At medical school we were taught about diseases according to organ systems. Effective enough I suppose as a way of learning the basics but I fear it helped increase my assumptions about the the separation of mind and body. Yet in real live general practice, we are very often faced with a collection of symptoms that simply do not fit into the pathology brackets of our medical training. Even while still a student this had already begun to happen. And there were unaccountable differences
between the disease symptom picture we were taught to look for, and the way people actually presented with a disease. No matter whether pathogenic in origin, or auto-immune or even iatrogenic, each person seemed to have their own unique set of symptoms.
This started me off on to the journey into asking ‘why?’ Why do we fall ill in the first place? Why is one person’s presentation of cancer, multiple sclerosis, ME, influenza completely different to the next person’s? Why does one person’s osteoarthritic knee, though it looks severe on x-ray, hardly seem to bother them, while the next person complains of severely debilitating pain even though the images look pretty normal? Over and over, clinical presentations would conflict with what
I’d learned at medical school, and the more I delved into these gaps the more questions arose, and the more dissatisfied I became with what I had been taught.
There were too many gaps and they needed filling, and this led me at first to explore complementary medicine (CAM) as an add-on to my conventional toolbox. In these approaches individuality and difference were valued and this started me joining the dots. For instance my homeopathic training gave me the skills to take an in-depth patient history, whereby a patient’s weird symptoms, which had formerly been irrelevant to the conventional diagnostic algorithm symptoms, began to form meaningful patterns. Homeopathy values a patient’s nonconforming chaos because the more unique the person’s symptom picture, the more precise will be the choice of their remedy.
Acupuncture training gave me the hands-on practical tools I needed to help with everyday musculoskeletal problems, and pains that so often defied straightforward clinical assessment and investigation. I realised it might even be possible to influence ‘the flow of Qi’ and so to trigger innate self-healing processes in ways I did not fully understand though I was aware that science was beginning to unravel these mysteries.
I think the service at Herstmonceux is absolutely incredible.The workshop and the team there are amazing, and I’m am so honoured to have experienced it.The combination of professionals you have available offer so much clarity and understanding regarding health and exercise, combining psychology with nutrition and physiological science. I believe it is having a really positive impact on the people who attend. I know for myself that being part of one session has helped my knowledge dramatically and I’m going to pass on what I have learned to as many people as possible.The combination of nutritionist, physio and a GP is really revolutionary and creates a hub of health and well-being which I think is the future of health and exercise.
Further training in energy medicine including heart rate variability techniques, Qi Gong, yoga and meditation made me ever more conscious of just how my medical training had disempowered me, and how important it would be for me to treat every patient within a very broad and holistic framework. I began to understand too that individuals can influence how they feel in the moment and how they experience their symptoms. Therefore as doctors we can only ever, in a quite limited way, predict the prognosis or influence the course of a patient’s symptoms. In fact our urge to fix things all too often implies that a patient should hand all control to the doctor. The practitioner undoubtedly has a part to play but more through guidance and support than by taking on too much responsibility for fixing the problem.
Each patient’s presentation is different, although there are similarities where organs are concerned – for example left-sided chest pain associated with the heart or upper right abdominal pain with the gallbladder. But there are many more subtle ways in which a health problem can affect the mind, body and spirit. Through meditation, I began to see how our state of mind fundamentally influences our feelings – perhaps of love, jealousy, grief – about what’s happening and changes how we perceive and respond to events and to sensations arising within us, whether that be pain, stiffness, heat or cold. The mind, which has been molded and programmed by one’s upbringing and life experiences, therefore governs our reactions to life moment by moment. And in turn this mind–body relationship fine-tunes each person’s unique psycho-physiology and the chemical processes that bathe each cell and regulate every organ.
It is my belief that we have the power to consciously influence this physiology. But to do so, a new sense of self-efficacy is needed, and self-awareness of this potential is a necessary step towards regaining agency. But how to explain the mind’s ability to affect our felt sense of health and wellbeing without seeming to imply a patient’s symptoms as imagined (in a negative sense ‘psychosomatic’) or worse, in some way made up! Unless conveyed very skillfully these contentious ideas could damage the doctor/patient relationship.
I began to wonder whether it’s because we somehow get in the way of our innate self-healing capacity that we fall ill in the first place: at the cellular level and influenced by the physiology of our internal milieu constant repair and renewal is under way. Some disruptors are beyond our control – pathogens like coronavirus, or environmental microparticulate pollution for example. Yet even so, our immune reactions can, I believe, be influenced for specific lifestyle areas that we can control.
