CREATING THERAPEUTIC ENCOUNTER
Some Comments & References on Human Healing
Here are some ideas, sources and links about healing capacity & reactions, therapeutic encounter and relationships. This is less of a ‘how to do it’, more of an encouragement, a celebration and an exploration of what we are doing and what is possible in caring work. It reminds us that while we have ‘tools in our tool box’ (such as our drugs, needles, herbs, rules, models etc), we bring much more to our care than this. In turn, I hope to stimulate your own ideas and your work. What can we do to enable people’s innate capacity for healing? Let’s study human healing – the common ground shared by all carers.
For more info you may wish to follow the links to the student BMJ series given at the end.
As John Ruskin said ‘When love and skill work together, expect a masterpiece’. In addition to technician skills, I find it helpful to directly explore a germinative model – founded on innate capacity, the seed. If we study healing reactions and the conditions which affect them, we can get better at catalyzing them. The maps above hint at some of the key components like – bringing your full presence, making a connection, exploring creatively together – ‘dancing’ – and allowing germination. Try “reverse engineering” your individual successes and failures with patients as a main means of understanding. We know from our personal lives how in human relationship even single encounters can be powerful, even transformative (or destructive) and can impact across the belief-mind-body spectrum. Whatever the problem, or the apparent intensity and method of engagement, the human and cultural aspects will have effect. Encounters are about more than technique. We don’t ‘deliver’ care, we care.
Sources of these ideas and further information:
Of course life and healing are not to be summed up in articles, books, single teachers or philosophies - but inspiration is potentially everywhere - especially in examples of what we want to avoid. As I am not advocating a technique or system there is no single area of reading I can recommend but I will list some books and references I have found useful. May be ordinary life is the best teacher in the struggle to get better as carers, and to reclaim our kindness and compassion in the face of stresses and losses. I find value in many disparate areas, especially when I do not view them as distinct. E.g.:
· When you can, see every consultation/encounter as an adventure and every patient as a teacher. When you cannot - just try and do no harm.
· Study inspiring examples of transformation, and make community with those sharing your aspirations, and offering positive support and kindly encouragement.
· It helps to get sick, unhappy - and not cope! - and then work your own recovery, or walk it as best you can. Learn to ask for help, and culture self care - see http://careerfocus.bmjjournals.com/content/vol326/issue7391/index.shtml for ideas.
· The literature on placebo is full of indirect pointers to what impacts on healing.
· Hypnosis and related approaches (such as NLP) were a rich source of discovery for me about how we impact on one another and ourselves, and our inner language.
· The field of psychoneuroimmunology offers challenge about mind-body medicine.
· The richness (and foolishness) of counselling and humanistic and psychological approaches are good to explore, and stuff on happiness and ‘positive psychology’.
· Biological / evolutionary perspectives, like ethology help keep our feet on the ground.
· New sciences like affective neuroscience give insight about brain and mind
· Spiritual disciplines and traditions have wisdom in their essence.
· Traditional and indigenous healing systems including Shamanism have spent a long time learning about these things - translating it to our world is the challenge.
· Complementary healing approaches bring insights and folly. Homoeopathy enriched my understanding of illness and recovery patterns and richer consulting.
· Anything that wakes up your creative process, is good. Go on, learn to draw or sing or play that instrument. The paradoxical mixture of art and science, discipline and freedom will translate to your healing work, if you see your work as creative. (I call this ‘artience’, now let that be suffused with your compassion - ‘hearatience’).
· Meditation is critical, that is anything that helps culture peaceful presence, mindfulness, greater awareness, energised absorption, compassion, creativity and emotional balance
· Humour about it all is a pre-requisite for sanity.
During the workshop I might refer to some of the following references. (My own publications are at the end and a few slides are on
http://www.show.scot.nhs.uk/sehd/ahp/presentations/0604_david_reilly_files/frame.htm
The Fifth Wave. Compiled by Andrew Lyon.Scottish Council Foundation 2003. 1 901 835 383 http://www.scottishcouncilfoundation.org/pubs_more.php?p=43 “This report outlines three major shifts in thinking and themes of history since the 18th century Enlightenment and associates four major trends in public health interventions with these, before suggesting that we stand at the point in history where an era shift, of the type which comes along every few hundred years, is occurring. How can we discern the next wave of public health improvement in this theme of history? If we are standing truly on the brink of a new era, what public health action is needed? In examining this shift from organisational/ bureaucratic to individual/creative paradigms, the report looks at some ideas developed in Glasgow by David Reilly.” Also Learning Journeys document gives more details on the dialogue about healing.
