This chapter needs a copmplete re-write, along the lines of the index above, pointing to other chapters where subjects are treated more fully (eg on Placebos, beliefs, spirituality etc)

Medicine in the developed world today

How are changes made to the medical model?

But surely medicine is changing all the time

So change is good, how do we influence it?

Some models of a whole-person approach

Role of counsellors and other therapists

Role of chaplains

The enlarging medical team

Some established models of whole-person care

Hospices

Burrswood

Karis practice in Birmingham

Bristol Cancer Centre

Research other good models

Integrated Health Care

Practical issues in applying whole-person principles

Value of continuity of care
Reasons why this may not produce the required understanding
Continuity does not necessarily lead to greater understanding because:

1. The interaction is based around the doctor-patient consultation, so is always on the doctor’s home ground, and conducted on his terms
2. The story developed is one around the relationship itself, which cannot help but be partly paternalistic
3. Five ten minute appointments is not the same as one whole hour with the patient. Value of giving time for patient to develop their story
4. Familiarity can lead to assumptions being made rather than digging deeper to discover underlying issues
5. Each consultation tends to be focussed around presenting symptoms, and the general background context is not explored because of lack of time
6. Danger of forming opinions too quickly in order to manage the consultation, so allowing bias and pre-formed notions to influence the judgement
7. Only one person hearing the patient’s story, so limiting the effectiveness of the interaction due to personal biases

Attitudes of patients themselves

Taking a physical history

Changing beliefs and behaviour

I am often asked the question “But how can you change people’s beliefs”.  This question is usually asked of me when the people in question have unhealthy beliefs and practices.  A recent example was in the Nile Delta region of Egypt where the local women still went to wash the dishes in the Bilharzia infected canal water even though they had good running water in their kitchen taps. The local health visitor found it almost impossible to get these women to change their health behaviour and so prevent the spread of a major disease.

So how do people get beliefs in the first place, and then how do they change them? First we need to be clear about the meaning of the words we use. The first distinction is between what people say they believe, what they actually believe and how this affects their actions and behaviour. It will help to first look at the issue of personal beliefs.

Personal beliefs
We all have a personal set of beliefs which we hold to be true or correct and these form our “world view”.  Define a world view. Most people would accept that this world view is largely determined by the culture and time we were born into, as it largely depends on cultural and educational upbringing. However I believe it is not quite as simple as that.
Our personal belief system may be considered in three layers. At the top and therefore the most accessible layer is that of beliefs. Underneath these beliefs are our personal faith actions and at the deepest level are our convictions.

Beliefs are the easiest to change – in fact we often change them daily. When I hear a confident speaker I often side with their beliefs, only to change them again when I hear an equally confident speaker argue the opposite view. Beliefs act at the “top” level of our reasoning being, we are normally aware of what our beliefs are, and if pressed we can usually articulate what these are.

At the next level down are our personal faith actions. Faith is simply belief put into action. This if we act on our beliefs then we are exhibiting faith. We exercise our faith every moment of every day. We put our faith in many people every day (such as the bus drivers on the D6 bus), and in things such as the electricity in our wires and the engine in our car. Faith is this reinforced and confirmed through experience. If things continue to work, then we continue to put our faith in them. When they fail us – then we lose faith. So I believe that the D6 bus will take me to work – that belief is put into practice by actually getting on the bus (converting my belief into a faith action) and seeing where I end up. If every day the same thing happens and I get to work, then my faith is re-enforced and becomes the deepest level in the belief structure which is conviction. Thus I have a deep conviction that the D6 will take me to work, and every day it actually does so. But what happens if tomorrow the bus departs from its usual route and goes in the opposite direction? I would usually see this as an aberration (a young new driver getting lost) and thus it would not necessarily shake my conviction, or make me lose faith or even change my beliefs. But what if the next day the same thing happened, now I would be worried, and if on a few more occasions the D6 ended up in varying destinations my whole belief system would be upset. I would have changed my belief (that the D6 bus will take me to work), lost my faith in London buses and have no conviction that I could rely on the D6 any more, and I would probably seek alternative methods of getting to work.

Thus in this model the beliefs themselves are the least important part of the behaviour forming system. They change easily and sometimes irrationally. Faith kicks in when enough of my beliefs are pointing in the same direction. Let us look at a health example. I have chronic backache and whilst various doctors have tried to help me I am still left with a regular and annoying pain. There is no definite diagnosis and no treatment other than “rest, exercise and losing weight”. Thanks Doc! In discussion with friends I am told of the benefits of acupuncture therapy, and a new clinic has opened in town and many people “swear by” the treatment. A close friend who I really trust has just been to this acupuncturist with backache and he feels much better. Several of my “belief gates” concerning acupuncture will have clicked over to a positive acceptance mode, but not yet enough to take action. There is then a positive article about acupuncture in the Sunday newspaper, and a TV programme in which acupuncture is praised, especially as a treatment for chronic musculo-skeletal pain. Now I have a bad back again, and as enough of my belief gates have clicked, I take the step of converting belief into action, and I put my own personal faith into acupuncture and make an appointment.

