Medicine as if people matter

THE BRITISH HOLISTIC MEDICAL ASSOCIATION

Volume 6

Issue 2

Aug 2009

ISSN 1743-9493

JOURNAL OF

holistic healthcare Medicine as if People Matter Supporting self-care in the 21st century Self-care on-line Expanding self-care Helping patients to help themselves Self-care for medical students Healthy choices on the street Self-care and CAM Self-care and ICT Self-care and the heart

Plus • • • • • A JOURNAL BASED IN THE SCHOOL OF INTEGRATED HEALTH UNIVERSITY OF WESTMINSTER, LONDON

News Reviews Events Research summaries From the frontline

JOURNAL OF

holistic healthcare

Contents Editorial. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

ISSN 1743-9493

News review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Published by

Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

British Holistic Medical Association PO Box 371 Bridgwater Somerset TA6 9BG Tel: 01278 722000 Email: admin@bhma.org www.bhma.org

Supporting self-care in the 21st century – a long-term (conditions) view. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Reg. Charity No. 289459

Editor-in-chief

David Colin-Thomé NHS LifeCheck – self-care online . . . . . . . . . . . . . . . . . . . . . . . . 9 Dr Sunjai Gupta and Maria Reeves Self-care, self-care, self-care…: have we been missing something? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Simon Y Mills

David Peters petersd@westminster.ac.uk

Helping patients to help themselves. . . . . . . . . . . . . . . . . . . . 17 Ruth Chambers

Editorial Board

Using mind-body medicine for self-awareness and self-care in medical school . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Jan Alcoe, Richard James, Willliam House

Scott Karpowicz, Nancy Harazduk and Aviad Haramati Helping street sex workers make healthy life choices . . . 24 Josie Hill

Editor Edwina Rowling erowling@tiscali.co.uk

Self-care and CAM: defining the differences, recognising the similarities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Karen Pilkington

Administrator Di Brown admin@bhma.org

Self-care and the need for interactive ICT . . . . . . . . . . . . . . . 35 Tuvi Orbach, Ameet Bakhai and Jane Vazquez

Advertising Rates 1/4 page £110; 1/2 page £185; full page £330; loose inserts £120.

Rates are exclusive of origination where applicable.To advertise, call Di Brown on 01278 722000 or email admin@bhma.org

Emotions and self-regulation for the heart . . . . . . . . . . . . . 40 Elizabeth Wilde McCormick

Products and services offered by advertisers in these pages are not necessarily endorsed by the BHMA.

Reviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

From the frontline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 William House Research summaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Design karen@jigsawdesign4print.co.uk

Printing

The journal is indexed, abstracted and/or published online in the following media: MANTIS, Zetoc.

Ashford Press Cover photo: M.C. Escher’s Drawing Hands. The M.C. Escher Company – Holland.

This issue has been sponsored by Health-Smart.

Volume 6

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Issue 2

The Journal of Holistic Healthcare is available through EBSCO, a world leader in accessible academic library databases.

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Aug 2009

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 no part of this publication may be reproduced in any form or by any other means – graphically, electronically, or mechanically, including photocopying, recording, taping or information 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 views expressed by contributors are not necessarily those of the editor or publisher.

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Editorial David Peters Editor-in-chief

Integrated self-care: developing individual and communal wellbeing Though the course of a human life is uncertain, in our privileged society people can expect longer, safer lives than their recent forebears: a mean of 77 years for men, and 82 for women in the UK. The NHS seems conceptually committed to extending lives further by permanently medicating us. Deals that cheat disease and death are a timeless part of the human story, but the mythic downsides are always clear to see. Big pharma’s Faustian bargain with the NHS is mirrored in soaring healthcare costs, and high rates of side-effects: too often, the years added by poly-pharmacy are spent feeling unwell.

Does pharmaceutical risk-reduction promote health or merely delay death? Wouldn’t it be more productive to support healthier ways of life? Or are lifespan and life quality just a matter of luck: the blind dice-thrower that lands us in this or that social class, or a particular place, or deals us certain genes? Because wealth and good social policy can shield us from the pernicious alliance forged when poverty, ignorance and unhealthy ways of life entangle, as they do. The shameful gulf between the lifespans of rich and poor, at home and in the developing world, is not due to a lack of biomedicine, or bad genes.

Genes (whatever the bio-fundamentalists tell us) don’t create social exclusion or decide the choices we make.

And, though some genes shift the odds of our developing cancer or heart disease, whether those genes actually get expressed depends a lot on environment, beliefs and behaviours; on the mind-body’s reading of the gene ‘text’, and its capacity for self-regulation.

Knowing that beliefs and behaviours are shaped by culture and community, and that mind-body coping skills can be learned, we can create integrated approaches to holistic self-care and health promotion. The triad of awareness, the supportive community, and its notions of ‘right living’ underpins many movements for social reform and spiritual regeneration; a threefoldness know to Buddhists as Buddha, Sangha and Dharma. Rather than just providing information, individuals and communities need to engage together in processes that support life.

Can we imagine something like this arising from the holistic health- and self-care movements? The pandemic of chronic disease and social dysfunction we face won’t be solved through mono-cultural responses fuelled by big pharma. The wish to stay well longer and cope better with chronic disease has launched a vast lifestyle industry, and reaching those with ears to hear and money to spend won’t be a problem. But narrowing the health gap is a bigger challenge. In this issue David Colin-Thomé charts a

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holistic strand of health policy, targeting social exclusion and providing street-level support for self-care. NHS LifeCheck for instance, which as Gupta and Reeves tell us is already putting self-care tools online.

Simon Mills looks at initiatives in pluralistic and communal self-care. Because self-care isn’t just about selfinterest: organisational and group self-care programmes are emerging too. A ‘good society’ (or a sustainable organisation, or a healthy community) can nurture wellbeing and resilience at many levels – from the genome to the ozone layer. Narrowing the health gap will mean going beyond individualistic, finger-wagging, victim-blaming styles of health promotion, as GP and writer Ruth Chambers explains in her article on helping people help themselves. Knowledge on its own isn’t enough: sustainable self-care requires novel educational solutions but also ways of actively supporting change. Four articles describe radically different approaches: George Washington Medical School’s mindfulness programme for medical students, a peer group health support project for sex workers, the potential of interactive computer-based learning support, and a profoundly holistic approach to healing self-care for people with heart disease.

As solutions like these interweave and snowball, we should see a cohort of holistic self-care practitioners emerging. Understanding change agency and how to promote wellbeing, they will work with mind, muscles and metabolism, and be skilled in helping people create authentic and sustainable resilience. The NHS health trainers are a new group who, though their sights are initially set low, will have a lot to contribute to holistic primary care. The field of complementary medicine (CM) too, as it matures, could take on some of this mantle.

Karen Pilkington explores the overlapping agendas of CM and self-care.

A knowledge of what is good for us implies a theory of human nature. The perspectives of evolutionary biology relate many 21st century ills to our being out of step with the hunter gatherer lives our human minds and bodies evolved for, in close-knit groups wandering on open plains.

There is no going back, yet this legacy is reflected in many of our basic bodily and emotional needs: we tend to thrive in community, when we live on simpler foods, and can exert ourselves, but find time for rest and recreation.

Perhaps this Neolithic heritage also shapes our aptitude for co-operation, our need to search for meaning, and to form respectful relationships with the non-human and the more than human worlds. Self-care and world-care are now intimately entwined: a connectedness JHH will be exploring in the autumn issue, whose theme will be deep ecology and the healing power of nature.

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Volume 6 Issue 2 Aug 2009

News review Obituary Dr Carl Simonton, a radiation oncologist and true pioneer in integrative medicine who popularised the mind-body connection in fighting cancer, has died. He was 66.

Early in his medical career, Dr Simonton noticed that patients given the same dose of radiation for similar cancers had different outcomes.

When he looked into why, he concluded that people who had a more positive attitude generally lived longer and had fewer side effects.

In the 1970s his use of techniques such as meditation and mental imagery were groundbreaking. He founded a cancer care clinic in Los Angeles in the early 1980s.

Ken Pelletier writes: My first meeting with Carl was in 1975 when I invited him to speak at the UCSF School of Medicine since I had heard about a military oncologist with some very heretical ideas. He arrived in his full dress Air Force officer’s uniform

and proceeded to articulate the applications of visual imagery with cancer patients. He was not well received but that did not and never did deter his courage, practice, and mentoring.

Later in 1977, he wrote the introduction to my book Mind as healer, mind as slayer and we remained friends and colleagues ever since. There are precious few individuals that I have truly considered as pioneers and mentors… that very short list includes Carl Simonton. A truly remarkable man, physician, friend, and healer.

BHMA student essay prize The BHMA will award £250 for the best 1,500 word essay from an undergraduate healthcare student on ‘Improving global wellbeing – improving personal wellbeing’.

The closing date is 1 April 2010. See www.bhma.org for full details.

Traditional medicine and children Researchers at Thames Valley University are exploring how patients use CAM and how their mainstream healthcarers react. The survey is part of The King’s Fund project exploring how traditional and complementary healthcare approaches are used for children.

The project has identified over 150 remedies that people use on their child, from ‘food remedies’ to spiritual interventions. The eclectic mix of ‘most popular remedies’ included honey and lemon in hot water, fennel tea, massage, yoga, homeopathy, ‘lots of fruit’, ‘lentils and rice’, reading the Koran, praying and cranial osteopathy.

The study is tracking how people make decisions about what to use.

As a healthcare professional, you can help TVU test their model by taking part in the survey at www.surveymonkey.com/s.aspx?sm= Kj6glHp9NBcKf8soEpG_2bYA_3d_3dt.

EVENTS 25–27

SEPTEMBER 9

The Future of the NHS – Westminster Health keynote seminar. Morning, Central London. Details at www.westminsterforum projects.co.uk/healthforum/bookfutureofnhs. html.

12–13

The British conference of acupuncture and Oriental medicine. Egham, Surrey.

Details at www.acupuncture.org.uk/conference.

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Building on PROMs: putting health outcomes at the heart of NHS decision making. The King’s Fund, London. Details and booking at www.kingsfund.org.uk/learn/index.html.

Landscapes of the mind. A Confer conference sponsored by the BHMA. Eden Project, Cornwall. Member discount. Details at www.confer.uk.com.

NOVEMBER 24

Transforming quality, creating value: developing health care for a new economic era. The King’s Fund Annual Conference 2009. Royal College of Physicians, London. Details at www.westminsterforum projects.co.uk/healthforum/bookfutureofnhs. html.

21–24

EnergeticNLP level 1.

26–29

EnergeticNLP level 2. Essential self-care techniques for healthcare practitioners. See www.energeticNLP.co.uk for more details.

To publicise your event send details to Edwina Rowling at erowling@tiscali.co.uk. Deadline for next issue: 1st October 2009

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Volume 6 Issue 2 Aug 2009

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NEWS REVIEW

Jane Ryan, Director, Confer When someone enters your consulting room, how often do they begin by declaring despair over climate change?

The relationship between mental, emotional, social wellbeing and the natural world is a critical theme for our time. Living on a planet that is poised at the tipping point of irreversible environmental destruction, we struggle to conceptualise such a potential catastrophe, while in the same moment knowing that it is preventable. Believing, perhaps, that we are individually helpless to impact on this terrifying escalation, this conflict is often felt as despair and moral bewilderment.

Yet how difficult it seems to find a detailed emotional language for this confusion. Could this be because the suppression required to manage this profound anxiety actually perpetuates it through the effort of denial? But does this not leave us to cope in frightening interpersonal isolation with the prospect of catastrophic alterations in nature?

How profoundly then does this drama play out in the psyche and impact on our emotional health?

What impact does denial and the effort of suppression have on the organ systems of the body? How often might practitioners actually be faced unknowingly with the health consequences of this profound – and profoundly hidden – source of distress? Do we as health workers, counsellors and psychotherapists have the listening ability and vocabulary in place to discover and relate to fears about environmental changes at a sufficiently deep level to be of real support to these clients? What would that sort of engagement sound like, and how could we develop such skills?

We intuitively understand that emotional, social and psychological health springs from a harmony with nature because it is quite literally the source of all life. As Satish Kumar, one of the speakers at the upcoming

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conference Landscapes of the Mind (25–27 September 2009, see opposite) says, ‘Our emotional, spiritual, psychological health depend on our relationship with nature.’

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The challenge of today is to save the planet from further devastation which violates … enlightened self-interest

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Deep ecology and our health

The purpose of this conference is to consider these crucial 21st century issues. Central to their unravelling is the concept of deep ecology, a term coined by the Norwegian philosopher Arne Naess1 and central to the work of Joanna Macy, who will speaking at this conference. Deep ecology challenges the assumption that earth’s resources are there to be exploited. It proposes that in the best interests of both the human and the non-human worlds, humankind must learn to view the natural world as a being to be respected rather than an object to be subjugated. ‘Earth is not just here for us’, says Satish Kumar. ‘There are 8.4 million species on this earth, and they have as much intrinsic value and the right to live and be undisturbed, unpolluted and uncontaminated as do human beings’. Deep ecology implies that the earth is a living, suffering entity that we are part of. This realisation gives birth to the ‘ecological self ’. Such a shift in consciousness would make environmentally responsible behaviour an expression of enlightened self-interest. Moreover it would be a sure foundation for both a sustainable future and a more emotionally healthy existence.

Joanna Macy, who is giving keynotes and a workshop at the conference, says, ‘What we have now is a shift – a transformational moment’. She calls this ‘the great turning’, a huge event in the history of humankind. Her vision for a new post-industrial, life-sustaining society also provides a methodology for confronting ecological despair and for transforming it. Deep ecology, she explains, is both a school of thought and an activist movement that has inspired a whole array of experiential practices and developments. ‘The challenge of today is to save the planet from further devastation which violates both the enlightened selfinterest of humans and non-humans, and decreases the potential of joyful existence for all.’

This conference brings together an exceptional panel of speakers, including highly respected Jungian and psycho-dynamic psychotherapists, eco-psychologists, other health practitioners and environmental campaigners. Together we will explore how an enriched sensibility to our place in nature can help us shift from passive anguish to both psychologically healthy problem-solving and greater emotional health. This landmark event will examine how we can creatively harness our awareness of our relationship with nature – rather than suppress it.

Join us there to question how we develop our mental health and new cultural depth by relating to nature as a subject to be nurtured rather than an object to be exploited.

The Landscapes of the Mind conference, 25–27 September 2009, sponsored by the BHMA* and organised by Confer, is being held at the Eden Project. To read the full programme or to book, visitwww.confer.uk.com

References 1 Næss A. Ecology, community and lifestyle.

Cambridge: Cambridge University Press, 1989. *BHMA members are eligible for a £50 discount on the booking fee

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GUEST EDITORIAL

Supporting self-care in the 21st century – a long-term (conditions) view David Colin-Thomé National clinical director for primary care, Department of Health

My commitment to healthcare reform and support for self-care are derived from three personal beliefs which have been further shaped by my experience of working as a GP in an underprivileged area for some 36 years.The public and individual patients need to have far more influence on the NHS and their personal care, the ideal clinical consultation should be a ‘meeting of two experts’. I am hugely proud of the NHS for its role in promoting social justice but there is far too much ‘unwarranted’ variation in the quality of access and care. Reform and empowerment are the necessary catalysts for culture change and service improvement.

The policy context There are more than 15 million people in England living with a long-term condition and this number is expected to double by 2030. The NHS and an increasing number of alternative providers support people through excellent clinical care every day, but people say they want to do more for themselves – as long as they get the right support.

We know that better-informed people achieve better health and quality of life. They are more confident and better prepared to manage changes in their condition.

People with long-term conditions are experts in how their conditions affect them and their lives. But being an active participant in improving your health and wellbeing is not always easy and can prove quite a challenge if feeling ill and vulnerable. In these circumstances, people often need the additional support of their clinicians as well as their family and friends.

care planning should incorporate many aspects of a person’s health and wellbeing, including looking after body, spirit and mind. The process will involve input from a multi-disciplinary team of professionals, but most importantly features a relationship between the person themselves and their key worker which in healthcare is usually a clinician. Ideally the key worker is the choice of the individual person.

What is self-care?

Self care is an integral part of daily life and is all about people taking responsibility for their own health and wellbeing, with support from and in conjunction with the people involved in their care. Self-care includes the actions people take every day in order to stay fit and maintain good physical and mental health; meet their social and psychological needs, prevent illness or accidents, and care more effectively for minor ailments and longer term conditions. (Supporting people with long term conditions to … self care, Feb 2006, DH)

Approaches to self-care support There is a range of approaches to self-care and the NHS can support people in involving them through a process of discussion, decision-making and ongoing support, as part of the care planning approach. A personalised care plan is a record of the discussion about the support and services available to help someone live with their condition, including agreed decisions, actions, goals and follow-up. Everyone with a long term condition should be offered a personalised care plan by 2010.

We know that the delivery of truly personalised care for people with long-term conditions goes beyond just treating an illness. It requires a holistic approach that puts the individual at the centre of their own care. Personalised

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The importance of supporting self-care The importance of engaging people to self-care in order to better manage their long-term condition is further highlighted by research conducted by MORI.1 This revealed that only half (53%) of those surveyed took an active role in taking care of their condition ‘all of the time’, of these 51% stated that they felt comfortable in doing so.

Two-thirds of those surveyed had also approached their GP, practice nurse or pharmacist within a six-month period seeking self-care advice and information, reinforcing the need for a more personalised approach to care.

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Volume 6 Issue 2 Aug 2009

GUEST EDITORIAL Supporting self-care in the 21st century – a long-term (conditions) view

Government policy to support self-care has been developing since 2000 when self-care was highlighted as one of the key building blocks for a ‘patient-centred NHS’.

This has been followed up with a wider strategy for improving self-care support for people with long-term conditions, most recently in the form of Your health, your way – a guide to self-care and long-term conditions.

This is a website, hosted as part of NHS Choices (www.nhs.uk/yourhealth), supported by a patient information leaflet and supporting information for professionals (www.dh.gov.uk/yourhealth).

Your health, your way brings together existing policy in an easily accessible format – the first time this policy has been given a public face. It aims to raise public awareness of the range of support people can expect from the NHS as they choose the degree of support to self-care.

Other developments include information prescriptions, a range of guidance for personalised care planning and development of core competences for the workforce.

The five key areas of self-care support Information – about the condition, provided in the way people want it, when they want it.

Services to support healthy lifestyle choice such as help to stop smoking, eat healthier, exercise more.

General or condition-specific training courses to help people feel more in control.

Access to and information about support networks/ self-help groups to help people get together with other people with the same condition.

Tools and equipment that can help people to manage their condition better and stay independent.

Delivering effective support for self-care It is important to recognise that supporting people to self-care requires a change in the traditional relationship between clinician and patients – to become one of ‘working with’, rather than ‘doing to’. Supporting self-care is about a culture shift which changes the relationship between the clinician and the individual.

What should happen is that people with long-term conditions should be able to have a conversation about their condition and how it is impacting on the things that are important to them. They should be able to discuss the range of self-care support available, the extent of their self-care, what support groups are available and the most convenient way for them to access further information.

Managing minor ailments is an aspect of self-care which is even more important when living with a longterm condition. The role of the community pharmacist in supporting self-care can be key in terms of managing minor ailments. Pharmacists have successfully built relationships with people in local communities and are increasingly raising their profile as not only managers of medicines, but also as healthy living advice centres. For

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people who are on lifelong medication, the community pharmacist is in a position to provide additional, convenient and professional support so people can manage their conditions more effectively.

Effective self-care support needs co-operation between all parties concerned – health, social care and local authorities working with community, voluntary and private sectors to provide local solutions to embed supported self-care as a practical option. But at the heart of this support is a trusting relationship between the person and their key worker. This is vital if people, not just those with long-term conditions, are to attain their full potential in terms of health and wellbeing in the 21st century.

Case study Self-care in respiratory practice While splitting his time between acute cases and a busy respiratory clinic and ward, consultant Jonathan Fuld has managed to evolve a new way of dealing with his patients which could help to achieve results that most definitely complement his specialist medical care.

Jonathan, who is a physician in acute and respiratory care at Addenbrookes Hospital in Cambridge, is now a firm believer in also providing his patients with self-care support which he sees as potentially contributing to a major impact on the lives of his long-term condition patients.

He explains: ‘Inhalers and other medical treatments definitely achieve a degree of stability for someone with primary respiratory problems such as chronic obstructive pulmonary disease (COPD), but the biggest interventions to maintaining health are actions the patients can take for themselves.’

Jonathan, who leads the Health Foundation-funded Co-creating Health Initiative at the Cambridgeshire Trust, underwent specialist training as part of the initiative to enable him to work with his patients in a more individualised and personal way, and now applies the new way of thinking wherever he can.

He says: ‘Self-care support is all about clinicians being there to support people making decisions that could impact much more than us just writing on a prescription pad.

‘It centres around supporting the patient’s own beliefs and actions about self-help. It’s talking with the patients, getting them to face their fears and ask questions in an effective manner. And for patients with a long-term condition, this is a vital additional resource that can be added to the care we provide.’

The training enabled Jonathan to learn to listen to his patients more; to understand their personal priorities; give them confidence in their actions; and to use his experience and authority to help them in making their decisions.

He now tries to provide a balance between specialist medical care and supporting his patients on their selfhelp choices, but as Jonathan admits, it’s not always enthusiastically received. continued…

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GUEST EDITORIAL Supporting self-care in the 21st century – a long-term (conditions) view

‘For someone with COPD, the best course of action would be for the patient to stop smoking and to introduce some form of pulmonary exercise regime.The effects of exercise and general wellbeing are now well recognised, but smoking can still remain a major sticking point with some patients.Yet it’s our role to do all we can to ensure individuals get the best care possible, so it’s an issue which I tackle frequently.’

recalls that after being told on several occasions that her future would be in a wheelchair, she stopped seeing doctors for a number of years as she believes she was never really asked how she felt or what she wanted.

Although Jonathan sees the support as a different resource to call upon to make his consultations even better, and ultimately achieve better outcomes for his patients, he also ensures they are made aware of the other support groups and services that are available to them.

For example, the smoking cessation and pulmonary rehabilitation programmes run by the hospital as well as the Breathe Easy Club run by the British Lung Foundation.

Jonathan adds: ‘I want to signpost patients to the care and support they can obtain beyond our consultation as well as help them make decisions that will have an effect on their long-term health.’

