Going beyond the biopsychosocial – The complex person in a complex environment and uncertain world
Betsan Corkhill, Wellbeing coach
Published in JHH 17.3 Beyond COVID
I specialise in working with people with long-term conditions, particularly ongoing pain. I have a clinical background in physiotherapy spending many years helping those with long-term medical issues. I left physiotherapy in 2002 having become frustrated at the ‘system’ I found myself in. I was working in the community and was expected to treat people with multiple co-morbidities of all ages in a few visits. Many had the capacity to improve significantly given time and ongoing guidance. I felt they should be offered the opportunity. I am a passionate advocate for a whole-person approach to health, from managing day-to-day stress and life’s inevitable challenges through to managing ill-health. My many years as a physiotherapist have enabled me to combine my clinical knowledge
with coaching to help individuals navigate our fragmented health and social care services, as well as to improve their health and wellbeing. I run my own Wellbeing for People with Pain programme with funding so that those attending can come for free.
All organisms are complex systems. All environments are complex systems too. These insights can and should be more widely applied in healthcare; in particular when a health problem is intractable, unfixable and long term. The human body consists of complex systems of cells and organs, where trillions of microflora interact in unknown ways, and the person is embedded in unstable environments in an uncertain world. We can’t untangle this whole. Our health, wellbeing, what we feel and experience all emerge from this interplay of interwoven, intertwining systems, which we experience through our lived body.
Complex systems are driven by the quality of the interactions between the parts, not the quality of the parts. Working on discrete parts or processes can proper bugger up the performance at a systems level. Never fiddle with a part unless it also improves the system.
(@ComplexWales, online)
When you affect one part of a complex system you affect the whole in unpredictable ways. Knowing this about complex non-linear systems, how might medicine and healthcare move away from reductionist, linear approaches and learn to embrace complexity?
Health, wellbeing, or ill health don’t happen in isolation. A person’s past, present, predicted future, expectations and beliefs will influence how they respond to adversity or interact with their world. Life itself depends on the organism’s capacity to maintain its integrity. However, for reasons – biological (eg nutrition), psychological (eg adverse childhood experience, traumatic events) or social (low status, poverty, pooreducation) the body and mind may lose their ability to differentiate between what’s actually dangerous and what’s not, and so they respond inappropriately.
How might medicine and health-care move away from reductionist, linear approaches and learn to embrace complexity?
Even though this biopsychosocial picture is widely understood, very often psychological or social problems come to be ‘medicalised’. Opioids and anti-depressants,
for example, are more frequently prescribed to those living in poverty, often with health-negative lifestyles. Medicating their ill-effects does nothing to address the root problems which, though they obviously require intervention at the appropriate level, few doctors are able to provide. Complex, dynamic, organic systems are hard to get your head around; it’s much easier to simplify and compartmentalise even though we lose sight of the person we are supposed to be helping. This is bad for doctors as well as patients. Surely then the time has come for the medical toolkit to expand.
Linear pathways of care have measurable outcomes, clear boundaries with procedures and pathways to follow. But people and their lives are not like this. And the longer someone lives with long-term health problems the messier and more complex it gets. As a result, someone living with long-term health problems will often have multiple labels, each one with its individual care pathway, in ‘delivery systems’ unable to consider the whole or communicate between specialties. In large-scale industrialised medicine this all too easily happens. In fact, given how the NHS is structured and organised, this fragmentation is all the more likely. Faced with the overwhelming enormity of the problems society now must face, it is helpful to keep reminding ourselves that:
- complexity gives hope because it offers many avenues for change
- small changes to one part of a complex system can trigger a big overall effect
- simple changes can have a big impact.
Understanding recovery
Alleviation of symptoms and improved function are welcome of course, but long-term conditions present greater challenges still. Former public health director
Margaret Hannah has observed that ‘Recovery is not simply about function and the activities of daily living, but about personhood, identity, self-worth. So often in current healthcare the focus and attention is on functional improvement’ (Hannah, 2014). If, as this implies, longterm illness can be an opportunity to discover (perhaps for the first time in a person’s life) a sense of agency and a more fulfilled, meaningful, life, how then are practitioners to support such a recovery of identity and self-worth?
It will be important to create the right context for recovery to happen. The clinician/patient relationship is key. This relationship can be a powerful enabler of change if there develops mutual trust, respect, belief and kindness: where two complex beings engage, connect and interact, together making sense and finding meaning that would not be possible acting alone.