The next step is very important, because all of the positive belief gates can be instantly negated if I have a terrible experience. I go to the clinic, pay £60 pound, have a painful treatment and then find my backache much worse when I get home. I will have lost faith in acupuncture very quickly, and as the proverb says “once bitten twice shy” it will take a lot of persuading to get me to try again. Thus faith is slowly won and easily lost. After a period of time where my faith is tested by experience, and is positively re-enforced on many occasions, then my faith will be converted into the deepest level of belief which is conviction. A deeply held conviction starts with belief, is converted into faith actions, and then re-enforced into a deep pattern of behaviour through my convictions. These convictions can withstand some negative examples (like the odd D6 bus driver getting lost), but usually stand and can only be changed painfully and with a long period of new experiences.

Taking a more regular real life situation closer to home – as a GP I see hundreds of kids with fevers, coughs, colds and upper respiratory infections. It is my belief, faith and conviction that antibiotics are not only useless in most of these infections, but are actually harmful. So you would expect that I would very rarely prescribe them. This belief system has been formed through medical research, teaching by experts and by my own experience. However the mother of the infected infant may have quite different beliefs – and she has real present needs, and so comes to me expecting to be given an effective and quick treatment, and all she has been told has led to her belief that antibiotics are needed. If you are a GP or a parent you may well imagine how the consultation will go. There is a clash of belief systems and one side or the other will have to back down. However if the doctor is good, and is not too rushed he might carefully expound the situation to the young mother, and if he shows that he cares he might begin to flip some of her belief gates into the “antibiotic bad” mode. (please note it could equally well be she the doctor and he the parent!)  If this belief is then re-enforced on future occasions, and she trust the doctor she may well come to have faith in no-antibiotics where she would refuse them if offered them by another doctor in the future.

Figure 4.7  The personal belief system.

Behaviour
And now how does this personal belief system affect our behaviour and actions. There would appear to be at least four major elements in the formation of behaviour –

1. Personal belief system
2. Cultural conditioning
3. Societal pressures
4. Personal needs

We have already looked at the personal belief system and seen that the deeply held convictions will be one of the most important drivers of behaviour. At times we will seek to put our faith in different beliefs and thus test them out. If they stand the test we will add them to our convictions, but if they don’t we will not allow them to influence our behaviour even though we have not acquired a new set of beliefs. Thus we can be in the situation where we give verbal assent to a belief – but when it comes to the crunch we don’t actually do it.
Cultural conditioning
Most of our deepest convictions are placed in our minds or hearts without conscious understanding through our cultural conditioning. These start with our family upbringing where our life role models are our parents and closest siblings. It is little wonder that children often grow up to not only look like their parents but also to act like them. A strong element in this formation is the language and world view in which we are brought up. Some world views are more powerful in this respect. So a child brought up in Saudi Arabia will think, believe and behave as an Arab believing in Islam, with beliefs about society, women, and virtually all aspects of life. The child has very little choice – all of these deepest convictions are given to him when he has no capacity to choose or select. Later in life if faced with other belief systems and a strong external stimulus to change (for example after emigrating to England) it would be a long, difficult and even painful process to change these deeply held convictions. The chances are very high that he would always “act like an Arab”, or at least only feel truly comfortable when he did.

Language playas strong part in this cultural conditioning, because our beliefs are re-enforced through what we say, and how we say it.

Societal Pressures
Peers, education, media and advertising, laws of the nation we live in.

Personal needs
Needs will drive behaviour, as will habits and addictions. In an emergency all of the above can be over-ridden although as soon as the emergency is over the behaviour pattern will almost certainly revert to the usual one for that person. Habits are just another name for those habitual actions which follow our deepest convictions, and of course they arte very difficult to change. Addictions work in a different way.

Summary about beliefs and behaviour

The Placebo effect

PLACEBO effect and how to harness it in routine practice

The placebo effect is basically due to deceit – where the patient is led to believe that the medication or management being offered is powerful and bound to work to achieve the desired effect, even though an inert substance is in fact being administered. It works on the doctor acting a strong belief in the treatment (which can be conscious or even unconscious) which persuades the patient’s beliefs and so enables them to put their faith into the management, and this act of putting a strong faith in a course of action is powerful enough to have an effect, even to the point of producing side effects if these are suggested to the patient. Of course if the patient is told that the treatment being offered is an inert substance and not the expected effective agent then this mechanism would not work.

We first need to weed out those cases which would have got better anyway within the time period, where the improvement is then credited to the placebo (or drug etc in real life). Several pathways of activity have been suggested (put these in here).

The challenge is how to use this “self-healing” pathway in a positive way where the patient is not fooled but encouraged to actively participate in the treatment.

We are bringing in to play natural mechanisms within the person which can have a positive healing effect.

Pain is an obvious example – my experience after the accident – many people have an outpouring of morphine like natural substances which relieve pain for a short period.

Bio-feedback gives us another possible mechanism – quote papers on blood pressure and bio-feedback.

