Book Reviews

A Mind for Sickness and Health

Any serious student of the healthcare industry eventually comes to realize that the diagnoses of greatest concern change over time. In the 1800’s, neurasthenia (bad nerves) was common. Today we talk about “stress” – and use very different methods to manage the problem.

In rationalizing these trends, we invoke the march of medical progress and changing social circumstances. In her book “The Cure Within,” however, Anne Harrington argues that in the area of psychosomatic complaints the trend has as much to do with the narratives we use to explain health and sickness.

I loved this book for several reasons. First, Harrington takes a positive view of those that struggled to understand how the mind affects the body. Each progressive step is rooted in the intellectual context that preceded it and treated as an honest attempt to improve public wellness. Secondly, Harrington captures not just the intellectual history but also the methods used to promote evolving methods. This is valuable insight when evaluating the integrity of a practitioner. Finally, the chapters on suggestion and hysteria are the most lucid history I have read of my discipline – hypnotherapy.

The impetus for this book reflects a disturbing fact: while clearly attitude and lifestyle affect our health, science has yet to elucidate the mechanisms in a way that benefits patients. Even so, patients flock to alternatives to “scientific” methods. Harrington explains this as a reflection of the narratives that we tell ourselves about our relationship with healing.

Initially those stories were religious, and early attempts to explain mysterious recovery were “scientific” explanations for the significance some attached to faith. People educated to the authority of a priest were easily swayed by Mesmer’s talk of “animal magnetism” and accepted his domineering attitudes. In our modern era, those traumatized by surgery and drugs idealize a gentler “Eastern” perspective on health – including practices that in most cases were cultivated for Western consumption.

Harrington proposes six narratives, each of them still active in modern society:

  1. The power of suggestion – largely the use of hypnosis.
  2. The body that speaks – illness as an expression of suppressed trauma.
  3. The power of positive thinking – from religious faith to self-control.
  4. Broken by modern life – the popularization of stress as a cause of illness.
  5. Healing ties – the important of community.
  6. Eastward journeys – rejection of Western medicine.

Harrington points out that as each of these narratives came into force, the diagnosis of illness changed. The influence of culture on health is bolstered by cross-cultural comparison – at menopause, Japanese women retain their cultural standing, and do not have hot flashes. But it causes me to wonder how much our current epidemics (asthma, cancer, dementia, diabetes) are aggravated by messaging that verges on propaganda. Are we being programmed to sickness?

Harrington does trace out the increasing rationality of our explanations for the influence of mind on health. The most solid are the ability of the brain to sustain the fight or flight response. The resulting effects on the body are well known – higher blood pressure, tissue damage, exhaustion, and immune suppression. What frustrates, however, are the uneven results from attempts to help patients learn to sustain homeostasis – the “feed and breed” state in which our body musters the energy to heal.

Harrington tends toward the opinion that we don’t understand mind-body dynamics, a conclusion that led her to offer her perspective as a historian. After the reading, however, it seemed to me that there were at least three factors that could help us to control variation, and therefore develop more effective strategies.

First, stop appropriating military studies for civilian use. While the persistence of shell shock after WWI was a useful tonic to Freud’s sexualization of psychology, in general the military experience is neither typical nor consensual.

Secondly recognize the importance of practitioner sophistication. An example is support groups for breast cancer patients. At the end of her chapter on healing ties, Harrington shares a disparaging comment from a participant. The original pilot study, however, was led by Irvin Yalom, one of the most sophisticated psychologists of the era. Given the hypothesis that cancer is driven by stress, increased longevity must deal not only with the pressures of surviving treatment, but also touch on the problems that created the stress. Yalom would have been capable of guiding such dialog – patients without such support might be expected to find less value in the process.

Finally we have the maturity of the patient. For positive thoughts to be expressed consistently, the patient must have mental discipline not typically in children. We tend to assume “maturity” in those that attain their majority, but even so there are levels of maturity. This is given in religion: Harrington offers a comment from the Dalai Lama that even he had experienced only “three of six” meditative states. Catholic sacraments explicitly recognize evolving maturity. Here I offer a hypnotherapist’s perspective on maturity.

