David McGavin, GP, Kairos Pain Management Clinic, Heronsgate Medical Centre, London

Published in JHH 19.1 – Integrative Medicine

Generally speaking, longstanding pain is poorly controlled with medication. The bio-psycho-social model of pain management therefore moves the focus away from medical interventions, encouraging the person to join in and share responsibility for outcomes which affect their lives. The National Institute for Health and Care Excellence’s (NICE) recent classification, Chronic Primary Pain (NICE, 2021) creates a category which acknowledges that the causes are not understood. Its guidelines discourage prescribed analgesics and lean toward more holistic treatments. With this new classification, another name is added to the growing list of conditions which now defy explanation by natural science, and which commonly appear in pain management clinics. They include irritable bowel syndrome (gastroenterology), atypical chest pain (cardiology), functional neurological disorder (neurology), fibromyalgia syndrome (rheumatology), dissociative state (psychiatry) and now long-Covid.

Since 2000, two NHS community pain management clinics, Blackthorn Trust in Maidstone and Kairos Rehabilitation Trust in Greenwich, have been developing an award-winning (HRH Prince of Wales Award for Integrated Health 2001; BMJ 2017 finalist, Innovation Team of the Year) rehabilitation method which tries to comprehend and address the multiple problems presented by these medically unexplained conditions, especially pain. The Greenwich project has published preliminary evidence (Wright, 2017) of effectiveness. In order to provide new rehabilitation opportunities, both clinics have sought out and tested concepts proposed by anthroposophic medicine (Kienle et al, 2013) which, although very foreign to those taught in English medical schools, are more commonly practiced abroad, especially on continental Europe. In complex pain where body, soul and spirit become entangled, entrenched and depleted, practical knowledge of their healthy interactions can offer some indications as to how to set about improving the situation (the spirit is understood to be ‘the non-physical part of a person regarded as their true self and capable of surviving physical death or separation’ (Oxford English Dictionary).

The Kairos Programme

Patients with chronic pain are referred by their GP to a central musculoskeletal (MSK) hub, Circle MSK, who triage them to Kairos, usually after conventional treatments have failed or been ruled out. A full clinical assessment precedes referral to the first of three therapies, rhythmical massage, eurythmy or therapeutic arts counselling. The duration of sessions is one hour weekly for blocks of 6 to 8 weeks, with a total of 12 months, all funded by the NHS. Frequent reviews between the patient, therapist and doctor assess progress and tailor the programme to the patient’s condition, intentions and needs. One-to-one therapy is usually prescribed initially; group work and social activities follow and are equally important. Adequate time for consultation and therapy, ease of access and continuity of care invite the patient’s enthusiastic participation.

Developing practical concepts of body, soul and spirit

Rudolf Steiner (1993), the founder of anthroposophic medicine, mapped out fields and happenings in the three adjoining worlds to which the human being belongs: the physical, soul and spiritual. Although you don’t need a map to get a great deal out of walking in the countryside, still it is satisfying to see a map at the end of the day to track where you have been. However, you might think twice about going into unfamiliar, perhaps dangerous looking territory without one. The question, of course, is, can one trust the map maker? Are Rudolf Steiner’s suggestions and indications to be trusted? The answer is only yes, if they stand up to testing and show results in difficult therapeutic territory. This has been our experience.

We have found these concepts of body, soul and spirit helpful in throwing fresh light on the causes, effects and meaning of matters which repeatedly loom in patients’ stories. For example, what happens in sleep, dreaming and insomnia? Is sleep not just a normal dissociative state where one loses consciousness through tiredness at the end of the day? And so, in dreaming, could one propose a partial dissociation from one’s body while still connecting with one’s senses? And in sleepwalking could one be asleep but still in connection with one’s limbs? If analgesics relieve pain by lifting out of the body (to the point of unconsciousness when one takes too many), could pain perhaps be an opposite kind of condition where spirit and soul are too strongly and forcefully present in the nervous system? With such picture thinking, we can try to get a closer understanding of patients’ stories, while still keeping our feet firmly ‘on the ground’. I recall a patient who still sings the praises of eurythmy therapy exercises, which ‘keep me in the room’. As a child, she learned how to partially absent herself from her body whenever she was about to be abused. Ongoing trauma meant that dissociation was a frequent occurrence. Psychologically driven behaviour can be backed up and given weight when there is a ‘physiological’ understanding of how body, soul and spirit interact.

Anthroposophic therapy

In the treatment of severely traumatised children, the neurosequential model of therapeutics (Perry & Dobson, 2013) encourages psychotherapists to adopt an approach which ‘regulates, relates, and then reasons’. Anthroposophic therapies can take this sequence to organic levels and work from ‘bottom up’.

It makes sense that as pain seems to come from the body, there is a need to calm down and regulate its mechanisms first. Besides, when patients first arrive, they are seldom in a condition to think and make decisions, but rather relieved to hand over responsibility for a while and just be looked after and done to. Rhythmical massage or an outer application, eg a ginger compress to the affected area, are usually welcome and appropriate introductions to the programme. These therapies start the gentle regulating and warming up process in all of its senses. Eurythmy (movement) therapy achieves a similar effect but through the person now becoming active and joining in. The conscious self is brought into a mindful relationship with the body through particular movements which aim to regulate organic circadian rhythms. These, in turn, stimulate and harmonise catabolic and anabolic processes which gradually re-boot the body by attracting the enlivening and healing activities of the nocturnal metabolism. Therapeutic art counselling may then follow. This is not really a talking or an intellectual reasoning therapy. It works with a method of painting which brings the patient’s individuality to light through guided creative expression, and thereby a chance to become reacquainted with oneself, one’s aims and aspirations. Anthroposophic, herbal and homeopathic medicines which formerly we found useful when a bridging is needed to reduce unnecessary medication, are unfortunately no longer permitted in the programme.