With their proud Indian roots, Stanter’s parents had equally never really questioned on her behalf and now Stanter was on a mission to find the freedom and independence she desperately craved. ‘Up till then I’d been scared to deal with things I was afraid of. For example, education – I had always viewed myself as not very bright.’

With his busy clinic and constant flow of acute cases, Jonathan does still try to see how else he can improve the self-care support provided and is currently looking at introducing a user group for the clinic to help his team develop their services even further.

‘This was a time when I was really testing myself. I was determined not to let rheumatoid arthritis define my life, like so many other people do. I wanted to prove that there was no reason why I couldn’t push forward and live my life to the full.’

Jonathan concludes: ‘It’s all about working together.

Ultimately, consultations should be viewed as a meeting of partners in care. One of the partners has obviously got more medical experience, but it is still a partnership which if managed effectively can achieve significant results for the patient, and that’s what we’re aiming for together.’

Along the way, Stanter discovered the benefits of meditation and yoga, and explored the whole issue of consciousness and spirituality. ‘My sister was working with a specialist centre in the US and I was able to attend as both a student and tutor which was a great way to learn.

I was able to build my self-esteem and also my very belief in myself.’

Case study

Back in the UK, Stanter has continued her quest to seek alternative care and support for her illness, concentrating on wellbeing, diet and her yoga and meditation. ‘I believe I’ve now found the perfect balance between clinical and alternative care. By looking after myself I can ensure my body remains strong enough to deal with the clinical side of my condition, and along the way I’ve become much more conscious and aware of everything that’s good in my life. I don’t dwell on the ‘ifs’ anymore. It’s taken me almost 30 years to get to a place where I am happy, healthy and have a job I love.

How I battled rheumatoid arthritis Stanter Kandola may have been born on India’s Independence Day and given a name which means liberation and independence, but she has only recently found what she believes is true freedom.

Born into a strict Indian family, Stanter was diagnosed with rheumatoid arthritis at 15 and for many years was faced with the dual dilemma of dealing with her restrictive traditional upbringing, while also coping with diagnosis and the inevitable complications from the chronic disease.

Now in her early 40s, Stanter says: ‘Ironically my name actually means independence, yet I strived for this for most of my early life. With such strict parents, I was dictated to over how I was supposed to live my life anyway, but then being diagnosed with rheumatoid arthritis was a double blow. I was a young Indian girl who was fighting against being controlled in every aspect of my life, including what I could do with my illness.’

The pressure became too much and eventually Stanter did the unthinkable, leaving home in a non-arranged marriage.

She says: ‘Looking back, I managed to leave with dignity, but it was all too much and maybe linked to me battling with wanting to do the right thing by my family and myself, my rheumatoid arthritis got very bad.’

At the same time, her experience with medical professionals was also extremely disappointing and she

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‘I was in a terrible place in my life and I was blaming everyone and everything. But thankfully in my late teens I took a grip and started to question myself, everything, to find answers, guidance and alternatives.’

But this proved far from the case as Stanter enrolled on an Access to Higher Education course and following a very emotive and challenging year out backpacking in India (again, as part of her mission to push the boundaries even further), she achieved a degree in social anthropology.

‘Yes, I’ve been bedridden numerous times, had multiple surgeries, and believe me I know what hell is, I’ve been there. But although my life journey has taken me to some very dark places, it has taught me so much about who I am and what I can achieve.’

Now, using the very experience she has gained over the past 25 years, Stanter is a health trainer in Kirklees, specialising in emotional work and sharing her knowledge and findings with other patients. Stanter concludes: ‘This job is the most valuable help we can give.This is fundamental support, showing people they have it in themselves to make changes and turn things around.’

References 1 Department of Health. Self care: A national view in 2007 compared to 2004–05. Available at www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_085351

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SELF-C ARE AND THE DH

NHS LifeCheck – self-care online Empowering the socially-disadvantaged to manage personal lifestyle change Dr Sunjai Gupta Deputy Director, Head of Public Health Strategy and Social Marketing Branch Health Improvement and Protection Directorate, Department of Health, England

Maria Reeves NHS LifeCheck, Department of Health, England

As head of the public health strategy and social marketing branch at the Department of Health and part-time consultant psychiatrist at the Maudsley Hospital, I am greatly interested in the point where the two roles meet – namely the development of health improvement initiatives that involve a partnership between the public and patients on the one hand and health professionals on the other. I chaired the implementation group for the Expert Patient Programme, and have been involved in several White papers on public health. I am keen to see how elements of cognitive behaviour therapy and social marketing may be used by the government in creating formative tools, such as NHS LifeCheck, which facilitate behaviour change.

Sunjai Gupta

Summary What measures should be taken to motivate socially disadvantaged individuals to

I joined the NHS LifeCheck team at the end of 2008, with a brief to use my experience in communicating with hard-to-engage groups to help shape each NHS LifeCheck product and subsequent media campaigns. I started my career as a journalist before moving into marketing and communications. Before working on NHS LifeCheck, I spent four years specialising in adoption and fostering in Kingston upon Thames, developing and instigating strategies for communicating with children and adults.

Maria Reeves

embark on a programme of health-related behaviour change? How can a simple lifestyle quiz promote selfcare and reduce health inequalities? Could a website increase an individual’s capacity for change? How does NHS LifeCheck fit into a health professional’s toolkit and impact on PSA targets without increasing their workload?

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Introduction Sometimes it’s good to be ahead of the curve. To be in a position where critics are suggesting something is perhaps too modern, too experimental rather than claiming the government has missed the boat or not seized the opportunity. When the Department of Health launched the interactive website NHS Teen LifeCheck in June, The Times was amused by what it termed the, ‘relentless quest to make health care cool’.1 In fact, NHS LifeCheck is a good example of a health innovation.

Four years ago, the government launched a consultation, Your Health, Your Care, Your Say.2 Those who responded, made it clear that they wanted to take more responsibility for their own health and wellbeing. And

three quarters of them identified regular health checks as a top priority to help them to do this. So, rather than making more demands on already stretched health professionals, the commitment made in the subsequent white paper Our Health, Our Care, Our Say 3, was bold and innovative. Services would be developed initially to enable three key age groups to assess and better manage their own health and wellbeing or that of their baby.

Today, thanks to an intense period of development, testing, evaluation4 and refinement, members of the public can log on to NHS Baby LifeCheck, for parents and carers of 5–8-month-old babies, and NHS Teen LifeCheck for 12–15-year-olds. NHS Mid-life LifeCheck for 45–60-year-olds

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The TeenLifeCheck.co.uk results page signposts young people

The role of government in health: NHS LifeCheck as a paradigm case The government of course has a dilemma. It could just sit back and say that individuals have been given the stark facts about their future health outcomes, and that it is for individuals to decide and determine for themselves what to do about it. On the other hand, it could take the view that health is not just a personal commodity, but a national treasure that is too precious to be left to the vagaries of individual choice. In which case, some would argue, it is for government to intervene, using the force of law if need be.

But there are not just two extreme positions that government can take, namely laissez faire inaction, on the one hand, and nanny state interference on the other.

There is a spectrum of interventions and approaches to public health, and it is the area between the two poles which NHS LifeCheck occupies.

Public health: a spectrum of approaches

NHS LifeCheck Purely individual choice

Providing information

Enabling Ensuring Empowering Incentivising Supporting Influencing

Performance Legislating managing Regulating

NHS LifeCheck aims to empower and support users

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In addition to providing useful personalised information, NHS LifeCheck facilitates behaviour change in a positive, helpful way by providing encouragement and support. It doesn’t leave people to sink or swim, but neither does it bully them into a particular course of action.

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Users are given tailored advice, top tips and guided to further information and local support

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has finished piloting and is being amended ready for a future launch.

Each NHS LifeCheck uses the format of a simple lifestyle questionnaire with multiple choice answers. But within the friendly, easy-to-use quiz lies tremendous potential. Users are given tailored advice, top tips and then guided to further sources of information and local support. The consequences, for those people engaging in or considering risky lifestyle behaviours, are explained in a non-judgemental tone. But is this just the ‘nanny state’ in covert, online form?

Each version of NHS LifeCheck guides the user to a goal-setting section, focusing on the topic of their choice.

They can either choose one of the carefully selected options or type in their own personalised goal.

For example: a first-time parent may elect to replace their eight-month-old baby’s bottle with a feeder cup, or pledge to only smoke outside; a 12-year-old may choose the option that they will tell a teacher about being bullied or that they will try not to skip breakfast; a 51-year-old may decide to choose tomato-based curries instead of cream-based dishes in order to begin losing weight, or to offer to be the designated driver on a Friday night and avoid drinking at the pub.

All of these things are small steps. But they could make a big difference. NHS LifeCheck is about empowering people with achievable goals. It helps them to take charge of their own lifestyle choices in a way that suits them.

Providing a user-friendly service is an essential step towards helping people to make the changes in lifestyle that are so critical to improvements in health. NHS LifeCheck is a truly holistic self-care tool.

So NHS LifeCheck is a litmus test of the government’s ability to facilitate behaviour change at both an individual and a population level. But it is not by itself a behaviour change tool. It forms part of a set of tools which also include, for instance, the increased use of effective social marketing, health literacy initiatives 5, the expert patient programme6 and the health trainer workforce programme.

Health trainers reach out to people who are in circumstances that put them at a greater risk of poor health.

They often come from, or are knowledgeable about, the communities they work with. In most cases, health trainers work from locally based services which offer outreach support from a wide range of local community venues.

Health trainers work with clients to assess their health and lifestyle risks. They have facilitated behaviour change, providing motivation and practical support to individuals in their local communities, since 2006.

NHS LifeCheck and health inequalities Now it may be that NHS LifeCheck is the type of thing people say they want but it would be of limited value

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SELF-CARE AND XXXX THE DH NHS LifeCheck – self-care online

unless it also helped to achieve a top priority of the government, which is to reduce health inequalities and aspire to Lord Darzi’s vision of ‘high quality care for all’.7 We know, for example, that it is those who live in the most socially disadvantaged communities and areas who are at the greatest risk of poor health and early death. We also know that many health inequalities are a preventable consequence of the social patterning of the wider determinants of health, the lives people lead and their access to, and use of, services. All of these take place within a social context that leads to a social gradient in health outcomes. Health inequalities may also differ according to ethnicity.

And now, in the midst of a recession, it is even more imperative that we do everything we can to ensure that action on health inequalities is not slowed or downgraded because everyone should have the same chance to lead a long and healthy life. Also by improving people’s health, we can help to maximise their chances of improving their own social and economic circumstances.

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We need more than an advertising campaign to raise awareness of NHS LifeCheck

The design, the language and the marketing of NHS LifeCheck particularly targets the long-term unemployed, those who have never worked, and their children. The ‘pull factor’ is a carefully selected publicity and communications plan using images, slogans and techniques which have researched well with the core audience and that are culturally appropriate.. However, a significant proportion of the people targeted may not pick up the NHS LifeCheck message through the mass media and also have a lower level of home internet access compared with other groups We therefore need more than an advertising campaign to raise awareness of NHS LifeCheck.

This is where the ‘push factor’ comes in. A significant stakeholder engagement plan is underway, presenting NHS LifeCheck to professionals, including the readers of this very publication. The strategy aims to demonstrate how stakeholders such as teachers, health visitors, youth workers and other health and social care professionals could use or recommend NHS LifeCheck in their work with patients, clients and students from disadvantaged groups and areas. Convincing these professionals that NHS LifeCheck can help them meet their individual objectives, without adding extra work, will be essential to the success of the programme.

In order to get a head start on this task, NHS Early Years (as Baby LifeCheck was then known) and Teen LifeCheck were launched initially in 83 of the most deprived local authorities in October 2008 and January 2009. With some financial assistance, many of these areas have embraced the challenge with some dynamic and inventive ways of introducing NHS LifeCheck to the public.

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Enthusiastic teenagers at the NHS Teen LifeCheck launch

For example, Sandwell focused on getting the NHS Teen LifeCheck message out through peer mentors at their own local launch. An event at a local secondary school started to spread the word, backed up by advertising on popular internet radio stations with a big regional following. A health information day at West Bromwich Albion’s football ground will give peer mentors from schools across the borough the chance to visit a ‘market place’ to hear about different initiatives and to attend a teen LifeCheck workshop.

In Corby, the challenge of bringing NHS LifeCheck to the rural villages a few miles from the urban centre, has been looked at holistically. The health MOT bus which already visits hard-to-reach areas to offer blood pressure, BMI and smoking cessation advice is being kitted out with computers to enable a core of young single mums to access NHS early years LifeCheck. A publicity campaign is planned in the villages the bus will visit and trainers will be on hand to facilitate if necessary.

NHS LifeCheck and the selfregulation of health-related behaviour NHS LifeCheck aside, the formation of new networks across PCTs, local authorities and schools has been enormously beneficial. A children and young people’s lead from Camden described how, ‘NHS LifeCheck gave

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SELF-CARE XXXX AND THE DH NHS LifeCheck – self-care online

everything a home. It was like an umbrella which has all of our health improvement projects underneath.’ In short, NHS LifeCheck has got people talking to one another.

This is reminiscent of the impact that some of those who took part in the expert patient programme had on their local communities8 and demonstrates that the principles of self-management of long-term conditions, on the one hand, and the principles that underlie the self-regulation of health-related behaviour, on the other, are very similar.9, 10 These in turn have much in common with the techniques of cognitive behavioural therapy initially developed to help those with common mental health problems and now in widespread use.11

Understanding one’s health is essential if one wishes to improve it

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It is very easy to criticise NHS LifeCheck by picking out imperfections but at this early stage, the flexibility of developing a service of this kind is invaluable. Questions can be added, changed or included. Responses can be rewritten to counter unforeseen misunderstandings.

Online advice can be amended according to the latest evidence and research without the fear that thousands of incorrect printed leaflets are stacked on shelves around the country.

Using an intelligent system, NHS LifeChecks will very soon be able to signpost users to the local sexual health clinic, drugs advisor or Sure Start centre, based on the submission of the first four digits of a postcode or by selecting a local area. In this way, NHS LifeCheck will help us to judge whether or not our public health delivery systems are fit for purpose.

It is in fact NHS LifeCheck’s capacity to confront the cold realities of the world out there that will be the acid test for this programme, and all such programmes, no matter how well conceived they might be in theory. If, as we hope, it does work at ground level, then we will have won half the battle because understanding one’s health is essential if one wishes to improve it. www.nhs.uk/lifecheck

NHS Baby LifeCheck Launched nationally in August 2009 Aimed at parents and carers of 5–8 month old babies Topics: development, playing and talking, feeding, healthy teeth, sleep routine, immunisation, safety, being a parent.

Includes: advice, topic-related videos, top tips, goal-setting and further information and support Relevant strategy/policy: The Healthy Child Programme

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NHS Teen LifeCheck Launched nationally in June 2009 Aimed at 12–15-year-olds Topics: being active, healthy eating, drugs and solvents, alcohol, safe sex, being healthy, smoking, feelings about yourself, feelings about school, bullying, self-esteem, home life, personal safety, crime, someone to talk to.

Includes: video text narration, topic-related videos, top tips, goal-setting, local and national links.

Relevant strategy/policy: Healthy lives, Brighter Futures; National Healthy Schools Programme.

NHS Mid-life LifeCheck National launch planned for end of 2009 Aimed at 45–60-year-olds (may expand to 40–70) Topics: physical activity, healthy eating, smoking, alcohol, emotional well-being, weight.

Includes: BMI calculator, goal-setting section including calendar and planner, simple interactive games to deliver topic information, on-screen video ‘doctor’ explaining confusing terms or definitions, local and national links, optional motivational emails.

Relevant strategy/policy: obesity; alcohol, drugs and tobacco; physical activity; sexual health; cancer screening; health and wellbeing; nutrition; health inequalities; mental health; carers; cardio-vascular.

References 1 The Times and The Times Online, 11 June 2009.

2 Department of Health. Your Health, Your Care, Your Say consultation, 2005.

3 Department of Health. Our health, our care, our say: a new direction for community services. London: DH, 2006.

4 Department of Health. Developing the NHS LifeCheck: a summary of the evidence base. London: DH, 2008.

5 Department of Health. Health inequalities: progress and next steps. London: DH, 2008.

6 National Primary Care Research and Development Centre.

National Evaluation of the Pilot Phase of the Expert Patients Programme – final report. Publisher - NPCRDC? 2006.

7 Department of Health. High Quality Care for All. London: DH, 2008.

8 Gupta S. The expert patient programme. A challenge and an opportunity. Proceedings of ‘Guiding us forward: The national chronic condition self-management conference 12–14 November 2003, Melbourne, Australia.

9 Gupta S. Full engagement in health (letter). BMJ 2005; 330: 255.

10 Michie S, Abraham C, Whittington C, McAteer J, Gupta S. Identifying effective change techniques in interventions designed to promote physical activity and healthy eating: a meta-analysis and meta-regression. Health Psychology, in press.

11 Gupta S, Umarji M. Behaviour change and social marketing.

Paper presented at conference ‘Legislation or Persuasion?

Behaviour Change and the Successful Delivery of Health Outcomes.’ London, July 2008.

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Volume 6 Issue 2 Aug 2009

EXPANDING SELF-C ARE

Self-care, self-care, selfcare…: have we been missing something?

Simon Y Mills

My passion is to help medicine become more meaningful to the people who need it.

After my medical sciences degree many years ago I chose to use plants as medicines that have always had both meaning and effect. I have since lived through various complementary medical initiatives, academic, professional and regulatory, and keep returning to the absolute importance of engaging with the story in each of our lives, and as lived in our community. I am also on the hunt for an alternative word for ‘patient’ and ‘client’ (‘valetudinarian’ – one seeking health – is good but does not easily flow!).

Herbal practitioner

Healthcare or self-care?

Summary Complementary approaches may be ideally suited to supporting self-care rather than extending prescriptive medicine, and practitioners may rediscover their role as mentors.The Department of Health may be ahead of the professions in understanding the importance of this.

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Health practitioners generally consider that their role is to treat their patients.

Professionals may even measure their status by their relative autonomy to prescribe or intervene, and even complementary practitioners may share this aspiration. So consider this: graduates of the only MSc course in herbal medicine in the USA1 are not permitted in most states to diagnose or treat illnesses, nor to prescribe or dispense herbal medicines. They are indeed well educated to understand pathologies and other medical and phyto-therapeutic disciplines.

However they are trained to keep these insights to themselves and to use their expertise instead to provide the best individual advice for ‘clients’ who have made a personal choice to use herbs to manage their own health.

Instead of saying ‘I will treat your [ulcerative colitis]’ they say ‘If I were you I would choose these herbs to help you improve your [digestive and immune] health: you can take this list anywhere you like to find them; however we also have them available if you choose…’ The client is being supported in a self-care choice: the practitioner serves that client, as counsellor, guide, mentor,

coach or trainer. They may adopt interviewing techniques to help their clients identify their health needs more effectively: more open-ended questions, less instructions perhaps.

This approach seems well suited to the role of guide (particularly in herbal medicine, so many of whose remedies are traditionally seen as supporting physiological and recuperative functions). But it also stimulates wider thoughts about self-care and practitioners’ influence on their clients’ choice-making.

All healthcare systems are struggling to meet growing demands for services, so the prospect of making more effective use of professional time and facilities is a crucial strategy, particularly in chronic illnesses. It has become more widely understood that approaches that motivate patients to make long-term behaviour change are likely to be more effective than those that only patch up immediate needs.

The Department of Health puts it this way: There is considerable national and international evidence to show that supporting self care results in health benefits for the people and therefore overall gain for the care system.2

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EXPANDING SELF-CARE Self-care, self-care, self-care…: have we been missing something?

It clearly makes sense to look for ways to encourage the public to manage their non-critical problems themselves, particularly where these are long term and where ongoing professional treatments are not cost-effective. In many areas of medicine for example the direct help a physician can provide a patient is limited, perhaps increasingly so, with the recognition that antibiotics, anti-depressants, anti-inflammatories and other prescription medicines should be constrained for wider community benefit. In many areas, for example persistent viral infections, emotional and mental distress and fatigue conditions, musculoskeletal pain and headache, functional digestive disorders and chronic inflammatory disease, and even family childcare, there are few rational prescription medicines available.

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It makes sense to look for ways to encourage the public to manage their non-critical problems themselves

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There are new visions for a patient-centred NHS that reflect the fact that the predominant pattern of disease in this country is of chronic rather than acute disease. For example the expert patient programme (EPP) is an NHSbased training programme that provides opportunities to people who live with long-term chronic conditions to develop new skills to manage their condition better. Set up in April 2002, it is based on research from the US and UK over the last two decades which shows that people living with chronic illnesses are often in the best position to know what they need in managing their own condition.

Provided with the necessary ‘self-management’ skills, they can make a tangible impact on their disease and quality of life more generally. Such initiatives are taking place to empower patients. They recognise that patients and professionals each have their own area of knowledge and expertise and need to work together.

Who decides what self-care to support?

The Department of Health has also provided a useful working definition of self-care.3 It is the care taken by individuals towards their own health and wellbeing, and includes the care extended to their children, family, friends and others in neighbourhoods and local communities. It includes the actions people take for themselves, their children and their families to stay fit and maintain good physical and mental health; meet social and psychological needs; prevent illness or accidents; care for minor ailments and long-term conditions; and maintain health and wellbeing after an acute illness or discharge from hospital.

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There is something fundamental here. Self-care by definition is not something that others can determine.

Evidence so far is that the public has its own views as to what it wishes to do for itself. For example public health policy over many years in many countries has been to encourage self-medication, in part to shift the cost of treatments from the public purse. Nevertheless in spite of this industry sources suggest that the conventional overthe-counter (OTC) consumer health industry has over 10 years not grown as expected or even as much as the prescription drug bill it was intended to replace. OTC market reports in 2009 still talk of potential growth rather than past performance. Apart from new ‘prescription-toOTC switches’, non-orthodox products like health supplements and complementary products seem better prospects in attracting more people to pay for their own medicines.

Indeed the evidence base for professional direction of ‘patient-centred’ interventions is mixed.4, 5 Rather than plan self-care strategies it may be more productive to see where the public is already going. If the purchase of healthcare approaches outside the NHS is increasing, the implications are that these are usually also outside the knowledge base and skills set of NHS personnel. They often arise from self-directed research of the internet and other media and occur in spite of the lack of support for such choices. They include well-established home remedies from different cultural traditions in the UK, media-promoted dietary and lifestyle advice and increasingly complementary and alternative treatments.

The evidence base for these approaches is variable: some have plausible rationales but undoubtedly there are cases in an unregulated sector where marketing promotion and hype can mislead. It will be necessary to engage this sector in a more collaborative fashion.