Of course, Harrington did not set out to offer solutions. Her goal was to record the history so that we might make more informed decisions regarding the opportunity we have to achieve health by managing our attitudes. In laying out the internal logic of these narratives and documenting their evolution, Harrington brings coherence that will help us avoid ceding authority that we should reserve to ourselves. Do whatever, but recognize that you as a mind-body unity are at the center of the system you seek to heal.

Book Reviews, Health Care

Loving Placebo

Modern medicine’s attempts to reduce wellness to biology have created a gulf between the patient’s mind and body. In “Elderhood,” Louise Aronson attributes this to medical specialization and a focus on record-keeping that prevents the doctor from addressing the whole patient. In “Mind Fixers” Anne Harrington paints psychiatry in even darker colors, revealing how hubris, greed and pseudo-scientific diagnoses have eroded our ability to manage our mental health.

Unrecognized in that analysis is a root cause: a social epidemic of failures to care and care for. Doctors and psychologists are both confronted with patients whose interlocking complaints arise from lifestyles driven by anxiety and restricted choice.

The parent working two minimum-wage jobs can’t sleep, and eventually reason collapses in exhaustion, loosing the reins on emotions that run amok. Stress suppresses the activity of the immune cells that eliminate cancer. To control tumor growth, chemotherapy is prescribed, disrupting routine and raising anxiety even higher. Anger and fear surge, driving wedges into relationships. Isolation breeds depression, weakening the self-esteem that guards against dependency on pain medications.

So where is the clinician to start? Confronted with this tangled knot, it is perhaps necessary to specialize, to prescribe the popular drug, to see the patient as a machine to be repaired. For in fact the alternative – to truly care – is to confront suffering that cannot be relieved.

Or at least not in modern medicine’s cost model. Doctors and psychiatrists charging $200/hr. cannot undo all the harm wrought in lives lived at $8/hr.

This is the ground truth that drives Melanie Warner’s “The Magic Feather” to its conclusion. A firm subscriber to scientific materialism, Warner surveys the studies of integrative health and concludes that it would all go away if only doctors could allocate the time to build rapport with their patients.

Warner’s survey starts at the fringes of alternative health and works its way toward Freud’s hysterical conversion: physical disorders born rooted in psychological stress (teeth grinding is a familiar example).

Energy healing and aura manipulation is eventually categorized as synesthesia – the blending together of the senses that brings colors with sound. Practitioners are self-deluded. Shading over toward physical therapy, acupuncture is dismissed by reference to studies that show random needle pricks are no less effective than carefully defined treatments, a conclusion reinforced by scholarly work that reads the original manuscripts not as energy healing but as blood-letting. From there Warner attacks chiropractic, resuscitating the debunked cure-all claims of its founder before observing that manipulations have no permanent physiological effect. (I might suggest, however, that manipulation could reestablish awareness of muscles, and thus allow re-adjustment that brings relief. Physical therapists do something similar to stroke patients, pounding on muscles that have gone silent in the brain.)

To her credit, Warner recognizes that these treatments bring real relief to patients – relief that often appears miraculous. This leads to an analysis of research on placebo – the activation of a patient’s natural healing powers through simple acts of caring. This is not an effect unique to alternative health – many studies conclude that a medical cure is dependent upon the patient’s belief that healing will occur. This is substantiated by the opposite effect: Warner introduces us to the European discipline of psychosomatic (mind-body) illness (a discipline discredited in America by the prejudicial “it’s all in your head”). Therapy begins with a relocation to peaceful surroundings in which the patient can rebuild healthful communication between the mind and body.

Warner synthesizes her studies to conclude that only medicine can make real physical changes in the body. Her hope to inspire doctors to see the whole patient, however, is undermined by results from Harvard Medical School that show a decrease in empathy as students advance toward mastery of clinical procedures. That might be expected: medical students are adopting jargon and a station in life that makes it ever more difficult to relate to those most in need of their care.

Warner affirms that alternative healthcare will survive until doctors learn to build rapport with patients. As an intuitive healer, that suits me just fine, for I see in medical knowledge elements that inhibit that outcome.

Unfortunately in slighting the integrity of alternative health practices Warner leads consumers astray, and therefore deserves a rebuttal. I wish that she had focused less on high-profile practitioners that surround themselves in cultish authority. Humble practitioners may walk blind into a therapy and find themselves manipulating auras in ways that are only validated after-the-fact by client disclosure. That is my experience of Reiki. I cannot state authoritatively why that force refuses to submit to scientific examination but given how all scientific insight is channeled for military use – well, it’s not hard to guess why love would be reticent to have its secrets revealed.