ILLNESS & LIFE-MIND-BODY-BELIEF-SPIRIT LINKS
1. Psychological Stress and the Human Immune System: A Meta-Analytic Study of 30 Years of Inquiry,” Suzanne C. Segerstrom, Ph.D., University of Kentucky, and Gregory E. Miller, Ph.D., University of British Columbia; Psychological Bulletin, 2004, Vol. 130, No. 4. http://www.apa.org/journals/bul/press_releases/july_2004/bul1304601.html
3 main findings:
1).293 independent studies, peer-reviewed scientific journals 1960 – 2001, 18,941 individuals - powerfully confirm the core fact that stress alters immunity.
2) Short-term stress actually “revs up” the immune system, an adaptive response preparing for injury or infection, but long-term or chronic stress causes impairs immunity.
3) the immune systems of people who are older or already sick are more prone to stress-related change
2. Murray Parkes C, Benjamin B, Fitzgerald RG. Broken Heart: a statistical study of increased mortality among widowers. Br Med J 1969;646(i):740-3. In the first 6 months deaths 40% above the expected rate, especially heart diseases. 22.5% of deaths from the same diagnostic group as the wife's death.
3. Ramirez A, Craig J, Watson JP, Fentimen IS. Stress & relapse in breast cancer. Br Med J 1989; 298:291-3. Those with severe life events had a risk of relapse 5.67 greater than those facing no difficulties.
4. Sims A. Marital breakdown and health BMJ 1992;304:457-8. Divorce doubled mortality in men of 35-45.
5. Hopelessness and a 4-year Progression of Carotid Atherosclerosis:The Kuopio Ischemic Heart Disease Risk Factor Study. Everson SA, Kaplan GA, Goldberg DE, Salonen R, Jukka T. Arteioscler Thromb Biol 1997;17(8):1490-1495. 942 middle aged Finnish men underwent carotid ultrasonography at baseline and 4 years later. Progression was greatest in men reporting high levels of hopelessness at baseline and follow up.
6. Depression and the Course of Coronary Artery Disease.Glassman AH, Shapiro A.Am J Psychiatry 1998;155(1):4-11.Overview of related studies published from 1993 support the view that there is an increased risk of ischemic heart disease among depressed persons. Seems to apply to disease risk and progression and outcome. For example after one study patients were 3.5 more likely to die after myocardial infarction if depressed. May be through changes in autonomic nervous system and platelets which are seen in depression.
7. Petrie KJ, Booth RJ, Pennebaker JW. The immunological effects of thought suppression J Pers Soc Psychol 1998 Nov;75(5):1264-72 . A significant increase in circulating total lymphocytes and CD4 (helper) T lymphocyte levels in the “emotional writing groups” while thought suppression resulted in a significant decrease in CD3 T lymphocyte levels.
8. Spiegel D, Moore R. Imagery and Hypnosis in the Treatment of Cancer. Oncology 1997;II(no.8):1179-1191. A year of weekly ‘supportive/expressive’ groups significantly increased survival duration in women with cancer.
9. Schliefer SJ,Keller SE, Camerino M,Thornton JC, Stein M. Suppression of lymphocyte stimulation following bereavement. JAMA 1983;250:374-377. Bereavement associated severe immune dysfunction
10. Solom GF. The emerging field of psychoneuroimmunology. Advances 1985;2:6-19. An introduction.
11. Reilly D, Harrison T. Creative consulting: psychoneuroimmunology, the mindbody Student BMJ 2002;97-99. A brief review of PNI
12. Goebel MG, Trebst AE, Steiner J, Xie YF, Exton MS, et al Behavioral conditioning of immunosuppression is possible in humans The FASEB Journal. 2002;16:1869-1873. http://www.fasebj.org/cgi/content/full/16/14/1869 Replicated double blind in humans the classic 1975 rat experiment (Ader R and Cohen N Behaviourlly conditioned immunosuppression. Psychosom. Med;1975; 37:333-340) with flavoured drink +cyclophosphamide conditioning subsequent immunosuppression just from the drink+placebo.
HEALING & LIFE-MIND-BODY-BELIEF-SPIRIT LINKS:
CONTEXT & CULTURE, EXPECTATIONS & INTENTIONS
13. Understanding the placebo effect in complementary medicine. Ed by David Peters. Churchill Livingstone. London 2001.ISBN0-443-060-31-2. Good theory, research and some practice – wider than CAM.. includes Helman. H . Placebo And Nocebos:The Cultural Construction of Belief.
14. Di Blasi, Z., Harkness, E., Ernst, E., Georgiou, A., & Kleijnen, J. Influence of context effects on health outcomes: a systematic review. The Lancet 2001;357:757-62.
15. Roberts AH, Kewman DG, Mercier L, Hovell M. The power of nonspecific effects in healing: implications for psychosocial and biological treatments. Clin Psychol Rev. 1993; 13:375-391. Review of efficacious treatments later abandoned as placebo.
16. Turner JA, Deyo RA, Loeser JD, Von Korff M, Fordyce WE. The importance of placebo effects in pain treatment and research. JAMA, May 25, 1994;271(20):1609-1614. Reviews of books and 75 articles on placebo.