Recognising and respecting the struggling humanity of the person seeking our help is vital; to see them as people who have complex problems, not as difficult patients, not as a list of symptoms or labels. This involves looking after our own wellbeing because when we are stressed it’s communicated in our approach, body language, the way we speak, little things that people pick up on. It’s important to be fully present, aware and receptive. It makes the difference between reaching a shared understanding of issues and simply being seen as a source of medication. In a YouTube interview, Kieran Sweeney, a GP academic who died from mesothelioma in 2009, describes how medicine involves ‘being with people at the edge of their human predicament’. He talks about how any inadvertent small humiliations can add up – being instructed to ‘take your top off, get on the bed’ with no introduction, smile or humanity – to traumatise and humiliate a person when they are already at a low point. He also reminds us that ‘what’s routine for you will be a big life issue for your patient.
Patients long for doctors who comprehend what they go through and who, as a result, stay the course with them through their illness. A medicine practiced without a genuine and obligating awareness of what patients go through may fulfil its technical goals, but it is an empty medicine, or, at best, half medicine.
(Charon, 2006)
Security/safety
Fear and feeling unsafe makes it more difficult to recover or heal.
For our physiology to calm down, to heal and grow we need a visceral feeling of safety.
Van der Kolk, 2014
The foundation of feeling safe comes from having life’s basics – housing, a living income, good nutrition. Our current benefits and social care systems deter recovery and make people sick by creating an uncertain, unsafe environment that the most vulnerable people in our society are dependent on. The combination of austerity/ poverty, inequality and cuts to services is making people sicker. And not just this generation – an impoverished childhood can impact future generations through epigenetic inheritance. National policy must recognise the complexity of health and wellbeing.
Poverty has a psychology and identity all of its own.
Hudson, 2019
However, as clinicians we can create a clinical environment that communicates safety. Simply approaching people with a smile in an open, friendly way promotes feelings of safety. Using plain English when we speak with or correspond with patients shows we respect and care about the human being seeking our help.
Seeing a familiar GP, psychotherapist or psychologist who knows your story can build stable relationships of trust and respect. Otherwise encountering a stranger creates fear and uncertainty; having yet again to retell traumatic story reinforces it.
The combination of austerity/ poverty, inequality and cuts to services is making people sicker
Learning that change is possible is empowering. Learning about stress and ways of managing it is important. Understanding the short- and long-term effects
of stress can help people to make sense of some symptoms and how it interferes with digestion and sleep.
Calming the survival reflexes of the lower brain calls for communication at the deepest level. In a crisis, trying to soothe it top down through language won’t work; meditation is difficult when you’re overwhelmed. But the embodied experience of feeling safe can work. I’ve spent some time researching the therapeutic benefits of knitting. Stories tell how people unable to meditate or practice mindfulness (top down) because they are too stressed, busy or distressed, are still able to knit (bottom up and top down) and may even achieve a meditative-like state. Rhythmic movement seems to be important here. Rhythmic bodily movement calms the mind. The brain likes rhythm because it is predictable. It makes the brain feel safe.
Movement is closely tied to our sense of safety. Immobilisation increases our primitive sense of fear because, in evolutionary terms, a sedentary being is more
likely to be attacked. At the same time, movement can feel unsafe because of a belief that it is harmful. Knowledge is key here. It can teach that pain isn’t a reliable measure of what’s going, that it’s not only safe to move but that movement nourishes the body, lubricating joints and strengthening muscles. Through experience, the person as a whole learns that it’s OK. It’s safe to go against what their biology is telling them.
We can make movement safer or more challenging by changing the context within which people move. Someone who can walk in the safe environment of a physio department may not be able to walk outside or in a crowded street. When people are ready, we can offer them experiences of moving outside in nature or in social
groups and think about moving for general fitness not simply to exercise the body part that is painful in a linear, biomechanical way.
Todd Hargrove (2019) advocates moving through play as a way of influencing our complex systems. Play involves exploration, fun, risk-taking, uncertainty, variability, creativity. Play, fun and laughter promote feelings of safety. On my own Wellbeing for People with Pain course we have a session playing with Lego. They get to the end of the session and realise they’ve had fun, laughed and haven’t thought about pain. We learn a lot in this session.
Laughter is rhythmic. I show contagious laughter videos and it doesn’t take long for a room full of people with
complex pain conditions to all be laughing out loud. It’s heart-warming, emotional and often comes as shock. Experiencing enjoyment of life, and learning that this is still possible, is powerful.
Laughter – a sudden realisation that there is nothing to fear in the moment …It is rhythmic, contagious and emotionally bonding
Knight (2019)
Keeping a gratitude diary can reinforce a sense of safety and help to recalibrate protective systems by helping to refocus on the good things in life, to re-attune them to picking up this information. You can get into the habit of only focusing on threat.
