never In our ongoing enquiry we use compassionate collective response be enough compassion to go round, Professor Paul Gilbert’s definition of are not themselves in a state of any spare compassion and kindness compassion. He views compassion compassion this creates a fundamental remaining in the system has to be ‘a s a sensitivity to the suffering of self problem. Apart from any other passed on to patients, and those and others with a deep commitment consideration, assuming a general lack providing the care will be left out. to try to relieve and prevent it ’. of compassion among health and Compassion, he says requires courage social care professionals and then The development of and dedication. Courage allows one exhorting them to do better is ‘to approach, understand and extremely damaging to morale. compassion circles engage with suffering, to look into Since its inception in 2004, its causes; and working to acquire Inclusive compassion Frameworks 4 Change has engaged in wisdom and skills to alleviate and an ongoing enquiry into compassion prevent suffering requires dedication ’. Why is the narrative about compassion in health and social care, and the Our work is much influenced not so often about other people? A central conditions that allow it to flow. I was only by Paul Gilbert’s Compassionate problem in our understanding of how fortunate to spend part of my child - Mind Foundation, but also the writings to cultivate compassion in our health hood living in what I now think of as of Nancy Kline ( Time to Think ), Jon and care system is that we project on a compassionate community (a care Kabat-Zin ( Full Catastrophe Living )

© Journal of holistic healthcare G Volume 13 Issue 1 Spring 2016 25 COMPASSIONATE Closing the compassion gap in health and social care

and Charles Duhigg ( Power of Habit ). As our project that truth. It encourages spontaneous expression evolved, it has centred around three questions: of who I am being right now. In doing this it also 1 What is it that activates a fierce commitment to counters one of the seven social processes that self-compassion? Zimbardo says “grease the slippery slope of evil”: the “de-individuation of self”.’ 2 How can we systematically grow safe and soothing spaces for reflection on the inhibitors and facilitators Maxine Craig, former long-time leader of organisational of compassion? development for South Tees Foundation Trust was one 3 How can we make more rapid progress in evolving of the early adopters of compassion circle practice. She systems that enable and encourage us to be more introduced it into the trust and, as part of NHS Change human with each other? Day in 2014, also offered space for the practice in the Town Hall. Maxine reflected on how challenging it can be Compassion circles developed as a response to these for people to think about self-compassion: questions. The first two-and-a-half-hour compassion circle took place in South Tyneside in June 2013. There, we ‘I come from a generation of healthcare provided a space for health and social care leaders to professionals who were trained to “leave their come together to talk about self-care, about blocks to emotions at the ward door”. Professionally compassion and ways of growing a more compassionate socialised to believe that we, the nurses, were system. One of the senior NHS leaders at the meeting unimportant, that our patient’s needs were (whose work is centred upon kindness in teams) was in paramount and they were best served with kind - touch next day to suggest that a one-hour version of the ness and compassion and technical expertise, compassion circle would have the potential to roll out which should always be on show, irrelevant of nationally. how you were actually feeling. We were taught This led us to design a one-hour compassion circle for that we should work hard, serve the patients, and up to 12 participants. Our vision was for all health and that the work would be highly emotional but that social care workers never to be more than a month away we should be able to control that emotion and from their next safe, compassionate ‘top up’ where they continue to care for others, putting our own could reconnect with their meaning and purpose, have needs to one side. Being authentic was not part space to think about self-compassion and to focus on of my initial training. The reward for this inhibitors and facilitators of compassion. approach was that the honour of caring for In these early days Professor of Psychology Steve others would sustain us. Now some of this is true Onyett, who energetically supported us (see note at end), and some of it we now understand better. had this to say after attending a training session for circle My work in the NHS will always be my calling, it facilitators in Exeter: is a true vocation for me, I came to make things ‘Zimbardo (‘The Lucifer Effect’) argues that “If better and the rewards of improving things, you want to change the person you’ve got to relieving suffering, fostering independence are change the situation”. In this he is asserting the indeed rewards without measure. However importance of culture: how we do things around “leaving your emotions at the ward door” was here. I have recently explored the issue of possibly understandable as an instruction before cultures of compassion and how to prevent the we knew about such things as emotional labour, tragedy of the failures of care in Mid burn out and the importance of authenticity. Staffordshire happening again and again . In What we now know changes things, the research order to understand a culture we observe others into all these areas tells us that … and act in order to see how the system responds. • to give our best we must be at our best We are hard-wired to do this very quickly. • and that means caring for ourselves, in order Compassion Circles have the potential to that we can care for others promote different ways of being by offering a space where I can witness the people around me, • so if you do nothing else this week in your and myself in the process, when we are voicing team, begin gently to ask the question “what our best values and hopes for the future. could you do more of to care for yourself more deeply?” ‘Zimbardo highlights the chilling power of anonymity, citing research that shows how Expect your colleagues to be quiet, a little people can act in the most bestial ways when uncomfortable, but please stick with it because they are able to hide their identity (for example in my experience it’s vital to the creation of in military uniform). Compassion Circles great teams’. encourage people to listen to themselves, focusing on what is being felt in the moment and to speak

26 © Journal of holistic healthcare G Volume 13 Issue 1 Spring 2016 COMPASSIONATE Closing the compassion gap in health and social care

Integrating compassion circles Mindfulness in the evolution of with other approaches compassionate organisations A large mental health trust in the south which has been Relational intelligence leading the way in implementing mindfulness-based The Director of Patient Experience for the NHS in the approaches has paved the way for the development of a South of England attended an open compassion circle in mindfulness centre. Psychologists and researchers from March 2014. At this time continuing healthcare (CHC) the centre were curious about compassion circle practice assessors were facing particularly high stress scenarios. and how it might complement its already well-established They had a programme on communication skills whose mindfulness work for patients and staff. lead trainer had previously led on design and training in Based on the feedback report from five compassion an advanced communication skills course for cancer circles in the trust we evaluated participants’ attitudes professionals. towards the compassion circles.

All participants said they had a positive experience of

the compassion circles. Satisfaction was rated high (mean Why do we hear about a lack of = 7.71). Most participants felt strongly that compassion a a circles could be used to look after their own wellbeing compassion for patients but so little (mean = 7.35), and the wellbeing of colleagues and clients (mean=7.16). But they were more moderate in rating the about the people who serve them? extent to which the circle helped them see the trust differently (mean = 5.99). The patient experience team was wondering about the In our ongoing collaboration with senior leaders and connections between compassionate practice (beginning the mindfulness centre, we have been presenting at with compassion for oneself) and a practitioner’s necessary conferences on leadership, mindfulness and culture ability to sustain their emotional connection and psycho - change. Most recently senior leaders took part in a two- logical wellbeing despite being frequently involved with day programme (‘Engaging meetings’) aimed at very difficult conversations. We therefore piloted a transitioning compassion circles from being ‘pure’ programme integrating a compassion circle into practices of mindfulness, towards becoming integrated communication skills training, and this was well received into the everyday business of running a large complex by participants. high pressure NHS trust. The aim of engaging meetings This programme for CHC teams, which continues to training is to help the emotional tone of compassion evolve, is now rolling out nationally. A report on the circles to cross over into organisational life and create the programme’s success invites a deeper enquiry into safe psychological conditions that enable healthier, more capacity-building. If, as this report implies, compassion is productive meetings to happen. Engaging meetings a process which supports practitioner resilience, good trainees are forming a community of practice. Responding communication and better patient experience, circles to a question about the most useful aspects of the could become more widely accepted as a way of supporting programme one of the participants said: ‘ Bringing in the growth of healthy compassionate organisations. humanity and vitality to de-humanised systems. Recognising the way the programme has evolved the Practicing ideas for how to run meetings differently – work is now described as an ‘advanced relational skills offering a different culture ’. programme’ and the trainers have developed a working definition of relational intelligence: Figure 1: Attitude towards compassion circles

‘The skills, knowledge and experience ) 9

required to relate effectively, both – 9 7.71 7.53 1 7.35 7.16 (

8

intra-personally (self-to-self) and inter - s 5.99

g 7 n personally (self-to-other); this includes i 6 t

a 5 r

relationships at communal and societal 4 e l 3 levels as well as the less than conscious a c 2 s

1 aspects of our relational patterns’. t r 0 e k

i Satisfaction Extent Extent Extent circles Extent circles

The trainers felt that this term captured the L with experience experience could be enabled you n spirit and themes of the day: acknowledging a experience could be could useful to to think e

the difficulties in our working relationships; m used to look support you colleagues about trust

l

a after own to attend to differently becoming more aware of how we get stuck in t

o wellbeing colleagues unhelpful relational patterns; and practising T and/or how to relate in more intelligent and caring client’s ways towards ourselves, our colleagues and wellbeing service users. Attitudes towards compassion circle

© Journal of holistic healthcare G Volume 13 Issue 1 Spring 2016 27 COMPASSIONATE Closing the compassion gap in health and social care

Can compassion circles and On the second round of comments it became related practices spread? clear that the group had come to a unanimous answer to the question of how we encourage At times it feels as though there are only two problems others to be more compassionate. The answer with spreading the practice – the first is the word was that we must show others compassion compassion and the second the word circle! ourselves. We all felt that it was the compassion

that we had been shown in our own lives that

had made us feel compassionately towards Most participants felt strongly that others. a a compassion circles could be used We ended with a round of thanks and they left with smiles and a much more positive outlook to look after their own wellbeing towards their work. Two members of staff actually shook my hand and said that they had enjoyed listening to what others had said as well In our overstretched dehumanised health and care as being listened to themselves. All said that they system, sitting together in a circle taking turns to think were looking forward to the next meeting and and being invited into an awareness of our own and each inviting others to attend. other’s needs is counter-cultural. Yet there are grounds for hope. As the general sense of crisis and of urgency around Reflecting on the meeting I was struck by the the need for cultural and systemic change grows, circle simplicity and beauty of the answer that the practice alongside mindfulness and advanced group had come to. I was also surprised at how it communication skills is finding a home inside the system. mirrored the message of so many ancient After attending a two-day compassionate practitioner philosophies, religions and teachings. programme, a care home manager decided to take Ancient wisdom….. in 29 minutes.’ matters into his own hands. Instead of the hour we usually set aside, he and the participants only needed 29 minutes Acknowledgements to attain what he calls Ancient Wisdom. Along with many of Professor Steve Onyett’s friends and ‘The afternoon of the meeting was a busy one and family we were devastated to hear of his sudden death in staff entered the room flushed with their efforts September 2015. Steve died suddenly as a result of a and the stresses of the day. They were initially cardiac arrest – he was cycling across Palestine to raising wary of the circular seating arrangement but all funds for Medical Aid for Palestine at the time. Steve was listened intently as I explained the format of the one of the most ardent advocates of compassion circles meeting and we concentrated on our breathing and his passion kept us going through times of adversity and clearing our minds of distractions. The and criticism. Together with Steve’s partner we are silence was eventually broken by me informing thinking about future compassion circles being renamed the group of our question which was “How can Onyett circles in his memory and with the intention that we encourage others to be more compassionate”. his spirit lives on through the practice. The first responses to the question were that We are indebted to Professor Paul Gilbert and people were either compassionate or they were colleagues at the Compassionate Mind Foundation and to not, and that we could not teach people to be Jon Kabat-Zin and Nancy Kline for pioneering new compassionate. Others felt that leading by approaches which help us to be human in this complex example was important. Gradually as we went and frightening world of ours. round the group, people began to recount We acknowledge all of the inspiring people we have influences and experiences that had affected been privileged to work with in the health and care them and instilled in them the importance of sector – your energy, courage and vision gives us the compassion for others. Tales of lost loved ones determination we need to carry on. and people who had touched their lives in a Please be in touch to discover more about compassion meaningful way were told, some tearfully, some circles and our work. with deep affection but all contributed to the [email protected] group’s understanding of the effect that compassion had had upon their attitude to others. The stories were incredibly moving and powerful.