Collaborative self-care?

Where the public are consulted, they confirm their interest and potential confidence in self-care, at least in the more socio-economically developed sectors of the population, but also demonstrate that their behaviour does not always meet intention and that more encouragement from healthcare professionals would be important.6 It is still the case that the doctor wields unparalleled authority in healthcare decisions.7, 8 However studies have consistently shown that doctorpatient communication about autonomous patient choices is poor,9 with non-disclosure about unconventional approaches as high as 77% in some studies.10 If doctors were to be more engaged in encouraging a wider range of patient self-care, then the potential benefit for personal and family health, for doctor-patient relationships, for doctors’ job satisfaction and for the public purse could be appreciable.

There appears to be an opportunity for negotiating with people’s self-care choices. Constructive engagement with personal choice may appeal to many patients who

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EXPANDING SELF-CARE Self-care, self-care, self-care…: have we been missing something?

The Culm Valley initiative The Culm Valley Integrated Centre for Health is a new family practice and primary care trust centre serving a mixed rural and urban population in Devon. It is committed to providing an integrated health service to its community, including a range of complementary treatments. Handing back healthcare autonomy is an important part of this vision and with Department of Health support the practice has embarked on a self-care project, with Bromley-by-Bow family practice in East London, the University of Westminster and Peninsula Medical School.

This project focuses on developing effective self-care in the context of family practice, for a range of conditions that are particularly demanding of NHS resources and GP time, are long-term, ill-defined and difficult to treat, with symptoms such as: • • • • • • • • • • • • •

back and neck pain tiredness stress and anxiety mild to moderate depression difficulty in sleeping headache irritable bowel syndrome recurrent infections (respiratory, urinary, thrush, herpes) osteoarthritis hayfever and allergies eczema and skin problems menopausal and menstrual problems non-specific muscle and joint pains.

These are also problems likely to engender frustration between patient and clinician because standard treatments are often ineffective or have side effects. They are thus doubly suitable as areas where patients could be enabled and empowered to find their own chosen therapeutic approach.

The project will concentrate pragmatically on what market data and surveys show that people already choose: home remedies, OTC medicines, supplements and ‘natural’ products, ethnic medicines, and complementary and alternative treatments. There are two parallel tracks: 1 A survey conducted by a team at the Peninsula Medical School to understand the range of patient’s self-care strategies.

2 A review by researchers at the University of Westminster of the available evidence base on a wide range of treatments and advice on diet, exercise and lifestyle.

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There will follow a collaborative and formal review of drafts among groups of patients and health professionals at Culm Valley and Bromley-by-Bow. Final documents in user-friendly English and other languages will be available for wider distribution, for website delivery and as presentation materials to patient groups and other educational outlets. These materials will include: • simple self-help measures that can be applied at home including diet, exercises, lifestyle changes, and the use of home remedies, cooking recipes, herbal teas, herbal medicines and supplements • the potential benefits and limitations of various hands-on therapies with clear guidance as to likely costs involved • appropriate use of prescription and OTC medication • appropriate use of family doctors, therapists and other health professionals.

Community care?

It is important to look closely at how best to provide the information generated in this project. There is much evidence to reinforce the findings from a Department of Health review, that some of the most sustainable outcomes of self-care initiatives involve support networks ‘in which participants form informal or formal associations, continue to stay in touch with each other and receive support from others as well as actively provide support to others…’11 There is agreement that the information generated should not be limited to leaflets and booklets and may for example be in the form of teaching materials and guidelines for group facilitators and health trainers, and in other ways support interaction between people with non-specific conditions and others in their community or in mutual support groups.

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Many approaches used by complementary practitioners are well suited to supporting self-care

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might otherwise not comply with healthcare direction.

With improved navigation aids they may be helped to choose more wisely. Patients who are supported in their instincts may be more likely to feel well tended by their practitioner and less likely to adhere to the wilder claimmongers.

Inspired by the community foundations of the Bromley-by-Bow centre other ways were sought to bring the community further into the Culm Valley practice and to support the objective of sustained self-care. The main initiative has been to set up a community café in the building, a place where all who visit or work at the health centre may feel comfortable and where ‘informal or formal associations’ may be born.

Self-care and complementary practice The rise of alternative approaches to healthcare, the professional redefinition of complementary medicine in the 1970s and 1980s,12 and the current maturation into integrated healthcare, have all been driven by public

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EXPANDING SELF-CARE Self-care, self-care, self-care…: have we been missing something?

demand rather than planning by the medical or regulatory establishments. It is arguable that the focus of many in this movement towards stronger professional recognition has shifted attention away from the fundamental needs of that public and the radical opportunities to be real agents of change. So many approaches used by complementary practitioners are well suited to supporting self-care and generally engaging with health improvement rather than disease management. In so many cases complementary approaches accord well with public instincts and personal stories of health and wellness.

Even the NHS has realised that there needs to be a new professional deal and has created the ‘health trainer’ as a person who can facilitate health change rather than instruct. Complementary practitioners could look productively at describing their work as ‘health training’, at encouraging real changes in their patients. They may be pleasantly surprised at how refreshing their work becomes in this context and how they increase their engagement with the wider public.

References 1 Master of Science Program in Herbal Medicine, Tai Sophia Institute for the Healing Arts, Laurel, Maryland USA (seewww.tai.edu).

2 Department of Health. Support for self care in general practice and urgent care settings – a baseline study. London: DH, 2006 (available at www.dh.gov.uk/selfcare).

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3 Department of Health. Self care – a real choice: self care support – a practical option. London: DH, 2005 (available at www.dh.gov.uk/selfcare).

4 Lewin SA, Skea ZC, Entwistle V, Zwarenstein M, Dick J. Interventions for providers to promote a patient-centred approach in clinical consultations. Cochrane Database Syst Rev 2001; 4: CD003267.

5 Nilsen ES, Myrhaug HT, Johansen M, Oliver S, Oxman AD. Methods of consumer involvement in developing healthcare policy and research, clinical practice guidelines and patient information material. Cochrane Database Syst Rev 2006; 3: CD004563.

6 Department of Health. Public attitudes to self care – a baseline survey. London: DH, 2005 (available at www.dh.gov.uk/selfcare).

7 Gorin SS, Heck JE. Meta-analysis of the efficacy of tobacco counseling by health care providers. Cancer Epidemiol Biomarkers Prev 2004; 13 (12): 2012–22.

8 Pinget C, Martin E, Wasserfallen JB, Humair JP, Cornuz J. Costeffectiveness analysis of a European primary-care physician training in smoking cessation counseling. Eur J Cardiovasc Prev Rehabil 2007; 14(3): 451–5.

9 Sleath B, Rubin RH, Campbell W, Gwyther L, Clark T. Physician-patient communication about over-the-counter medications. Soc Sci Med 2001; 53 (3): 357–69.

10 Robinson A, McGrail MR. Disclosure of CAM use to medical practitioners: a review of qualitative and quantitative studies.

Complement Ther Med. 2004; 12 (2–3): 90–8.

11 Department of Health. Research evidence on the effectiveness of self care support. London: DH, 2007 (available at http://tinyurl.com/2wgabu).

12 Mills S. The development of the complementary medical professions. Complement Ther Med 1993; 1 (1): 24–9.

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Volume 6 Issue 2 Aug 2009

SELF-C ARE AND GPs

Helping patients to help themselves Ruth Chambers GP & clinical champion for the Lifestyle Support Programme, NHS Stoke on Trent, Honorary Professor Staffordshire University

Introduction

Summary If people want to live for as long a time as their genes allow and be as healthy as possible then they have to take responsibility for their own health and wellbeing.

There’s only so much the NHS can do for people with long-term health conditions: nagging and motivating them to better their lifestyle; sharing the ‘power’ of medication in jointly agreed management plans. An allround integrated approach means consistent advice, person-friendly local lifestyle services, with high ratings for everything that will help – conventional treatments, alternative therapies and personal support.

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Being a GP for 30 years and honorary professor at Staffordshire University makes me sound old and wise. But I’m still learning how to get people motivated to change their adverse lifestyle habits long-term (don’t they want to be healthy and well? We in the NHS want that for them!) as a clinical champion for the Lifestyle Support Programme of NHS Stoke on Trent. Of course we need good quality and effective services too which is where my other jobs come in – clinical champion for the PCT’s Quality Improvement Framework and clinical lead for Practice Based Commissioning.

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Self-care is the individual responsibility people take in making daily choices about their lifestyle and risk taking.

This may be in relation to their work, travel and hobbies, and other aspects of their everyday lives.

Self-care can only work in the healthcare setting if health professionals enable people with longterm conditions to help themselves.

Health professionals can only help such patients to help themselves if the local primary care organisation (PCO) has commissioned hospital and community services to support and promote self-care. And information about the availability and reliability of alternative therapies is easily accessed and well known.

The often shown slide at self-care workshops describes a typical person with diabetes receiving up to three hours of care a year from health professionals, the rest being self-care.

That diabetic patient needs GPs and practice nurses who encourage their self-management with a jointly agreed plan. The patient should be able to understand how to achieve good blood sugar control – through regular monitoring and probably adjustment of their prescribed treatment. They may bring home blood pressure readings to their clinical reviews at their GP’s surgery. They may actively review their weight and cut down on their food intake accordingly. There needs to be

local lifestyle services that aid weight management, good nutrition, physical activity and support people with mental health problems – maybe via one-to-one sessions with lifestyle coaches. The community or secondary services they are referred to should endeavour to encourage self-care.

Tips for practices Patient choice is only possible if people know what is available and have an understanding of how likely it is that the various treatments are applicable to them, might reasonably be expected to work, are safe and could suit them as individuals. So good patient literature, recommended websites and other sources of information are all vital, presented in a way and language that fit the person’s needs and preferences.

Information is all well and good but patients often need a way of navigating patient choice, as well as the advice and guidance they receive from their health professionals. The recently established network of locally based health trainers in the NHS are one group of guides who can help individuals choose to practise self-care and opt for local lifestyle services available to them. One of the positive attributes of such health trainers is that many originate from the local community so that they have a cultural understanding of their clients.

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SELF-C ARE AND GPs Helping patients to help themselves

equally shared care

complex cases

re ca

high % of self-care

high risk cases

80% of people

ca re

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high % of professional care

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PCOs need to actively commission self-care services.

Clinical pathway development needs to extend from selfcare in the local community for the majority of people with long-term conditions to secondary or tertiary care for the small minority. Figure 1 reminds us of the high proportion of care for any long-term condition that is down to self-care, whatever the setting. Self-care is a continuum with shared care, carried out by health professionals together with their patients, as individuals cope with acute and long-term health conditions. At the tip of the pyramid there is pure medical care with little or no opportunity for self-care in the immediate episode, until the start of recovery when shared care and self-care can emerge again.

So PCOs need to ensure that they commission services along the continuum of the self-care pathway, valuing business cases that focus on providing support for a range of self-care for all population groups – where the ‘savings’ may be assumed from prevention of long-term conditions rather than immediate gains from reductions in use of secondary care services.

There is a great deal of evidence for what has been traditionally regarded as complementary medicine, such as acupuncture or acupressure for the treatment of back pain, neck pain or dysmenorrhoea. Acupuncture is within the range of self-care in that people can organise it themselves without going through the NHS. But PCOs are agreeing successful business cases for acupuncture clinics where savings come from fewer outpatient referrals for orthopaedics or rheumatology and less surgery for, for example, osteoarthritis of the knee.

PCOs need to work with partners to provide resources for self-care, taking advantage of what the local council or

Health, 2006)

l na sio es of pr

Tips for primary care organisations

Figure 1 The health care pyramid (Department of

se

It can be confusing if health professionals in a practice team give different messages to the same patient about what works, what treatments might be considered for their situation, or how and if people can practise self-care.

So consistent advice and guidance should be a watchword in every practice.

Health professionals should be aiming at agreeing self-management plan templates for every long-term condition. The extent of self-management agreed will vary between individuals depending on their ability, personal drive and preferences but should not depend on the health professional’s knowledge, skills or attitudes as it often does at present.

Soon independent providers will be required to register their services with the Care Quality Commission.

The practice will have to show that it meets a generic set of registration requirements, based on essential safety and quality standards that include ‘respecting and involving service users’ and ‘monitoring the quality of provision’ and ‘care and welfare of service users’. Promoting and supporting self-care is central to these standards – and practices will need to consider how they demonstrate that they meet these standards from April 2010.

voluntary groups may be able to provide. For instance tele-healthcare is a growth area where patients are empowered, as well as the more common resources that support healthy lifestyles.

PA R T The aims of promoting and supporting self-care to patients or the local population at large are to encourage individual people to: P A R T

Prevent the condition developing Await resolution of the symptoms Use self-care skills for Relief of symptoms Learn to Tolerate symptoms that do not resolve or cannot be reasonably alleviated.1, 2

This model involves everyone – individuals themselves, practices and PCOs, and others in the community – in advocating and supporting people’s self-care. The approach is based on the European definition of general practice.3 This describes the core competences that health professionals in primary care share, including community orientation and holistic modelling, which include the psychosocial and cultural dimensions of an individual’s life. All of these competences are needed for health professionals to support patients’ self-care in effective and integrated ways.Practitioners who practise alternative therapies can model themselves on these competences too.

So what we need is integrated healthcare that values self-care, with health professionals and the PCO commissioners putting people first – the central theme of the first annual conference of The Prince’s Foundation for Integrated Health earlier this year.

References 1 Working in Partnership Programme (WiPP), Department of Health.

Self-care in primary care – a new way of thinking. London: WiPP; 2005 (www.wipp.nhs.uk) 2 Chambers R, Wakley G, Blenkinsopp A. Supporting self-care in primary care. Oxford: Radcliffe Publishing; 2006.

3 World Organisation of Family Doctors (WONCA). The European definition of general practice/family medicine. Barcelona: WONCA Europe; 2002.

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SELF-C ARE FOR MEDIC AL STUDENTS

Using mind-body medicine for self-awareness and self-care in medical school Scott Karpowicz Third year medical student, Mind–body Medicine Group participant

Nancy Harazduk Director, Mind–body Medicine Program, Georgetown University School of Medicine

Aviad Haramati Professor of Physiology and Medicine, Georgetown University School of Medicine

Participating in the mind–body medicine programme has had a noticeable impact on my wellbeing throughout medical school, and I am convinced it will have a lasting effect on my career as a physician.The programme goes far beyond mere stress management – it has improved my self-awareness and listening skills, given me a stronger sense of compassion and empathy, and helped build a supportive community within the medical school. I look forward to taking the skills and experiences gained from this programme into the realm of daily patient care.

Scott Karpowicz For the past eight years my passion has been to create a culture that embodies compassion, respect, self-reflection, and authentic collegial relationships among medical students and faculty. I envision a culture that encourages collaboration rather than competition, support rather than judgment, and connection rather than isolation.

We have begun this journey with our mind–body medicine programme.And what a remarkable journey it is, as students, faculty and administrators work together toward a more balanced, effective and humanistic model of medical education.

Nancy Harazduk My career as a renal physiologist – with a 20-year research focus on fluid and electrolyte homeostasis – took a distinct, non-conventional turn nine years ago, when we embarked on an educational initiative at Georgetown University to incorporate CAM and integrative medicine, especially mind–body medicine skills, into the medical curriculum. Along the way, I learned quite a bit about education and health. I also learned about authenticity, relationships and non-judgment, and now expend significant effort to rethink the way we train physicians. It continues to be quite the adventure!

Aviad Haramati

Introduction

Summary An innovative educational program at Georgetown University School of Medicine teaches mind–body medicine skills to blend science and humanism to foster student and faculty self-awareness and self-care.

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For many medical students, medical school proves to be an extremely stressful time. A challenging and time-intensive curriculum, increasing student debt, exposure to death and suffering, student abuse, and sleep deprivation are several of the stressors contributing to a difficult medical school environment. Existing literature consistently demonstrates that medical students exhibit significantly higher psychological distress relative to both the general population and to their peers.1 Such psychological distress has a variety of harmful consequences, including the development of substance abuse, other mental illnesses, a decrease in academic

performance, and a reduction in provider quality of patient care.2 Recent research demonstrates that medical student distress decreases empathy, a characteristic that correlates with clinical competence and whose development has been identified by the Association of American Medical Colleges as a key goal for graduation.3 Medical students also demonstrate greater levels of depression and anxiety than reported in the general population or age-matched peers.1 This fact takes on even greater significance when considering that psychosocial characteristics, including levels of depression, anxiety, and self-esteem, may in fact be better predictors of clinical competence than medical admissions test scores.4

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SELF-CARE FOR MEDICAL STUDENTS Using mind-body medicine for self-awareness and self-care in medical school

Growing evidence demonstrates that a variety of self-care curricula have been effective at reducing medical student distress, depression and anxiety and improving a variety of other factors, including self-awareness, emotional competence, and empathy. Shapiro et al 5 found that a mindfulness-based stress reduction (MBSR) program aimed at medical and pre-medical students reduced levels of anxiety, depression and distress and increased levels of empathy. Rosenzweig et al 6 further demonstrated that an MBSR intervention improved coping skills and decreased mood disturbance scores among medical students. These findings led our group to consider developing and implementing a program at Georgetown University School of Medicine (GUSOM), which would expose medical students to mind–body medicine techniques such as meditation, imagery and movement. Our goal was to provide a curricular intervention that would foster student self-awareness which could lead to self-care, and thereby help students to manage stress and improve their wellbeing.

❛

❛

A variety of self-care curricula have been effective at reducing medical student distress

Table 1: Competencies and objectives of the mind-body medicine programme Competencies This course is designed to facilitate the student’s mastery of the following defined competencies at Georgetown University School of Medicine: A–5: An understanding and knowledge of oneself, including the scope and limits of one’s knowledge, skills, and values.

B–7: The ability to learn independently with a critical awareness of the scope and limits of one’s knowledge, skills, and values.

C–5: An awareness of the importance of maintaining one’s own well-being and of balancing the demands of professional and personal life.

Learning objectives At the completion of this elective course students will (a)

Describe a variety of healing modalities including meditation, guided imagery, autogenic training, journal writing and movement and reflect on the ways these skills can be helpful personally and professionally.

(b)

Articulate the importance of self-awareness and self-care for personal health and well-being and the importance of maintaining a balance between the intellectual, emotional, physical social and spiritual aspects of their lives.

(c)

Comprehend the value of an on going commitment to personal growth as fundamental to the practice of medicine.

Development of the mind–body programme We were fortunate to obtain a small curriculum innovation grant from the School of Medicine, which enabled us to apply for a five-year education grant from the National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health. With the award of the NCCAM-funded education grant in 2001, resources were now in place to support the efforts of a group of faculty members to develop the mind–body medicine program and integrate knowledge, skills and attitudes of this area into the medical curriculum. Initially, three faculty members from the department of physiology took a week-long professional training program in mind–body medicine skills, offered by the Center for Mind–Body Medicine in Washington, DC. Over the following year, one of us (NH) was recruited to direct the program and to develop an in-house training program.

The training of four–six faculty members a year then began in earnest and now averages 10–12 a year. Most of the faculty involved were invited to participate because of their high profile role at the school (course and clerkship directors or division chiefs), as well as their willingness to commit time and effort to the goals of the program. At the same time, learning outcomes for the program were defined in terms of desired student competencies that were consistent with the school’s mission. Those objectives and competencies appear in Table 1.

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Description of the course The course in mind–body medicine at Georgetown University School of Medicine is currently being offered to first, second and third year medical students. A separate opportunity is offered to interested faculty members.

Classes meet for two consecutive hours, once a week for 11 weeks, with two faculty members who co-facilitate each session. The course is designed with nearly 60% of the activities devoted to experiential learning, and with the remaining time devoted to the sharing of student insights and reflections and to the discussion of skills that were experienced.

Over the 11 sessions, students are taught various mind–body medicine skills including self-awareness, meditation, guided imagery, bio-feedback, autogenic training, art, journal writing, and movement (see Table 2). Students learn the techniques, practise them and discuss their experiences with members of the group. Thus, students have the opportunity not only for individual attention and instruction, but also for sharing what they are learning about mind–body medicine and about themselves.

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SELF-CARE FOR MEDICAL STUDENTS Using mind-body medicine for self-awareness and self-care in medical school

Table 2: Mind–body medicine techniques • Breathing (slow, diaphragmatic) • Meditation (mindfulness/awareness) • Guided imagery (several types) • Bio-feedback (thermal) • Autogenic training (self-hypnosis) • Art (emphasis on non-cognitive drawing) • Music (used in meditation and imagery sessions) • Movement (shaking/dancing, walking meditation) • Writing (journals, dialogues)

About a week before the course begins, an initial orientation is held, where students learn expectations and intended outcomes for the course. In addition, pre-course self-assessment forms are completed at that time, which include a number of survey instruments. Students receive a packet of information including guidelines for group behavior, course assignments, a list of recommended readings and various articles that focus on the most current evidence for health benefits of mind–body medicine and theoretical underpinnings for integrating mind–body medicine skills into medical practice.

Of importance to the healing quality of the course is the physical environment in which it is held. To that end, the students meet in a serene, dimly-lit room in which 12 chairs are arranged in a circle with a table in the centre of the circle. A candle, a vase filled with fresh flowers, a dish containing chocolate, and a set of tingha bells (with which to begin and end each meditation) are placed on the table – not the typical medical school setting!

opening meditation, which allows students to shift their focus from their hectic lives to become present in the moment.

After the brief opening meditation, the ‘check-in’ period begins. Students are invited, one at a time, to share aspects of their daily experiences, discuss any issues they have and explore insights and revelations that they have discovered about themselves. Facilitators participate along with students, sharing their week’s experiences, reactions, and perceptions with the group. The active engagement of the faculty facilitators is essential to create a safe setting and also because these individuals (some of whom are course or clerkship directors) serve as important role models for the students. Of critical importance is the atmosphere of generous listening, confidentiality, nonjudgment, safety, and respect that is facilitated by the group process.

Following the hour-long ‘check-in’, a mind–body medicine skill is introduced by the faculty co-leaders. Each week, a new skill is presented. At this time, the techniques are explained, if relevant, the scientific basis is discussed, and then the skill is demonstrated and experienced. The skills include various meditations (sitting, eating, walking and forgiveness), guided imageries, autogenic training, bio-feedback, art sessions, journal writing, and movement.

Students practise and process their understanding of this new skill and are invited (but not compelled) to reflect and share their insights with the group. Sessions typically end with a five-minute closing meditation.