I’ve included sleep in this section on safety because good sleep is closely related to a sense of safety. Your brain will only allow you to sink into deep restorative sleep if you are safe, because you can’t run or fight in deep sleep. Other animals go into uni-hemispheric sleep where one side of the brain stays alert for danger. This has a cost to the brain. Humans have evolved away from this as our environments have become safer. However, we have retained the ability to keep one area – the left cortical default-mode network – vigilant and alert in a dangerous or new environment. In these circumstances part of the left hemisphere is not sleeping as deeply as the right. It is more vigilant in an unfamiliar environment or one we perceive to be unsafe.
Learning how to improve sleep can be hugely beneficial. It helps to establish routines for sleep, eating and activity. Routines are a form of life rhythm. They make you feel safe because they are predictable.
Belonging/social contact
Social contact and feeling you belong is very closely tied to feeling safe Click To Tweet
Referring back to evolution, lone individuals will be singled out by predators, so we feel safer in a tribe or herd. It is often useful to refer back to evolution. Everyone needs a tribe.
The feeling of loneliness puts our brains into survival mode, ‘increasing implicit vigilance for social threats along with increased anxiety, hostility, and social withdrawal to avoid predation’ Cacioppo et al, 2014). Loneliness increases inflammation through the stress response. Loneliness puts a different filter on your lens of life: the world as more threatening. People who are lonely can often come across as rude. As a result, their interaction with others, communication – verbal and body language – changes. This impairs their ability to communicate, make friends or read a situation.
The Frome Model of Enhanced Primary Care was set up in 2013 by GP Helen Kingston and Jenny Hartnoll (service lead for Health Connections Mendip) in Frome – a small town just outside Bath. It includes moves to create compassionate communities and has reduced emergency admissions to hospital by 30% over three years.
It aims to connect people to:
- their own local support networks
- networks that support the basic activities of life, such
as help with shopping, gardening, looking after pets
or providing transport - extensive community activities.
William House, a retired GP in Keynsham near Bath, has set up Keynsham Action Network (KAN) where the community comes together to help each other.
Rather than configuring all health services around deficits and illness, this frame grows an economy of wellbeing, configuring recovery and aspiration through quality relationships.
Hannah, 2014
Social prescribing can significantly ease the pressure on clinicians who can then become guides, while ongoing support is done in and by the community. But it needs to be done with the same diligence, asking always – ‘How might this change this person’s story…affect their biology…have side effects?’
An eight-week course won’t heal a lifetime of problems. Ongoing support groups leave provide a sense of safety and stability on their ongoing journey of improvement and a safe haven for those who cannot escape the trauma of their everyday lives: somewhere to forget, laugh and enjoy the company of others, if only for a short time. Practitioners can learn a lot joining in at these settings and their (occasional) presence helps create safety and stability. These activities help people who are fearful of social contact, or on the margins of society, find a place in a community; opportunities to ‘just be’ in the company of others without necessarily having to participate.
Space
Finding safety within yourself even though the world is falling down around you is powerful. The safe space might be in a place where people share, or a safe sanctuary in the home – somewhere to escape to. Essential though less tangible places of safety can be found in mindful breathing, in meditation…. or by slowing down the flight and fight response just by counting slowly to 10.
As practitioners can we keep in mind that someone with a long-term health problem is more than their medical condition? The patient may be struggling to find
some psychological space for who they are over and above the diagnostic label and its everyday impacts. Rather than focusing only on managing symptoms, a focus on wellbeing and reconnecting to what matters to them as a person, their passions and relationships, will help create this space. It nourishes them as a person without the burden of labels.
Natural space can help. Spending time in nature can re-awaken awe for the world and open up a bigger perspective. Enjoying space in nature re-awakens curiosity. Becoming curious about the world may shift the mind towards more constructive thoughts. I sprinkle my wellbeing programme with facts that are designed to create an interest and awe in the world again. Shinrin Yoku translates from the Japanese to ‘forest bathing’. There is increasing evidence that being out in nature is beneficial in many ways. Just being in nature can help us to begin sorting our own chaos.
I cannot say exactly how nature exerts its calming and organizing effects on our brains, but I have seen in my patients the restorative and healing powers of nature and gardens, even for those who are deeply disabled neurologically. In many cases, gardens and nature are more powerful than any medication.
Oliver Sacks, 2019
Creativity/curiosity
Rediscovering curiosity and creative ability can steer us away from life’s problems and relentless negative thinking patterns. Creative activity groups can be hugely beneficial for wellbeing. If you’re thinking creatively you have more options open to you.