28 © Journal of holistic healthcare G Volume 13 Issue 1 Spring 2016 INTEGRATED Medicine as if people matter – integration rather than breakdown

Michael Dixon Chair, College of Medicine

Ten years into general practice, I was burnt out. Swamped by patients presenting with a range of problems from chronic tiredness, frequent minor infections, irritable bowel, headaches and back pain to stress, loneliness and sheer misery. Discovering complementary medicine gave me back my professional life and radically altered my views on how to heal and the importance of balancing the perspective of clinician and patient. The College of Medicine advocates an open-minded approach to health and healing that includes complementary medicine and other non-biomedical interventions such as the arts and healthy eating, which are being increasingly offered under the umbrella of ‘social prescription’, which is another college-led initiative.

A place for evidence is unlikely to be available persistent back pain. Most clinical complementary in the near future, and this lack of commissioning groups (CCGs), funding for research leaves despite their statutory responsibility to medicine in the NHS? complementary medicine in a cleft innovate, have continued to withhold Ask a conventional scientist or public stick and largely excluded from the funding for these options on the basis health physician and the answer to NHS. It has to be said that there is that they do not have enough money this question would most probably be more than a trace of hypocrisy in this, for engaging new services. Perhaps, ‘no’. Patients (at least 75% of them given that much conventional primary given the current state of our cash- according to a number of surveys, care (25% by conservative estimates) strapped NHS – which can barely meet including two by the BBC) appear to also lacks an evidence base. However, demands for standard treatments – we disagree and say that complementary a forthcoming scoping study should sympathise. medicine should be offered on the supported by the Department of NHS. Meanwhile, clinicians are split in Health is looking into the potential Clinicians and CM their opinions. Is there any room for role of complementary medicine. Led compromise? by Bristol Professor of Primary Care If commissioners and central Many conventional scientists and Debbie Sharp, it could, if it produces government seem negative then medics would say that the issue can be a case for greater research investment what about clinicians, many of whom resolved with high quality comparative for complementary medicine, in time already provide complementary cost effectiveness evidence showing if redress the balance. medicine as part of their NHS service? and where complementary medicine That includes 50% of physiotherapists (CAM) might offer better value than Double standards who offer acupuncture. An unknown currently provided conventional number of GPs offer acupuncture or treatment. Therein lies a problem. Yet the NHS’s double standards prevail hypnotherapy, homeopathy or (a That is because the much-needed even when complementary medicine meagre few) even osteopathy and studies – pragmatic service-based research has produced an evidence other complementary techniques. comparative trials of cost effectiveness base. Take for example the much They do this because they have found – have seldom been done in an NHS reported NICE guidelines (now under these skills help relieve patient that spends 0% of its research budget revision) which include acupuncture, suffering where conventional medicine on complementary medicine. So such chiropractic and osteopathy for fails. As just such a clinician myself, I

© Journal of holistic healthcare G Volume 13 Issue 1 Spring 2016 29 INTEGRATED Medicine as if people matter – integration rather than breakdown

have found that using these approaches in my everyday conventional scientists must be right and that therefore clinical work increases patient (and my own) satisfaction. patients’ experience is worthless? But the ground that Furthermore it gives me something extra to offer while fundamentalists stand on appears to be moving. The reducing my referrals and overall patient costs. In addition Rotherham Clinical Commissioning Group does not we now have some complementary practitioners on site, directly commission complementary medicine but it has and this has led most of my GP partners (believers and introduced social prescribing. This initiative, directed at non-believers) to recognise their value. In a few cases the 2/3% patients who use hospital services the most, these practitioners have been the early detectors of enables them to access a range of extended services they serious problems in patients referred to them: among my believe might be helpful. This has substantially reduced own patients, melanoma, temporal arteritis and spinal their hospital use and overall costs and notably one of the secondaries. most common requests has been for complementary medicine. By default and by a process of subversive patient-led sub-commissioning, the health service is once The problem is that we have again paying for complementary medicine. If this is a way a of saving costs and meeting patients’ needs, this trickle of

established a very linear form of change through the dam of prejudice could, as personal

biomedical science that doesn’t budgets come on line, become a flood. fit the real world of patients and a Fully human medical science their frontline practitioners The Rotherham example suggests that something has gone wrong in the system elsewhere. The problem is that we have established a very linear form of biomedical science that doesn’t fit the real world of patients and their Integrated services frontline practitioners. It doesn’t even conform to good A decade ago, this kind of integrated service was less of a science, but demands instead the narrowest possible rarity than now. And, since it can add so much value on so definition of what is real and true according to experiment: many levels – not least economic – it is curious to say the a version of science that views human nature, the least that the many integration innovations of the 90s and mind –body connection and therapeutic relationships as noughties have withered away. Yet there are a few staunch nuisance elements. Consequently, many patients and quite innovators left, such as Whitstable GP John Ribchester. a few frontline practitioners who take human factors very The triaging service for people with musculoskeletal seriously, and who integrate them into their work, are problems which John has developed, offering acupuncture finding better solutions than current science is prepared and chiropractic, has shown significantly reduced secondary to embrace. This response does not disregard science but care referrals and overall costs over several years. demands that science widen its scope to embrace the real world of experience. Integrated clinical science includes a patient’s history, culture, beliefs, and aspirations; it factors Fundamentalism in science in psychosocial as well as mere biological considerations; Yet tolerance of clinical opinions outside the box is now it tries to balance the realities of individual differences under threat. The Council of the Royal College of General with the validity of traditional averaged out population- Practitioners recently voted against GPs providing home - based evidence. opathy. There is growing hostility towards clinicians who do not fit a ‘conventional norm’: the government plans to Individualised medicine blacklist the use of homeopathic medicines by GPs – a decision hardly based upon economics for the total cost In the same way that genetic mapping and the very latest of these medicines is only £110,000 a year (approximately focused treatment of cancer aims to fit the individual £10 per GP practice). Nor apparently is it even founded on patient, so the art/science of treatment generally, but principle but, allegedly, on fear of legal action from those especially in primary care, needs to become more specific who oppose complementary medicine. Homeopathy may for each individual patient. It also needs to become more in clinical and public eyes be less credible than many other generous and understanding. Conventional science would complementary therapies but surely it does not justify say, for instance, that if a trial of a given therapy produced what seems dangerously akin to a McCarthy-like purge? negative results for those that didn’t believe in it and positive ones for those who did, then the treatment did not work and should not be funded. That is not a logical What do patients want? scientific conclusion: surely it would be justifiable to offer If the NHS is institutionally biased against complementary such a treatment to those who believe in it, as long as medicine and its practitioners are to be ostracised, then costs are saved. To say otherwise is to deny a treatment what about patient opinions? Are we to say that that works for some and will make more resources available for others.

30 © Journal of holistic healthcare G Volume 13 Issue 1 Spring 2016 INTEGRATED Medicine as if people matter – integration rather than breakdown

It’s complicated Courage, collaboration and This takes us to the heart of the issue. Increasingly, the confidence mainstream view of medicine confines it to applying We need more of this kind of courage if we are to experimental and population-based research; hopefully re-humanise primary care. There can be no doubt that (but not necessarily) delivered in a compassionate high-tech secondary care using population-based research environment. But good medicine is more complex, has conquered some of the high ground: cancer, heart artistic, subtle and intelligent. In real life many symptoms disease and a number of life-threatening conditions. But are metaphors: the headache or chronic tiredness that where long-term disease and less serious conditions are represents an accumulation of negative features in a involved, complementary approaches and lifestyle patient’s life; the pains in back, guts or genitals that arise interventions and mind-body medicine may prove from chronically held tensions whose back-stories can’t cheaper, safer and more satisfactory to the patient than be told; the chronic diseases rooted in lifestyle or environ - expensive conventional treatment. More often than not, it mental pollution. Additionally the beneficial effects of seems that providing patients with a choice may lower some treatments may derive from some cultural or costs. Perhaps it is time for scientists, commissioners and personal symbolic significance. How else to explain the clinicians to trust better the judgement of their own greater use of acupuncture in China or suppositories in patients and research the outcomes and implications of France? Medicine must not be dumbed down to the letting them decide. mindless application of biological guidelines doled out by practitioners who have become coerced medical clones.

Patients (and most doctors) know there’s more to Healthcare is in a crisis. medicine than this, but the corporate NHS it seems, a prefers to ignore it – because of course, it complicates Intolerance, conflict and things. faction-fighting won’t helpa us Is there a way forward? find ways out While the NHS examines the potential role for complementary medicine (and hopefully supports some Indeed, if we do take the rhetoric of a ‘patient-centred’ proper cost-effectiveness evidence with which to judge it) NHS seriously then we clinicians, rather than foisting our clinicians and commissioners should be encouraged to narrow ‘scientific’ opinions and beliefs on them, should try out the intelligent introduction of complementary see ourselves as their servants. Patients deserve a voice, therapies because we need to find out what they can and a voice that must now be taken seriously by NHS achieve in real world situations rather than atypical commissioners and clinicians. Now is the time for a more experimental settings. The question is, are they cost- mature and curious attitude to complementary medicine, effective with typical patients in typical clinical settings, and for its leaders and clinicians to feel less bullied by the and can we show – through audit and comparative lobbying and aggressive anti-CM voices and their pragmatic studies – that they are helping patients and mysterious agendas. saving money. Whitstable and Rotherham are leading the Healthcare is in a crisis. Intolerance, conflict and way. There, clinician and the commissioners, though faction-fighting won’t help us find ways out. Though some agnostic on the complementary versus conventional issue, bloggers still like to amuse themselves by stoking CM have been free-thinking and innovative enough to enable controversies, and a few pundits have built careers on local clinicians and patients to find their own solutions. these flimsy foundations, actually these people are just climbing up the signpost. For CM controversies actually tell us a lot about what’s gone wrong with medicine.

Additionally the beneficial effects Understanding, open-mindedness and tolerance are what

a we need, not just for CM but for the very idea of medicine of some treatments may derive as an art as well as a science. from some cultural or persona l symbolic significance

© Journal of holistic healthcare G Volume 13 Issue 1 Spring 2016 31 COMMUNITY-MINDED The Lambeth GP Food Co-op: An emerging model of community co-operation

Ed Rosen Principal lecturer, London South Bank University Faculty of Health and Social Care; director, Lambeth GP Food Co-op I became involved in learning how to support change in the NHS firstly as education advisor at London Deanery where I led early work on patients as partners in post - graduate medical education. Learning to help the system better understand itself and change effectively and humanely brought me into leadership roles in workforce development, which launched my short-lived career as builder of new national learning systems otherwise known as NHSU where I was Head of Learning and Teaching. The Lambeth GP Food Co-op represents all that I’ve learnt over more than 20 years in working with communities and individuals both in the NHS and beyond. I am an experienced inventor.