Expectations of students are that they will practise the skill that they learned during each session for a minimum of 10 minutes a day throughout the upcoming week. In addition, they are asked to write at least one journal entry of any length each day, practise a form of meditation (sitting, eating, walking) for a minimum of 10 minutes a day, and participate in at least one physical activity (walking, jogging, exercising, playing a physical sport) three to five days a week.

At the conclusion of the course, students are asked to complete post-assessment forms. These are analysed along with the pre-assessment forms that were completed during orientation before the course began. In addition, they are asked to answer six open-ended questions that inquire as to whether the course affected their view of medicine, medical school, and their relationship with their classmates.

Summary of outcomes Students in the mind–body medicine course begin each session with an opening meditation

Each session follows a structured format. An opening ritual such as lighting a candle begins each session. The purpose of the candle is to provide a focal point to help bring the participants’ attention into the present moment and to remind them why they are there. This is followed by the ringing of the tingsha bells to begin a 10-minute

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To date, more than 700 individuals have participated in the mind–body medicine skills program, including more than 500 medical students, 130 graduate students (primarily students enrolled in the CAM MS and PhD degree track in physiology), close to 90 nursing students, and more than 50 members of the faculty. The program is first introduced to first year medical students in the spring semester. We chose the first year for mind–body skills groups because it is a time when attitudes toward medicine are just beginning

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SELF-CARE FOR MEDICAL STUDENTS Using mind-body medicine for self-awareness and self-care in medical school

to be formed, but could be powerfully shaped. The students were required to write a short paragraph and explain their motivation for taking the course.

Approximately 60 students, representing a third of the class, enrolls. Many were not sure what they were getting into, but had heard from upper classmates that the experience was very worthwhile. Working with first year students also offered us the opportunity to engage students at the beginning of their career so they could use the techniques they learned and the insights they gained throughout their training experience. We hoped that the friendships they made, and the feeling of the community they created in the intimacy of the small groups, would be supportive and sustaining throughout medical school.

A number of survey instruments are used in the student groups to document some of the changes that occur. These include the 10-item Perceived Stress Scale (PSS) 7 the 15-item Mindful Awareness Attention Scale (MAAS) developed by Brown and Ryan,8 and a newly created 21-item survey instrument, the Mind–body Skills Attitudinal Scale (MBSS).9 We consistently find reductions in students’ perceived stress and an increase in mindfulness awareness. Moreover, there are a number of attitudinal shifts that occur related to increased sense of coping with the stresses of medical school and greater empathy of participating students towards their classmates.

The students also respond to six open-ended questions that address how the course helped the student, if at all, and how has it changed the students’ attitudes towards medicine, medical school and their classmates, if at all.

Data regarding the qualitative content analysis was published a number of years ago.10 Five central themes emerged from the student responses which were related to: 1 connections, 2 self-discovery, 3 learning, 4 stress relief, and 5 medical education. From all our analysis it appears that students self-awareness and self-reflection increases, and we believe their degree of empathy is fostered as well.

Back issues of JHH Back issues of the Journal of Holistic Healthcare include themed issues on nursing, education, spirituality, mental health and resilience. Other issues contain a range of interesting papers.

They are available at £12.50 each plus £2.50 p&p.

To order, visit our online shop at www.bhma.org or call 01278 722000.

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Our analysis of the impact on faculty is less well defined. However, the course surveys are replete with poignant statements about how the experience has transformed individuals to reflect on their lives, their priorities, and the necessity to introduce more balance in how they conduct their day-to-day affairs. There is also the acknowledgement that taking time for oneself is essential for optimal wellbeing.

Conclusion Our experience to date suggests that incorporating a course in mind–body medicine skills in medical school may represent a unique and important way to help advance several desirable educational goals, such as increased student empathy and mindfulness, in addition to reducing students’ perceived stress in medical school.

Acknowledgement The development of the mind–body medicine programme and the research described was supported by an educational curriculum grant (R25 AT 00419 from the National Center for Complementary and Alternative Medicine), and by a curriculum innovation (CIRCLE) grant from Georgetown University School of Medicine.

References 1 Dyrbye L, Thomas M, Shanafelt T. Medical student distress: causes, consequences and proposed solutions. Mayo Clinic Proc 2005; 80 (12) 1613–1622.

2 Dyrbye L, Thomas M, Shanafelt T. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad Med 2006; 81: 354–373.

3 Thomas M, Dyrbye L, Huntington J, Lawson K, Novotny P, Sloan J, Shanafelt T. How do distress and well being relate to medical student empathy? A multicenter study. Soc General Int Med 2007; 22: 177–183.

4 Hojat M, Robeson M, Damjanov I, Veloski JJ, Glaser K, Gonnella JS. Students’ psychosocial characteristics as predictors of academic performance in medical school. Acad Med 1993; 68: 635–637.

5 Shapiro SL, Schwartz G, Bonner G. Effects of mindfulness-based stress reduction on medical and premedical students. J Behav Med 1998; 21: 581–599.

6 Rosenzweig S, Reibel DK, Greeson JM, Brainard GC, Hojat M. Mindfulness-based stress reduction lowers psychological distress in medical students. Teaching and Learning in Medicine 2003; 15: 88–92.

7 Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav 1983; 24: 386–396.

8 Brown KW, Ryan RM. The benefits of being present: mindfulness and its role in psychological wellbeing. J Pers Soc Psychol 2003; 84: 822–48.

9 Tractenberg RE, Chaterji R and Haramati A. Assessing and analyzing change in attitudes in the classroom. Assessment and Evaluation in Higher Ed 2007; 32: 107–120.

10 Saunders PA, Trachtenberg RE, Chaterji R, Amri H, Harazduk N, Gordon JS, Lumpkin M and Haramati A. Promoting self-awareness and reflection through an experiential Mind–body Skills course for first-year medical students. Medical Teacher 2007; 29: 778–784.

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Volume 6 Issue 2 Aug 2009

Somatic Experiencing® Training

Starting 2010 (Dates to be confirmed)

A three year training in Peter Levine’s Somatic Experiencing® leading to certification as a ‘Somatic Experiencing Practitioner’.

Family Futures is administering the above training which consists of three 4-day courses per year.

The course is suitable for therapists, bodyworkers and other professionals in the trauma field. This is a professional training.

What is Somatic Experiencing?

‘Somatic Experiencing®’(SE) is a short-term naturalistic approach to the resolution and healing of trauma developed by Dr. Peter Levine. It is based upon the observation that wild prey animals, though threatened routinely, are rarely traumatised. Animals in the wild utilise innate mechanisms to regulate and discharge the high levels of energy arousal associated with defensive survival behaviours. These mechanisms provide animals with a built-in ‘immunity’ to trauma that enables them to return to normal in the aftermath of highly “charged” life-threatening experiences.

SE employs the awareness of body sensation to help people ‘renegotiate’ and heal their traumas rather than relive them. With appropriate guidance with the body’s instinctive “felt sense”, individuals are able to access their own built-in immunity to trauma, allowing the highly aroused survival energies to be safely and gradually discharged. When these energies are discharged, people frequently experience a dramatic reduction in or disappearance of their traumatic symptoms.

Because traumatic events often involve encounters with death, they evoke extraordinary responses. The transformation process can allow people to deepen their sense of self and others. The healing journey can be an ‘awakening’ to untapped resources and feelings of empowerment. With the help of these new allies, people can open portals to rebirth and achieve an increased sense of aliveness and flow. The experience can be a genuine spiritual awakening, one that allows people to re-connect with the world.

The very structure of trauma, including hyper-arousal, dissociation and freezing, is based on the evolution of the predator/prey survival behaviors. The symptoms of trauma are the result of a highly activated incomplete biological response to threat, frozen in time. By enabling this frozen response to thaw, then complete, trauma can be healed.

Traumatic symptoms are not caused by the dangerous event itself. They arise when residual energy from the event is not discharged from the body. This energy remains trapped in the nervous system where it can wreak havoc on our bodies and minds. Wild animals have the ability to ‘shake off ’ this excess energy. The key for humans in dispelling traumatic symptoms lies in our being able to mirror wild animals in this way.

Dr. Levine has developed a safe, gradual way to help trauma survivors develop their own natural ability to resolve the excess energy caused by overwhelming events.

For an example of Dr Raja Selvam talking about SE see http://www.4shared.com/file/108785257/a4dc4f7/ Raja_Selvam_31509_Part_I.html. For more links please email the address below:

For further information about the 3 year course, contact Joanne Collett at Family Futures, tel 020 7354 4161 joanne@familyfutures.co.uk or Giselle Genillard Senior Course Assistant gisellegenillard@aol.com

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SELF-C ARE IN PRACTICE

Helping street sex workers make healthy life choices Josie Hill Fundraising and Publicity Co-ordinator, One25

Having worked for a range of health-focused charities, I’ve come to recognise that offering an integrated, holistic approach of conventional medicine with complementary therapies is the best way of transforming lives. I strongly believe that we need a new model of health in the UK, one that offers everyone greater choice and empowerment over their health needs. In developing One25’s new therapeutic programme, I anticipate that we will reduce the burden of these vulnerable women’s chronic ill-health and help them reach their full potential.

Introduction Summary One25 is the England winner of the 2008 Prince’s Foundation for Integrated Health awards. It has a unique impact as the only organisation in Bristol that focuses on the specific needs of women trapped in street sex work. One25’s extraordinary service brings food, therapies and medical services to women, and as a result many have left sex work behind, reclaimed their children from care and now lead normal lives.

One25 gives these vulnerable women the support they need to escape and build towards a healthier future.

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One25 is a Bristol-based charity that benefits women who are trapped in a chaotic lifestyle of street sex-work, homelessness and addiction. The charity provides four key services: night outreach, a daytime drop-in centre, casework support and a unique 24 hour mother and baby home called Naomi House. Where services are inaccessible or inappropriate, One25 raises awareness of the needs of this group in order to bring about change in provision.

One25’s mission is to enable these vulnerable women to: • break free from this abusive lifestyle and achieve their full potential • make healthy life choices and foster positive relationships with their families and communities.

One25 aspires to the WHO definition of health: ‘Health is a state of complete physical, mental and social wellbeing and not merely the absence of disease of infirmity.’1 From its inception in 1995, One25 has been committed to providing long-term, holistic support for each beneficiary at whatever stage she is at and One25 continues to develop its services

accordingly. It has built up a good reputation, has support from the Bristol community and trusting relationships with the client group. The charity’s founder, Val Jeal, was awarded an MBE for her work with One25 and in May 2009, the charity won the England Award from the Prince’s Foundation for Integrated Health.

The women supported

by One25 Typically, One25 sees around 200 different women every year, all of whom are socially excluded and trapped in a lifestyle of street sexwork, multiple chronic health needs, and addiction to heroin, crack cocaine and/or alcohol. Added to this: • 65% have reported that they suffered appalling childhood abuse, including cases of rape as young as three years old • 32% left school aged 14 or younger • 66% are homeless • 92% have been the victims of violent crimes including domestic violence, kidnap, GBH, attacks using weapons and gang rape.

Only 1% of these incidents have resulted in a conviction

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SELF-CARE IN PRACTICE Helping street sex workers make healthy life choices

• 68% suffer from chronic traumatic stress disorder on the same level as victims of torture • 65% have had children, but 79% of these mothers have had their children removed from them.

Many are desperate to escape this lifestyle, but with such complex, deep-rooted problems, achieving change may require several progressions through a cycle of contemplation, change and relapse before finally breaking free.

Case study ‘Melissa’

supportive relationships with the women. In January 1996, One25 opened a temporary drop-in centre in the basement of 125 Cheltenham Road, which gave the project its enduring name. Around this time a consultative group was formed with representatives from relevant agencies such as Bristol Drugs Project and the Bristol Royal Infirmary’s sexual health clinic.

In 1996, ‘the custard tart’ – a bright yellow van nicknamed by the women it served – started evening outreach on the streets. This greatly increased the opportunity for effective contact with the women and enabled One25 to grow. At this point, One25 was supported by 18 dedicated volunteers and no paid staff.

Melissa grew up in a household of neglect and abuse. From the age of four, her stepfather started sexually abusing her and eventually she was taken into care. She started using drugs at just nine years old to ‘blank it all out’ and by the age of 13 was a heroin addict. By the time One25 met her in her early 20s, Melissa had been selling sex on the streets for six years. Her life was in chaos: she was being beaten by her boyfriend and often got caught up in two-day working/drug-using binges without breaking to sleep or eat unless the One25 van came round. She became pregnant but her baby was taken into care. It was the loss of her child that provided the turning point for her. She says: ‘When my baby was taken away from me I lost it for a bit.

I couldn’t stand to think that she might end up with a life like mine. I ended up in hospital. My caseworker sent me cards there and visited. I realised my life could not go on like this – you’ve got to focus on thinking you can do it.

She was waiting for me at the gates and helped me get to a detox to do my recovery. I don’t think I would have got there otherwise – before it had just been straight out onto the streets and dealers hunting you down. Even now I’ve escaped the streets, she still meets me and we have coffee and she helps me with the next steps – I want to be a social worker one day and help other women out there.

Best of all I’ve got my kids back, got a nice home for us together and I can be a good mum to them. Everything’s changed.’

Brief history One25 was the first organisation in Bristol to reach out to these women and meet their expressed needs. It was founded in 1995 as a result of concerns from local agencies and churches about the health and wellbeing of female street sex workers in Bristol. There was a total lack of joined-up service provision for this group in Bristol as other relevant services were not going out to meet these women’s needs but expected them to navigate disparate provision. One25 consulted the women and the result was that they created a service that goes out to them, offers a relational service aimed at the whole person not just one aspect of their needs, and offers the possibility of longterm relationship and support.

Founder Val led a small but dedicated group of like-minded people in developing the work of forming

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The ‘custard tart’ – outreach on the streets

In 1997, One25 became a registered charity and moved to occupy its present site in the St Pauls district.

This meant many more women in sex work were able to get support, as the new drop-in was larger and in the heart of the drug dealing and sex working area in Bristol.

In 2005 the building, which was previously rented, was given outright to the project by Bristol Christian Fellowship.In January 2009, One25 opened Naomi House.

This is an innovative residential family unit providing intensive, therapeutic and practical 24-hour support for up to five pregnant women or mothers with babies where maternal substance misuse and risk from sex work has been a problem. Naomi House is the only supported mother and baby home in England for women with addictions and a history of sex work.

Today, the charity employs 17 staff and is supported by around 130 volunteers.

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SELF-CARE IN PRACTICE Helping street sex workers make healthy life choices

One25’s services Outreach One25 provides six sessions of a night outreach service which spans five nights a week. The outreach service offers nutritious food and drinks, condoms, healthcare and information on violent attacks. The women tend to be so caught up in their life-controlling cycle of selling sex to buy and take drugs that they have no chance to take care of their basic needs. One25 sees women who are acutely malnourished, who are so ill that they should be hospitalised, who have just been beaten and raped, and yet are still continuing to sell sex. One25 meets their basic needs in a way that meets their emotional and spiritual needs. As a result, this service has been described by a number of women not only as a ‘lifesaver’ but also as ‘a turning point’. The outreach teams made 4,223 contacts with women in 2008, giving out more than 4,000 food packages, 43,000 condoms, and 1,000 instances of health and housing advice.

Most of the women that One25 meets have rock bottom self-esteem and suffer from deep-seated traumas because of their life experiences. One25 understands that the women require a holistic approach that can take care of their basic needs and simultaneously improve their overall physical, sexual and emotional health. Staff and volunteers encourage the women to become aware of the link between their bodies and their psychological wellbeing and treat the mind and body as an integrated, dynamic whole.

Drop in sessions Monday • City of Bristol College basic skills tutor • Representative of local drug agency helps women with addiction issues • General health nurse and doctor clinics Tuesday • Sexual health nurse and doctor • Creative writing tutor • Massage therapist • Mums and tots group (mornings) Wednesday • Representative of local drug agency helps women with addiction issues • Pottery and ceramics session Friday • Therapist offering pedicure and general foot care and massage Daily • Homeopathy • One-to-one counselling

Casework

Work from a creative art drop-in session

Drop-in The van teams encourage the women to come to the drop-in centre. This is open four afternoons a week. It is a safe, women-only space where the women can have a cooked meal, get healthcare, and use hygiene and laundry facilities. The drop-in offers women a chance to relax and engage with visiting or in-house clinics, ranging from a no-appointment GP to creative writing classes. One25 recognises that the women need encouragement and emotional support. Therefore staff and volunteers promote feelings of self-worth through words of affirmation and by offering opportunities to take part in therapeutic or educational sessions, have a professional massage, receive homeopathy treatment, take part in arts therapy or take part in cognitive behavioural therapies.

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The relaxed atmosphere gives opportunities for caseworkers to talk in depth with the women, to help them make and attend appointments, or to take steps to arrange detoxification programmes. During One25’s first three years, the charity saw just five or six women make any significant changes in their lives. Over the next 10 years One25 responded to various needs suggested by the women, for example increasing the amount of outreach, campaigning for health visitors to set up clinics at the drop-in and establishing a casework service.

Of the 51 women receiving casework support in 2008, nine (18%) exited sex-work; 28 (55%) saw improvements to their addiction issues; 35 (69%) gained more secure housing; 22 (43%) attended a GP or dental appointment and four (7%) took up formal employment or further education.

The Big Lottery Fund recognised the importance of complementary therapies in March 2009 when it awarded One25 with three years’ funding for a therapeutic caseworker (Dee Parkin), as well as a generic caseworker.

Dee is a trained homeopath, mental health worker and counsellor and runs one-to-one and group sessions in each of the four weekly drop-in sessions, giving advice,

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SELF-CARE IN PRACTICE Helping street sex workers make healthy life choices

treatment and consistent intensive casework. She also runs sessions at Naomi House once a week. She has already built up a strong relationship with doctors, nurses and therapeutic practitioners in the city, as she feels that complementary and conventional therapy fit in with each other. She has persuaded the Red Cross to provide massage, medicated camouflage make-up for women with scars and bruising, and first aid training. Dee is planning to take in occupational therapist students who will provide a range of treatments at Naomi House and at the drop-in.

Dee uses her skills and extensive experience in counselling and homeopathy to explore the underlying issues behind what she sees as the women’s ‘self-medication’ with heroin, crack cocaine and alcohol.

‘The complementary therapies deal with the issues rather than plaster over them’, says Dee. ‘It is integral to One25’s work that the women have free access to complementary therapies. The therapies enable them to explore the reasons behind their need to blot out all memories or feelings with heroin or give themselves a false sense of joy with crack cocaine. The treatments help them to look at why they put themselves in such high-risk, unhealthy situations on the streets and ignore their own basic needs. Treatments also work wonders with building up their self-esteem and lessening the chance of relapse.

Medicine is useful up to a point but it is vital that we offer the biggest possible range of therapies and complementary healthcare if we wish to see real changes in the women’s lives.

‘We have a two tiered health system in this country – the NHS and complementary healthcare. If you are rich enough to pay for complementary therapies then you do it and you see your health improving. The poorer members of our society rarely have the money or the awareness of these treatments to be able to access them and so suffer as a result. One25 makes both levels accessible to the women and we see radical results. Last year, over half of the women saw dramatic improvements to their addiction issues, including going into detox centres and becoming abstinent. One in five of the women exited sex work and street drugs altogether. These women also gained secure housing for themselves and saw real boosts in their self-confidence and self-care.’

Naomi House Before this service was opened, there was no appropriate support for drug-using pregnant women and mums with babies in Bristol and in fact no supported residential homes in the country for mothers with a history of addiction and sex work. The alternative was that pregnant women were put in potentially risky accommodation that was not supportive to their aspirations to safe, healthy motherhood. In the majority of cases we saw, the situation ended in the woman’s relapse and the removal of her baby.

To respond to this great need, One25 opened Naomi House in January 2009. The home provides 24-hour, intensive support to these new families, with a weekly programme of therapeutic and practical skill sessions

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A bedroom in Naomi House

and individual casework, both in-house and out in the community. The sessions range from Shiatsu and art therapy to parenting skills classes and healthy eating. The sessions are practically supported by a range of specialist agencies and professionals. The ultimate aim of Naomi House is to support women who want to change and become equipped with the skills needed to raise their children in a safe, loving environment thus giving the families a better start in life. The project accepts referrals from many different agencies, including the NHS, probation services and drugs projects and has two beds available for women from outside Bristol. Naomi House won a government grant of £187,050 from the Parenting Fund towards two years of salary costs and drugs/alcohol treatment. This has boosted its reputation in the country and ensured its sustainability for the next few years. The new mums at the project are all engaging really well with the programme of support. They give regular feedback on suggested changes or additions to the project, which the staff and volunteers implement when they can. One recent suggestion from ‘Jennie,’ which has been implemented, was for certificates for each month of drug/alcohol abstinence, as she had left school without qualifications and felt her confidence and motivation would be increased by this formal recognition of her achievement.

Another recent request was for more art therapy and massage sessions from ‘Sally’, who said: ‘This is amazing!

I feel so calm. Why do we need drugs?!’

Events One25 runs three annual events: a Christmas dinner for women, a Christmas party for mums and their children with circus entertainment, and a summer outing to the beach or to an adventure park. All of these are extremely popular and give these women and their families a sense of ‘normality’. Taking part in an event builds up the trusting relationship with staff and volunteers and gives the women a break from the streets. In 2008, record numbers of women and their children attended these events. All of the women and children received Christmas presents sponsored by local businesses.

The charity also runs a variety of fundraising events for the wider community and always tries to do something unusual and attention-grabbing to attract the attention of the local media. Over the last year, the charity has had a multi-media club night, a fancy dress 10-mile night walk

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SELF-CARE IN PRACTICE Helping street sex workers make healthy life choices

with more than 100 participants (raising more than £7,000), an auction supported by local and national businesses, and a 100-strong Bristol 10k running team that raised more than £20,000.

A fund-raising fashion show

‘Andrea’s’ story ‘The people at One25 got alongside me for some five years while I was working.They became friends but it took time. I didn’t have the level of self-worth to accept help, I wanted to die.I haven’t been working the streets for about four years now.They turning point came when my health was an issue…I nearly died a few times. My worker at One25 kept visiting me and she helped me get all the agencies together to find accommodation and money to live. It’s a fantastic organisation because they have everything under one roof and they are consistent in their help whether or not you mess up. Knowing someone cares is huge.’