Creative activity groups also reintroduce the feeling of ‘being successful’. Many people have nothing in their lives they feel successful at. Experiencing success can have a powerful effect. It can change your personal story. It creates a desire ‘to do’, a springboard to other activities… hope. All these things help to lessen the load on a person to enable them to put their burdens down. They also help a person find their ‘reason for being’, the reason they get out of bed, something to live for. The Japanese call it your Ikigai – having a direction or purpose in life, the motivation for living life well. Most of the people we see will have lost this. In fact, many of us practitioners may have lost sight of this under a burden of work.
Whereas unwanted loneliness is detrimental to health and wellbeing, wilful enjoyment of solitude, and learning to ‘just be’ in your own company can be highly beneficial.
General wellbeing
Approaches that focus on improving general wellbeing:
- take focus away from symptoms
- focus on things people can do, their values and passions
- find purpose and meaning – their reason for being
- give hope for meaningful change
- can provide the trigger to move from survive to thrive
- encourage measurement of success in areas other than pain reduction
- social
They share knowledge about:
- pain and tension
- a less inflammatory life
- sleep and the importance of light and circadian rhythms
- nutrition, hydration, gut biome.
Poverty and austerity make it difficult for millions of people in the UK to eat a nutrient-rich, diverse diet. Many who live with health problems consume nutrient-poor, high-sugar diets which cause ill health. Intensive farming has depleted soil biodiversity and the nutritional value of the plants we eat. The inhumane treatment of animals kept in constrained environments and fed a cocktail of poor food and medication has done the same for the meat we eat.
Lessening the clinical load
No one can do this alone. The load on clinicians, particularly GPs, is unsustainable, and too often makes it impossible to be the kind of doctors they would like to be. Too often they are confronted with social and emotional crises they have no treatment for, and which are made worse by medicalising them. Exhaustion and a sense of failure lead to burnout. A better NHS could ease the load by spreading it to appropriately trained community resources and creating relationships of trust and respect within a wider network. The future is already here in healthy living networks, social prescribing, communitybased groups and programmes, peer-led networks of mutual support with multiple entry points, and through the empowering work of health champions in asset-based communities.
The implications go far and wide. We are all connected parts of the complex system that is the world. Someone struggling to survive isn’t able to care about wider world issues: survival is their primary focus and they can’t expend energy on climate change or afford a sustainable diet. If it’s bad for individuals it’s bad for communities and for the planet. But societies that organise to nurture individuals and their communities will be good for the planet and world.
What’s missing is a recognition of the abundance and complexity of real life, which offers surprises, paradox and the potential for more radical change.
Margaret Hannah, 2014
The connectedness of people and planet is a scientific fact. The future of the NHS will depend on its recognising this complexity as the basis for nurturing healthy people in a healthy world. Cheap global travel renders us only as healthy as the weakest link; Covid-19 is a stark reminder of this. Yet, as we’ve seen during the pandemic, rapid shifts in health and social care policies and systems is possible if the political will is there. And small shift have vast consequences in complex system. For, as Trisha Greenhalgh said on Twitter ‘….the logic of complex systems, multiple interventions might each contribute to an overall beneficial effect even though none of these interventions individually would have a statistically significant impact on any predefined variable.
Simple or small actions can have a big impact. It’s complex, always happens in context, is all connected and crucially, it’s all interdependent. significant impact on any predefined variable’.
References
Cacioppo J, Cacioppo S, Capitanio J (2014) Toward a neurology of loneliness. Psychological Bulletin, 140(6) 1464–1504. Charon R (2006) Narrative medicine: Honoring the stories of illness. Oxford University Press. Hannah M (2014) Humanising healthcare. patterns of hope for a system under strain. Triarchy Press.
Hargrove T (2019) Playing with movement. How to explore the many dimensions of physical health and performance. Better Movement. Hudson K (2019) Low Born. Growing Up, Getting Away and Returning to Britain’s Poorest Towns. Penguin Books. Knight C (2019) Did laughter make the mind?https://aeon.co/essays/ does-laughter-hold-the-key-to-human-consciousness (accessed 6 October 2020). Sachs O (2019) Everything in its place: first loves and last tales. Alfred A Knopf. Sweeney K (2012) [online]. Available at: https://www.youtube.com/watch?v=3TignNvHNx4 (accessed 6 October 2020). Van der Kolk B (2014) The body keeps the score. mind, brain and body in the transformation of trauma. Penguin Books