The Lambeth GP Food Co-op is a emerging abundance as we explore Could we transform and co-operative of patients, doctors, the key themes which have influenced creatively use unproductive space in nurses and local residents. We build our thinking since the Lambeth GP a GP surgery to engage patients in gardens in GP surgeries which are Food Co-op began its life in March productive activity? Could we transform designed for food growing. Patients, 2013. an alleyway into a food growing many of whom are socially isolated The Lambeth GP Food Co-op garden? Could we create a network of and have long-term health conditions, emerged as an idea from conversations food growing gardens linking separate are invited to become actively involved that included patients, GPs and others GP practices into a borough-wide in food growing. The co-operative is at Lambeth Walk surgery in May 2012. organisational network? Could we the first of its kind in the NHS but the These informal conversations had co-design and develop our own model ideas which have inspired our work been going on for some time and of people-powered health across our are not new and some of these ideas were focused on engaging patients community? predate the creation of the NHS. specifically from the Expert Patient Funding was secured from The borough of Lambeth is located Programme on exploring new roles Lambeth Council’s Co-operative in South London with a population of that they might take on within general Investment Fund and match funding 313,000 and is an inner-city borough, practice and a wider NHS environment. from the newly established Lambeth it has significant levels of social and We were interested in discussing how Clinical Commissioning Group. We economic deprivation as well as nearly new roles might be best supported began a three-year development cycle 40,000 residents with one or more within a transformed environment in from Spring 2013 with the following long-term health conditions. Last year, general practice. The informal aims and objectives: the borough’s Food Banks reported discussions allowed us to think far • Work collaboratively with GP that nearly 15,000 people had beyond the role definitions that we surgeries to create a resilient accessed food supplies from one of had begun exploring, and these borough-wide network. the five Food Banks in the borough. included patient facilitator, patient • Transform unused space in GP There are also pockets of conspicuous mentor and patient navigator to surgeries into food producing wealth dotted across Lambeth, each of include patients and professionals gardens. which reflect the growing prosperity being engaged in transforming the of significant numbers in our local actual space in which general practice • Engage patients especially those community. We will return to this exists. It was a ‘what if’ conversation. with long-term health conditions dynamic between unmet need and who are often socially isolated and lonely in gardening.

32 © Journal of holistic healthcare G Volume 13 Issue 1 Spring 2016 COMMUNITY-MINDED The Lambeth GP Food Co-op: An emerging model of community co-operation

• Create a community-led co-operative embedded the Coalition government in 2012/13, with implementing in general practice as a model for a wider health the Health and Social Care Act provided an opportunity community. for beginning a local innovation through which several • To build a new social business which would sell policy themes were interwoven. These included a more locally-grown produce through procurement to a local radical approach to direct patient involvement in the hospital. organisational life of general practice: readjusting relation - ships between the wider general practice workforce and • Provide employment pathways into the horticulture/ the local community; exploring the creative use of ‘Public’ fruit sector for local residents who are currently space in general practice and deepening our understanding inactive due to poor health. of what it really means to work together as a community

of co-operators. Could almost complete strangers, many

of whom were not very happy co-operate? Our theoretical We have learnt to take a flexible framework included for example, Richard Sennett’s: a a Together: The Rituals, Pleasures and Politics of approach to engage in the Co-operation. The work of the Late Professor Bob Sang. co-design process (Better Health in Harder Times: Active Citizens and Innovation) on the Frontline. Policy Press 2013, provided a rich and radical conceptual landscape which helped us We began a three-year developmental cycle which think about patient empowerment in a community included creating a sustainable network of GP surgeries, context, its potential and its limitations. ranging from a single-handed practice to a multi-partner organisation. We worked with a diverse range of GP surgeries with the aim of deepening our learning about the project’s fit with different organisational forms of primary care. A further aim was to deepen our learning about change in general practice by working with a diverse collection of GPs and their organisations. One of the challenges we faced was to introduce a food growing garden which went beyond one model fits all. We worked as far as possible with patients and staff on a co-design process which more often than not resulted in a food growing garden designed to fit with the spatial requirements of the individual surgery and the cultural acceptance of the project as presented in the form of a garden. This was time consuming and required skilled, patient facilitated dialogue which enabled everyone with an interest to find his or her voice and contribute to the Our first photograph (above) shows members of the eventual launch of a garden in the GP surgery. We have Lambeth GP Food Co-op building a garden at Mawbey learnt to take a flexible approach to engage in the Health Centre in Vauxhall. Andy who is seen at the fore - co-design process which has often resulted in us changing ground of the photograph is a member of the Lambeth our original ideas and expectations. For example, we GP Food Co-op but his real claim to fame is he previously began probably naively, thinking that we could build built the stages at Glastonbury. He is contributing his gardens in all GP surgeries who were interested in professional skills, personal knowledge and organisational working with us. This was not the case and for example expertise developed primarily at Glastonbury and else - at Edith Cavell surgery, we discovered that there was where, in helping build in a physical sense the garden absolutely no physical space onsite for a garden except needed to be used by patients who are unable to do so. on the roof which had no railings and therefore was This is community mutuality in action. It is one example of impractical. the hidden potential in all our communities to draw on We overcame this problem by linking Edith Cavell into what we have across our populations and to use people’s a large garden at Gracefield Gardens at Streatham High potential to create new forms of health generating Road, with Gracefield Gardens becoming the “hub” for people-centred social activity. Streatham High and Exchange surgeries as well as Edith Our second photograph (p34) is of Hilda and Cavell. Bernadette. Hilda is a midwife and master gardener who We began building the Lambeth GP Food Co-op at a has been facilitating the group at Lambeth Walk surgery at point in time when there was significant turbulence in the Kennington. Hilda is a founder member of the Lambeth wider healthcare sector which we used as opportunity to GP Food Co-op and represents the small group of nurses introduce what appears to be on the surface a simple idea: with expertise in food growing who have facilitated many building gardens in GP surgeries. The pause introduced by of the patient groups involved in food growing.

© Journal of holistic healthcare G Volume 13 Issue 1 Spring 2016 33 COMMUNITY-MINDED The Lambeth GP Food Co-op: An emerging model of community co-operation

resonate with our experience of working with patients, doctors, nurses and others in the actual task of building gardens, planting seeds and growing food.

If general practice is to survive in a a the future, it might need to become more community-based

We have extrapolated from the Expert Patient Programme, an approach to self-management which we have shaped to meet the needs of our project and have drawn inspiration from other self-management processes Our third photograph (below) was taken in mid-July and systems including self-managed learning and self- 2013, when we opened the garden at Lambeth Walk managed work teams within management and business. surgery to the wider community. If general practice is to To what extent has the project contributed to deepening survive in the future, it might need to become more our understanding of patient self-management beyond a community-based, and we think this photograph disease specific context into a wider organisational cultural expresses how an empowered community could be context? Do patients have the potential to become active engaged with its local health and wellbeing centre. and purposeful partners with health professionals in the future management and leadership of primary care. If patient participation was the answer, what was the original question? We are a co-operative. We are a community-led co-operative at an embryonic stage in our development having spent three years developing ourselves, our networks and our vision. The co-operative provides a home for us to begin exploring ways in which the NHS in its widest sense belongs to us and we belong to it as taxpayers, users/patients, decision-makers, active participants and critical friends. (NHS Constitution 2012: ‘The NHS belongs to us all.’ In June 2013, we were awarded the Best Sustainable Food Initiative in the NHS by Public Health England/NHS Sustainability Unit. This came as a wonderful surprise to Buckminster Fuller once wrote: me personally as we hadn’t actually grown anything. By early 2016, the project includes nine GP surgeries with ‘If you want to teach people a new way of more expressing an interest in joining the network. Last thinking, don’t bother trying to teach them. year, we extended the Lambeth GP Food Co-op into King’s Instead, give them a tool, the use of which College hospital. The Trust allocated the Jennie Lee will lead to new ways of thinking.’ garden for food production as their contribution to The Lambeth GP Food Co-op, from organisational change developing a partnership with the Lambeth GP Food perspective could be understood as a tool for catalysing Co-op. It is a rare example of a community-led, GP systems change at local levels. It has acted as a tin opener focused project working with a large acute hospital within the local system from which emerged the first signs involving patients from local GP surgeries growing food in of new thinking about social co-production, patient self- a hospital environment. The food grown from across the management and active citizenship. The concept of social project will, in time, be used in hospital menus to feed co-production is being explored at different levels across patients. We hope Aneuran Bevan would be delighted to the project’s activity and we are still at a very early stage in know that the Lambeth GP Food Co-op is blooming in his thinking about how models of social co-production partner’s garden.

34 © Journal of holistic healthcare G Volume 13 Issue 1 Spring 2016 RESILIENT A conversation with David Reilly Director of The WEL Project

I almost left medicine as a fourth year student. Science was ascendant in a system I found dehumanising. In staying, I resolved to change it, at least within myself. Rather than diseases and interventions, my work became centred on people, their capacity for healing change, and the conditions that affected this – within themselves and the surrounding relationships, environments and systems. Such talk was out of step back then, though not with patients then or now – and I found myself immersed in as rich an enquiry into human healing as I dared to imagine as that empassioned younger man. I have been part of change, and now, 38 years on, I have almost left the NHS, making ready for the new. David Reilly (DR)

Ever since my student days I have felt that medicine, though full of extraordinary people, too often bends its practitioners out of shape. Our emotionally demanding work steers us towards some strange ways of coping, and the casualty rates are so striking that only denial can explain our failure to prepare students better. The Westminster Centre for Resilience is developing training and exploring ways of reducing doctors’ rates of burnout and mental illness. This summer our symposium will bring together a national group of medical teachers working to build students’ resilience. David Peters (DP)

DP According to the research, morbidity. This is why I was so enjoy their work more, they are empathic doctors are more unhappy in general practice and also the ones most likely to resilient. I suppose being more had to leave, if I had stayed and suffer burnout 2 when as Aileen engaged, more capable of sacrificed my empathy there says, the workplace squeezes having positive therapeutic would have been no doubt that I out the space and time and encounters helps improve our would have burnt out! Hopefully, needed for whole person care. own sense of wellbeing. 1 We this [resilience] work can prompt A lot of great people work in know from experience, as well change within the system itself to the NHS. My hope is that as from research studies, that allow GPs to work to the best of resilience work like ours will this has a positive impact on their ability in deprived areas.’ help them find the energy and patients too of course: Balint focus to survive and become DP It’s a shame Aileen’s patients used to talk about ‘the doctor part of the change that’s and the NHS have lost one as drug’. needed. more empathic GP. I’m glad she DR Yes to all that, but for doctors had the freedom to get out: DR I think the slide into burnout working in deprived areas with most don’t. The great thing starts when you feel you’re multiple co-morbidity there’s no about being a GP is that it’s a disrupting your own integrity. denying that the systems we job for life, but that’s possibly Remember that GP survey I did? 3 work in constrain just how good the worst thing about it too, Back then I was trying to wave a job we can do when external unless you can find a way to the warning flag about this. predicaments pile up. Aileen make 30 years of meeting Nearly 90% of GPs in my survey McGrane, one of my team, just people in distress sustainable. said they felt holism was an sent me an email in response to And let’s face it, the primary essential prerequisite for good an article about the pressures on care frontline is a harder place primary care. But only one in five GPs in Scotland. She says … ‘the to thrive than ever it was; felt they could deliver holistic structure of the system doesn’t perhaps especially so for care! And that’s more than ten have room for empathy in a busy empathic doctors with high years ago. If your job involves time-constrained working day values. Although they’re complex person to person with patients with multiple potentially more effective and medicine there’s a terrific but