The emphasis of treatment is first to recondition the body, so that the individual can feel themselves a bit revived, with some hope be restored. Change is usually noticed by the therapist first; for the patient it comes as a surprise, eg better sleep, new motivation or perhaps better generation of warmth. Changes in warmth are considered to be crucial. Warmth is understood to be the vehicle within which the ‘I’ or individuality moves through body and soul, co-ordinating conscious activity and also holding the balance in countless bodily activities.

The sequence of therapies is flexible and sensitive to the individual’s disposition and need. They can also be graded according to the challenge appropriate to patient’s condition. Practice at home is encouraged and when confidence and strength are more evident, challenge can be introduced to strengthen the will both toward therapy and other worldly demands which are now calling for action. By agreeing to a progressive proposal for change, the tricky problem of dependence on therapy can be averted. While very reasonable in the early stages, providing comfort and relaxation is not the eventual purpose of a rehabilitation programme.

Listening, attitude and strength of the team

It is not so easy to listen open-mindedly to patients with too much on their mind and on their plate. Medical training taught me to listen out for what I recognise, usually in typical symptom and sign combinations which attract certain investigations and treatments. After a few years I realised that these tick-boxes did not fully serve the patient. I was having to fib and bend the rules to get by, but not always in the patient’s best interests. Frank (1998) has written an instructive and inspiring aid to listening without prejudice to stories of the very ill especially when one feels one has little to offer them. In his Just listening: Narrative and Deep Illness he helps cultivate interest in and wonder toward the other person, in a way that honours them and their achievements.

Be prepared to learn more about yourself than about pain. These patients used to make me feel inadequate because I didn’t have any answers for them. Yet still they kept coming because they found a trusted friend in me. Easy then to find oneself operating at two levels, smiling on the outside but inside just longing for them to move somewhere else. Patients are not really responsible for putting one in a bad mood and getting rattled with them only makes things worse! I can recommend Rudolf Steiner’s seven exercises for overcoming nervousness’ (Steiner, 2008). I did two of them consistently when my enthusiasm for general practice was at its lowest ebb. Within three months, I found patience strangely arising and got a first experience of the late Cicely Saunders’ (founder of the UK’s hospice movement) revelation that ‘time has a depth as well as a length’.

Good teamwork is a key to success. Staff need to be well looked after if a ‘can do!’ attitude is to energise the project. There are many obstacles to success but with a team that meets regularly and some patient who are ‘coming on board’, it’s seldom someone doesn’t have a good idea to break any deadlock.

The social care element

People with long-term disability issues often have to tackle a host of bureaucratic hurdles. The friends and contacts we have cultivated in other fields help us address the many official tasks that the programme itself cannot handle but which, unless properly dealt with, can delay rehabilitation. For instance filling out forms for state welfare benefits, or providing strong written medical evidence for any occupational fitness (UK’s Department of Work and Pensions) assessments. Some patients are obliged to attend, others can face legal issues. In a mandatory reconsiderations of fitness assessment and court appeals the right legal support will make all the difference. Government-targeted welfare payments – an Employment and Support Allowance (ESA) claim, or a Personal Independence Payment ( PIP ) to help with extra living costs – may have to be fought for. A successful claim, or sometimes a convincing letter to an employer, a housing department or a local Member of Parliament will have life-changing benefits.

Conclusion

Anthroposophic therapies can demonstrate their worth in the rehabilitation of patients with complex long-term conditions. However, the concepts involved present a considerable challenge to those of us brought up in and secure in the conventional medical world and its ways. A clinician content with their own approach to practice would probably not want to invite the necessary upheaval of thinking which concepts such as these demand! Nonetheless, a health professional intrigued by these ideas, should they want to get a taste of the approach I have written about, is invited to contact the author with a view to visiting, so they can meet the team and hear from patients.

References

Frank A (1998) Just listening: Narrative and deep illness. Families, Systems & Health, 16(3).

Kienle G, Albonico H, Baars E, Hamre H, Zimmermann P & Kiene H (2013) Anthroposophic medicine: An integrative medical system originating in Europe. Global Adv Health Med, 2(6) 20–31.

Mao J (2017) Challenges of managing chronic pain. BMJ Editorial, 356:741.

NICE (2021) Guideline 193: Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain. NICE.

Perry B & Dobson C (2013) The neurosequential model of therapeutics. In: J Ford & C Courtois (eds) Treating Complex Stress Disorders in Children and Adolescents. Guildford Press.

Steiner R (2008) How to cure nervousness. Rudolf Steiner Press.

Steiner R (1993) Knowledge of the higher worlds. How it is achieved? Rudolf Steiner Press.

Wright E, Zarnegar R, Hermansen I & McGavin D (2017) A clinical evaluation of a community-based rehabilitation and social intervention programme for patients with chronic pain with associated multimorbidity. J Pain Manage, 10(2) 149–159.