Monday, 29 December 2014

Anything But That!

Amazingly, this is once again going to be about health, or "herbalism" as I might put it.  You'll know when this blog gets back on track when I stop announcing entries which are on-topic, but so far this doesn't happen much.

It's hard to know exactly how to put this without breaking patient confidentiality, but there is an interesting process which occurs in my mind as well as those of my patients which affects my behaviour, and it's this:  people will often go to extraordinary lengths to avoid taking the simple course which is most likely to improve their well-being.  There is very often one simple decision which they simply will not take which would solve their problems if they did.  I'm going to give two examples, one of which is interesting to me because of its source being close to the other explicit subject of this blog, but I must protect patient confidentiality.  You probably know what I'm referring to.

I once had a patient with whom I worked for quite some time who was suffering from a recurrent and fairly severe problem.  When I looked at her lifestyle and diet, it turned out that she was one of those annoying people who are doing everything right but still have a health problem.  Or so I thought.  On closer examination, it turned out that there was one tiny little detail of her diet which was less than perfect, but it was a doozy.  It was a seemingly trivial ingredient in one beverage she drank which one might imagine to be easy to change, and which correlated supremely well with suffering from the problem she had.  We spent the next few months tinkering with the rest of her almost perfect lifestyle, unsurprisingly to no avail, and her problems continued.  When I tried to get her to make the one tiny change, it was the one thing which she simply wouldn't.  However, the approaches she took to it were that it was trivial, a minor change which surely couldn't make any difference to her health, and she would take extraordinary measures to avoid changing it.  It was like her entire mind was devoted to not changing that one minor detail of her life.  Eventually our consultations came to an end and I was able to help her to improve things somewhat, but I never managed to get her to make the one most important change which would undoubtedly have not only solved her health problem but also meant that she could have taken pleasure from other things which, in order to make the smaller differences, she had been willing to change and which seemed less important.

The second set of cases I have in mind follows a pattern I saw during training.  This is someone who clearly has a major health problem of some kind which is a mixture of the mental and the physical.  We try various different prescriptions, all of which she gives up very quickly, long before they were likely to have any effect, and reports adverse reactions to all of them.  However, these prescriptions consist entirely of herbs which it is very rare to have an adverse reaction to or entirely of herbs which are actually present in the patient's diet without them causing problems for her there in similar doses.  Due to the fact that she gives up on them so quickly, a nocebo effect builds up where her scepticism and negative expectations perpetuate the problem because she fails to take seemingly straightforward action to escape.   It's hard to draw a conclusion about this.  It may be that this kind of negative expectation, learned helplessness and focus on the negative has driven her into this situation in the first place, or it may be that the condition she is currently in serves some kind of purpose for her which would have to be replaced by something else if she took the way out.  Also, just because I happen to be able to see the psychological aspects of how she paints herself into a corner, it doesn't mean I think the process is primarily psychogenic.  Firstly, it may be that the depression and the condition have a common cause, and secondly, she may realistically fear very serious and concrete consequences of "escaping" into the fire, so it's better the devil you know.

This happens to be in the context of herbalism, but that's not important really.  Looking at it from a quasisceptical point of view, the point is that we are working within a context where we believe this constitutes a method of improving health.  Replace it with drugs or other procedures if you want.  The point is really that the process concerned is ineffective not because of the inefficacy of the recommended course of action but because of psychological and behavioural processes, and these centre on what's called limited concordance.  The patient is not taking the recommended course of action for personal reasons which from the outside look perfectly simple.

This means that often the psychological side is overwhelmingly important compared to the physical disease process, and is in fact the most important part of the disease process, not because its psychogenic - it isn't - but because the way out is clear and simple to an outsider but won't be taken because of things like fear of the consequences or avoiding a bigger issue.

Turning this round to me, I can think of two areas where this might be true.  One of them is in the area of getting published.  It has sometimes been suggested that I get a literary agent and thereby get my stuff published and derive an income from it.  I don't do this and in my perception I can't.  The other area is obvious.