© Journal of holistic healthcare G Volume 13 Issue 1 Spring 2016 35 RESILIENT A conversation with David Reilly: Director of The WEL Project

mostly unacknowledged tension: you need empathy, biology that when humans witness suffering, you value it and you want to express it. But at the we mirror it unconsciously: because of mirror same time you’re the GP sitting with a list of 40 neurones – as you know David. So we reflexly people to see that day. So you drop into survival mode. frown or tense up when we see someone hurt We can say a lot about internal factors that build themselves. EEG studies that show how the resilience and support a truly therapeutic attitude, mirroring system triggers activity in our pain-brain yet we really mustn’t ignore the external factors; nor when we witness another person’s pain. But some that they are intensifying and the situation’s really interesting research shows that doctor’s brains getting worse. And yet still, when a therapeutic don’t mirror another person’s pain in the same 4 encounter and co-partnership happens, there can be way as a non-doctor’s. a moment of real opening: a space between two So what’s bound to happen when, as students people which makes a therapeutic zone not just for without any emotional preparation, we come on to the patient, but for the practitioner too. On the other the wards and encounter lots of people who are hand if you’re expecting to deal with complex human needy and suffering? Thrown in at the deep end problems without the temperament or skills, let we more or less consciously feel the impact of this alone the time and (yes) funding to open that space, mirrored pain and suffering in ourselves. Naturally then that’s only going to end in cold-heartedness and we have to find ways of tolerating. But if we end eventually burnout. up defending ourselves psychologically so that we DP By structural factors you mean inhuman work - can do our day job and appear to be coping it’s no loads, austerity pressures, deprivation, soaring wonder if even as students we end up learning to expectations of magic bullet medicine, and maybe be less empathic. even people’s increasingly negative views and loss DR Well, I wonder if words let us down here. It’s easy to of trust in doctors? Faced with that kind of conflate concepts like sympathy, empathy and predicament isn’t it only natural for doctors and compassion. But they are not the same and I think those on the frontline to protect themselves this misunderstanding creates a lot of concern and psychologically and physiologically? confusion about ‘compassion fatigue’. I’d say the DR Yes. You try to protect yourself by a reflex shutting spectrum of interpersonal connectedness begins with down of the open-hearted inter-personal space. sympathy, but it can move into genuine empathy and But that can only be a short-term strategy at best, may even transform into compassion. I believe it’s because then you’re cutting yourself off from the the sympathy response that depends on a strong energy and values of your work as a doctor. I think mirror neuron effect. Because of the way evolutionary that when the kind of doctor we are talking about development proceeds by prioritising traits that engages successfully with someone – no matter how enhance the chances of survival, we are as you say grief-stricken, broken, stressed, or how much multi ple wired for attunement to other people’s emotional co-morbidity – there’s a real human to human join- states. So another’s feelings hit us in the way they do, up which results in both people feeling better. The because parts of the central nervous system vibrate in practitioner may start the morning clinic in dread, at sympathy like a tuning fork would: something like a a logical level feeling, ‘Oh my God, I’ve got so many neurological resonance happens. Then what began as people to see’, and yet somehow the opening of that one person’s suffering becomes two. And clearly engagement space leaves the practitioner in better that’s just no use at all: it’s like a man having labour shape by the end of the morning! But if the system pains when his wife is giving birth! But with empathy and circumstances make empathy and engagement we begin to choose to enter into and understand the impossible, and the practitioner is experiencing other person’s circumstances and experiences. This physical exhaustion, blood sugar dips and is something quite different from sympathy, and dehydration (which is what happens to many of our maybe it’s a stepping stone into the opening of permanently overstretched junior docs) then no compassion. And I’m convinced this can be a healing wonder they put up that wall and cut themselves off. space for the practitioner; something that isn’t But then you’ve cut yourself off from yourself too draining at all. and your source; from your source of wellbeing and I think this rapport requires a quality of mercy: a satisfaction in the work. deep wishing for the best for the person in front of you. And secondly, the practitioner has to approach DP And your patient will sense that you’re not suffering as a natural process, something each person engaging with them, so the consultation will can only learn to experience and hold. If you’re a become more or less dysfunctional: you will know doctor that means moving away from being the fixer, it and they will know it too. the pain-reliever; maybe even giving up on thinking I think this points to the fundamental tension at you’re the healing catalyst; otherwise, our habitual the heart of a doctor’s job. It is wired into our resistance to the experience of pain and suffering

36 © Journal of holistic healthcare G Volume 13 Issue 1 Spring 2016 RESILIENT A conversation with David Reilly: Director of The WEL Project

risks making your patient feel worse. Instead, we I think that’s partly why the idea of the patient have to find a way of sitting with that person as they journey has emerged in the last 10 years: of under - process their own way towards their own release. standing getting well as a process that needs time This practitioner shift, begins when we understand and which unfolds as a narrative that can be full of that suffering is natural but that strength is inherent unexpected twists and turns. And as I’ve said, it has too. And in the WEL programme [www.thewel.org] to be an internal journey as well as an external one, ‘News Flash Number One’ announces that it’s normal with the outer journey serving the inner journey. But to suffer and normal to get sick, normal to age, normal so much of doctors’ training has been the other way to die. That’s the way of it. And if the practitioner is round: as if we could achieve inner wellbeing and sitting there battling on with an internal model that peace by fixing from the outside. We have lost most says suffering shouldn’t be happening then yes it is of the practical Western inner traditions that might going to create an unbearable tension. once have embraced this aspect of our journey – for example the early meditation and contemplative DP We know that being in the presence of suffering traditions (as drawn on and developed by practitioners triggers the neurobiology of the threat response. like Laurence Freeman referencing the desert fathers Perhaps then, a lot of what we do in modern and mothers of the first to fourth centuries medicine and the ways we think about our work http://wccm.org/sites/default/files/users/images/PDF/ acts as a kind of defence against our own and our TheTraditionofMeditationLFRead.pdf ). This is a patients’ suffering. If we can depersonalise diseases cultural vacuum, and medicine has been the victim as with our labels and explain them as rogue cells or well as an accomplice in that loss. Yet maybe, as the messages of mad molecules, then we can contemplative practices such as mindfulness enter disappear the person along with their suffering the mainstream, science is going to step into this body and mind. So ‘the medical gaze’ (was this space and create a kind of secular spirituality. Foucault?) helps us cope emotionally yet at the same time it has yielded some amazing advances DP Secular versions of spirituality. This links to in treatment. Yet sadly, in the process, doctors and something we are working on at our centre: ways patients end up depersonalised. I’d say that may be of monitoring the physiology of resilience and OK in truly life-threatening emergency situations, recovery. It seems as if difficult medical encounters but in complex care the battle against the disease fire up our flight and fight system. When we meet and death model doesn’t work. Then, who we are a stranger, there is an initial unconscious threat comes to matter a lot. Maybe we need the humility response. Basic mammalian survival biology. to accept that deep down we are vulnerable, Nonetheless it’s not hard to open a friendly space limited and dependent on others. Medical school provided you have time and goodwill on your side. and everyday culture of medicine as potentially This is important because if one is operating in omnipotent teaches us to deny all this, so we can what Paul Gilbert calls threat-mind, our mirror survive by dissociating from sensual, embodied neurones turn off (making us less sensitive to reality. But then we find ourselves unable to unconscious cues) and the social engagement tolerate the presence of suffering without it leaving system tends to tune out (so body language, us feeling helpless…even guilty. expressions and communication style become less friendly). When human beings want to be properly DR What you described as happening externally actually present and open with one another, they need to reflects our whole psychological and bodily make-up. get out of threat-mind and into parasympathetic- The ego believes that to feel safe enough it needs to dominant affiliation mind. I call it cave mind, maintain control. It’s forever striving for unattainable because it’s a state of mind and body that evolved peace in the face of predicaments and circumstances so that after hunting, fighting or escaping, we can that can’t really be controlled. And so, the therapeutic relax and relate. One way of telling the story of journey is about accompanying someone out from medicine is that it’s become too much about suffering by engaging with them in order to nurture goal-seeking (hunting) and sheer survival when we a releasing process from the ego’s war with reality. As feel overloaded by targets, workload and emotions Paul Gilbert says, compassion is a call to action but in (hunted): Gilbert call these high sympathetic these complex situations there’ll be a limit to what arousal states drive-mind and threat-mind. can be done externally. If a practitioner can do anything external and practical then let that be done. So David I think you may be talking about doctors But in the face of scientific medicine’s many needing to school their affiliation mind, and for limitations, is there not a lot more we can do to healthcare organisations to reduce the burden of liberate peace and equanimity and a feeling of ease; threat-avoidance and goal-seeking imperatives that not just for the sake of the patient’s healing but now drive medicine along. But very little is said within our own being too – especially in predicaments about the inner journey of the doctor, and how to we can’t control? prepare ourselves for being in the presence of

© Journal of holistic healthcare G Volume 13 Issue 1 Spring 2016 37 RESILIENT A conversation with David Reilly: Director of The WEL Project

suffering. I think it was Erich Fromm who talked DR You know that old story? You’re on holiday walking about the difference between being with and doing through the long grass and you stand on a snake. I to. But of course in medicine, we have to do both. use this scenario with people and ask them to Perhaps it’s because we don’t learn how to be with imagine this and tune into how their body reacts. But suffering that we so continually struggle to find then I continue the story, and say that as they stagger fixes, even when what’s clearly called for is being back from what felt like a snake they realise it was with, rather than (or as well as) endless doing to. only a piece of rope. That’s one of the hooks I use to How can we practice this art of being with? I have open this dialogue, using ordinary experience to get found it very valuable to find circles of people with a handle on what this reactivity might be. What whom I can feel safe enough to share the kind of caused that distortion of reality? Where is that conversation we’re having right now. suffering? And of course we come to view our predicaments as snakes. We may get so burned out DR I think it’s a deeply personal growth process for a that we start seeing our clients as snakes. But where practitioner. And I would say the fight-flight response is this reaction happening? What’s driving it? And you’ve described mirrors the internal struggle – our how can I regain genuine self-mastery in this relationship with our own suffering. I think we have situation, so I’m not just being dictated to by these to make peace with our own suffering. But that’s a distorted perceptual frameworks, and reflex reactions? tall order given that the mind’s evolutionary default You know, I think that in our culture right now we all mode is threat-avoidance: it tends to back away from need this ability. And to get there we are going to too much of that kind of reality! I’m certain though need a lot of support, a lot of understanding, that unless we come into relationship with our own education, practice, mentorship. I don’t idealise the hurt and can learn to accept and soothe it, we can’t past, but there were avenues of spiritual enquiry in equip ourselves to deal with another person’s the roots of our culture into equanimity and inner distress and pain or understand our (in many ways journeying, albeit they later became corrupted into natural) reaction to it. Obviously, this is foundational anthropomorphised religious structures. for building the sorts of effective practice that won’t lead to burnout but could lead to our clients learning DP But as you said before, there’s a real resurgence and growing. And that’s one of the reasons I scaled of curiosity about why we are the way we are and up my study of the one-to-one therapeutic relation - how our culture shapes our perception of the ship to start working with patient groups. That began world. And in a culture such as ours many of us in 2004, but in 2010 I began taking it to staff groups feel alternately over-driven or in a state of threat, in the StaffWEL project too, because I’ve found this or trapped. So it’s no surprise if we start seeing dialogue to be absolutely central to helping them snakes where there are only ropes. The culture of understand how the mind resorts to fight and flight, medicine itself, the expectations it has raised and and to find ways of accessing pathways towards the way doctors are trained all seem to encourage nurture. I think so many practitioners are themselves states of high-arousal. I’m left wondering how the adrift with this, when dealing with other who are human race is to deal with its levels of alarm at the similarly adrift. state of the world, since the alarm reaction make us ever more prone to fall into threat-avoidance DP This is in tune with how I’ve been thinking about mode and so see snakes everywhere, which of doctors’ predicament. I’ve become really aware of course alarms us all the more! how difficult it can be, when something presses my buttons, to notice what is going on inside – the DR We’re unwittingly fanning the flames, instead of at associated physical tensions and sensations as well least addressing the influence we have over in the bit as the mental and emotional shifts that follow. I of the world that we can change, which is our own can experience a more or less subtle loss of internal state. I did a workshop recently for 15 senior control, a kind of dissociation from good sense. At GPs and the only dream they expressed was of their one extreme – not for me I’m relieved to tell you – impending retirement and release! It was in many this is the proverbial red mist descending, but at ways a demoralised group of people. But then one of the other, when someone is just too exhausted to them told us how his practice had changed since two engage, it’s more of a freeze response: like a rabbit doctors from troubled parts of the world had joined in the headlights. I see the rage response as being them. He said their smiles affected everybody around at the root of early burnout and the freeze of its them. These doctors were always expressing gratitude: late stages. And of course it’s not just in the clinic. flick a switch, and the light actually comes on; turn The trigger could be a client on a difficult day, but the tap and clean hot water comes out; and to have a it could also be something in the family or just job – and a job with some meaning! These two anything that throws us into threat-mind – which people were not just in a neutral state: beyond just is, as you say the organism’s default mode for our feeling safe, they had somehow built up a state of survival’s sake. inner nurture founded on gratitude.

