How to develop a ‘MindBody’ approach to How to develop a ‘MindBody’ approach to physical disorders in medical practice!physical disorders in medical practice!

Brian Broom Brian Broom MBChB, FRACP, MSc(Imm), MNZAPMBChB, FRACP, MSc(Imm), MNZAPConsultant Physician(Clinical Immunology), Psychotherapist, Consultant Physician(Clinical Immunology), Psychotherapist, Department of ImmunologyDepartment of Immunology, Auckland City Hospital., Auckland City Hospital.

Adjunct Professor Adjunct Professor MINDBODY HEALTHCARE Post-Graduate Programme, MINDBODY HEALTHCARE Post-Graduate Programme, Department of PsychotherapyDepartment of Psychotherapy, , AUT University, Auckland, New ZealandAUT University, Auckland, New Zealand

If we desire to be effective as ‘whole person’ If we desire to be effective as ‘whole person’ clinicians there are only three issues!clinicians there are only three issues!

ParadigmParadigm

Attitudes and SkillsAttitudes and Skills

The Clinical FrameworkThe Clinical Framework

Meaning-full disease: How personal experience and meanings initiate and maintain physical illnessMeaning-full disease: How personal experience and meanings initiate and maintain physical illness . . B C Broom (2007) Karnac Books, LondonB C Broom (2007) Karnac Books, London

Somatic Illness and the patient’s other story. A practicalSomatic Illness and the patient’s other story. A practical integrative approach to disease for doctors and psychotherapistsintegrative approach to disease for doctors and psychotherapists. . B C Broom (1997) Free Association Books, B C Broom (1997) Free Association Books, New York/LondonNew York/London

Symbolic Disorders and MindBody Co-Emergence. Symbolic Disorders and MindBody Co-Emergence. A challenge for psychoneuroimmunology.A challenge for psychoneuroimmunology. Broom, B., Booth, R., and Schubert, C. Broom, B., Booth, R., and Schubert, C. EXPLORE: Journal of Science and Healing (IN PRESS)EXPLORE: Journal of Science and Healing (IN PRESS)

A case of ‘idiopathic’ A case of ‘idiopathic’ ANGIOEDEMAANGIOEDEMA

Clinical ParadigmClinical Paradigm

In my clinical frameworkIn my clinical framework

PersonhoodPersonhood

People are unitivePeople are unitive

Body and mind, physicality and Body and mind, physicality and subjectivity are not dividedsubjectivity are not divided

Body and mind co-emerge SL3Body and mind co-emerge SL3

Personhood core conceptPersonhood core concept

ClinicallyClinically

Avoid Avoid medicalmedical dualism SL1 dualism SL1

Avoid the Avoid the either/oreither/or, body or mind , body or mind defaultdefault position position

Avoid Avoid defaultdefault linearity i.e. body first, linearity i.e. body first, then mindthen mind

Diagnosis is a role-related activity Diagnosis is a role-related activity based on a certain way of seeing SL1based on a certain way of seeing SL1

We can have the diagnosis but not We can have the diagnosis but not have the ‘story’have the ‘story’

Diagnosis takes its place within a Diagnosis takes its place within a wider view of the personwider view of the person

Think person, think Think person, think storystory, think , think diagnosisdiagnosis

Co-emergenceCo-emergence

Assumes unbroken continuity between internal Assumes unbroken continuity between internal body processes and external interpersonal body processes and external interpersonal meanings and influences, meanings and influences, Asserts that disease-related 'internal' bodily Asserts that disease-related 'internal' bodily changes and collateral ‘external’ interpersonal changes and collateral ‘external’ interpersonal and environmental fluxes are mutually and environmental fluxes are mutually contingent and crucial to the development of the contingent and crucial to the development of the disease. disease. Offers an expanded PNI and medical framework Offers an expanded PNI and medical framework

Co-emergence ofCo-emergence of

Physicality and subjectivity Physicality and subjectivity

Body and mindBody and mind

Body and storyBody and story

Illness/disease and symbolIllness/disease and symbol

Illness/disease and meaningIllness/disease and meaning

Illness/disease and ‘story’Illness/disease and ‘story’

Medical dualismMedical dualism

the the widespread assumption in Western widespread assumption in Western healthcare that physical diseases (in healthcare that physical diseases (in particular) can be worked with particular) can be worked with therapeutically without much attention paid therapeutically without much attention paid to mind (subjectivity) factors i.e. that mind to mind (subjectivity) factors i.e. that mind and body are and body are in essencein essence or or functionallyfunctionally separated in some way such that mind separated in some way such that mind factors may be ignored. factors may be ignored.

What is a DIAGNOSIS?What is a DIAGNOSIS?

An observed pattern of dysfunction, recognized by a group An observed pattern of dysfunction, recognized by a group of people who look at patients and dysfunction in the same of people who look at patients and dysfunction in the same way, and in a way that enables them to use agreed upon way, and in a way that enables them to use agreed upon therapies, which are based on that same way of looking. therapies, which are based on that same way of looking.

In practice what does this mean?In practice what does this mean?

Every medical behaviour flows from Every medical behaviour flows from clinician’s paradigm-the first hurdle to a clinician’s paradigm-the first hurdle to a

‘mindbody’ practice‘mindbody’ practice

The first big hurdle is paradigmThe first big hurdle is paradigm

What you say, how you introduce ‘mind’, how you educate, What you say, how you introduce ‘mind’, how you educate, when you educatewhen you educate

We Drs are more the problem than the patientsWe Drs are more the problem than the patients

Patients greatly prefer being treated as persons rather than Patients greatly prefer being treated as persons rather than diagnostic objects (they want diagnosis as well!)diagnostic objects (they want diagnosis as well!)