Jesus said to those cured in his presence: “Your faith has healed you.” I wish Warner would give it an honest college try, and perhaps demonstrate to herself the foolishness of a standard of reproducible proof. After all, we are each unique, and love must adapt itself accordingly.

Book Reviews, Mind Management

Psychiatry in Disorder

Any accredited professional college must educate students on the legal requirements for their practice. In the case of hypnotherapy, in most states the law makes psychology a dominant field. I have been forced to turn away clients because their concerns might be due in part to an actual illness of the mind – something that I was unqualified to diagnose or treat. Sometimes that’s made easier because the client is actually under the care of a psychologist – I’ve learned to expect that I just need to turn them away, because I’ve never found a psychologist that was willing to work in tandem with me. They don’t even answer my e-mails.

In the gray zone are clients that have read the pop psychology press and tell me, for example, that they have “PTSD.” Given what I know about the diagnostic definition, I ask a few questions and determine that they probably have post-traumatic stress, or PTS. Now I can work with PTS, but not PTSD. Here’s the rub: I can’t tell them that they have PTS, because that would be a diagnosis that I am not qualified to offer. You can imagine how difficult this becomes with more common psychiatric designations: depression and general anxiety disorder, for example.

Against the backdrop of this frustration I now report on Anne Harrington’s “Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness.” Obviously I would like to be assured that there’s a valid scientific basis for the designations offered by psychologists – and something in their treatments beyond the power of suggestion. Because if that basis is weak, then the legal pressure I am under is hurting not just me, but my potential clients.

I regret, then, that Harrington mounts a devastating critique of psychology. It is not just that psychology has no sound scientific basis – the dynamics of its development have systematically brought suffering to those it characterizes as patients.

In considering the history surveyed by Harrington, I think that it would be generous to say that, desperate for some therapeutic method, psychiatrists have systematically seized upon symptoms as causes. Each generation of psychiatrists took up tools that addressed the purported cause of the era, only to discover that the treatment tended to increase the aggregate suffering of their patients.

This generalization applies to both of the broad classes of therapeutic approaches. The first assumes that mental illness reflects a biologic imbalance in the brain that can be treated with surgery or drugs. The second sees the imbalance as a learned response to a toxic environment that can only be corrected with therapy that builds new behaviors in a supportive environment. These two approaches are known popularly as “nature or nurture.”

Harrington’s history develops as a pendulum swinging between these two approaches, driven by shifting political winds. Reflecting the stark contrasts, psychiatry’s torch-bearers tend to be absolutists.

On the medical or nature side, anatomists first treated asylum patients as laboratory specimens, extended in their second era with legislative policies of sterilization and euthanization. This was followed by the practices of electroconvulsive therapy and prefrontal lobotomy. As biochemistry advanced, drugs were sought to target the specific pathways. Manipulation of metabolism (for depression and mania) was pursued using addictive drugs, followed in the modern era with drugs that target neurotransmitter balance. Unfortunately, Harrington reveals that early drug trials did not assess serious long-term side effects of metabolic drugs, and that more rigorous tests of neurotransmitter drugs show that they are only marginally better than sugar pills. Having hidden those results while marketing directly to consumers, Big Pharma is abandoning mental health under pressure from European advertising regulations that require that any new drug must be demonstrably better than existing remedies.

On the nurture front, Freud first blamed sexual repression for all mental illness. Mental institutes abandoned treatment to function largely as warehouses of sufferers deemed to be incurable. In the aftermath of World War II those concerned with valor blamed mothers for mental illness. Seeking early intervention, psychologists formulated categories of “deviance” that were seized upon by parents and schools as justifications for anesthetizing unruly youth. Finally legal decisions forced the disbanding of mental institutions, eventually leaving the prison system to step in as de facto provider of care for those that that cannot align their behavior with our civil codes. Of course prison society is not an incubator for civil behavior, and certain practices (solitary confinement foremost among them) are known to trigger psychotic breaks. While Harrington does not reference a statement of policy that blames the mentally ill for their condition, today American society does choose to punish them.