38 © Journal of holistic healthcare G Volume 13 Issue 1 Spring 2016 RESILIENT A conversation with David Reilly: Director of The WEL Project

Given that so many NHS staff are now feeling over - DR Yes, beginning with our own practice. whelmed, I think the resilience and hopefulness of DP Because that’s the only place you can begin these two doctors shines like a candle in the darkness. I know we have to address the crumbling DR Yes. That’s the beginning. And from there, act. Being structures as best we’re able, but we mustn’t sacrifice in the snake state doesn’t make us effective agents ourselves in the process. Therefore we must do all of change. The ego wants to trick us, to tell us that we can to restore our own equilibrium, find strength, stressful thinking and stressful states are somehow nurture our wellbeing. In the StaffWEL project, we required to address predicaments. But that’s a lie accept that we are not about to wake up in a that renders us less effective. transformed system nor fix it in the short term. So to thrive and do good work we need to learn to restore 1 Newton BW (2013). Walking a fine line: is it possible to remain an empathic physician and have a hardened heart? F rontiers in ourselves. Human Neuroscience , 7(233). doi: 10.3389/fnhum.2013.00233 DP Yes, though there’s a danger that the word 2 Zantinge EM, Verhaak PF, de Bakker DH, van der Meer K, BensingJ resilience is becoming a tainted brand in medicinal M (2009) Does burnout among doctors affect their involvement in patients’ mental health problems? A study of videotaped circles. It can sound like it’s about making us consultations. BMC family practice , 10(1), p.1. Duracell bunnies who can endure the current 3 Reilly D (2005) Holism in primary care: The views of Scotland’s dysfunctional mess. But actually no, we are talking general practitioners. A major survey of GPs views on the state of about the kind of resilience that can help us stay the art of holism. Primary Health Care Research and Development , human and empathic in a system that could 6 pp 320–328. dehumanise us and industrialise our craft. So we 4 Decety J, Yang CY, Cheng Y (2010) Physicians down-regulate their pain empathy response: an event-related brain potential study. have to find what it is in ourselves that can help Neuroimage 50(4) pp 1676–82. redeem medicine.

© Journal of holistic healthcare G Volume 13 Issue 1 Spring 2016 39 MEANINGFUL A meaningful encounter

Justin Haroun I trained as a bodyworker in 1999 specialising in an integrated approaches to working with people. This way of working encouraged me to incorporate structural and functional work with a commitment to helping people understand their bodies and their relationship to the world. This led me to train as a Hakomi therapist and mindfulness teacher. I have brought this approach into my profession as a therapist but also as an academic and feel passionately about supporting humanity in healthcare and education. In recent years this has led to the work we are doing at the Centre for Resilience at Westminster University. We are committed at the centre to helping people from healthcare, education and industry live more human and flourishing lives that are both meaningful and sustainable for the individual and communities in which they live.

Introduction The therapist: Take this place for The therapist: disconnected plots example. It’s a meaningful place for and disintegrated, incoherent and This article is written as a reflective me. meaningless narratives. Lives lived in play in which an academic and a [The academic nods] that way are confusing. therapist take a seat on a metaphorical park bench to pause, reflect and The therapist: I always come here in The academic: But how do we then discuss meaning in professional day- between sessions. I enjoy the space, help people, and ourselves become to-day life and how that enables or and it helps me to get perspective, top integrated and live more meaningful detracts from living a meaningful life. myself up and rejuvenate. It also helps lives? The two characters represent the me to integrate meaning. I suppose [Two visitors join them on the multifaceted and often-divided lives that’s one of the reasons people come bench] professionals lead. At times during the to see me. Polkinghorne: I think there are some scene some theorists join them on the The academic: your patients? inherent problems with studying bench and contribute to the dialogue. meaning (1998: p6). The therapist: yes, but I don’t like to The scene call them my patients. I don’t think [The academic and therapist listen they are mine, and secondly, I find to this new visitor on the bench] [It’s a warm spring day. Flowers are when I use the term ‘patient’ it Polkinghorne: Firstly meaning exists opening tentatively. A well-worn increases my sense of them being in different forms than natural objects. wooden park bench entices those passive. Meaning is an activity, not a thing. It walking past to take a seat, to pause The academic: Hmm! I think that may cannot be picked up and held. Nor for a moment and reflect. A steady be true for ‘my students’ as well. I will can it be measured by an impersonal stream of people walk past, some have to think about that one. instrument. look to be enjoying the walk but others seem lost in the past or The therapist: Anyway, I think many The therapist: yet so many people use worried about some imagined of the people who come to see me are external measures to make sense of future. The therapist and the often struggling with a loss of meaning their plots. In the consultation they academic sit side by side on the or feel confused about themselves. tell me their stories, and there is often bench. Though they seem as if they Their disease, pain, symptoms, and a disconnect. There is a story being are one person, there is a division histories are causing them to suffer. told which is often a jumble of others’ but you could only notice it if you It’s as if they have disconnected plots stories. Tales from their doctor, part - knew them intimately. They are deep in the narrative of their lives. ners, mothers, culture, test-results…a in conversation about the meaning whole list of contributors weaving a The academic: I often feel like my of the word ‘meaningful’. We join patchwork narrative that seems to organisation is a series of disconnected them half way through the make sense to the outside world. But plots. conversation. [During the scene, then if you listen, if you truly listen others come to join them briefly to [They both laugh] you can begin to hear a storyteller offer their insights] who is telling a story. And it’s often an

40 © Journal of holistic healthcare G Volume 13 Issue 1 Spring 2016 MEANINGFUL A meaningful encounter

entirely different tale with a different plot. For me, the Polkinghorne: We only have direct access to one realm trick is to listen to the storyteller as well as the story. of meaning: our own. The region of meaning must be approached through self-reflective recall or introspection George Sweet: in our mental realm. However, the activity of producing ‘What I need to know most of all is; and recollecting meaning normally operates outside of for this client, What Is? awareness, and what is available through self-reflection is to observe, to be aware of What Is, only the outcomes of the meaning-making process, not without giving it any slant or interpretation. the process themselves. A further problem is that in every - to recognise without day living we are normally busy attending to the world, judgement, condemnation, justification, and meanings express themselves merely in our actions agreement, disagreement. and speech; recognition of their presence requires that to follow What Is, calls for a still mind, we consciously change the focus of awareness to the a pliable heart, a tranquil energy, realm of meaning itself. Yet when we focus on the realm of a Body in Tao. meaning in self-reflection, the meanings that are available Because What Is to us can be limited by other mental operations, such as is constantly changing and moving’ (1989) repression (1998 p7). The academic: Yes, it seems we need to learn to listen to The academic: that’s interesting, I often find that in my the storyteller within us as it speaks from the present everyday life I can get lost in the busyness inherent in my moment organisation. through our I can lose bodies and meaningfulness movements. in my day-to- But how are day life as I am we to hear too busy our untold managing the stories when distress of they’re blocked being in a by a version large, and what of ourselves often feels like that are an inhumane programmed organisation. not to listen? Perhaps if we The therapist: learned to I am glad I observe, don’t have to recognise, deal with any become pliable of that. I can’t in our hearts imagine the then we could tension of live a more working meaningful life somewhere moment to like the NHS, moment. trying to find space to Polkinghorne: ‘It’s like looking in a mirror. What we see engage in self-reflection – let alone find time to explore is a fleeting indication, a whisp. But the meanings of the how the outcome of the self-reflective process influences reflection are continuously being reconstituted. The my day-to-day life and the meanings I live by. Perhaps we reflection we see is not a fixed thing; it is constantly need more ‘park benches’ in large organisations where changing. So for us, meaning can be difficult to get a hold people can feel safe enough to explore their meanings of. Once we think we have it, it can change’. with others. The therapist: Perhaps that’s why we miss so much. The academic: I think you are right. Sitting here right Moments are fleeting, and before we know it, we are now I feel safe and present. But when I feel pressured or following plots that don’t serve us well. Steady cultural, threatened in some way, my mental default operations are organisational, infrastructural plots that give us an illusion likely to cloud my reflective lens. Then add in trying to of certainty when in reality there is no such thing and stay present while looking through smudged and fear- what we need is ways of being more open, curious and tinted lenses organisations so often view the world flexible. Maybe from this open place, we can respond through! Once the fear lenses tap into some older part of more effectively to others and ourselves. my brain, suddenly everything feels like a threat.

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The therapist: Ahh it’s a reptilian response to a human The academic: When I do that, I need to feel a deep problem, closing down rather than opening up. No caring for myself. A sense of self-compassion and some - wonder so many big ‘solutions’ seem inhumane. times, I need to make a self-compassionate act. Anyway, firstly I have to recognise my fear in the moment, then The academic: I think that’s the real challenge, how soften towards that scared place in myself, and let the does one stay open in order to live a meaningful life in inner noise stop screaming at my amygdala. communities, organisations, families (and oneself!) when the rumbling background narrative is so often one of fear. The therapist: : Ahh, quieting the noise. The landscape That’s not how I want to live. Fear disconnects us from always looks different when there’s less traffic! Then you one another and from ourselves. get a chance to see what paths are open to you. There [Another joins them on the bench] are many paths better suited to teaching or practicing medicine than fear. But so often I find myself going down Parker Palmer: Good teachers possess a capacity for the old paths that lead me into unnecessary suffering, and connectedness. They are able to weave a complex web of I’ve cut myself off from a meaningful life. connections among themselves, their subjects and their students so that the students can learn to weave a world Thomas Moore: In psychotherapy we deal with wounds for themselves (1998 p11). of the heart, issues of love. And, therefore the cure is love. Our heart asks for appreciation, acceptance of complexity The academic: I try to weave worlds in my day-to-day and to speak for the disowned part. It may be necessary to work. But when I weave I don’t want to let go of my stretch the heart wide enough to embrace contradiction golden threads, the core values threads that make what and paradox (1992). we are weaving meaningful. The therapist: Life smudges us, knocks, caresses, strokes, The therapist: It’s the same for me. Without those, I just stings us…I could go on! But these hurts can incite us into could not do what I do. I would have to do something making sense of the conflicting stories that spin around else. Working in harmony with our values is essential. within and outside us, though their plots may be hard to The academic: The trouble is you are often ordered to follow, if we don’t weave meaning from them they will weave with threads that, at best scratch and irritate the produce a divided self and a divided life. skin and at worst destroy and corrode the very fabric you The academic: so for me living a meaningful life has to be are trying to weave. There are threads that ought not to a choice. I need to wake up. It’s far too easy to go to sleep have any place in the world of education. when fear, shame or some other emotion that is not The therapist: Or healthcare. appropriate for the situation hijacking my body and mind. But when I am awake I can make a choice in each The academic: Indeed. When I’m teaching I need to hold moment to live a more fully human life where I can listen on to the threads that make teaching meaningful for me. to others and to myself respectfully, with openness, Parker Palmer: The courage to teach is the courage to curiosity and care. keep one’s heart open in those very moments when the [The academic and therapist sit for a moment in heart is asked to hold more than it is able, so that teacher silence; enjoying the sounds, smells and sights of spring. and students and subjects are woven into the fabric of They both get up and walk off together knowing that community that learning, and living require (p11). the park bench will be there tomorrow offering its safe The therapist: that’s what a meaningful life requires. An space to sit together and with others to explore yet more open heart that allows individuals and communities to contradictory, disconnected stories, plots and narratives flourish. That won’t come from fear and disconnection. in the messiness that is life. But for today at least, they are both feel more able to act in more meaningful Parker Palmer: Each time I walk into a classroom, I can ways that support a more meaningful life] choose the place within myself from which my teaching will come…I need not teach from a fearful place: I can Moore T (1992) Care of the soul . New York, NY: HarperCollins. teach from curiosity or hope or honesty, places that are as Palmer PJ (1998) The courage to teach: exploring the inner landscape real within me as are my fears. I can have fear, but I need of a teacher’s life . San Francisco, CA: Jossey-Bass. not be fear – if I am willing to stand someplace else in my Polkinghorne, DE (1988) Narrative knowing and the human sciences . inner landscape (p 57). Albany, NY: Suny Press. Sweet G (1989) The advantage of being useless, the Tao and the counsellor . Palmerston North: The Dunmore Press Ltd

42 © Journal of holistic healthcare G Volume 13 Issue 1 Spring 2016 INTUITIVE Neural networking, confabulation and subtle information

William Bloom Director, Spiritual Companions Trust

My main work is leading a small educational charity the Spiritual Companions Trust, which has just submitted a new qualification for accreditation to Ofqual, the Diploma in Practical Spirituality and Wellness. My books include The Endorphin Effect and The Power of Modern Spirituality. At the moment I am on a learning curve as I begin to master the arts of digital and media technology to produce video classes. I love meditating and teaching. My main hobby and favoured form of transport is tootling around on a motorbike.