While working in general practice I began to suspect that regardless of their symptom picture, patients’ disease origins could be tracked back to a dysfunction or distortion in one or more of four distinct areas: nutrition, movement, emotional resilience and self-awareness. Eventually, after many years of personal and professional enquiry, I was able to distil these thoughts and observations into four principles of health and wellbeing: eat, move, breathe, love (© VitalityWorks).
Our relationship with food, how and what we eat, is critical to the way our body functions. Food can inflame or inform; food can nourish us or harm us. Diet and our microbiome play a huge role in managing inflammation. Many foods, especially those high in refined sugar and grains, and of course processed meat, and fried or highly processed foods, can be pro-inflammatory. On the other hand, a diet of foods made from wholesome ingredients and full of colourful phytonutrients, whole grains, legumes and healthy fats will be relatively anti-inflammatory. Our eating patterns can also be inflammatory: frequent snacking, late night eating and grazing all being key factors in weight gain, obesity and type 2 diabetes. Adipose tissue is full of pro-inflammatory cytokines. Within the gastrointestinal tract an extensive nervous network, which is constantly communicating with our brain and other organ systems, has a big influence on how we feel. And the messages this ‘gut brain’ conveys can mediate either inflammatory or anti-inflammatory processes (Tozzi, 2014).
Movement, both as mindful practice and for cardiovascular fitness, is crucial to effective cellular functioning. Being active builds stamina, maintains flexibility and strength, and ensures the health and optimal functioning of our heart–lung system. In addition we are discovering more about fascia and its potential role both in storing emotional memory and ensuring co-ordinated musculoskeletal functioning (Pickard et al, 2017).
Stress is not something that happens ‘to us’. It is to do with how we respond. Our perception of events, emotions and sensations is constantly being shaped by how we feel about ourselves and others. Truly ‘we see the world through how we feel’, but our view of the world and ourselves is filtered through all that we have learned and experienced and witnessed in the past. These assumptions and emotions have a huge impact on our core felt sense of wellbeing. Although no emotions are ‘negative’ or ‘bad’ per se, prolonged states of anxiety, anger, frustration, jealousy, envy, rage etc are not healthy, for their impact on the cardiovascular, nervous, immune and hormonal systems is massive. On the other hand some emotions, among them joy, contentment, appreciation, are restorative. The easiest way to begin the process of emotional self-regulation is through the breath. This has been recognised in spiritual traditions for thousands of years: by the Buddha while sitting under the Bodhi Tree, by centuries of yogic and Qi kung practice, and in the practice of rhythmic chanting and prayer. For very sound physiological reason, slow regular breathing upregulates the parasympathetic nervous system, which is one reason why developing conscious breathing can be a gateway into a more peaceful emotional landscape of self-regulation and readjustment.
The word love has many meanings. From the perspective of our health and wellbeing project it is about nurturing self-compassion, a more conscious life and restoring a positive sense of self. Many people were not well enough nurtured and supported in early life. As dependent children they may have felt insecure and unable to express their vulnerability even when life was harsh and painful. As necessary defences develop, an inner critic holds them back from feeling the rawness and richness of life with an open heart. Children whose early needs for love and security were not nurtured in a supportive way grow into adults whose sense of self and safety is distorted: they have fallen out of love with themselves. They may be unable to love those nearest to them, or their community, wider society and the planet. Falling out of love with life itself, and in forgetting how wellbeing feels, they lose their way back to health.
The love principle really underpins each of the other three and interweaves through them. However, when working with patients towards health goals it is often
better to make small steps with the other principles first. But it will not be possible to sustain better health if love and the self are not addressed somewhere along the way. In realising ourselves as part of something bigger than individual human experience, and as a sense of shared humanity arises, the danger of getting stuck in fear and of being overwhelmed by feeling alone in suffering recedes.
Now it seemed I had a framework for approaching diverse presentations, and could begin to navigate patients towards a programme. This might involve nutrition or a movement, or use breath work, energy medicine and self-awareness sessions. While a programme could be selfdirected or entail supportive therapy – in my experience people have different needs within each principle – I find they never heal fully without addressing all four. I would argue that all four principles are in the category of lifestyle medicine. Nothing in them is new, but they bring together elements of established wisdom that over millennia have helped millions of people live life with greater ease and less suffering. What’s more there is no great expense involved in making and sustaining these lifestyle choices.