17. Branthwaite-A, & Cooper-P. Analgesic effects of branding in treatment of headaches. Br-Med-J-Clin-Res-Ed.1981;282((6276)):1576-8. Fashion and cultural expectation.
18. Holm, S., & Evans, M. Product names, proper claims ? More ethical issues in the marketing of drugs. British Medical Journal 1996; 313:1627-9.
19. Blackwell B, Bloomfield SS, Buncher CR. Demonstration to medical students of placebo responses and non-drug factors. Lancet 1972;13:1-11. ‘Dose-response effects’ for placebo: two placebo capsules more pronounced effects than one; injections may produce larger effects than pills; impact of colour.
20. Buckalew LW, Coffield KE. An investigation of drug expectancy as a function of capsule colour and size and preparation form. J Clin Psychopharmacol 1982;2:245-8.
- de Craen, A. J. M., Roos, P. J., de Vries, A. L., & Kleijnen, J. (1996). Effect of colour of drugs: systematic review of perceived effect of drugs and of their effectiveness. BMJ, 313, 1624-1626.
- Gracely RH, Dubner R, Deeter WR, Wolksee PJ. Clinicians' expectations influence placebo analgesia Lancet 1985;i:43. Startling example of endowing non-specific effects with success or failure varied by the transmitted clinicians expectation of outcome.
- Individual Patients and their Responses. The Overall Progress Interactive Chart (OPIC). Reilly DT, Taylor M. Published on pages 26-28 in: Developing Integrated Medicine. Report of the RCCM Fellowship in Complementary Medicine. The University of Glasgow 1987-90. Complementary Therapies in Medicine 1993;1 Suppl1:1-50. Graphically demonstrates in asthma opposite effects in the same patient from 2 placebos given by the same care team. Appears to highlight the powerful impact of adjusted expectation of experimenters on outcome. The rest of this report might also interest you.
THE PHYSICAL ENVIRONMENT – see http://www.ghh.info/welcome.htm
THE ENCOUNTER
- ATTENTION, CONNECTION & GERMINATION
Presence & The Dance
24. Empathy is important for enablement Mercer, S. W, Watt, G. C M, Reilly, D. BMJ 2001; 322:865 http://bmj.com/cgi/content/full/322/7290/865. First report from a pilot study of outpatients attending the Glasgow Homoeopathic Hospital. Using Howie's Patient Enablement Scale demonstrated significant positive impact in a sample of 200 consultations before any medicines had been used. There was no instance of high enablement in the absence of empathy. A full in-house report with qualitative research available from www.adhom.org.
- The importance of empathy in the enablement of patients attending the Glasgow Homoeopathic Hospital.. Mercer SW, Reilly D, Watt GC. Br J Gen Pract 2002 Nov;52(484):901-5. Follows on from previous ref with a fuller report.
26. A Pilot Prospective Study on the Consultation and Relational Empathy, Patient Enablement, and Health Changes over 12 Months in Patients Going to the Glasgow Homoeopathic Hospital. Bikker AP, Mercer SW, Reilly D. J Altern Complement Med. 2005 Aug;11(4):591-600. Empathy is crucial for enablement, which, in turn, is strongly related to perceived change in main complaint and well-being. The length of the first consultation was related to initial and subsequent CARE scores, overall enablement, and GHHOS scores at 3 and 12 months.
27. Consultations at GHH. A pilot qualitative study and commentary on some therapeutic consultations. Zelda diBlasi and Jos Kliejnen. Available from www.adhom.org . My consultations studied in a preliminary way.
28. “Let me see if I have this right.." : Words that build empathy. Annals of Internal Medicine 2001;135(3):221-227 www.annals.org Coulehan JL, Platt FW, Egener B, Frankel R, Lin C-T, Lown B, Salazar WH. Nice summary and practical guidance.
29. Mercer, S. W. and D. Reilly (2004). "A qualitative study of patient's views on the consultation at the Glasgow Homoeopathic Hospital, an NHS integrative complementary and orthodox medical care unit." Patient Educ Couns 53(1): 13-8. Patients explained how they valued 'time', the 'whole-person' approach, 'being treated as an individual', that their story was being listened to (often for the first time), and that their symptoms were taken seriously. They felt that the doctors were compassionate and positive, often engendering hope. Equality of relationship was found to be a major theme, with a strong sense of mutual respect.
Patient Participation
30. Monty Roberts. Join-up. Horse sense for people. HarperCollins, London 2000.ISBN 0 00 257107 2. Useful parallels in the issues of establishing trust and safety with people learned from working with animals.
31. Greenfield S, Kaplan SH, Ware JE Jr, Yano EM, Frank HJ. Patients' participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med. 1988 Sep-Oct; 3(5):448-57. A 20-minute session to prepare patients to negotiate medical decisions with the doctor resulted in lower blood glucose than controls… and experimental patients were twice as effective as controls in eliciting information from the physician and reported fewer functional limitations.