The sexual health doctor’s view ‘The impact One25 has on the local community is unique as there are no other providers. From my own perspective as a sexual health doctor, the One25 clinic is a tremendous asset. Most of the women seen in the drop-in live such chaotic lives that it is impossible for them to access a hospital clinic however much we try to make the clinic acceptable. When I began to work as the doctor at One25, I was soon aware of how the women who sell sex to fund their drug habits wanted to reduce the incidence of sexually transmitted diseases not only for themselves but for these other innocent women who would be caught up in the diseases from no fault of their own. If the facilities were present, most of the sex-working women wanted to take ownership of their health. In order to bring the help to the women numerous other agencies are invited into the One25 drop-in to give advice.This covers drugs and drug dependency, housing, health, benefits and the police. In the healing process that has to go on in these women’s lives, it is essential that as many facilities as possible can be at their disposal.This is why places like One25 need all the support they can get.’

FAQ Q Why are One25’s services needed?

A The women One25 work with are some of the most disadvantaged and marginalised people in society and are unable to access services that most people take for granted. They have specific needs and specific histories that don’t fit easily into generic services. Currently One25 is the only service in Bristol that provides an essential outreach service for this client group.

Q Haven’t the women chosen this lifestyle?

A No. Many of the women that One25 support have had an incredibly chaotic and dysfunctional childhood, filled with neglect and abuse. They have turned to drugs as a means of escape from an early age. A large percentage dropped out of school in their early teens, which limits their choices further. Today, many are in violent relationships where they are forced onto the streets in order to support their partners’ drug habits.

With the lack of joined-up, specialised services in Bristol to deal with their complex, multiple needs, it can be incredibly difficult for them to exit sex work and addiction.

Q Aren’t the babies better off in care?

A No. There is a lot of evidence to show that children are more likely to thrive when they have a secure attachment to their mother. Naomi House provides expert parenting skills sessions alongside an intensive programme of highly supportive, therapeutic activities and practical skills sessions, maternal recovery and offer mentoring and support in daily childcare routines.

Q What do you think of the current policy of cracking down on kerb crawling?

A We empathise with the problems that street sex work causes for local residents. To pursue an anti kerbcrawling campaign in isolation increases risk of violence for women as activities are displaced to times and places away from support services and these campaigns do not deter the more predatory, dangerous punters. In order to have a positive effect on the women also, anti-kerb crawling actions must be part of a holistic, well resourced strategy that includes help for the women with their problems of drug abuse, homelessness, ill health and violence.

All names have been changed to protect confidentiality.

References 1 Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19–22 June, 1946.

Dr Sue Norman

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SELF-C ARE AND C AM

Self-care and CAM: defining the differences, recognising the similarities Karen Pilkington Senior Research Fellow, School of Life Sciences, University of Westminster

Summary Self-care is promoted as an integral part of a ‘patientcentred health service’. But how is self-care defined?

And when is CAM considered self-care? Some of the basic tenets of self-care and of CAM are compared to highlight similarities. CAM appears to have a primary role in chronic, poorly defined and difficult to manage conditions. Patients with these conditions seek selfcare options and frequently choose to use CAM. Choice is affected by cost and accessibility. Feasibility in practice and personal recommendation also play important roles in decisionmaking.

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Starting my career as a clinical pharmacist, I first worked at the ‘high-tech’ end of healthcare with paediatric patients undergoing cardiac and transplant surgery. Following this, I moved into an educational role supporting health professionals in their quest to apply relevant research in practice. Initially focused on drug therapy, many of the questions arising later focused on complementary therapies. In 2003 I moved from the NHS into academia to develop my interest in CAM and to begin to answer some of the questions that had arisen.

Introduction Self-care has been highlighted as an integral part of a ‘patient-centred health service’ and is defined as: ‘the actions people take for themselves, their children and their families to stay fit and maintain good physical and mental health; meet social and psychological needs; prevent illness or accidents; care for minor ailments and long-term conditions; and maintain health and wellbeing after an acute illness or discharge from hospital’.1 Complementary and alternative medicine (CAM) comprises a diverse range of approaches, philosophies and individual therapies. But there are certain common features that are particularly relevant to self-care. For example, one of the attitudes said to be shared by CAM approaches is that they place ‘as much emphasis on psychological and preventive care as on the treatment of pathologies’.2 Emphasis is also placed on the individual’s choices and preferences: access to the majority of CAM therapies

is self-sought while during treatment there is considerable effort to develop an effective and ongoing ‘therapeutic relationship’ or partnership between the patient and practitioner.3 In many cases, the patient is introduced to a range of possible actions including lifestyle changes to manage or improve their condition and general wellbeing. For example, for individualised self-help acupuncturists see advice as an integral part of treatment and it is embedded in the acupuncture diagnosis.4 In fact, patients expect to receive self-help advice as part of a CAM intervention and this expectation is an important factor in the decision to seek CAM treatment.5

Common features of CAM and self-care • Focus on a range of needs (not solely health).

• Emphasis on prevention of illhealth and promoting wellbeing.

• Dependent on patient preferences and choices.

• Takes place mainly outside the conventional health care context.

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SELF-CARE AND CAM Self-care and CAM: defining the differences, recognising the similarities

When is CAM self-care? The spectrum of care Recent guidance documents from the Department of Health present healthcare as a spectrum which extends from ‘100% self-care’ such as the action of brushing teeth regularly to ‘100% professional care’, in this case the example being neurosurgery.1 Between the two ends of this spectrum is shared care defined as the situation ‘where individuals or families partner with practitioners in the care of the individual’.

Patients expect to receive self-help advice as part of a CAM intervention

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However, there are differing perspectives on the concept of self-care. In a recent systematic review on self-care activities among adults in the UK, studies on selftesting, over-the-counter medicine, private care, CAM and home blood pressure monitors were all included.6 The authors’ rationale was two-fold: firstly, that they can all be initiated without the involvement or recommendation of a conventional health professional; secondly, that they require the user to take an active role. So ‘the actions people take for themselves’1 might include purchasing medications or treatment or diagnostic or monitoring equipment or kits, visiting non-NHS CAM practitioners for treatment or attending classes to learn a technique.

The Cochrane Collaboration defines complementary medicine as ‘all such practices and ideas which are outside the domain of conventional medicine… and defined by its users as preventing or treating illness, or promoting health and well being’.7 The similarities with the Department of Health’s definition of self-care are apparent – and clearly there is, at the very least, a significant overlap between the two fields – but the overall role of CAM in self-care is not necessarily a clear one.

Who chooses self-care and why?

The review of self-care by Ryan and colleagues6 located 49 relevant UK studies suitable for inclusion, 30 of which were on the use of CAM. Analysis of the users confirmed previous studies: people who use CAM are usually female, middle-aged and affluent and/or educated. Interestingly, users of over-the-counter (OTC) medicine have a similar profile, and both groups were found to have some measures of poor health. Anecdote and opinion played a crucial role in decision-making: therapies were chosen primarily because of personal recommendation or previous experience by a friend or family member.

Conventional medicine’s perceived disadvantages – rushed appointments, long waiting times, over-reliance on drugs, and limited effectiveness in solving particular health

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problems – were cited as reasons for seeking out other options. Conversely, the perceived effectiveness of CAM in specific conditions and the wish for ‘sensitive practitioners with interest and time to listen’ were contributory factors for selecting CAM rather than conventional medicine. It seems significant too that, compared with general practice patients, CAM patients had healthier lifestyles and were more likely to believe they were responsible for their health or less likely to believe that doctors controlled their health.

Self-care, CAM and specific conditions It has been suggested that CAM is generally more relevant in chronic, psychosomatic and non-specific conditions, while conventional medicine is more successful in acute, traumatic and specific conditions.2 This idea has been supported by subsequent research, and the potential for CAM to fill some of modern medicine’s ‘effectiveness gaps’ was highlighted by Fisher and colleagues in 2004.8 Interviews with 22 London GPs highlighted gaps in the management of various conditions: chronic musculoskeletal problems, depression, eczema, chronic pain, and irritable bowel syndrome, anxiety/stress, headache, perennial rhinitis. A survey of CAM organisations on the conditions that were most likely to benefit from CAM therapies resulted in a similar list.9 Conditions considered to benefit most were: stress/anxiety, headaches/migraine, back pain, respiratory problems, insomnia, cardiovascular problems and musculoskeletal problems.

In both studies, the response rates were relatively low but there does seem to be some agreement between conventional and CAM practitioners on the potential role of CAM. This appears to be primarily in the management of chronic, often ill-defined conditions for which effective conventional treatment is currently unavailable.

Chronic fatigue Chronic fatigue syndrome (widely known as myalgic encephalomyelitis or myalgic encephalopathy) (CFS/ME) is a relatively common condition affecting at least 0.2 to 0.4% of the population in the UK.10 The aetiology remains unexplained but the condition can cause prolonged illness and disability that substantially affects patients and their families. Management has proved a challenge to conventional medicine; drug treatment is relatively unsuccessful while therapies such as counselling and cognitive behavioural therapy (CBT), although apparently effective, are not widely available nor fully evaluated in primary care.11 Diagnosis of the condition is also problematic – there is no definitive test for CFS/ME – so that it is primarily a diagnosis reached only once other causes of prolonged fatigue have been excluded.

Consequently, one would expect use of CAM by people with this condition to be high. And indeed this appears to be the case.

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SELF-CARE AND CAM Self-care and CAM: defining the differences, recognising the similarities

One large-scale survey from the US investigated CAM use in ‘chronic fatiguing illness’.12 It included people with prolonged fatigue (one to five months duration), chronic fatigue (at least six months duration), and ‘CFS-like’ conditions (chronic fatigue not alleviated by rest and accompanied by at least four of eight recognised CFS symptoms). CAM use was extremely high (81.6%) in the fatigued groups but was also high in the non-fatigued group (72.5%). On average, 37.5% discussed CAM therapy use with their physician but this ranged from 26.1% in the non-fatigued group to 57.6% in the CFS-like group.

Individuals previously diagnosed with CFS reported more CAM use than people with fatigue who were not diagnosed with CFS. Body-based (chiropractic and massage therapy) and mind-body therapies (imagery/visualisation therapies, mindfulness based practices, relaxation techniques) were significantly more likely to be used by those with chronic fatigue or CFS-like illnesses, compared to non-fatigued controls.

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Their exploration of options appears to have been the first stage in taking control of their treatment

An insight into how CAM use fits into self-care is provided by more in-depth research with CFS patients.

Such a study was conducted by Edwards and colleagues13 who interviewed eight participants of a self-help group in the UK. Initial attempts at seeking help were described as having been unsatisfactory and it was common for feelings of ‘being let down and disbelieved’ to be expressed.

Participants reacted to this situation by taking more responsibility for their illness and its treatment. All except one of the participants described actively searching for treatments including CAM that could help them to recover from CFS. Among a wide range of complementary therapies tried were acupuncture, homeopathy, dietary supplements, kinesiology, osteopathy, Reiki and visiting a spiritual healer. Yoga, meditation and relaxation were also practised by several participants. Some of the participants began searching in the hope of finding a cure for their condition. But on reflection, their exploration of other options appears to have been the first stage in their taking control of their treatment and of finding ways to cope that worked for them and that fitted their own understanding of their illness.

This fits with the latest NICE guidance on CFS, much of which focuses on lifestyle, and thus patients’ selfmanagement of their condition.14 Furthermore, although complementary therapies and dietary supplements are not actually recommended (because there is ‘insufficient evidence of benefit’), the guidelines nonetheless suggest that ‘patients may wish to try these therapies for symptom control as part of a self-management strategy’. Appropriate use of relaxation, physical activity and exercise is advised,

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and clearly this could include some complementary approaches such as meditation, visualisation techniques and non-aerobic exercise-related therapies such as yoga or tai chi. CAM has also been suggested for managing the related symptoms of sleep disturbance, pain and mood disturbances.15 Indeed, within the NICE guidance, patient testimonies do mention use of acupuncture, homeopathy, yoga and tai chi for specific problems.

Fibromyalgia/chronic pain Fibromyalgia has similar characteristics to CFS: it has a high prevalence (between 3 to 6% of the world population),16 a poorly understood cause, an association with frequent co-morbidities and a shortage of effective conventional treatment.

A recent online survey of people with fibromyalgia generated an impressive response.17 The survey, hosted by the National Fibromyalgia Association, was completed by 2,569 people over a period of three days. The majority of respondents were middle-aged Caucasian females from the USA who had been symptomatic for approximately four years. Participants were given a list of interventions and asked whether they had used these and if so how effective they had been. Rest, heat modalities, prescription pain medications, anti-depressants, prescription sleep medications, prayer, massage/reflexology, and pool therapy were rated as most effective (≥ 6.0 on a 1–10 scale). Chiropractic, relaxation/meditation, non-aerobic exercise (stretching, yoga, tai chi), acupuncture, pilates and energy healing were rated as slightly less effective, while nutritional supplements, hypnosis and biofeedback received low ratings (less than 4). In-depth interviews with fibromyalgia patients suggested that access to alternative care is restricted by cost considerations.18 Another survey involved patients presenting with non-malignant chronic pain persisting for three or more months at 12 US academic primary care practices.19 Of the 463 who responded, 52% reported current use of CAM. The most common form of CAM use reported was vitamin and mineral supplementation; of those using CAM, 64% reported taking supplements. Herbs, massage, garlic preparations, and chiropractic were the next most frequently cited CAM modalities. The benefits of using CAM were mixed: 54% agreed or strongly agreed that non-traditional remedies helped their pain, while 46% disagreed or strongly disagreed.

Chronic headache Chronic headache is another common pain-based condition for which CAM treatment is often sought. A total of 110 chronic tension-type headache patients attending a headache clinic in Italy participated in a physicianadministered structured interview on CAM use.20 Recent use of CAM therapies was reported by 23% of the patients surveyed. The patients appeared to prefer CAM practitioner-administered physical treatments to selftreatments, the most frequently used being chiropractic

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SELF-CARE AND CAM Self-care and CAM: defining the differences, recognising the similarities

(21.9%), acupuncture (17.8%), and massage (17.8%). The majority sought CAM care after visiting a doctor, most often on the recommendation of a friend or relative.

However, only just over 40% of the patients felt CAM to be beneficial.

Responses suggest that a holistic approach was particularly appreciated

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Additional insight into decision-making processes comes from qualitative studies. In a study of migraine self-care conducted in the UK, participants generally expressed an interest in what complementary therapies had to offer.21 Not all the participants had consulted a therapist because of the cost implications. Participants who had consulted CAM therapists, whether or not they found the treatment effective, compared these consultations favourably with traditional medical consultations, and generally expressed satisfaction with the time and advice offered by CAM practitioners. Their responses suggest that a holistic approach (ie one where a range of therapeutic options and lifestyle changes can be considered) was particularly appreciated. Although in one case, this approach was offered by a GP, participants felt this was not usually the case. A study of women with migraine in the USA also showed that self-care interventions are often searched for and discussed.22 The participants were eager to hear about self-care treatments described by other participants. A third study, conducted in the UK, confirmed that participants engaged in a great deal of selfhelp, in managing their lives and in seeking out treatments — particularly within the field of complementary medicine.23 This study suggested that self-help was frequently a response to poor experience of conventional medical services.

Insomnia Chronic sleep disorders are a widespread health problem often linked to chronic pain, anxiety and depression.24 A telephone survey about sleep problems involved 2001 randomly selected French-Canadians.25 In the 12 months preceding the interview, 15% of them had used natural products (herbal/dietary) at least once to alleviate insomnia symptoms. Prescribed medications had been used by 11% of respondents during the previous year. People had also tried reading, listening to music, and relaxation to promote sleep. Massage, acupuncture, and hypnosis were far less commonly used options.

Non-medical practitioners and professionals such as pharmacists, acupuncturists, and homeopaths were each consulted by less than 1% of the sample. It seems that where sleep problems are concerned, people are far more

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likely to see doctors – usually a family doctor. Of those participants who had consulted someone, 83% had seen a GP, 17% a medical specialist (other than a psychiatrist), 6% a psychologist, and 3% a psychiatrist. However, the findings suggested that before seeking professional help, these individuals try self-help remedies for a considerable period of time.

Depression Depression, like insomnia, is commonly linked with other chronic health conditions. Unlike insomnia, it appears that many of those suffering depression do not consult a health professional, possibly because of the perceived stigma surrounding mental illness.26 Consequently, selfchosen approaches are frequently used.27 The many and diverse potential strategies available to individuals with depression were revealed in one large Delphi consensus study of self-help.28 A literature search initially identified 2,214 possible self-help strategies finally organised into 282 strategies. International panels of depression ‘consumers’ and professionals were involved in assessing the usefulness of these strategies. This resulted in 48 strategies being endorsed by both patients and health professionals although patients endorsed more strategies than professionals (70 versus 46 in the first round). There was agreement in general about the types of strategies most likely to be helpful which were primarily lifestyle or psychosocial in nature. There were also some differences: aromatherapy, massage, listening to music and taking vitamin supplements were rated much more highly by consumers. However, few strategies were rated as very easy or easy to carry out by consumers while professionals generally rated self-help as easier in practice than users.

CAM-based self-help strategies for depression endorsed by at least 80% of consumers and professionals • Learning relaxation methods – – – –

progressive muscle relaxation autogenic training breathing exercises self-hypnosis.

• Using a website or book based on cognitive behaviour therapy.

• Practicing mindfulness or meditation.

Adapted from Morgan and Jorm 28

In another study, ratings of helpfulness were compared with the actions that people with anxiety and depression actually take.29 The findings clearly demonstrated that perceived helpfulness does not accurately predict use. For example, counselling was rated as likely to be helpful by 93% of participants, yet only 15% actually used counselling in the following six months. Similarly, learning relaxation and seeing a mental health professional were rated higher

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for likely helpfulness than for use. The interventions most often used were those that are simple, cheap and readily available. This included pain relievers, vitamins and consulting a pharmacist. Special diets, sleeping pills and antibiotics were also used. Other predictors of use included gender: women were more likely to use a range of interventions, particularly those involving lifestyle changes, while men’s choices were more limited.

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The stage at which patients seek alternative treatments varies

Discussion Healthcare is presented as a spectrum with 100% self-care at one extreme and 100% professional care at the other and it is clear that CAM extends across this spectrum.

The surveys discussed in this paper took place in varied contexts, with differing populations and data collection methods. Aspects such as patterns of use cannot be compared but the studies support a particular role for CAM in self-care of chronic conditions for which there is no conventional answer. These conditions are relatively common, poorly understood in terms of aetiology and diagnosis is often difficult. The studies also offer some insight into the processes and decision-making by patients with these types of problems.

In many cases, patients seek CAM options as a first step in taking control or responsibility for their condition.

The stage at which patients seek alternative treatments does however vary. It appears that for patients with poorly recognised conditions such as chronic fatigue syndrome and fibromyalgia, lack of satisfaction with conventional healthcare over a period of time is an influence, so that CAM is a last resort. For other conditions such as insomnia, a range of self-care (including CAM) approaches are tried initially, prior to consulting a doctor. In depression where there is some reluctance to consult health professionals, self-care and CAM appear to be used as alternatives to conventional medicine.

Women have consistently been shown to be the main users of CAM. They are more likely to seek out a wider range of treatment options in general than men. They are also interested in strategies used by others with the same condition and initiate discussions on this. This correlates with findings that decision-making around CAM and self-care is often based on anecdote and personal recommendation rather than evidence of effects.

However, perceived effectiveness of specific strategies may not accurately predict use. Again, there are a number of possible reasons for this including accessibility, time limitations and cost. One study suggested that when considering feasibility of self-care strategies including CAM approaches, health professionals and consumers seem to differ in their opinions.

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Conclusion It appears that CAM has a significant role within self-care.

Conditions for which CAM is often used are prevalent and chronic, requiring ongoing contact which has significant implications for the NHS. CAM’s role in the treatment process may be as first line or last resort depending on the condition and the therapy. Finally, the importance of discussing feasibility of specific strategies (including CAM) cannot be underestimated if self-care is to become an integral part of a patient-centred health service.

References 1 Department of Health. Self-care – A real choice. Self-care support – A practical option. London: DH, 2005.

2 Fulder S. The handbook of alternative and complementary medicine: the essential health companion. 3rd ed. London: Vermilion, 1996.

3 Kelner M. The therapeutic relationship under fire. In M. Kelner and B. Wellman. Complementary and alternative medicine: challenge and change (pp 79–98). London: Taylor & Francis, 2000.

4 MacPherson H & Thomas K. Self-help advice as a process integral to traditional acupuncture care: implications for trial design.

Complementary Therapies in Medicine 2008; 16 (2): 101-6.

5 Richardson J. What patients expect from complementary therapy: a qualitative study. American Journal of Public Health 2004; 94 (6): 1049-53.

6 Ryan A, Wilson S, Taylor A, Greenfield S. Factors associated with self-care activities among adults in the United Kingdom: a systematic review. BMC Public Health 2009; 9: 96.

7 Manheimer E, Berman B. Cochrane Complementary Medicine Field. About The Cochrane Collaboration (Fields) Cochrane Library 2008, Issue 2. Art. No. CE000052.

8 Fisher P, van Haselen R, Hardy K, Berkovitz S, McCarney R. Effectiveness gaps: a new concept for evaluating health service and research needs applied to complementary and alternative medicine. Journal of Alternative and Complementary Medicine 2004; 10 (4): 627–32.

9 Long L, Huntley A, Ernst E. Which complementary and alternative therapies benefit which conditions? A survey of the opinions of 223 professional organizations. Complementary Therapies in Medicine 2001; 9 (3): 178–85.

10 Department of Health. A report of the CFS/ME working group: report to the chief medical officer of an independent working group. London: DH, 2002.

11 Wearden AJ, Chew-Graham C. Managing chronic fatigue syndrome in U.K. primary care: challenges and opportunities. Chronic Illness 2006; 2(2): 143–53.

12 Jones JF, Maloney EM, Boneva RS, Jones AB, Reeves WC. Complementary and alternative medical therapy utilization by people with chronic fatiguing illnesses in the United States. BMC Complementary and Alternative Medicine 2007; 7:12.

13 Edwards CR, Thompson AR, Blair A. An ‘overwhelming illness’: women’s experiences of learning to live with chronic fatigue syndrome/myalgic encephalomyelitis. Journal of Health Psychology 2007; 12 (2): 203–14.

14 Turnbull N, Shaw EJ, Baker R, Dunsdon S, Costin N, Britton G, Kuntze S, Norman R. Chronic fatigue syndrome/myalgic encephalomyelitis (or encephalopathy): diagnosis and management of chronic fatigue syndrome/myalgic encephalomyelitis (or encephalopathy) in adults and children. NICE Guidance. London: Royal College of General Practitioners, 2007.