The health coaching programme
In the current micro-managed world of general practice it became clear that Herstmonceux Integrative Health Centre was an outlier. It was meeting all of its targets, identifying pathology, referring in a timely way and appropriately. Yet patient demand, prescribing costs and overall referral rates were significantly lower than any other comparable local practice. I had assumed this was due to our integrative approach. The best form of medicine is one that helps people stay well and not need their doctor in the first place. And, if they do develop an illness or symptoms, the approach should enable them to take back control and work with their doctors to get the knowledge and skills they need to play their full part in recovery and health maintenance.
Obviously with these aims in view, patient education and engagement with self-care were major elements in our way of working. However, as I realised that I was sharing the same one-to-one information with several patients, it occurred to me to get a few of them together and impart it in groups. Our health coach programmes teach the four principles, and another called the Ten steps of resilience is available to further empower our patients to take back control to achieve and maintain their health goals.
Everybody over 18 is eligible to be referred into the programme. As most of my GP colleagues are not integrative and often miss the appropriate ones to refer, the workshops are now offered directly to patients who want to self-refer. People who say they want look at their health more holistically are obviously more primed to work with the programme and embrace the necessary changes. Obviously their readiness to change will help too. High anxiety, patients with medically unexplained symptoms (MUS) or other vague non-conventional presentations are also likely to be good for the programme. Fibromyalgia, chronic pain and MUS are hard work but generally do well; gastro-intestinal dysfunction and tension-type headaches and fatigue syndromes too, once pathology has been investigated and pathology excluded. I’m more and more convinced, though, that everyone can benefit whatever their health status.
Our local CCG was very supportive. They initially commissioned a pilot within the practice and then allowed us to extend it to the local population of around 30,000 patients. This meant training health coaches in the four principles of health and wellbeing, so that each participant could be offered two hours of one-to-one health coaching, and in addition attend a drop-in programme where the four principles were explored in greater depth. We were aiming to co-create individual toolkits for self-care practices that would meet and sustain their particular health goals.
The ten steps of resilience programme
This was done on a drop-in group basis, and participants could drop in as often or as little as they wanted. Each step, which runs for a month, explores resilience from the perspective of the four principles, with each patient setting their intentions for behaviour changes in relation to eat, move, breathe and love.
Outcomes so far
Patients were selected and referred by GPs only after investigation and assessment had excluded sinister pathology. The early data comparing the six months before starting the course with the six months afterwards showed a 66% drop in GP attendances. This fell to 56% reduction in attendance after 12 months. This finding was a key factor for securing initial CCG funding released from the General Practice Forward View which emphasises improving the general practice work environments.
It has been a game changer. It has made me really tune in to things I didn’t want to and to know that it really is OK not to be OK.
When the coronavirus pandemic began the programme still needed to continue. Feedback on its benefits was good and people could not be left hanging having only done part of their enquiry. We therefore rolled out a virtual programme on the Zoom platform introducing the four principles, and followed by the ten
steps of resilience. Now each step can be performed weekly and further resources are available on the website. Participants are sent worksheets before each session outlining the aims, objectives and learning outcomes and afterwards they complete exercises setting intentions to embed the knowledge further. The feedback continues to be overwhelmingly positive.
In the first group of 46 people only three people dropped out after the first six weeks. There are obvious benefits of working virtually: men are happier to access
this more anonymous format and sometimes attend as the partner of the primary attendee. Anxious and depressed people have also have found it easier to work from the comfort of their own home. These are important advantages for such hard-to-access patients.
For me personally it has been a journey into the unknown: pushing my own boundaries, taking me out my comfort zone and making me step into an arena using
skills I did not know I possessed nor thought I would be comfortable with.
Many of the patients who access this course are from really difficult and challenging environments. Among them are people with long-term physical health issues such as autoimmune disorders or chronic pain; others with persistent anxiety, panic and low mood. They often have very little insight into how much of a bearing they themselves have on how they feel and their condition. Their impatience to not feel anxious or low or ill or in pain is understandable but the process of helping them take control has to be navigated slowly, with great care through the programme’s gradual structured step-wise progression.
An important concept we share early on is of how symptoms can be a positive experience: that they can act as real-time feedback on the body’s attempts to heal itself. This may be hard for a person to grasp when they are in the depths of pain, fatigue and bodily dysfunction. However, once someone learns to pause for a moment, still the mind, and focus attention inwardly they may start to find ways towards a more resilient sense of what health and wellbeing could be.