‘The moment I see a patient question, the appropriate touch, the Fast forward a couple of decades and standing in the doorway I sense of which remedy is most suitable. I am happily living with my partner, can intuit their syndrome.’ In the Yoga Sutras of Patanjali Sabrina Dearborn, who is one of these hints and impressions, this Europe’s most reliable and intelligent Thus spoke my father, Philip, a Harley subtle information, comes to us from psychics. Now here we have someone Street psychiatrist who specialised in the ‘raincloud of knowable things’. who is a quantum leap away from the psychosexual problems. (He had This is a beautiful metaphor but hardly psychiatrist’s intuition. Sitting quietly originally trained as a gynaecologist scientific. It is similar to the assertive with clients, she enables a healing and the family joke was that he had response I once heard when someone atmosphere and comes into rapport worked his way up.) But what was he was being challenged because of his with them. Her intuitive sense then talking about? Intellectually I wanted sense of nature spirits: ‘Don’t be so distils into something more solid and to challenge him. You are just showing armoured’, he responded to the formed, and she can ‘see’, ‘intuit’ or off. It makes no sense. Where’s the sceptic, ‘where is your poetic ‘directly know’ the clients’ psychologi - logic? imagination?’ cal and spiritual state, their history and But I was also comfortable with When I asked my father the source their potential. She then shares with what he said because it matched my of his intuition, he responded that it her clients what she sees in a narrative own experience. From very early years came from experience. But that made that lasts between one and two hours. I experienced a direct knowing about no sense to me. How could body Over and over again clients are people – their emotional and mental language and facial expression inform moved by the accuracy and insights of state, sometimes their story – without him of a patient’s syndrome? Were her readings. (I was deeply distrustful actually knowing anything about them. blind people excluded from this of psychics until I experienced her That is the heart of intuition, isn’t it, intuitive faculty because they could work.) One academic scoffer, an that we know stuff when there is no not see? engineering professor, listened to a actual information. When I pushed further with my reading Sabrina did for his wife and But how do we know? This is a enquiry he became defensive and was strangely impressed. ‘I do not particularly crucial issue for holistic evaded the issue. He thought of believe in any of this psychic stuff,’ he practitioners because many sessions himself as a hard-core humanist and he said, ‘but nevertheless the narrative include moments when practitioners knew that there was no scientifically she tells is completely coherent and pause and allow their next action to acceptable explanation. He liked being engaging.’ And it is here in this idea be guided by intuition. Experienced intuitive, but he did not like thinking of narrative that we can find, I suggest, practitioners trust the subtle inner about it. a clue as to what is happening in knowing, the quiet feeling that guides intuition. Through exploring the where they go next: the appropriate * * *

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function of narrative we may begin to explain some in response to not seeing what happens in the end. We aspects of intuition. do not like not knowing how a story ends. It triggers us into survival-threat mode. * * * In psychoanalytic theory confabulation is called Human beings love narratives, love stories. We also like rationalisation; when we make up psychologically self- filling in gaps in stories. We can listen to plays on the radio protective stories that deny and cover up the truth of and our mind-brains complement the audio with visual what is actually going on. So for instance children may representations. When we are shown an ambivalent image, idealise parents who abuse them. The mind-brain creates like the famous Rubin vase, our mind-brains can complete a narrative for survival. the narrative in two ways. Is it a vase or is it two faces This confabulatory dynamic also has its benevolent facing each other? Similarly with the Kanisza triangle, our side. We see a friend whose body language is miserable mind completes the picture. and we make up a narrative of what might have The most important thing to notice is the way our happened. This is also an aspect of empathy. We cannot mind-brains automatically work to fill in gaps and make a help but do it. coherent picture out of incomplete information. We are As a species we compulsively and unavoidably fill in hard-wired to do this. It is a core feature of homo sapiens. gaps and create stories. It is at the heart of being human. From one perspective it is only an evolutionary step From primal myth to Tolstoy and Shakespeare through to forward from a predator who smells moisture in the air Hollywood movies we are a species of coherent narrative and surmises that water will be available in a certain place, makers because unknowing is uncomfortable. which will attract other animals who will make for an enjoyable meal. From the simple sense of moisture the * * * animal constructs an instinctive narrative that will deliver To bring this all back to intuition and holistic practitioners, supper. to psychiatrists and psychics, we can see now how our mind-brains are wired to create a coherent story out of minimal amounts of information. The Harley Street The most important thing to psychiatrist looks at the patient in the doorway and from a all the subtle signals of body language surmises the

notice is the way our mind-brains possibilities. Based on experience, the psychiatrist

automatically work to fill in gaps confabulates the story. Bodyworkers feel the tension in their clients’ tissue and know where to go next because and make a coherent picture out a they have a natural ability to fill in the gaps and complete the story. The instinct to complete the narrative guides of incomplete information their touch. But what about the blind counsellor or the psychic? What are the signals that trigger their confabulations? This narrative-making is partly an evolutionary survival Whence are the blind counsellor and the psychic deriving mechanism; for humans must be able to complete their information? How can Sabrina be so insightful and incomplete stories. How else can we handle the accurate with no hard information at all? complexity of multiple relationships with multiple possible This is a challenging enquiry and it takes us to the actions and outcomes? We are wired to fill in spaces with heart of a contemporary paradigm war. Readers of this probabilities that make sense of a situation. journal will be only too aware of this conflict for it is often This filling-in-the-gaps function is driven and extremely nasty, and for those of us working in the public compulsive. When someone says they will phone us, but sector it can have severe ramifications in terms of funding does not phone us, our minds speed off creating stories of and partnerships. We are discussing here whether there is why they did not phone. This creation of a story to make such a thing as subtle energy that contains information. sense of an incomplete perception is called confabulation. At the present time there are no scientific instruments We do it all the time. At its worst it leads people, when or rigorous methodologies for measuring and explicating asked directions to a place for which they do not know the theory that information is held in subtle magnetic the route, nevertheless to tell us how to get there. It leads fields. There is no established and persuasive body of to white lies when for example, having forgotten to peer-reviewed scholarship that presents a substantial answer an email, we meet the person who complains that argument for subtle information. we have not replied and without thinking we respond that There may on the other hand be a tsunami of ‘the email must have got lost’. The lie is out of our mouths anecdotal evidence based in experience. There may also before any conscious thought. It is fuelled by a compulsion be a substantial body of multicultural custom, practice and to complete the story satisfactorily, to survive. literature. But there is no methodologically rigorous We can experience this primal arousal if we are theory or evidence to satisfy contemporary scientific watching, for example, a film or a tennis match, and enquiry. (The reader can find the best overviews of the someone switches channels 15 minutes before the film’s current state of play in this research in the November 2015 or the match’s conclusion. The angry arousal can be fierce Global Advances in Health and Medicine Special edition

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Biofield Science and Healing: Toward a Transdisciplinary Increasingly in recent years I have been reframing this Approach (www.gahmllc.com/digital_issues/biofield2015/) uncomfortable paradigm – especially uncomfortable for and the Institute of Noetic Sciences project Mapping the those in the middle – as a difference of worldviews based Field of Subtle Energy Fields (http://noetic.org/research/ in peoples’ individual experience. It seems clear to me projects/mapping-the-field-of-subtle). that underlying the debate is something as straightforward This dearth of scientific evidence is a tough truth as this: differences in physiology lead to differences in for those people who are naturally aware of subtle sensitivity, empathy and intuition. (My viewpoint comes information. It is also tough for those holistic practitioners from anecdotal evidence supplied by hundreds of learners who enjoyed the glory days of the seventies and eighties in my classes over the last decade, when I have asked when it looked as though the paradigm war was going the them to self-audit their levels of sensitivity.) holistic way and practitioners could freely use terms like People are different: different characters, temperaments, qi, prana and energy. weights, heights, inclinations, abilities; different vulnerabilities and susceptibilities. Some people have * * * better hearing and vision than others. In this natural We can perhaps skirt around this conflict of worldviews kaleidoscope some people are more highly strung and by referring to classical mainstream western philosophers sensitive than others. They can ‘feel’ more easily what is who addressed the awkward issue of intuition. Plato going on around them. I do not see this as any different described intuition as a pre-existing knowledge residing from the fact that birds that migrate long distances may in the soul of eternity. Kant explained it as a form of be more sensitive to the Earth’s magnetic field than birds transcendent mathematics. Descartes described it as who live in just one location. Swallows have a different access to pre-existing knowledge. Well! If modern scientists physiology from ostriches. think that holistic practitioners can be flaky because of It is common sense to surmise that many people are their inclination to work with subtle information, then born with a certain physiology, often inherited, which renders them sensitive to atmospheres and magnetic It is common sense to surmise fields. Other people are born without such a pronounced a tendency. (Did you for example ever move to a new home that many people are born with a because you were influenced by the place’s ‘atmosphere’?)

Therefore could the paradigm war be interpreted not as certain physiology, often inherited, one founded in a clash of theories, an argument between a science and metaphysics, but rather as deriving from which renders them sensitive to different types of personal experience? Those who are born with nervous systems that atmospheres and magnetic fields render them less sensitive simply do not experience subtle information. As they do not experience it, they reject the idea of it. And then there are those who do experience what do they make of these classical philosophers? The subtle information, but because of their science based soul of eternity indeed! enculturation, are intellectually incapable of recognising it. So let us be clear. Within the western scientific paradigm These folk however are comfortable with the notion of which currently holds the leading position, intuition has intuition. It is a useful, seemingly safe, word that explains no place except as a neural networking event that a neural mechanism that is not yet fully mapped. confabulates on the basis of prior experience and of actual For holistic practitioners however, who recognise that information that can be evidenced. Intuitive psychiatrists they are swallows rather than ostriches, intuition can be a do not want to be compared to psychics. core tool that improves with experience. It is the arena On the other side is a wealth of personal experience where neural processing and confabulation meet subtle and traditional practice that claims there is a realm of information. subtle information, held in an ocean of consciousness or magnetic field that is not fully understood. And, that it is in this subtle field that we can find the information that triggers intuitive knowing. * * *

© Journal of holistic healthcare G Volume 13 Issue 1 Spring 2016 45 WISE The juggler – being wise in the modern NHS

William House

During 30 years as a general practitioner in Somerset I watched and shared with people struggling with misfortune, laughing at absurdity, weeping with joy or misery, showing their resilience or giving up at the first hurdle: above all, living out who they are. Over this time my wife and I brought up our two children, numerous pets, and chickens. In my medical role I became exasperated by the dominance of diagnosis, technical treatment and commodification at the expense of the human side of illness. Now retired from clinical practice, I work towards restoring this balance. I am currently chair of the BHMA and also chair of a local experimental community development network in the town where I worked.