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15 Action for ME. Information sheet: Controlling symptoms. Available at www.afme.org.uk/res/img/resources/Controlling%20symptoms.pdf.

(Accessed June 2009). Action for ME, 2003.

22 Moloney MF, Strickland OL, DeRossett SE, Melby MK, Dietrich AS. The experiences of midlife women with migraines. Journal of Nursing Scholarship 2006; 38 (3): 278–85.

16 WHO (World Health Organization). Scoping Document for WHO Treatment Guideline on Non-malignant Pain in Adults. Adopted in WHO Steering Group on Pain Guidelines, 14 October 2008.

Available at: www.who.int/medicines/areas/quality_safety/ Scoping_WHOGuide_non-malignant_pain_adults.pdf. Accessed July 2009.

23 Belam J, Harris G, Kernick D, Kline F, Lindley K, McWatt J, Mitchell A, Reinhold D. A qualitative study of migraine involving patient researchers. British Journal of General Practice 2005; 55 (511): 87–93.

17 Bennett RM, Jones J, Turk DC, Russell IJ, Matallana L. An internet survey of 2,596 people with fibromyalgia. BMC Musculoskeletal Disorders 2007; 8: 27.

18 Cunningham MM, Jillings C. Individuals’ descriptions of living with fibromyalgia. Clinical Nursing Research 2006; 15 (4): 258–73.

19 Rosenberg EI, Genao I, Chen I, Mechaber AJ, Wood JA, Faselis CJ, Kurz J, Menon M, O’Rorke J, Panda M, Pasanen M, Staton L, Calleson D, Cykert S. Complementary and alternative medicine use by primary care patients with chronic pain. Pain Medicine 2008; 9 (8): 1065–72. 20.

20 Rossi P, Di Lorenzo G, Faroni J, Malpezzi MG, Cesarino F, Nappi G. Use of complementary and alternative medicine by patients with chronic tension-type headache: results of a headache clinic survey.

Headache 2006; 46 (4): 622-31.

21 Peters M, Abu-Saad HH, Vydelingum V, Dowson A, Murphy M. Migraine and chronic daily headache management: a qualitative study of patients’ perceptions. Scandinavian Journal of Caring Sciences 2004; 18 (3): 294–303.

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24 Morphy H, Dunn KM, Lewis M, Boardman HF, Croft PR. Epidemiology of insomnia: a longitudinal study in a UK population.

Sleep 2007; 30 (3): 274–80.

25 Morin CM, LeBlanc M, Daley M, Gregoire JP, Mérette C. Epidemiology of insomnia: prevalence, self-help treatments, consultations, and determinants of help-seeking behaviors. Sleep Medicine 2006; 7 (2): 123–30.

26 Ebmeier KP, Donaghey C, Steele JD. Recent developments and current controversies in depression. Lancet 2007; 367 (9505): 153–167.

27 Badger F, Nolan P. Use of self-chosen therapies by depressed people in primary care. Journal of Clinical Nursing 2007; 16 (7) 1343–52.

28 Morgan AJ, Jorm AF. Self-help strategies that are helpful for sub-threshold depression: a Delphi consensus study. Journal of Affective Disorders 2009; 115 (1–2): 196–200.

29 Jorm AF, Medway J, Christensen H, Korten AE, Jacomb PA, Rodgers B. Public beliefs about the helpfulness of interventions for depression: effects on actions taken when experiencing anxiety and depression symptoms. Australian and New Zealand Journal of Psychiatry 2000; 34 (4): 619–626.

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SELF-C ARE AND INTERACTIVE IT

Self-care and the need for interactive ICT Tuvi Orbach CEO, Health-Smart

Jane Vazquez Health Education ‘Physiologist’, Health-Smart

I am an entrepreneur who focuses on harnessing advanced science and technology to enhance life. I have set up several companies with this aim in mind. My ultimate aim is to provide solutions which can empower people to improve all aspects of their life and overall wellbeing; from their physiology, emotions, and cognitive state, to their social and spiritual lifestyle, in order to enjoy longer, healthier, happier, enhanced, fulfilled lives.

I believe that it is important to enhance current mainstream science and medicine to encompass consciousness, awareness and a holistic approach.

Tuvi Orbach As a result of a childhood where encyclopaedias and alternative healthcare books were my bedtime reading, I decided to study physiology at university. My studies fuelled my amazement at the human body and I became a great believer in a holistic approach to health which I enthusiastically conveyed to all I met through the years. At Health-Smart I have been able to convert my own knowledge and that of other experts to help write and develop a programme aimed at empowering people to take care of themselves and lead happier, healthier lives.

Summary Long-term conditions

Jane Vazquez

threaten to bankrupt the NHS, as lifelong drug packages allow us to live longer but less healthy lives.

If our overfed, stressed, under-exercised lifestyle is at the root of the problem, then millions of us will need help to make big changes.

The health trainer role is full of potential, but they and people with or at risk of LTCs also need expert knowledge and support.

Fortunately, advances in interactive ICT can now put a health coach in every pocket and every home.

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Introduction – why is self-care essential?

The purpose of healthcare should be to enhance an individual’s total wellbeing (physical, emotional, social and spiritual), to prevent and reduce disease, and to enable and empower individuals to live longer, healthier and happier lives. Modern medicine has achieved a huge improvement in acute care and dramatically reduced infant mortality rates. But more than 75% of the healthcare costs in the UK, Europe and America are related to long-term or chronic conditions (LTC). This high prevalence is partly due to our longer lifespan, but arguably it has a great deal to do with the 21st century way of life.

Our body (and mind) is a wonderful holistic system: intelligent, interconnected, self-regulating and self improving. The human organism evolved for, and is still best adapted to, what is commonly termed the huntergatherer way of life. But our modern lifestyle bears little relation to that of

our neolithic ancestors, and is very different from the conditions and ways of life that our bodies have been finetuned for.

For most of us, car, bus or sofabound, life involves minimal necessary physical activity. And there is an abundance of food, often intensively produced and processed, though too little of what we choose to eat is the sort of fresh fruit and vegetables that our metabolism is programmed for.

Yet, sluggish though the modern lifestyle can be, our appetite for sugar, salt, meat, and alcohol is undiminished.

Add to these factors the modern day curse of sustained psychological stress, and it seems unsurprising that so many metabolically overloaded, torpid 21st century bodies fail to cope with this long-term abuse; nor that they eventually break down, causing many people to develop chronic illnesses and LTCs. Obesity, hypertension, diabetes, and cardio-metabolic syndrome have become endemic problems that undermine the health and wellbeing of millions.

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SELF-CARE AND INTERACTIVE IT Self-care and the need for interactive ICT

The InterHeart research project published in the Lancet 1 included more than 26,000 patients in 52 countries. It found that:

• Nine simple and modifiable risk factors are strongly associated with acute MI worldwide.

• The nine risk factors account for more than 90% of the population attributable risk (PAR) globally and in most regions.

• Implementing preventive strategies based on our current knowledge would prevent the majority of premature CHD worldwide.

The pharmaceutical solution has been to develop drugs that affect the chemistry of small sub-systems in the body.

This approach, though it might improve bio-chemical markers and extend lifespan, and even stop or reduce symptoms, often gives rise to long-term side effects when the medication impacts on other systems of the body.

Furthermore, in order to work, drugs such as statins and anti-hypertensives need to be taken every day, for life. The aim of this enormously expensive pharmaceutical project is life extension, and the reduction of harm for strokes and heart attacks. Research tells us that it is achieving these aims, and in the process generating staggering profits for the big pharmaceutical companies. But is this the only solution for the millions of individuals involved, or the best solution for the NHS? Treating people this way has caused the healthcare costs to rocket, but already the figures suggest that people, though they live longer, do not gain quality of life in proportion to their added years.

Healthcare costs are therefore increasing while at the same time, major end-of life care expenditure is merely deferred. So the current solution is simply not working and governments everywhere are beginning to realise that sustainability will depend largely on a move away from over-reliance on drugs, and the promotion of self-care.

Empowering and enabling individuals to take care of themselves ‘There are over 15 million people in England with longer term health needs. They are a large and growing group. Recent national surveys have shown that we need to do more to empower these people with long-term health and social care needs through greater choice and more control over their care. Health and care services still do not focus sufficiently on supporting people to understand and take control at an early stage of their condition. As a result, resources are wasted, medication goes unused, people’s health deteriorates more quickly than it should, and quality of life is compromised.’ 2

The DH strongly recommends self-care because investing in it ‘…will reduce GP visits by between 24% and 69% and hospitalisation by 50%’.3 The DH, having found that more than 90% of people with long-term conditions want to be more active ‘self-carers’, has made it a high priority that people should be ‘…supported and enabled to self-care and have active involvement in decisions about their care and support.’3 The Prime Minister announced on 1 April 2009 that the NHS will begin offering screening to all people aged between 40 and 74 (NHS HealthCheck) to assess their cardiovascular risk.4 The question is whether this becomes just a jumping off point for yet more lifelong prescriptions, or whether it is used as a great opportunity to empower people, motivate them and educate them about reducing their risks by living healthier lives.

However, ways of life that have been ingrained by habit and culture over many years will not be easy to change. It will require more than a few leaflets. Perhaps personalised coaching, monitoring and periodic follow-ups would help ensure that people maintain their new positive habits. But they would be very costly programmes, and GPs have neither the time nor the training needed to motivate their patients, educate them and support their change in lifestyle and behaviour. Nor would the majority of GPs necessarily be able to ‘walk the talk’. So although the initial screening is likely to be conducted in GP centres, there is a danger that time-poor GPs, whose training is biased toward prescribing, will instead simply reach for their prescription pads. Yet if patients fail to change their lifestyle, the NHS will incur ever greater costs and perhaps these patients will develop other long-term risks and side effects. And so the vicious circle of disempowerment, high costs and unhealthy lifestyle closes at the very point where it should be broken.

How can we deliver an effective self-care solution to over 10 million people?

An obvious way forward would be to train more (and less costly) healthcare trainers. They would be taught how to assess each patient’s risk factors and how to best motivate them, and would know how best to coach them to improve their nutrition and lifestyle, reduce their stress, and stop smoking. The problem is that to do these things well each trainer would have to learn quite a lot about nutrition, understand some cardiology and physiology, and very importantly – psychology and coaching, especially in the area of motivating people to change their lifestyle, and implement positive habits. Yet even trained psychologists are not necessarily successful in helping people to change poor eating habits, reduce weight, or stop smoking. So even with 10,000 brilliant healthcare trainers it would take a long time and be very expensive for each one of them to successfully coach 1,000 of the 10 million patients who might benefit. Clearly we need to tackle the problem another way.

Norman Warner, Minister of State for NHS Reform

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SELF-CARE AND INTERACTIVE IT Self-care and the need for interactive ICT

For example could we use IT to combine in some user-friendly way the relevant knowledge and support approaches that coaches/trainers would find useful? What if we brought together the contributions of cardiologists, nutritionists, and psycho-physiologists, and were to combine them with what’s known about motivational interviewing and behaviour modification? Would it not be very helpful indeed to encapsulate all this knowledge in an interactive self-care multi-media coaching programme and make it available to millions of people at minimum cost and maximum quality? A self-care multimedia system such as this would not just help to train the trainers costeffectively, but would also give every patient confidence that their efforts for change were based on the best selfcare knowledge available.

Are there effective methods to change unhealthy habits and prevent LTC? There are two additional interesting challenges: Some habits, such as smoking and exercise, are ‘extrinsic behaviours’ although they affect our long-term health and risks of LTCs. Certain subconscious habits – our breathing rate, heart rate, blood pressure and responses to stress for instance – are crucially influential,

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for these ‘intrinsic behaviours’ can seriously dysregulate our organism, undermine health and wellbeing and so set the scene for the development of LTCs. For example imagine this scenario. John is 42-years-old and spends most of his time at work sitting in front of a monitor. He is not aware that the combination of sitting most of the time, and the stress (pressure from his boss and customers and bursts of anxiety) changes the way that he breathes. His breathing has become fast and shallow, his heart rate and blood pressure have also increased. It would be a necessary challenge for John to improve this intrinsic behaviour, before its dysfunction converts into frank pathology. But how can he be taught to breathe more slowly from his abdomen and so reduce his heart rate, anxiety levels and blood pressure?

John also smokes, drinks a lot of coffee and alcohol, eats too much junk food, and is overweight. He is used to this lifestyle – even thinks it is ‘normal’, so the second challenge would be to change such habits. John already knows that smoking is not good for him; it is written on every cigarette box, and it isn’t likely that one session even with a very good health coach would change a habit so deeply physiologically, psychologically and culturally entrenched. Changing always takes us out of our comfort zone, so it calls for special kinds of intervention, and motivation; and it simply takes time. They are costly commodities.

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SELF-CARE AND INTERACTIVE IT Self-care and the need for interactive ICT

However, it has been realised that these challenges can be met by integrating information and communication technologies (ICT) and inexpensive sensors with interactive self-care programmes. A number of good clinical trials have demonstrated how several chronic conditions, including hypertension, diabetes and irritable bowel syndrome, can be better managed and controlled by using interactive ICT to modify both extrinsic and intrinsic behaviours, and to support lifestyle changes.

Evidence-based examples of interactive self-care solutions A large percent of the population suffers from anxiety and depression. Drugs are not effective for most of the population (mild and moderate depression). However cognitive behavioural therapy (CBT) has been shown to be more effective than medication especially in preventing relapses, but there are too few trained CBT psychologists and there is a long waiting list to see them in the NHS. We have collaborated with psychologists and psychiatrists from the Institute of Psychiatry to develop eight sessions of interactive self-care presented as a computer-based multi-media programme (called Beating the Blues). Clinical trials have shown that this programme was more effective than ‘usual treatments’ in primary care.

NICE recommended this programme for the treatment of

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anxiety and depression and many thousands of NHS patients have benefited from it.5 IBS is a long-term condition affecting more than 15% of the population, and medication is often relatively ineffective, especially in severe cases. We collaborated with Professor Epstein at the Royal Free Hospital and developed a bio-interactive self-help programme to treat IBS. Two clinical trials have suggested this system could deliver very promising results.6 Patients with several years’ history of IBS who had not responded well to other treatments and who completed eight interactive self-help sessions showed between 75% and 82% improvements in anxiety, abdominal pain, stool consistency and bowel urgency.

Improved global wellbeing was reported by 85%, and long-term improvement by 65% of those taking part.7 To the best of our knowledge no medication has produced such good results.

Bio-interactive self-care systems can help patients to modify ‘intrinsic behaviour’. In the case of IBS patients, severe anxiety and bowel urgency are associated with high arousal levels (stress) and faster than normal peristalsis (the rhythmic contraction of the intestinal muscles which push the food forward). The team created a 3D animation of a ‘journey inside the bowel’, and linked it to the user’s arousal level, which is measured by a ‘skin resistance’ sensor attached to the finger. As the user learns to reduce their arousal level, the images in the animation reflect their relaxing, and so, through a biofeedback process, the

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SELF-CARE AND INTERACTIVE IT Self-care and the need for interactive ICT

user learns to slow down the animation and their peristalsis. Most patients can learn to control the animation, and within eight weeks to control and improve their anxiety and peristalsis. This type of bio-interactive coaching can be used to train patients to control other ‘intrinsic behaviour’ and prevent and control other conditions such as hypertension and asthma.

The latest generation of biointeractive self-care programmes In order to train patients to overcome anxiety and depression, we have incorporated psychological knowledge and methods into interactive multimedia sessions that include audio, video and animation. The aim is for patients to learn the principles of CBT, and acquire self-help skills for life. Though CBT can be useful for some conditions and some people, not every patient and every condition benefits. However, one of the advantages of computerised coaching is that it allows each individual to chose the particular combination of the best known treatment methods customised to their conditions, preferences and needs.

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SmartHeart educates users, empowering and motivating them to improve their habits

During the last five years Health-Smart Ltd has developed an advanced bio-interactive self-care system that integrates knowledge from a multi-disciplinary expert team, with wireless multi-parameter sensors and advanced psychological and behavioural methods. The team has also created a comprehensive software engine that can transform interactive protocol scripts into user friendly and effective bio-interactive self-care programmes.

Dr Ameet Bakhai, a senior consultant cardiologist at Barnet & Chase Farm and The Royal Free Hospital has been guiding Health-Smart in the development of a comprehensive self-care solution – SmartHeart – to prevent and control hypertension and other vascular diseases. SmartHeart’s bio-interactive healthcare assessment can monitor the user’s physiology (breathing rate and pattern, heart rate (HR), and HR variability, blood pressure, stress/anxiety level, ECG), as well as track body measurements (weight, height, waist circumference and so on), detailed nutrition and lifestyle profiles (including alcohol use, smoking and physical activity), medical history and medications. Clinicians can add test results such as lipid and glucose levels. In fact a point of care blood test machine can even be connected to SmartHeart.

SmartHeart can then present users with their modifiable risks, and encourage them to see how they might reduce their risks and gain extra healthy years of life by modifying some unhealthy habits. SmartHeart is designed to help users choose targets, and to prepare their own customised prevention plan. Patients with modifiable

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risks can also attend interactive self-help sessions in primary care or community settings, and eventually at home or via interactive applications on their mobile phones.

SmartHeart educates users, empowering them and motivating them to improve their habits, and coaching them on how to make healthy changes and implement them in their daily lives. Each session is customised to the user’s risk profile and preferences. For example a patient with high blood pressure and high anxiety who is overweight but not a smoker will be trained on how to improve nutrition, achieve and maintain weight loss, reduce anxiety and to relax. Users can also be trained to slow their breathing down (which can significantly reduce BP) and so reduce their heart rate (and increase heart rate variability). In addition, a smoker would receive the smoking-cessation coaching.

We intend to find ways of making SmartHeart available to everyone who needs it, so that healthcare stakeholders will be able to benefit from this new generation of biointeractive self-care. Our hope is that PCTs who implement it will find that they reduce their costs, while improving the long-term care and health of their patients. We believe that GPs who use it will save time, get more information about their patients, and that their time will be freed up to focus on improving other areas of care. And we know from previous experience of bio-interactive self-care systems that they powerfully motivate patients to improve not just their lifestyle but even to directly stabilise their dysregulated physiology.

We believe it may be possible using bio-interactive self-care technology to bring about a new era in the prevention and management of long-term conditions, enabling people at risk to live longer and healthier lives with far less need of medication. Our planned research also aims to show that bio-interactive self-care can produce a healthy reduction in the NHS’s disastrous over-dependence on lifelong drug-taking.

References 1 Yusuf S, Hawken S, Ôunpuu S, Dans T, Avezum A, Lanas MF, McQueen M, Budaj A, Pais P, Varigos J, Lisheng L, on behalf of the INTERHEART Study Investigators. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. The Lancet 2004; 364 (9438): 937–952.

2 Supporting people with long term conditions to self care – A guide to developing local strategies and good practice. London: Department of Health, 2006.

3 Raising the profile of long term conditions care: a compendium of information. London: Department of Health, 2008.

4 Website of the Department of Health. www.dh.gov.uk/en/index.htm.

5 Website of NICE. www.nice.org.uk/guidance/TA97.

6 Barrison I. GUT 1999; 44 (suppl. 1).

7 Leahy A, Clayman C, Mason I, Lloyd G, Epstein O. Computerized biofeedback games: a new method for teaching stress management and its use in irritable bowel syndrome. Journal of the Royal College of Physicians of London 1998; 32 (6).

Health-Smart has sponsored this issue of the journal.

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SELF-C A RE FOR TH E H E A RT

Emotions and selfregulation for the heart Elizabeth Wilde McCormick Psychotherapist, teacher, writer

Summary This is drawn from my experience as a psychotherapist working with patients who have heart problems.They come to me through referrals made by GPs, cardiologists or physiotherapists or because they self-refer having read one of my books.The psychological interventions I use are varied and could be as brief as a single hour-and-a-half assessment with a three or six month follow up, shortterm weekly interventions for eight to sixteen sessions or occasionally longer therapy stretching over several years.

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I have been practising as a psychotherapist for nearly 30 years. My background is in social psychiatry and cognitive analytic therapy at Guy’s Hospital, and transpersonal and contemplative psychotherapy. I am a founder member of the Association for Cognitive Analytic Therapy and was, with Nigel Wellings, Director of Training at The Centre for Transpersonal Psychology from 1996 until 2001. I have a special interest in the heart and in working with patients presenting with heart associated problems.

‘We shield our heart with an armour woven out of very old habits of pushing away pain and grasping at pleasure. When we begin to breathe in the pain instead of pushing it away, we begin to open our hearts to what is un-worked.’ 1

Introduction My introduction to the complexities of the heart as a physical organ and the way its function is inextricably bound up not only with the lungs and breathing, but also with emotion and feelings, came in a very personal way.

I was about to begin my psychological training in 1977 when my husband John had a heart attack at the age of 52, while we were on holiday.

On returning home to the UK he asked ‘what do I do now?’, and his GP answered: ‘just go home and relax.’

But how was a young, fit, busy chairman of an advertising agency actually to accomplish that? He had already given up smoking and suffered the intense surge of difficult emotions this usually heralds. He was angry about having a heart attack, and beneath the anger was fear. In a 1990 film by Mark Kidel for Channel Four in which we both took part, John describes himself in the post-heart

attack period as ‘feeling like a wounded animal in the jungle of commerce ready to be picked off by hungry competitors’.

It was out of these very personal experiences that I wrote a self-help book for families called The heart attack recovery book. It was first published in 1984, and by then I had qualified as a psychotherapist with a largely transpersonal orientation, and been invited by Dr Peter Nixon, who was pioneering sleep therapy for heart patients, to work with him at Charing Cross Hospital. At the same time I was working with Dr Anthony Ryle at Guy’s Hospital on the brief therapy project out of which cognitive analytic therapy evolved. All these influences have contributed to the development of my own model of working with heart patients and their emotions using a psycho-therapeutic approach.

Based on my experience of what has seemed to be most helpful for these clients, this article explores the importance of: • compassionate listening and containing • ‘psycho-education’ and the invitation to learn ‘self-regulation’.