Residual dualism Residual dualism

All disease is multidimensional and multifactorialAll disease is multidimensional and multifactorial

Disease is a dysfunction in a whole person (system)Disease is a dysfunction in a whole person (system)

The patient’s story is always important—The patient’s story is always important— in some wayin some way

Physicality and subjectivity up front togetherPhysicality and subjectivity up front together

What does this mean in practice?What does this mean in practice?New patients-beginning issuesNew patients-beginning issues

the pre-emptive strikethe pre-emptive strike

declare up front that illness and disease occur in a person, not declare up front that illness and disease occur in a person, not just in a body separated off from the rest of them. just in a body separated off from the rest of them.

I am interested in the whole of them, and I will be asking I am interested in the whole of them, and I will be asking questions about the whole of themquestions about the whole of them

we get unwell for both visible and not so visible reasonswe get unwell for both visible and not so visible reasons

transference or ‘baggage’ from previous encounters: nutter, transference or ‘baggage’ from previous encounters: nutter, hypochondriac, making it up, not realhypochondriac, making it up, not real

hope/investigation/’normal’/pushed awayhope/investigation/’normal’/pushed away

Attitudes and skills Attitudes and skills the ‘fix-it’ mode versus the listening/empathy modethe ‘fix-it’ mode versus the listening/empathy mode

suspending focus, expanding ‘marginal capacity’suspending focus, expanding ‘marginal capacity’

accurate recognition and reflection of storyaccurate recognition and reflection of story

honoring the ‘little’ (you are seeing what ‘is’ already)honoring the ‘little’ (you are seeing what ‘is’ already)

educating about paradigmeducating about paradigm

stories, normalisation, universalisation, self-revelationstories, normalisation, universalisation, self-revelation

the smorgasbord questionthe smorgasbord question

prism metaphorprism metaphor

comfortable with affective intimacycomfortable with affective intimacy

using specialists as contract investigatorsusing specialists as contract investigators

avoiding psychiatrisationavoiding psychiatrisation

The Story in the MacroThe Story in the Micro

(Exploring the Fault-lines)

LISTENING VERY CAREFULLY TOTHE PATIENT’S ACTUAL USE OF LANGUAGE

Believing in the Mind/Body Connections against the Odds.

DerailmentOrganic/functional dichotomies

Self–doubt: haven’t got the skillsFear of medico-legal consequences

Issues of respectHumanistic waiting

When will the patient be ‘ready’?

Discovering the undeniable

The Pursuit of the Particular

Must Go Slowly, and Expect to Find what is Needed in the Little that is Given

Believing in the Mind/Body Connections against the Odds.

Adequate investigation The problem specialist (overinvestigating/or

nothing wrong with you)

Believing in the Mind/Body Connections against the Odds.

Adequate investigation

The problem specialist (overinvestigating/or

nothing wrong with you)

HELPING PATIENTSACCEPT THE M/B

CONNECTIONS

But it is difficult!

“If the therapist has the wit to seeit, the truth is there to be seen inthe first session’(Harry Stack Sullivan--quotedby E. Levenson).

“Nothing certain can be saidabout the nature of truth,except perhaps that it is whatour peers will let us away with”Rorty

“No map includes every detailof the territory that itrepresents, and events thatdon’t make it onto the mapdon’t exist in that map’s worldof meaning.”Freedman and Combs

HELPING PATIENTS ACCEPT THE M/BCONNECTIONS

“bits and pieces”

SupervisionThe power of intuitionAn issue of intimacyThe ‘fix-it’ mentalityThe doctor’s reality

Symbolic DiseasesSymbolic Diseases

Symbolic diseases (SDs) are defined as Symbolic diseases (SDs) are defined as occurring when “occurring when “the organ system involved, the organ system involved, and/or the pathological process, and/or the and/or the pathological process, and/or the clinical phenomenology, appears to be clinical phenomenology, appears to be particularly congruent with, or appropriate to, the particularly congruent with, or appropriate to, the patient’s subjective meanings or “story”, as patient’s subjective meanings or “story”, as ascertained from the patient’s language, life ascertained from the patient’s language, life history, and behaviours” history, and behaviours” [4]. [4].

HELPING PATIENTS ACCEPT HELPING PATIENTS ACCEPT THE MIND/BODY THE MIND/BODY CONNECTIONSCONNECTIONS

HELPING PATIENTS ACCEPT THE M/BCONNECTIONS

Discovering the undeniable in a waywhich is acceptable

I Believe in Education educating the patient -the Prism Metaphor other patient’s stories normalisation/commonality the pre-emptive strike. The clinician’s ‘story’

Auckland University of Technology Auckland University of Technology Dept of PsychotherapyDept of Psychotherapy

Post-Graduate Program in MindBody HealthcarePost-Graduate Program in MindBody Healthcare

Diploma and MastersDiploma and Masters

Part-time, block course-based, multidisciplinary, open to Part-time, block course-based, multidisciplinary, open to clinicians of all kinds clinicians of all kinds

HELPING PATIENTS ACCEPT THE M/BCONNECTIONS

Believing in the Mind/Body Connections againstthe Odds.

The Disarming CharmerThe Slow Learner

The Sceptical Eroder

HELPING PATIENTS ACCEPT THE M/BCONNECTIONS

Believing in the Mind/Body Connections againstthe Odds.

Either/Or ResiduesIn the patient/client

In meIn my colleagues

HELPING PATIENTS ACCEPT THE M/BCONNECTIONS

Believing in the Mind/Body Connections againstthe Odds.

The courage to keep going

Enduring intense scepticismCoping with being undermined

Financial implications/losing patients