A virtuous, ordinary life, Eleanor: I was just thinking of that Penny: …and mind maps, digitally striving for wisdom but patient we both know – she has generated. never far from folly, is purely fatigue and she’s convinced it’s William: So every patient is unique achievement enough. something in her mouth. So it’s very and so the challenge is to have a way Michel de Montaigne difficult. Complaints of fatigue are so of thinking about that uniqueness. common. She’s an incredible woman; In March 2016 I had a fascinating she’s very high-flying, very gifted at Eleanor: Almost, you have to under - conversation for an hour with two what she does, but she has these stand as much where they are coming young general practitioners. I shall call episodes of profound tiredness where from. Now this woman is a computer them Penny and Eleanor. The purpose she can’t do her music – she plays programmer. She is very used to was to explore their understanding of the piano – and she can’t do her problems being presented to her, being wise in medical practice. This composition. She has started to link and I imagine being able to think …. is the first time I have explicitly this with an infection that followed discussed this topic in a medical Penny: …very logical. dental treatment and has seen setting – which itself tells us some - max-facs [maxillo-facial surgeon] on Eleanor: …Yes! Very logical, Oxford thing about the medical culture. I was numerous occasions and has had graduate, very intelligent and having immensely impressed by these two surgery which hasn’t really helped and something outside her control, young women. Perhaps, when you’ve although the pattern recognition for perhaps she can’t immediately fix, but read this, you will be too. Though the stress side of things is quite she’s open to the fact it could be in both intelligent and under a great deal common, the specific details of the her head. It’s tricky because she keeps of stress, they approached the subject surgery and her thoughts on it are going back to wanting more and more with an endearing humility, but tinged unique and quite difficult, because she surgery, private referrals to max-facs. with frustration. We must do every - is quite convinced that it’s all linked thing we can to protect and nurture with this infection. their enthusiasm and dedication. Pattern recognition Our conversation was wide- William: …and she’s intelligent and … In her initial description of Margaret’s ranging with, at its centre, the story of Eleanor: …yes very intelligent, she case, Eleanor mentioned ‘pattern Margaret, a patient they both knew. I comes in with everything written on recognition’. Earlier she had said this: will start with that story (disguised to an iPad… protect anonymity, otherwise faithful Eleanor: When you see a patient you transcription throughout). can kind of… have a flavour…that can

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be triggered when you see other patients in the future, If we take it that the contemporary wise GP has the with a similar flavour about them. I was thinking about a episteme (and even Sophia ) from their undergraduate lady I saw yesterday with really awful headaches. She’d education, and phronesis , from their postgraduate years, been on the phone with triage and she came in very very what could she offer to Margaret? The generation of GPs distressed and I quickly asked, what she thought was trained in the 1960s and 1970s had the option of becom ing causing this and she very much felt it was all stress-related skilled as GP psychotherapists in the style pioneered by which I think then enabled us to cut one type of work Michael Balint. This was achieved through GP discussion out….and when you start to see those patterns, groups. This approach might be helpful to Margaret and recognition of different patients over time… I think you could be characterised as phronesis . But it is now can learn patterns from patients. uncommon to find time and energy in the whirl of work Eleanor’s ‘flavour’ is a variant on the commonality that experienced by doctors like Penny and Eleanor. In most defines a diagnosis: pattern recognition applies just as areas, there is no other similar NHS option available to much to medical diagnosis. In fact, you could give a patients like Margaret. medical diagnosis to both of her patients: somatoform disorder for Margaret and tension headache for the Being intuitive second lady. The difference is that you cannot measure a ‘flavour’, so they fit uncomfortably with quantitative Creativity is knowing what to do when the rules research methods such as the randomised control trial. run out, or there are no rules in the first place. With little interest from academia, biotech and pharma Frank Levy industries they have a second class feel about them and So the young doctors are relying on intuition. This came the label alone does not help much with what to do next. up in the first few minutes of the conversation: Here is Penny and Eleanor: Penny: I find myself talking to patients not necessarily Penny: I just think as a job we are relying an awful lot on about medical things. They’re asking for advice, but it our intuition and decision making that is not necessarily doesn’t come from textbooks whatever … [hesitantly] based on something that we have learnt in a book. As It comes from …the advice they are seeking …I try to each day goes on I realise that actually …some things are support and give, but often I can hear my dad talking, or just medical …. my sister….I don’t think that’s a bad thing, so long as it’s Eleanor: …and you can just move through… not a prejudiced view… we learn wisdom from others. During postgraduate training these ‘others’ turn out to Penny: .. [but many things are not, so] it’s not a job that be good GP teachers. After becoming fully accredited, it is somebody who is just medically-minded, could probably the ethos or culture of the team. Eleanor spoke about her be satisfied with …and want to carry on doing. sessional work in the local memory clinic for patients with From Bruce Charlton: suspected dementia: The need to relate the practice of medicine to the Eleanor: You’re making diagnoses, but it’s not like when rest of the human world is unavoidable…. When you have a piece of histology and you know whether it’s medicine is the only system of thought available to cancerous or not, it’s a subjective decision, and yet you are a doctor, when all available time and energy are having to give a label of dementia or not and I find that spent on medicine, when the doctor is only an one of the hardest things – breaking bad news when the expert technical specialist then how can he or decision is based solely on the history you take and not on she become aware of the incompleteness and anything …. Sometimes you can get CT brain scan imperfection of medicine? Medicine must be seen changes, but normally it’s based on the history…that is in context, practised with wisdom. very much turning something subjective into something objective…so there’s a huge amount of wisdom, knowing This balancing challenge is not new. The Classical Greek the patient and you’re trying to ascertain all that within philosophers and poets were very well aware of the need 20 minutes and I initially found that incredibly stressful for wisdom to combine both the hard technical and the …I wasn’t sleeping … it’s just because of the decision soft feeling parts of humanity. Aristotle wrote that wisdom …every time you tell somebody they’ve got dementia it’s requires both Sophia and Phronesis . Sophia is theoretical …devastating. wisdom concerning universal truths. It includes episteme which is a type of knowledge that is logically built up, William: Has it got easier? teachable and sometimes equated to science. Phronesis Eleanor: It has got a bit easier…umm… it’s experience in is practical wisdom, related both to virtue and practical part, and also, umm, realising that I’m not on my own, details. It includes techn ¯e, meaning a craft. So in Classical having spoken with the other doctors realising that it is Greece wisdom was a combination of knowledge subjective and that it’s OK sometimes not to make a (including universal truths) and practical, virtuous diagnosis, to delay that and not to feel like it’s the wrong know-how. thing to do …um... and giving myself permission to say, even if you suspect quite highly this is going to be a

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dementia, to give a diagnosis of mild cognitive impairment the ability to distinguish between those things and when to give hope, and having the flexibility to do which are relatively certain and those things that, and the confidence and pattern recognition and which are matters of opinion. It needs to be seeing different patients in different settings, and under - underpinned by that healthy scepticism which standing they have problems and the degree of problems offers the possibility of setting a limit to error. the family are having and that’s what improves it. Scepticism which provides some protection against fashion, some protection against From Marcel Proust: accepting the received wisdom of superiors, We don’t receive wisdom; we must discover it teachers, consensus and the written word.’ for ourselves after a journey that no one can …and his worries about too many rules even in 1994. take for us or spare us. Of course we now have very many more protocols,

guidelines, standards and the Quality and Outcomes

Even the most apparently Framework…. ‘The practice of medicine is risky and difficult. a a straightforward consultation requires Risk-taking is necessary because the price of being on the safe side is often intolerable…waste of resources and the exercise of judgement iatrogenic harm….’ Doctors, like other people are ‘hot for certainties in this our life’, and, like other people, they Judgement would welcome any commandment that could not be questioned and thus absolve them from painful decision’ Eleanor described learning to exercise judgement during (quoted from Theodore Fox ‘Purposes of medicine’, her sessional work in the memory clinic. She felt the pain The Lancet , 1965)…. There is a place for rules in of responsibility when the (apparent) safety of rules, medicine, rules which can only be broken in exceptional measurements, statistical predictions are either unavailable circumstances and which if ignored carry the possibility or irrelevant. Eleanor’s experience and the supportive of grave harm…. In a sense these are simple situations in team enabled her to cope with this. But how does she which there can be no difference of opinion about the know that the team are not subject to some kind of immediate necessities…. Most decisions in medicine are groupthink? Teams can reinforce bad practice as easily as not simple and straightforward but require the exercise good practice. Here is a quotation from James McCormick’s of judgement….’ brief 1994 essay The Place of Judgement in Medicine in Here is a speech from Penny that vividly portrays which he poses eight questions that may go through the some of the issues from her lived experience: clinician’s mind when exercising judgment: Penny: … starting when newly qualified … timid is ‘Wisdom and judgement are close friends. Both (laugh)…I don’t think you trust your decisions as well, but rely on adding weight to the imponderable, the more …the longer you are in the job, the more you value to that which cannot be quantified… move through, you are always either …you are thinking in Even the most apparently straightforward your head, what is the worst that can happen? … if I, not consultation requires the exercise of judgement ignore that, but if I leave that, watch this, don’t treat that, in order to make wise decisions. How certain and actually the more you think about, the easier things is the diagnosis? What information should the become then because you end up with two decisions: act, patient be given? Should uncertainty be shared? don’t act …don’t act – review, that sort of thing. I think it’s What are the consequences to the person of the not that easy at all and I discuss cases all the time with you disease label? What is the probability that guys and with senior partners and I don’t think you can investigation will clarify rather than confound? get by in the working day without sharing …sharing the What are the risks of missing the diagnosis of a burden, because basically, I find with every patient, you serious disorder at this stage of the illness? What know, there’s several different…and everyone will do are the costs, risks, and potential benefits of different things from the one I might do and it might not treatment? What prompted the decision to be what you would do, and you realise that when we have consult – pain, anxiety about the meaning of meetings and things, and there isn’t …and I say this symptoms or the need to take up the ‘sick role’? patient’s… it’s not that simple, there’s no right or wrong – As a general rule reliable and proven answers try this, if that doesn’t work we’ll stop that and try this and to these questions do not exist, yet they cannot …(sigh) in some ways that is the role of the GP isn’t it, be ignored if doctors are to offer wise advice.’ because we get lots of specialist letters back saying, please Later, McCormack extols the importance of knowledge start frusemide, spironolactone and this and check bloods and scepticism… weekly blah, blah. Then the patient sits down in front of you and says ‘I feel dizzy, I feel awful, and I’m not going to ‘The first requisite for wise judgement is do this’. And you quickly realise you are not going to be appropriate knowledge…. Judgement requires able to titrate these things in the timeframe that …and

48 © Journal of holistic healthcare G Volume 13 Issue 1 Spring 2016 WISE The juggler – being wise in the modern NHS

you end up doing your own thing. Little bit by bit, and consultations in the dementia clinic. Here is another actually and as long as we try reaching the end point that exchange with Penny and me. I open by referring to some is safest for the patient, I think we have a lot of…I feel like remarks before the recording started about how many half the instructions never get done as quickly as they are unread letters both Eleanor and Penny had. suggested but actually where is the harm in that, as long William: OK, yes, we’re back where we started aren’t we, as you are listening to the person in front of you?

with that having so many letters to read and eventually running out of time. So let’s talk about that.