This might entail using mindfulness of breathing and feeling to allow both emotion and sensation to be

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SELF-CARE FOR THE HEART Emotions and self-regulation for the heart

Compassionate listening and ‘containing’ All psychotherapies share an understanding that how we relate to others and to ourselves underpins our capacity for self-awareness and self-regulation. Emotional intelligence can be found within all groups of people, however apparently disadvantaged, once they have been introduced to, and learned from, the practice of selfobservation and self-care. All psychotherapies recognise the value of the therapeutic relationship between therapist and patient as the fundamental building block for dialogic communication and within which self-regulation, selfawareness, and self-compassion might evolve. Stephen Porges, Director of the Centre for Developmental Psychobiology at the University of Illinois, explains that our organisms have evolved in such a way that ‘people need people’.2 This is especially so in infancy, a period when the heart-face connection is a critical component of the ‘social engagement system’. It is this crucial body-tobody relationship through which ‘the good enough mother’ makes the infant’s first chaotic and terrifying experiences of emotion feel safe by her own ability to tolerate and accept her baby’s rage and terror.3 Inherited factors play a part in determining our capacity to cope with stress but even so, during the first year or so of life this ‘containing’ relationship – which will determine future capacity to tolerate and make sense of emotion – shapes our potential to manage stressful situations in future life.

If the process doesn’t go well, the nervous system will tend towards dominance by the sympathetic branches of the autonomic nervous system, which promote the flight, fight and freeze responses. Neurobiologists are now confirming the patterns of hyper- and hypo-arousal levels in early brain development that keep an individual on high alert, or shut down, but unable to regulate their response to emotional stress.

In the healthy organism, there is a reciprocal relationship between the two sides of the autonomic nervous system: when the sympathetic tone is high the para-sympathetic is low, and vice versa. One way of tracking the reciprocal balance between the sympathetic (flight and fight) system and the para-sympathetic (stillness and

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secretion) side is by means of heart rate variability (HRV) monitoring. Studies at the HeartMath Institute indicate that HRV takes on a regular pattern – termed ‘coherence’ – when the body is relaxed and the mind is in a state of ‘appreciation’. Curiously, it also appears that when two people are together and experiencing the sort of empathic relationship typified in compassionate listening, both practitioner and client develop coherent HRV. I find it helpful in this regard, when in the therapeutic setting, to ask permission to share a few minutes of mindful breathing at the beginning of a session, and at the end. This also helps to regulate rhythms of breathing, something I believe essential for heart patients, and which helps set the tone for further exercises in mindful awareness of the body.

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The shock, escalating pain and loss that are typical of a heart attack can be overwhelming

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recognised, and to befriend fear. The aim is to find ways of linking feelings in the heart and body with the patient’s emotional life; to become more aware of what emotions feel like as they arise in the body.

• Helping patients explore their feelings and make sense of them through symbols and creativity. Finding the patient’s own form of symbolic language and creativity.

• Teaching awareness of feeling states as they arise in the body and using mindfulness of breathing or feeling to allow both feeling and sensation to be recognised, to rise and fall; and to befriend fear.

• Developing a compassionate awareness.

Mindful breathing example Body and chair exercise Make yourself comfortable on a chair. With eyes closed or just half closed, allow your attention to rest on your experience of your body in the chair. Notice the rise and fall of the breath. Notice where any tension lies within your body, the neck, shoulders, down the arms, the weight of the head. Notice any tension in your back down the spine, into your buttocks, legs, ankles and feet. Notice any tension in your belly or chest. Each time you notice any tightness or difficulty in the different parts of your body, try to relax the muscles and let any tension be taken away into the air and earth.

Now just notice your body sitting in the chair.

Feel the support of your back and buttocks by the chair.

Let the chair take your weight and let your whole body feel supported by the chair.

Just rest in these feelings of support from the chair for a few minutes.

Whenever you are feeling anxious, unsupported or lonely, return to this practice which helps to build a nourishing reciprocal role such as caring/supporting in relation to cared for/supported.

Psycho-education and the invitation to learn self-regulation There are two maps which I have found extremely helpful for teaching patients to be more aware of physiological dysregulation and what triggers emotional stress.

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SELF-CARE FOR THE HEART Emotions and self-regulation for the heart

The autonomic arousal model

The human function curve The human function curve was developed in 1946 to help soldiers returning from battle recognise their levels of catabolic exhaustion and to measure their recovery. I was first introduced to this concept – which is also used in the work of the HeartMath Institute in Colorado – at Charing Cross Hospital and I now use it with heart patients and other exhausted patients, particularly those who have had a physical or psychological breakdown.

The first map, which helps patients recognise when they are over- or under-aroused, is derived from Pat Ogden’s sensorimotor psychotherapy, a body-orientated talking therapy she developed in the 1980s.4 Enriched by contributions from neurobiological research, it uses bodily experience as the primary entry point for psychotherapy.

Rather than life events, conflicts or narratives about feelings (the customary material for psychotherapists), and before it attends to emotional and cognitive meaning-making, this approach focuses first on the client’s immediate experiences of their body, because these sensations reveal how the person is processing information.

The shock, escalating pain and loss that are typical of a heart attack can be overwhelming. This overwhelm compromises the nervous system’s ability to process information: to create and store memories. This is what the over-used and misunderstood term ‘traumatic’ really implies. And, after traumatic events, it is common for the events themselves, and the emotions they aroused, to become inaccessible. So if they are to be better integrated, they need to be expressed safely and in ways over which the patient has control. If they are not integrated in this way, they may continue to disturb thinking and feeling even many years after the event. For instance people may remain hyper-vigilant for pain, or may even find that certain innocent situations – unconscious reminders of an event only dimly recalled – trigger irrational and overwhelming emotions such as panic. My experience of teaching self-regulation and the capacity to tolerate emotions using the sensorimotor model, is that it helps patients become aware of their under- or over-arousal.

They also learn to more safely reflect on whatever might be triggering the unregulated state, and to find ways of returning to the ‘window of tolerance’. In parallel, patients are shown how to identify existing or new positive resources; perhaps music, objects or imagery. Working with these embodied feelings can build a sense of having a safe place in the body; a felt-sense that helps restore calmness when doing this work.

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The graph illustrates the upward curve of healthy arousal, which increases as more is demanded, and how up to a point the increasing arousal helps us deliver more.

But as we reach the peak of what we can achieve we experience tiredness, and the need to withdraw, rest and so recover. The healthy response to tiredness is to stop, restore energy levels and so return to the start of the graph; and to be able to accomplish this on a continuing basis. But there are those whose life circumstances or temperament do not permit them to stop; who cannot or will not reflect on their sense of fatigue, or whose inner pressures impel them to carry on at all costs.

Consequently they slide into the zone where increased arousal is not met by improved performance. Running faster but making ever less headway, their anxiety increases as they move on to this downslope becoming ever more exhausted and unwell until, at point P, they breakdown.

On the downslope of this curve patients are trying to bridge the gap between their intended action and what is actually happening: which is a lessening of achievement even though arousal levels are rising. Understandably in such circumstances, feelings of anxiety, panic and fear of failure, as well as rage against the body, all escalate.

Underlying this phase is a flight and fight mode that promotes upper body tension and breathing patterns that encourage habitual hyperventilation. Hyperventilation in itself not only compromises cognitive faculties and circulation, but can also be a cause of chest pain and unnecessary cardiac testing for heart disease.

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SELF-CARE FOR THE HEART Emotions and self-regulation for the heart

Sleep therapy In my work at Charing Cross Hospital it became clear to me that every patient I saw, whether with cardiac pain or during post-infarction recovery, had their own unique emotional response. Whatever had been hidden in the shadow was brought to light by the cardiac events; the undigested and unexplored emotional forces that had been maintaining tension and stress were suddenly on the surface. Forced to rest in a darkened room, taught how to regulate breathing and how their body felt after relaxation, and being looked after, often opened a vulnerability that was a window on to their real emotional and psychological life. During the 10 days, as the patient began to recover his or her ability to relax and breathe naturally, their emotional landscape would open up. Rage at betrayal in relationship or loss; frustration and feeling trapped in an impossible job; being under the arbitrary control of others, marginalised, demoralised, discriminated against; there was often tears of despair at being overwhelmed with a life of difficulty with none to speak to and no relief.

Each story and the relationship with the patient imbedded within it would offer seeds for what each patient might need for recovery. This would include outside help with rehabilitation such as exercise, diet, breathing, but most

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importantly help with managing emotional arousal through individual emotional education and a good enough map of the journey that had led them into their physical and emotional suffering, and a face to face person with which to share this understanding and follow up.

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Every patient had their own unique emotional response

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I have known patients to live on this downslope for as long as two years, experiencing a cascade of poor health: headaches, back pain, menstrual problems, fatigue, irritability, sleep disturbance are among the common complaints they suffer once strain on the muscular, nervous and endocrine systems is unrelenting. The unconscious may express itself through physical symptoms such as these, or in symbolic language, through dreams of being trapped, of running for a train or in fantasies connected to the longing for escape. This is a time when, in a desperate attempt to find relief, patients tend to drink more, drive faster, become more unpredictable or obsessional, to make unsuitable life decisions, or even attempt suicide. Then at P on the curve some precipitating factor, perhaps a quite trivial event will trigger breakdown.

Sometimes this takes the form of a heart attack.

When I ask people where they think they are on this curve, they always seem to know. The conversation that follows explores questions such as: what makes it hard for me to stop and breathe and regulate my fatigue; what makes me colour-blind to fatigue and exhaustion? I believe that finding answers to questions like these can be a crucial part of recovery. Because only once they have been answered can people who survive the crisis of a heart attack (and providing that they are given permission and time to recover fully) become better managers of rest and effort. What’s more, they may then – in a positive sense – get more in touch with their vulnerability, and so be more available in their relationships, both with others and with themselves. Some heart patients I have known, who clearly benefited from the gratitude they felt for having survived, were subsequently more able to be compassionate to themselves and to others.

The sleep therapy at Charing Cross in the 1980s allowed patients to rest for up to 10 days. This simple intervention was intended to restore the heart’s adaptive capacity. Patients were taught abdominal breathing techniques, how to manage the balance of rest and effort through exercise, and how better to understand their emotional response to others and themselves.

Alexithymia We eventually recognised a group of patients who did not do well with this approach to rehabilitation; a group who appeared to be in a ‘given up’ position. Feeling defeated by life, and by their inability to cope with its demands and its changes, they were hard to reach, seemed not to connect with others and were unable to say what they really felt. At first I wondered whether they were too angry, too afraid to relax, and receive care, too suspicious to let go. What seemed clear was that although their stories brimmed with cycles of events involving the heart, these patients appeared to be blind to their emotional significance. Consequently, as I sought to understand this I came across the concept of alexithymia, and began to understand that some people lack the words and symbols required to make sense of emotions, and so to communicate with themselves and others about their feelings.

‘Prone to action and deficient in words, these patients can often express their internal states more articulately in physical movements or in pictures than in words. Utilising drawings and psychodrama may help them develop a language that is essential for effective communication and for the symbolic transformation that can occur in psychotherapy.’ 5 Neuroscience has made links between alexithymia and somatisation. In some individuals it seems, early emotional or physical trauma may interfere with aspects of brain development that normally allow us to make sense of feelings. When this happens, emotions may come to be mutely expressed through a dysfunctioning body, or even split off entirely so that they trigger dissociated states. In either case progress can be made once psychological interventions allow feelings to be communicated nonverbally, and the lost emotional landscape may be gradually re-integrated.

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SELF-CARE FOR THE HEART Emotions and self-regulation for the heart

Helping patients explore their feelings…

I see transpersonal psychology as a creative way of making symptoms more emotionally meaningful. If a safe enough therapeutic alliance can be established, then through imagery and visualisation, symptoms may be interpreted.

When this works well, it is possible for a client to evolve their own symbolic ‘emotional language’; one that is in a manner of speaking ‘embedded in the heart’, and that helps them reconnect with its emotional function.

❛

❛

Her simple drawing gave us a starting place for exploration

I want to give an example of how this can succeed. A patient suffering from alarmingly high blood pressure and angina gave me details of all her treatments and told me something of her lifestyle, which seemed to be regular and organised. As the session continued I felt that there was something she was not saying. I allowed the space between us to become reflective and more contemplative and I asked her if she might be able to give me an image of her heart as it was right now. She smiled, looking surprised and said: ‘ Oh, a red cracked vase.’

We sat with this image together and I asked her to draw it. She drew a simple outline on the pad of paper I had offered and when she got to the base she included a long crack, out of this crack she drew small circles, like drops of water, which she drew slowly. We sat contemplating this image together. When I asked her what she felt the image was expressing she said simply: ‘my divorce’. And then her tears came. She had divorced six years previously but never talked about it, stoically ‘trying not to make a fuss’. Her simple drawing gave us a starting place for exploration and permission to speak of what had previously felt unspeakable. It also opened up her sense of wonder at the unsuspected language available within her, and that once listened to, how a simple feeling could express itself. The vase and its crack also invited a language of resolution: subsequent to her insight she was able to mourn for the wound the crack represented, to ask what needed to be done to heal it, and how she might bring to her heart the feelings of relief it needed.

Another patient found visualisation very helpful.

During her post-infarction period she experienced painful sensations in her chest, along with feelings of intense heat.

Working full time as a successful and busy academic with a large family, she had been trying to rationalise her discomfort, yet continued to feel frightened and trapped.

I felt that her focusing on her body sensations was compromising something that John Welwood might have called her ‘basic aliveness’.6 So I asked her to monitor

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these sensations and to draw them if she could. What transpired was a series of drawings and paintings that communicated the complex emotions her body and her heart in particular had been expressing.

She began regular mindfulness practice which encouraged a more relaxed non-judgemental awareness of her chest area. This helped her recognise a longing for something cool, like water, and this insight was soon followed by an experience on holiday when, while walking in a garden, she saw a wellspring emerging from a dry rock. At that point she experienced something ‘breaking open’ at the back of her chest. She started using this image – of bringing the cool clear clean flowing water into the heat and dryness of her heart – and it was this conscious process that gradually brought about a much more accepting relationship with her heart.

Cognitive analytic therapy (CAT), pioneered by Dr Anthony Ryle, is an integration of cognitive and psychoanalytic ideas that has been evolving since the early 1980s.

It aims, through patient-therapist collaboration, to create descriptive and diagrammatic reformulations of presenting problems. At its core this therapy recognises that all humans evolve through interactions with others. So our becoming who we are is always in relationship to ‘the other’. And the physical development of our brain and nervous system is shaped by our early relationship with whoever this ‘other’ is. If the communication is reciprocal, and care is ‘good enough’ then we are likely to grow up with a more comfortable relationship with our body and emotions, more able to love and receive love, to care for others and ourselves and enjoy happiness. If early experiences of relationship were more problematic however, we may come to feel and anticipate – in our grown up relationships, our work and the world generally – that others are rejecting or abandoning us. And so, in continuing to feel rejected and abandoned, we have to develop ways of interacting with ourselves and others that help ameliorate the powerful emotions clustering around our experiences of relationship. CAT names them as ‘core pain’.

‘A very large number of depressed and somatic symptoms are connected to the inability to express anger in a useful way.’ 7 Researchers at Johns Hopkins School of Medicine followed 1,055 medical students for 36 years. The ones whose psychological tests as students identified them as hotheads were six times more likely to suffer heart attacks by age 55 and three times more likely to develop any form of heart or blood vessel disease.8 In fact intense anger is known to be one of the precipitating factors during the two hours prior to many strokes and heart attacks: not the ordinary healthy anger that has a cause and is directed at something or someone though. The dangerous emotion is the sort of free-floating undirected, generalised hostility that is common in depression, in defeat, in frustration and in long-held buried or denied resentment about one’s lot in the world.

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SELF-CARE FOR THE HEART Emotions and self-regulation for the heart

The hostile heart is a vulnerable heart. Harvard researchers have demonstrated that anger has both short- and long-term consequences. In a longitudinal study, scientists evaluated 1,305 men with an average age of 62.

Each participant took a psychological test that used the Minnesota Multiphasic Personality Inventory anger scale to rate his anger level.The men returned for detailed medical exams every 3 to 5 years; they were checked for heart disease and cardiac risk factors such as smoking, hypertension, high cholesterol, and diabetes. None of the men had coronary artery disease at the start of the study, but 110 developed it within 7 years. All in all, the angriest men were three times more likely to develop heart disease than the most placid men.The link between anger and heart disease was not explained by differences in blood pressure, smoking, or other cardiac risk factors; hostility was heartbreaking in its own right. 9 In the long run, anger can increase a middle-aged man’s risk of developing coronary artery disease, but can a single burst of anger trigger a heart attack? Another Harvard study found that it could. Doctors interviewed 1,623 patients about four days after they had suffered a heart attack; 69% were men.The patients used the Anger Onset Scale to rate the intensity of any episodes of anger they had experienced during the 26 hours prior to their attacks, as well as throughout the previous year. Intensive anger was clearly dangerous for the heart, more than doubling the risk of heart attack if the emotion took place in the two hours previous to the heart attack.10

During the therapy of a man in his early 50s who had suffered a myocardial infarction and was having difficulty accepting rehabilitation after bypass surgery, a CAT diagram was created. He had symptoms of depression with gloomy thinking and early morning waking. He hyperventilated and suffered continual chest pain. His self-monitoring reports revealed that his symptoms were worst when talking with his wife, so we created the diagram in our attempts to understand something of what went on in the relationship between them and in the course of this work we evolved a series of exits for him to practise.

Teaching awareness of feeling states…

The distinguishing characteristic of emotion is that it dominates our attention and cannot be ignored, while a feeling can remain in the background of our awareness.

Feelings, such as gladness, sadness or anger are relatively familiar and recognisable. Emotions however, are far more intense forms of feelings: the feeling of sadness may build into grief, the feeling of irritation can become a fierce rage.

The therapeutic process can begin once the core emotional pain has been named. In the diagram below it happens to be fury. Subsequently the aim is to make sense of the way the patient has adapted in order to cope with it; in this case learning to please others by working hard.

The invitation to become aware of these patterns can in turn help a patient to start identifying different emotional states, as connections (and disconnections) between the states as they are discovered. Having worked with the coping strategies the patient has developed, it may be possible to help him be aware of and even befriend the unbearable emotions lying beneath. Finding words or phrases to describe the feeling or the body sensation through which the feeling is trying to make itself known helps to bring a slight but useful distance from it. Here are some examples: • Frenetically active Staying busy to avoid thinking or feeling • Agitated or confused Anxious • Out of control Rage • Scared Fearful • Vulnerable Needy, helpless, waiting for rescue • Cut off Blank Finding the right word to describe the feeling or body sensation is a first step to relating to it. The next step might be to find ways of monitoring when the experience arises in everyday life in order to get used to a new language. It may also be possible to go a further step, and to safely feel into the actual feeling or sensation. The in- and out-breath can be used in a powerful way as in: ‘breathing into hurt’, and ‘walking with and breathing out anger’. A further step would be: noticing what I feel, I accept my feeling and have compassion for my feeling.

For patients who are alexithymic, who don’t know they are angry or hurting, these steps need to be taken very slowly so that the new cognitive learning can gradually form a new awareness and thus a vehicle for connection with feeling and sensation.

Developing a compassionate awareness Over time, it may be possible help a patient find what Gendlin calls a ‘felt sense’ – through their body – of unfamiliar aspects of their feelings.11 This ‘felt sense’ is often fuzzy at first, and finding the words that fit the

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SELF-CARE FOR THE HEART Emotions and self-regulation for the heart

feelings takes time. But when there is a fit, and a ‘felt shift’ – an actual change of energy within the body as the word meets with feeling – patients are able to both accept ordinary feeling and feel kindly toward it. This is the beginning of self-compassion and beginning to relate more kindly to oneself. Compassionate awareness can help us to have a relationship with our range of feeling and emotion, however powerful and gripping, without having to act out, dissociate, or somatise and express as symptoms.

‘Seeing the suffering in the world around us and in our own bodies and minds, we begin to understand suffering not only as an individual problem, but as a universal experience.

It is one of the aspects of being alive.The question that then comes to mind is: if compassion arises from the awareness of suffering, why isn’t the world a more compassionate place? The problem is that often our hearts are not open to feel the pain. We move away from it, close off, and become defended. By closing ourselves off from suffering, however, we also close ourselves to our own wellspring of compassion. We don't need to be particularly saintly in order to be compassionate. Compassion is the natural response of an open heart, but that wellspring of compassion remains capped as long as we turn away from or deny or resist the truth of what is there. When we deny our experience of suffering, we move away from what is genuine to what is fabricated, deceptive and confusing.’12

A meditation on unconditional friendliness, or loving kindness Find a place to sit comfortably, with your body and shoulders relaxed.

Take a few minutes to connect with the rhythm of in-breath and out-breath, allowing this rhythm to help the body relax.

Now, allow some memories or images of being given kindness, however small, to arise.

Some people find it valuable to say to themselves ‘May ‘May ‘May ‘May

I I I I

be be be be

free from ignorance.’ free from greed and hatred.’ free of suffering.’ happy.’

Once you have established in yourself a centre of loving kindness, you can take refuge there, drinking at this renewing and nourishing well.

You can then take the practice further. Having established the well of loving kindness within your own being you can let loving kindness radiate out and direct it wherever you like.You might like to direct it first to members of your family or friends, visualising them and sending them loving kindness.You can direct loving kindness toward anyone – those you know and those you do not.You can also direct loving kindness to those you are having difficulty with. And finally, you can direct loving kindness to all sentient beings, animals, plants and the universe itself.

The body and chair exercise was given as part of a continuing professional development training day in CAT in Norwich, led by integrative psychotherapist and trainer Margaret Landale, in October 2007. I am grateful to Margaret for permission to use the exercise.

References 1 Chodron, P. Start where you are. Boston, MA: Shambhala, 1994, p37.

2 Porges S. Orienting in a defensive world: mammalian modifications of our evolutionary heritage. A Polyvagal theory. Illinois: Brain-Body Centre, University of Illinois, 1995. www.psych.uic.edu/bbc 3 Winnicot DW. Playing and reality. London: Routledge,1991.

4 Ogden P. Trauma and the body. New York: Norton, 2006.

5 Van der Kolk B, McFarlane A, Weisaeth L. Traumatic stress: the effects of overwhelming experience on the mind, body and society.

New York: Guildford, 2007.

6 Welwood, J. Awakening The Heart. Boston, MA: Shambhala, 1985.

7 Ryle A. In: E. McCormick. Change For The Better. London: Sage, 2008.

Notice where these memories touch you in your body.

8 Chang P, Ford DE, Meoni LA, Wang N, Klag MJ. Anger in young men and subsequent premature cardiovascular disease: The precursors study. Archives of internal medicine 2002; 62 (8):901-906 (38 ref).