Rename it the Faith Effect – look at the mechanism of faith we believe, we take faith actions and this leads to deeply held convictions. Can we switch on this faith effect without deceiving the patient, but getting them to cooperate. I believe we can. The following key principles should help us.

1. Self-healing is in-built into the body
2. We believe authority figures in our lives (Mummy kissing it better, or doctor saying you will get better)
3. The confident doctor is taking away anxiety which may inhibit healing
4. Bio-feedback involves using the brain to re-enforce positively feedback loops.
5. Adaptation to disease and illness
6. Relaxation and refief of stress allows healing
7. Upbringing – eg Peter’s mother taking a pill for car sickness – now she is often sick – educated to be sick in the car. Inner programming from childhood
8. We have a positive belief in people – their expertise we can trust. – honesty based on knowledge.

So how do we make positive use of this faith effect.

1. We understand the prognosis and can positively talk about the good outcomes, whilst not denying the bad ones, but concentrate on the good. Stress the positive side – the half full glass effect.
2. Deal with anxieties and fears
3. Understand self-healing mechanisms and encourage them
1. Need to think what these are and enumerate them
4. Encourage sensible actions (diet, exercise etc) so that the patient is doing something themselves
5. Provide positive bio-feedback, monitor progress and re-enforce good outcomes.

Part of the answer will be in the motivation and enabling of the individual’s “Personal coping resource” which includes such concepts as Sense of Coherence by Aaron Antonovsky and Locus of Control which will look at –
            Sense of optimism rather than pessimism
            Belief in personal control
            Sense of coherence
            Perceived competence
            Resilience
            Hardiness
            Self-esteem
            Coping mechanisms with life stressors

Some of these measure personality characteristics, others coping mechanisms, others learned methods of how much the person can influence their own life.

In helping people – we need to undertake the following steps –

1. Measure where the person actually sits in these measures
2. Explain to the person what the range means and that they do have the ability to change
3. Choose one of these, and indicate to the patient that they can change for the better.
4. Help them to change – How?
5. Keep on re-enforcing positive behaviour
6. Give them tasks to do which will help relaxation etc.

Perceived Competence Measures

Locus of Control Scales

Time
Whenever I make presentations about WPM to health care professionals I always receive the same response – “It’s sounds good, and we would like to do it, but we do not have enough time”

Time is the most important and precious commodity in health care – n o-one has enough time. Of course there is plenty of time, but it is taken up doing other things. So the issue is how do I give this a higher priority than the other medical tasks I am required to perform. And of course they are right – there is no spare time when HC professionals are sitting around wondering what to do. So time has to be made by taking it away from other tasks. The questions are –

1. Is the time taken in the whole person approach worth while and of such benefit that I need to find time for it?
2. Will there be any time saving in the long run even though there is a time cost in the short term?
3. How much extra time will it actually take?
4. What other tasks that I do can be dropped?

To begin to introduce whole-person medicine we need to tackle these questions head on.

Is time spent on the WP approach well spent?

Is there any time saving in the long term?

How much time does it actually take?

How can I re-organise my schedule to make time?

Counselling Assessment in whole-person care

Basic approach to assessment!

Simple tools of counselling

Life event map

Relationship map

Broad knowledge base

Medical

Counselling

Spiritual

Life experience

Spiritual Assessment

About the human spirit and not just religious experience

Varies according to known Christian or religious beliefs of the person

Assessment and not therapy at this stage

Start with explanation of what the spirit is and does

Spiritual Assessment Process

Two pastoral counselling sessions of an hour or more

Structured interview based on the seven areas of spiritual activity

Getting the patient to tell their health story again

Concentrating on their beliefs

Exploring in depth the spiritual aspects of health in these 7 areas of spirituality

1 Relating to Self

Self-Image

Describe their strengths and weaknesses

Self-acceptance

Locus of control – internal or external

Creativity, leisure and time for themselves

Maturity

Learning from failures

Handling success

2 Relating to the world

How they deal with authority figures

Attitudes to work

Attitudes to science

Dealings within society

Caring for others

Taking responsibility

3 Relationships

Are they able to give and receive love?

What is the quality of their close relationships?

Do they argue, or passively withdraw when there is conflict?

Can they confront in a positive way?

Can they act as peacemakers?

4 Ethics and Morality

What do they think of their conscience

What is their life ethic based on?

What is truth for them?

Discuss actions in the past they feel bad about

Are they able to forgive

themselves

others

5 Purpose and meaning

Do they have hope in the future?

What is their purpose in life?

What do they live for?

Have they been fulfilled in life?

Discuss the dreams of their heart

6 Faith and Belief

What belief system were they given as children?

Struggles with belief and doubt

What do they put their faith in?

Self

Others

Medicine

God

7 Religious Experience

Childhood religious experiences

Helpful events in past

Harmful events

Understanding of God and religion

Relationship with God

prayer

church

beliefs

Final integrated assessment

Three therapists (doctor, counsellor and pastor) come together

Pray and put together combined report

One therapist takes this back to the patient

Patient alters the report so that they can OWN it

Action plan produced with the patient

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