I would enjoy the work a whole Penny: Yes, it’s time. Time’s a big one. Time management. a a And these are the people we are using wisdom on: they lot more if it wasn’t so pressured, tend to be the ones who are complicated with multiple morbidities, difficult social circumstances or family because as a job, it’s a great job surroundings, where you don’t get to know them in one or two consultations. You get to build a relationship, get to Penny is learning to pace her practice, to hold the this point where maybe you are both stuck for a variety of uncertainty and ambiguity, even to enjoy the syncopations. mental health or physical health reasons. Marshall Marinker, one of the early pioneers of general At the end of the conversation: practice as a bona fide academic discipline, described general practice as: ‘the jazz of medicine’. William: Do you want to carry on doing it [general practice]? Time Penny: Yeah, definitely …if it wasn’t so busy! I think something needs to change in terms of workload, it’s Of course, lack of time is a perennial complaint from staff ridiculous! I think I would enjoy the work a whole lot in the NHS, especially from general practice and we’ve more if it wasn’t so pressured, because as a job, it’s a already heard about the challenges of Eleanor’s 20 minute great job.

© Journal of holistic healthcare G Volume 13 Issue 1 Spring 2016 49 Crisis in medical manpower: the real story…

William House Retired GP; Chair of the BHMA

These are difficult times for the NHS: junior doctors in GPs will recognise these stories – they are part of the dispute with government, recruitment (particularly job. With Jack Coulehan’s patient, science and industry general practice) difficult, many doctors leaving the have nothing to offer. In the case of Mohamed, if we fail profession early or working abroad. Why? The February to improve his diabetes medically, our income will fall 2016 issue of the British Journal of General Practice and our competence will be questioned. These cases (BJGP) includes several articles on practitioner morale and will demoralise doctors, but in different ways, each mental health. One of these is based on interviews with represents a failure of the biomedical paradigm and the GPs in England who had left practice early. In terms of industrialisation of healthcare. So what can be done about reasons given, the overarching theme was the ‘changing the misfit of expectations and reality? role of general practice and its impact’. The sub-themes Martin Marshall’s article, (Mohamed’s story) focuses were: ‘organisational changes, clash of values, increased on coping with the uncertainty deriving from the workload, negative media portrayal, workplace issues and incompatibility of the unique individual and the lack of support’. standardised protocol. His first ‘way forward’ is to Like all other NHS roles GP work has become ordered restate, in his own words, HL.Mencken’s famous by procedure. This reflects the dominance of science with aphorism: ‘For every complex problem there is a solution industrial process. Yet science and industry are blind to much human suffering. Here are two examples: that is neat, plausible and wrong’. He goes on to suggest ways of clarifying and ordering the complexity, calling The knitted glove upon ancient wisdom, new business practices and You come into my office wearing a blue research. BHMA founder member and GP, Dr David Knitted glove with a ribbon at the wrist. Zigmond, would suggest that this is attempting to turn You remove the glove slowly, painfully Wilder-Ness into Orderly-Ness. Of course, this Wilder-Ness And dump out the contents, a worthless hand. is real life. How could we imagine that science, theory, What a specimen! It looks much like a regular hand, Warm, pliable, soft. You can move the fingers… abstraction and industrial procedure could entirely capture the crooked timber of humanity? … This thing, the name for your solitary days, So what is to be done? For the hips, the hand, for the walk of your eyes The BHMA is on an ambitious journey to rediscover Away from mind, this thing is coyote, the trickster. I want to take it by its neck between my hands. the human qualities: the skills and especially language But in this world I don’t know how to find needed to counterbalance the hegemony of science and The bastard, so we sit. We talk about the pain. industry. There is an extraordinarily rich domain of Jack Coulehan ‘treasures in the mist’ that show us how to approach these difficult problems. By the time you read this, a Mohamed major new feature will be available on the BHMA website Mohamed has been in the UK with his wife and two young (www.bhma.org) the Dimensions of Being Holistic – a children for 12 years and is currently unemployed. He is obese treasure trove. For the Coulehan story try the ‘intuitive’ with a BMI of 32, has type 2 diabetes and hyper tension. His blood sugars are poorly controlled despite medication change. dimension. For Mohamed try ‘community-minded’. Then The GP revisited Mohamed’s diet. He said proudly that he ate browse the other ten dimensions. There are also many ‘very nice food’. This turned out to be two large meals a day of more recent sources in the back issues of this journal and deep fried chicken and chips at one of the many fried chicken also, for example, the February 2016 issue of the BJGP . shops in the area….He lives in an apartment with 17 other If we do not find a set of solutions to these problems mostly family members, with four beds shared on a rota. His we risk losing the best of our practitioners from the social life revolves around the chicken shop. Mohamed is a profession. content man, happy with his lot. Adapted from Martin Marshal, BJGP Feb 2016

50 © Journal of holistic healthcare G Volume 13 Issue 1 Spring 2016 Research Summaries

A healthier, cooler, and richer Pollution tied to premature births, vegetarian world especially in women with asthma – By eating less meat and more fruit and vegetables, the world US study could avoid several million deaths per year by 2050, cut planet- A new study suggests that women with asthma exposed to air warming emissions substantially, and save billions of dollars pollution, even before conception, significantly increase their risk annually in healthcare costs and climate damage, researchers say. of delivering a premature baby. Researchers studied 223,502 A new study, published in the Proceedings of the National pregnancies among 204,175 women in 19 hospitals across the Academy of Sciences of the United States of America, is the United States, gathering data on air quality in each region. The first to estimate both the health and climate change impacts of study, in the Journal of Allergy and Clinical Immunology , found that a global move toward a more plant-based diet, they said. all women with asthma were more likely than those without to www.reuters.com/article/us-food-health-climatechange- deliver preterm. But there were significant increases in preterm idUSKCN0WN248 birth in asthmatic women exposed to air pollution, including traffic-related pollutants. Air pollution also appeared to take a Hong Kong study: E-cigarettes a toll even before conception. Asthmatic women exposed to pollutants in the three months before conception were at a million times more harmful than 28% higher risk for pre-term birth than women without asthma outdoor air for cancer-causing exposed at the same time in the same conditions. substances www.nlm.nih.gov/medlineplus/news/fullstory_157539.html Electronic cigarettes were found to contain one million times more cancer-causing substances than outdoor air in a study by Money can’t buy you love Baptist University. Researchers also discovered a type of flame Across three studies (N = 30,645), the authors of this study retardant that affected the reproductive system and could lead show that for people in relationships, sexual frequency greater to cancer – the first such discovery in e-cigarettes. The Hong than once a week is no longer significantly associated with Kong Council on Smoking and Health, which commissioned the wellbeing. There is helpful further discussion of this article at study, called for a ban on e-cigarettes as soon as possible before www.cbsnews.com/news/does-more-sex-make-couples-happier/. they become more popular. In analysing 13 types of e-cigarettes Note the fascinating finding in the article that the increase in bought on the market, researchers found that the level of wellbeing gained from sex once a week compared with less than polycyclic aromatic hydrocarbons (PAHs) – a by-product of once a month, is larger than the increase in wellbeing gained burning petroleum that is commonly detected in roadside air from making $50,000–$75,000 a year rather than only between – ranged from 2.9 to 504.5 nanograms per millilitre. The US$15–US$25,000 per year. substance, which contains highly carcinogenic chemicals such as benzo(a)pryene, also carries various kinds of chemicals that Muise AU et al (2015). Sexual frequency predicts greater well-being, but more is not always better. Social Psychological and Personality Science. promote growth of cancer cells. http://spp.sagepub.com/content/early/2015/11/16/1948550615616462. www.ibtimes.com/e-cigarettes-one-million-times-more-harmful-air- abstract hong-kong-chinese-study-finds-2327122 29% of young doctors are depressed Healthy heart may also mean A systematic review searched for studies on depression among healthy brain medical residents (= junior hospital doctors) published between If you eat right, exercise, and take care of your heart, you may January 1963 and September 2015. It estimated the prevalence also be doing good things for your brain, a US study suggests. of depressive symptoms among residents at 20.9% to 43.2% Researchers assessed memory, thinking, and brain processing depending on the instrument used. This suggests that about a speed in more than 1,000 New York City residents and found third of junior doctor are depressed and that this increases year people did much better on these tests when they had heart- on year. The authors recommend more research to identify healthy habits like avoiding cigarettes, maintaining a normal strategies for preventing and treating depression among doctors weight, and keeping blood pressure and cholesterol in check. in training. Journal of the American Heart Association , online March 16, 2016. Mata DA et al (2015) Prevalence of depression and depressive www.reuters.com/article/us-health-cardiovascular-brain-function- symptoms among resident physicians: a systematic review and idUSKCN0WI2UH meta-analysis. JAMA . 314 (22) pp 2373–83. www.ncbi.nlm.nih.gov/pubmed/26647259

© Journal of holistic healthcare G Volume 13 Issue 1 Spring 2016 51 Reviews

If you want good personal economical and social issues throughout this very thoughtful healthcare see a vet book which evoked powerful personal memories of the excellent and personal healthcare my own parents received Industrialised humanity: why and how should in the 1970s and 80s. I reflected on two thankyou cards I we care for one another? received on leaving my last practice. One was from the wife of a patient I’d ‘two-weeked’ (referred urgently to hospital as David Zigmond suspected cancer) who turned out to have bowel cancer. New Gnosis Publications, 2015 I didn’t feel worthy as it was a ‘tick-box’ exercise courtesy of modern day healthcare and the patient met the referral There is no substitute for experience and in his writings criteria. However, on reflection, the colonoscopy (initial David Zigmond captures wonderful experiences through hospital test) had missed the tumour and the patient several decades of personal care as a medical practitioner. cancelled a subsequently scheduled CT scan as he felt ‘fine’. He reflects on and contrasts his experiences of typical Luckily it was a small enough practice and I followed him up healthcare in his younger years during the 1950s delivered in and encouraged him to attend for the scan which probably the doctor’s own house with that of the modern, turn-key saved his life. The second patient was in his 30s and had semi-industrialised National Health Service. unfortunately spent time in ITU recovering from acute One could argue that his attention to the mind-body pancreatitis before I met him. I again felt I hadn’t done that connection and its role in illness and health detailed in much for him but in his card he told me that he’d always articles written in the 1980s is at least as pertinent today as been frightened of attending medical appointments and how it was back then. David shares many clinical experiences to through just listening to him and providing the same friendly demonstrate the role of holistic healthcare in healing and the ear he felt he could overcome some of his fear. interwoven fabric of the psyche and the physical being: the I finished the book with mixed emotions; as the age of phenomenon of shingles occurring after the loss of a loved federated GP practices begins it feels like the end of a one is common knowledge but less so that of Takotsubo chapter in the life of the NHS and the end of personalised cardiomyopathy or ‘broken-heart syndrome’ which can be healthcare. I’m fortunate in that I work at a small GP practice fatal. in Hampshire which still strives to deliver high-quality David has spent most of his four decades in the NHS personalised healthcare and David’s book has inspired me to as a single-handed GP and part-time psychiatrist and strive further. I highly recommend this book as a catalyst for witnessed first-hand the government’s policy and shifts a revolution in holistic healthcare. towards homogeny and hegemony in healthcare and the apparent disregard for holistic considerations. David argues Mark Lown, GP that the ‘industrialisation’ of healthcare is likely to confer its greatest benefit when dealing with well-defined ‘physical pathology’ but that considerably more difficulties are encountered and generated when faced with the full complexity of human unhappiness or dis-equilibrium or ‘functional pathology.’ In my own experience of today’s system of barrages of ten minute appointments, it’s sometimes more convenient to flick the autopilot switch and deliver a well-rehearsed spiel on an abnormal blood result and save some energy for the next punter who may or may not be in more need or personalised and skilful human contact, particularly if they are distressed. In his narratives David also cleverly suggests that attempts to strive for greater safety and efficiency, particularly in general and psychiatric medicine, have led to both the fragmentation of services and the demotivation of staff and patients alike. He also reflects upon wider

52 © Journal of holistic healthcare G Volume 13 Issue 1 Spring 2016