Notice the sensations in your body – tingling, opening, softening.

9 Kawachi I,Sparrow D, Spiro A, Vokonas P, Weiss ST. A prospective study of anger and coronary keart disease. Circulation 1996; 94: 2090.

Let the in-breath touch these sensations and the out-breath open the sensations further.

10 Mittleman MA, Maclure M, Sherwood JB, Mulry RP, Tofler GH, Jacobs SC, Friedman R, Benson H, Muller JE. Triggering of acute myocardial infarction onset by episodes of anger. Circulation 1995; 92:1720–5.

Allow these sensations to expand until they fill your whole being.

Allow yourself to be cradled by these sensations and feelings connected to kindness. Become aware that you are being filled with loving kindness.

11 Gendlin E. Focussing orientated psychotherapy. New York: Guildford, 1996.

12 Goldstein J & Kornfield J. Seeing the heart of wisdom. Boston, MA: Shambhala, 2001.

Let yourself bask in this energy of loving kindness, breathing it in, breathing it out, as if it were a lifeline, offering the nourishment you long for.

Invite feelings of peacefulness and acceptance to be present in you. continued…

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Sound health resources from the BHMA New and updated materials to help both practitioners and patients cope with stress and enhance their wellbeing.

Each of the six booklets and CDs give a programme to help with different aspects of health, relaxation and stress: titles are Imagery for relaxation, Coping with persistent pain, Introducing meditation, Getting to sleep, Breath of life and Coping with stress.

Final stock half price – all titles £6 each. To order call 01278 722000.

Coming soon to www.bhma.org Self-care downloads for your mp3 player – or burn your own disk

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Natural Natural medicine medicine seminars seminars Learn about the spiritual aspects of medicinal plants for healing.

• Ireland (Galway), 10 October 2009 • London, 22 November 2009 For professionals and nonprofessionals interested in the ancient wisdom, energy medicine and the latest medical issues.

More information at www.spagyricmedicine.com jag.naidu3@ntlworld.com

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FROM THE FRONTLINE… William House GP

Self-care and the expert Most mornings I listen to the Today Programme on BBC Radio 4. Like much of current affairs programming, ‘stories’ are accompanied by comments from people directly involved and by experts, often professionals or academics. Inevitably swine flu has been a frequent feature.

On 20 July the focus was on swine flu risk for pregnant women and the ‘conflicting advice’ being offered by the NHS website and other ‘expert’ sources. A pregnant woman was heard complaining about this and, scattered through the programme, there were interviews with Professor Steve Field, president of the Royal College of GPs, Dr Boon Lin from the Royal College of Obstetricians and Gynaecologists, Jane Draper, BBC health correspondent and Andy Burnham, Secretary of State for Health. The story added up to a substantial chunk of the broadcast.

Finally, the minister said ‘Everyone must make their own judgements ... they don’t want government to tell them how to live their lives’.

This story was about self-care and it tells us much about the pickle we are in as a society. Firstly, it tells us about the media. I guess most people would consider Today to be a relatively serious current affairs programme aimed at an educated middle class audience. What will listeners have taken from these items on swine flu? Perhaps ‘none of them

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know what to do’ or ‘they can’t even agree among themselves.’ Yet the experts all emphasised the same simple advice: getting on with your life as usual, good hand hygiene and covering your mouth with a tissue when you cough or sneeze. But, of course, repeating this endlessly doesn’t make for exciting broadcasting, so a story is contrived which distorts the message.

A deeper problem is the implied message about experts. The very fact of calling in the expert portrays a problem as complicated. It’s easy to imagine listeners to that programme thinking: ‘If these ministers and professors don’t know what to do, how am I supposed to know?’ This is a disempowering response, and if repeated over and over (in and out of the media) it will lead to a disempowered population. Of course, most experts, whether doctors, academics or ministers of the Crown, are happy to allow themselves to be cast as the vessels of knowledge and expertise.

The minister’s words quoted above belie the position generally taken by politicians: politically attractive but simplistic generalisations that often work poorly in the individual case.

But it gets worse! The language of the expert has crept into everyday thinking and speaking. In healthcare particularly, technical medical information is readily available from the internet and we can easily believe

that this medical-speak will enable us to look after ourselves. But this is not real empowerment. I am often asked how I feel when a patient walks into my surgery clutching web downloads or magazine articles. Of course, many of these are tainted by a vested interest – to sell a product or make a good story – but even if they are not, they are often a distraction from an underlying health problem which is being masked by anxiety over disease, the narrow discourse of the expert and a sense of detachment from the deep sources of health and wellbeing.

Mainstream medicine says much about technical fixes and prohibiting unhealthy behaviours, and little about finding wellbeing.

The role of the holistic physician is to become a mirror for the patient, enabling them to understand their predicament at a different level so they are empowered. This doesn’t call so much for technical expertise but rather self-knowledge and ‘empathic projection’ – knowing and feeling some of what the other feels.

It is an imaginative and creative act that entails showing vulnerability.

The most powerful self-care is not done alone, but in partnership. This is a different kind of expertise that enables us to know the meaning for us of what we hear and read. You don’t have to be a professional to do this, but it is better not to listen to too much radio!

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Research Summaries The research page is compiled with the help of Greenfiles (www.greenfilesjournal.com) and James Hawkins.

Excessive wealth is damaging the nation’s health In their new book The spirit level: why more equal societies almost always do better, Richard Wilkinson and Kate Pickett have laid out data showing that the steeper the gradient of socioeconomic inequality across a given society, the worse are most dimensions of social thriving.The government talks a lot about doing something about poverty in general and child poverty in particular, and the health service finds itself repeatedly charged with the responsibility to tackle health inequalities. However, the assumption seems always to be that these worthy objectives can be achieved without any explicit policies concerning the growing disparities in individual wealth.The slogan ‘excessive wealth is damaging the nation’s health’ is conspicuous by its absence. Health equality cannot be achieved without explicit policies to reverse the growing disparities in individual wealth.

In his 1749 poem The Vanity of Human Wishes, Samuel Johnson sounded a warning: ‘Wealth heap’d on wealth, nor Truth nor Safety buys,The dangers gather as the Treasures rise.’ This echoes today in the stories of contemporary corporate greed.

Wealth and poverty are always linked, and the poor are always exposed to the comparison, continually aware of the possibilities and opportunities that are available to the rich but that appear forever inaccessible to themselves.Yet, as Dr Johnson made clear, while excessive wealth is undoubtedly bad for the poor, it is also a problem for the wealthy and certainly for any society that rich and poor are obliged to share.

Heath I. BMJ 2009; 338: b1293

Every picture tells a story Arts visits and activities can improve physical health, social functioning, and vitality. Members of the local government officers’ union in the health services in Sweden, took part in fine arts visits once a week for eight weeks in this study to see if attending cultural events is conducive to improved health when baseline health, income, education, and health habits are taken into account.They chose films, concerts, or art exhibitions visits, or singing in a choir and were then randomised into 51 cases, starting at once, and 50 controls starting after the trial. Health was assessed before randomisation and after the experimental period using the instrument for perceived health, short form (SF)-36, and tests of episodic memory, saliva-cortisol and immunoglobulin. Physical health improved in the intervention group and decreased among controls during the experiment and social functioning improved more in the intervention group than among controls.

Bygren LO et al. Psychosom Med 2009; 71(4): 469–473.

Food for thought Our eating habits have a considerable role to play in our good health and in saving the planet, in more ways than one.

1 Life’s a gas The contribution of humans to global warming is caused mainly by emissions of greenhouse gases such as carbon dioxide, methane, and nitrous oxide, with agriculture as a main contributor for the latter two gases. Other parts of the food system contribute carbon dioxide emissions that emanate from the use of fossil fuels in transport, processing, retailing, storage, and preparation. By the time they reach our table, food items differ substantially in their contribution. A recent study of 20 items sold in Sweden showed a span of 0.4 to 30 kg CO2 equivalents/kg edible product. For protein-rich food, such as legumes, meat, fish, cheese, and eggs, the difference is a factor of 30 with the lowest emissions per kilogram for legumes, poultry, and eggs and the highest for beef, cheese, and pork. For vegetables and fruits, emissions are comparatively low, even if there is a high degree of processing and substantial transportation, air transport being an exception.This study suggesst that changes in the diet toward more plant-based foods, toward meat from animals with little enteric fermentation, and toward foods processed in an energy-efficient manner offer an interesting and little explored area for mitigating climate change.

Carlsson-Kanyama A, Gonzalez A. Am J Clin Nutr 2009; 89(5): 1704S–1709.

2 What’s the beef?

Modern agricultural practices have resulted in polluted soil, air, and water; eroded soil; dependence on imported oil; and loss of biodiversity.The goal of this research was to compare the environmental effect of a vegetarian and non-vegetarian diet in California in terms of agricultural production inputs, including pesticides and fertilisers, water, and energy used to produce commodities.The working assumption was that a greater number and amount of inputs were associated with a greater environmental effect.The literature supported this notion. Study results show that, for the combined differential production of 11 food items for which consumption differs among vegetarians and non-vegetarians, the non-vegetarian diet required 2.9 times more water, 2.5 times more primary energy, 13 times more fertiliser, and 1.4 times more pesticides than did the vegetarian diet.The greatest contribution to the differences came from the consumption of beef in the diet.The research found that a nonvegetarian diet exacts a higher cost on the environment relative to a vegetarian diet. From an environmental perspective, what a person chooses to eat makes a difference.

Marlow HJ et al. Am J Clin Nutr 2009; 89(5): 1699S–1703.

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RESEARCH SUMMARIES

3 Seeing red

Flakey information

Red and processed meat intakes are associated with increases in total mortality, cancer mortality, and cardiovascular disease mortality.This study sought to determine the relations of red, white, and processed meat intakes to risk for total and causespecific mortality.The study population included half a million people aged 50 to 71 years. Meat intake was estimated from a food frequency questionnaire. Main outcome measures included total mortality and deaths due to cancer, cardiovascular disease, injuries and sudden deaths, and all other causes.

Breakfast cereals are seen by many people as the healthy option and manufacturer’s spend a lot of money portraying a health image alongside their products. But Which? has produced a report that lifts the lid on this, showing many cereals to be high in salt, sugar and/or saturated fats. 100 cereals were analysed and findings include:

Sinha R et al. Arch Intern Med 2009; 169(6): 562–571

4 Going against the grain What has the meat you eat been fed on? And does it matter?

The increasing mechanisation of animal production often means an artificial diet for the livestock. Confined cattle, for instance, are fed a grain diet. Research, though limited, indicates that the fat profiles of meat from such a source are changed for the worse from those of grass-fed cattle. The type of trans fatty acid is changing (pro-inflammatory TFAs are increasing at the expense of omega-3 fatty acids).This is replicated in milk production.

Connelly P. J Aust Trad Med Soc 2009; 15(1)

5 Going green A number of studies have evaluated the health of vegetarians.

Others have studied the health effects of foods that are preferred or avoided by vegetarians.The purpose of this review was to look critically at the evidence on the health effects of vegetarian diets and to seek possible explanations where results appear to conflict.There is convincing evidence that vegetarians have lower rates of coronary heart disease, largely explained by low LDL cholesterol, probable lower rates of hypertension and diabetes mellitus, and lower prevalence of obesity. Overall, their cancer rates appear to be moderately lower than others living in the same communities, and life expectancy appears to be greater.There is evidence that risk of colorectal cancer is lower in vegetarians and in those who eat less meat; however, results from British vegetarians presently disagree, and this needs explanation. It is probable that using the label ‘vegetarian’ as a dietary category is too broad and vegetarians need to be divided into more descriptive sub-types.

• 59 contained more sugar per recommended portion size than a jam doughnut

• 10 contained as much salt as a packet of salt and vinegar crisps. Only 15 had low salt levels.

• 27 of the 29 cereals aimed at children were very high in sugar

• labelling information can be misleading – serving sizes given are often much smaller than the amount actually eaten – thus the amount of salt, fat and sugar looks lower to the casual consumer

• some cereals aimed at children show the ingredients as a percentage of adult guideline daily amounts, making them seem better (less bad?) for children than they are

• claims are made to cover the shortcomings of less healthy cereals, for instance by claiming ‘less than 3% fat’ when the cereal has high sugar levels.

Cereals report 2009, www.which.co.uk

Don’t say cheese A happy disposition is often said to lead to a longer life, but a long marriage may not be part of that. This study examined whether the degree to which people smiled in photographs predicts the likelihood of divorce. Researchers posited that smiling behaviour in photographs is potentially indicative of underlying emotional dispositions that have direct and indirect life consequences. In the first study, they examined participants’ positive expressive behaviour in college yearbook photos and in the second study they examined a variety of participants’ photos from childhood through early adulthood. In both studies, divorce was predicted by the degree to which subjects smiled in their photos.

Hertenstein M, Hansel C et al. Motivation and Emotion 2009; 33(2): 99–105.

Fraser GE. Am J Clin Nutr 2009; 89(5): 1607S–1612

Man’s best friend 6 Vegetables under pressure Fruit and veg are the major source of anti-oxidants in our diet and have a number of acknowledged health benefits. However their anti-oxidant activity varies depending on how they are cooked.This paper evaluates six cooking methods for 20 commonly eaten vegetables, describing the losses (and perhaps surprisingly the gains in some instances) in anti-oxidant and radical scavenging activity. Beetroot, green beans and garlic come out top for most cooking methods. Griddling and microwaving are the best methods of cooking for most vegetables. Boiling and pressure-cooking resulted in the greatest loss.

If your dog barks, licks you and stares intently at you, they may not just be asking for food as you thought. This behaviour has been found to indicate hypoglycaemic episodes in dog owners with type 1 diabetes. Some dogs showed signs associated with fear instead, such as trembling, running away and hyperventilating. Although not definitive, results indicate smell is the cause of the behaviour.

Well DL et al. J Alt Comp Med 2008; 14 (10)

Jimenez-Monreal AM et al. J Food Sci 2009; 74 (3): H97-H103

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Reviews I welcome readers’ contributions. If you’re reading something you want to share, please let me know.

You can also contact me if you think there is something – book, DVD, CD, video – that we should be reviewing.

Richard James, Reviews Editor (richard@integrativehealthcare.co.uk)

Music therapy and neurological rehabilitation: performing health David Aldridge (Ed) Jessica Kingsley Publishers, 2005 ISBN 978 1 84310 302 8

£19.95

General readers of the journal, and those who work with people with neurodegenerative disorders or within more general rehabilitation settings, will find much to stimulate and inspire in these chapters.

The inspiration for me was in reading how music therapy helps people, ranging from those in a persistent vegetative state (chapter 6 by Ansgar Herkenrath from the University of Witten-Herdecke, Germany) to those with multiple sclerosis (chapter 7 by Wolfgang Schmid) to begin and sometimes achieve a reawakened identity through performance.

Different forms of interaction are reflected in the description of individualised approaches. Each person requires a tailored programme to aid in the recovery of dialogue in aphasia (Monika Jungblut) and paraplegia. Music, rhythm and gesture reconnect us to being able to move away from isolation and reconnect.

The book, despite the difficulties in outcome research in a multivariable approach to therapy, describes research that shows that music therapy works and that the effect sizes confirm this.

The correlation studies that need to be extended are beginning to determine why this occurs.The chapter titled ‘looking for the why, how and when’ stands out as a masterly summary both of the difficulty in research design and what is achievable by extended case study analysis.The randomized control study of patients with multiple sclerosis described in detail in this book confirms that significant improvement occurred in both HAD depression and anxiety scores, in the Beck depression index, the self esteem and self-acceptance findings.The effect was not maintained longer than nine months but this is a significant finding in a group of people where quality of life and self acceptance are of great benefit.

However the most moving and stimulating chapter, at least for this reviewer, was the review of consciousness as being separate from mere brain mechanics in the chapter on conscious being of people in persistent vegetative state. Here our humanity, and belief in the autonomy of individual human life, creates a truly remarkable insight into the inner life of someone even in a persistent vegetative state and the coming back to relate that is re-established by music therapy. ‘Is a right to life for patients in coma vigile possible because they are treated by those who assume the possibility of an existing

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Volume 6 Issue 2 Aug 2009

consciousness in these patients compared to the ‘medical’ standpoint that they have no consciousness and no cognitive potential’.This inevitably leads to a fascinating discussion of consciousness and when to ‘end life’.

There is one missing ingredient in a book that is essentially talking about rhythm and performance.This is the need to work more consciously with breath evaluation. Is hypocapnia (reduced carbon dioxide levels brought about by over breathing) present or not? Is this finding intermittent or chronic? Is there a correlation with internal hyperarousal that needs to be included in base measures for therapy and research?

Do obtain this interesting book and when you do you will find much to enjoy and then promote relevant applications within rehabilitation settings.

David Beales

Auricular acupuncture and addiction Kim Wagner with Sue Cox Churchilll Livingstone, 2008 ISBN 978 0 443 06885 0

£31.99

This work explores the treatment of addictions to nicotine, alcohol, cocaine, ecstasy, LSD and others, and proposes protocols to incorporate acupuncture into the treatment plan.The authors claim extensive experience helping those with a broad spectrum of addiction.Their treatment strategy aims ultimately to achieve a drug-free life without the props of methadone, naltrexone or buprenorphine.Those drugs are currently the freely prescribed medications of choice offered by those doctors and care workers in the front line assisting addicts.These existing treatments don’t cure the addict of their problems, but simply replace one mind-controlling chemical with another.

The authors suggest that acupuncture offers a valid alternative strategy to replacement drugs, and they provide the physiological basis for justifying their optimism. Some of the evidence base is obtained from acupuncture techniques used in the treatment of addicts within the prison service.These studies seem to suggest that those receiving auricular acupuncture report an improvement in their general energy levels, reduced anxiety, better sleep quality and other positive behavior outcomes.

Any reader expecting instructions on how to use Five Point Technique will not find them here.The book concerns itself with the principles behind treatment and the results which can be obtained by fusing orthodox medical approaches with Western or traditional acupuncture. We’re guided through the essentials to understand where acupuncture treatment fits in to the

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REVIEWS

conventional view of addiction.The material is clearly written by experienced practitioners who cover the basics well.The initial chapters discuss neurological function, neurotransmitters, and what we understand pain and emotion to represent in scientific terms.

There is a particularly well-written description of what happens to the body physically when signs of addictive behavior are recognized outwardly.The full spectrum of substances which can become addictive is described in detail from alcohol and nicotine to LSD, amphetamines and ecstasy.

Wagner and Cox handle the potentially complex matter of describing what Qi (the Chinese term used to describe universal life-force or energy) is, by being pragmatic.They suggest that the research on the human brain is already vast and mind bogglingly complex, so we don’t need energy concepts complicating it further.The book is careful not to get sidetracked by Eastern semantics nor disappear down the pathway of sub-molecular particle theory, though they do examine electrical properties of meridians and Qi and electromagnetism and bioelectronics.They do so with a strictly conservative position, failing to be convinced as to the existence of meridians, and accepting that acupuncture is merely a means of stimulating the nervous system to bring about physiological change.

The subject matter may act as a stimulus to those unfamiliar with acupuncture theory or encourage practising acupuncturists to delve deeper into auricular methods.

Towards the end of the book several practitioners discuss the ways in which they incorporate auricular treatment under the heading of Diversity of Practice and I found this section particularly helpful and inspiring given that it provided a personal if anecdotal description of their therapy in action.

I think this book makes a major contribution on how complementary and alternative medicine can be incorporated in the management and treatment of addiction in the United Kingdom. What I’m not clear about having read this text is why there has been so little research into what would seem a highly plausible and relatively inexpensive therapy? There is a lurking suspicion in reading this material that is based on Derrida’s observation…

If things were that simple…. word would have gotten around.

Why haven’t more addicts received this type of treatment bearing in mind the relative failure and expense of the existing programs? With the social consequences of addiction being so vast, you would imagine that many more studies of this innovative method would have been funded.

Donald Scott

Homeopathic pharmacy theory and practice (2nd edition) Steven B Kayne Elsevier Churchill Livingstone, 2006 ISBN: 0 443 10160 4

£36.99

My first impression of this book is that it has the look and feel of a textbook and this, combined with the word pharmacy in the title, evokes long distant memories of baffling chemistry lessons. Homeopathy is often described as both a science and an art and I freely admit that I generally feel more affinity with the art than the science! All the more reason, then, to get my teeth into this interesting book.

Visually, the style and layout of the book serve it well. Each chapter is broken down with nice clear subheadings and throughout the book there is very good use of graphs, tables, diagrams and photos, which support and enhance the text well.

In a way, the title is a little misleading.The book does cover all aspects of homeopathic pharmacy thoroughly, but it is also much more than a pharmaceutical handbook. As well as being a good resource for health professionals and other CAM practitioners, this book would bridge the gap very well for anyone who who wanted to deepen their understanding of the subject. I can’t think of an aspect of Homeopathy that it doesn’t, at least, touch on.The first chapter is an introduction to CAM which helps to contextualise Homeopathy.This is followed by chapters on its history and global development.Then follows the pharmacology. I hope I am not insulting other practitioners when I say that knowledge of remedy preparation and the mathematical intricacies behind dilutions and potencies is often only studied and understood at a level just sufficient to enable us to practice.This is just the book to address any such knowledge gaps. Everything is covered from source material, extraction method and potency scales, right through to quality control and the legal status of remedies.There is also an interesting passage on the vexed (to the scientific community) question of succussion and dilution and the hypotheses pertaining to it.

In part 3, both theoretical and practical matters are addressed in the section on theory of disease and treatment.

Within this chapter Kayne offers explanations of miasmatic theory and constitutional types. While it summarises the theory of miasms fairly well I must confess to irritation at seeing the simplistic constitutional profiles rolled out here. A person can have characteristics and themes of a remedy running through their core and yet be quite untypical of the remedy ‘picture’ as presented here. If only it were possible to prescribe Nat Mur on the basis that the patient was pear shaped and constipated!

However, the chapters on choosing the remedy and first aid and acute applications are clear, informative and fairly thorough.

With evidence based medicine being so crucial for acceptance of CAMs by the medical establishment and health care funders, it is good to see Kayne’s chapter on Homeopathic research, including a section on veterinary research. It is comprehensive and does a good job of explaining the difficulties and complexities which make obtaining consistent results in conventional trials so difficult and makes a convincing argument for finding alternatives to existing clinical trial models.

Julia Mathias, homeopath

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Volume 6 Issue 2 Aug 2009