In grappling with these outcomes, psychiatry has recognized that therapies cannot be evaluated effectively until mental illness can be diagnosed accurately. Thus was born the institution of the Diagnostic and Statistical Manual. At this time it recognizes over two hundred conditions. Perhaps because of this complexity, Harrington reports that two clinical evaluations are likely to disagree roughly 70% of the time – and thus that treatment will follow different paths. Harrington does not report any studies that elucidate the discrepancies, but I am familiar with reports that suggest that overlap of criteria means that the diagnosis is often biased by clinical predisposition. If a psychiatrist has had success treating schizophrenia, they may look for schizoid symptoms and thus bias towards that diagnosis.

Harrington concludes her survey with the admission that the scientific foundations of psychiatry are vague, and calls for clinicians to return to basics. Should they fail, she foresees that they will surrender therapeutic initiative to those that lack prescribing authority: counselors, therapists and social workers.

I have deeper concerns. Hypnotherapists understand that the brain is not the mind – and this is a view shared by followers of Jung, who split with Freud over the matter. Through personal experience, I believe that the human brain is best understood as a multi-channel radio receiver, and that most of our thinking is done in the soul. This undermines biological investigation for the causes of mental illness. There may be correlations between diseases of the soul and brain biology, but attempts to change only the biology will be ineffective in treating the disease.

As a hypnotherapist, my response to Harrington’s indictment of her discipline was angry. Given that “science” was the justification for preferential licensing, it now appears that in fact the regulators were snookered by a chest-thumpers seeking to engage in restraint of trade. I plan on promoting Harrington’s revelations, and will be far more aggressive in seeking to help clients that have been disempowered by the industry.

For that is where the real answers are to be found: empowering self-care. After more than a century, the evidence is in, and the human mind is beyond biological understanding. Psychology should recognize that it is largely a philosophical discipline – which in the best sense serves to provide citizens with understanding to manage their minds and relationships. The obfuscating complexity of psychiatric terminology must be removed from public dialog, and replaced with something with greater utility. Perhaps the Kappasinian Theory of Mind?

Book Reviews, Specializations

A Geriatrician Advocates for the Elderly

When I reached 50, friends began advising me to color my hair. I laughed – given what I’d been through in my 40s, I was proud of the evidence that I’d made it that far.

In “Elderhood,” Louise Aronson reflects on a career in gerontology (the medical specialty that focuses on the elderly) to expose the cultural disease of opportunism that infects our experience of aging – both within medicine and the larger culture.

The challenge of caring for the elderly is that normal aging changes body chemistry, making invalid many of the strategies pursued when caring for adults. Since all medications and medical procedures are proven for adults, gerontologists must understand the entire body when planning care. The liver and kidneys no longer may be able to eliminate drugs before harmful side-effects occur. As conditions accumulate, physical therapy requirements may overwhelm the patient’s decreased stamina. And procedures designed to restore full functioning in younger patients may instead cut short the life of a less resilient senior.

Paradoxically, the complexity of caring for a senior created the opportunity for Aronson to operate for most of her career as a dying breed: the home-calling general practitioner. Financial limits meant that radical treatments were often out of reach to her patients, and so common-sense behavioral and environmental adaptations were acceptable options. Perhaps not surprisingly, many seniors report greater satisfaction with their care when offered options that preserve their social setting, whereas hospitalization would have left them isolated for long periods – if not permanently.

Unfortunately, Aronson’s written contribution to this public debate was triggered by burn-out. Systemic factors – medical specialization, rigorous reimbursement policies, and profit-conscious administrators – generated resistance to providing the kinds of care that were best for her patients. To illuminate those factors, Aronson’s writing develops two themes in parallel: how medical care should evolve as a patient ages, and then the professional history that finally drove her to collapse in frustration when praised for her outstanding performance. While laudable in intent, the mixing of these two stories dilutes the focus of the book. In the end, only the most careful reader can form an independent judgment about Aronson’s views.

To a degree, Aronson seems to have accepted this outcome. Her afterward opens with a quote in which another author describes his work as a polemic – as intended to stimulate emotions that would drive political change. Taking this as Aronson’s goal, “Elderhood” builds a strong case: 50% of doctors “burn out” as Aronson did, and leave medical practice. More desperately, young and heavily indebted doctors choose suicide at rates far higher than the general public. It is only the narrowly qualified specialists that thrive, and they are precisely those unable to deal with the complexity of aging. Aronson takes the point further, believing that myopia extends even to treatment of “normal” adults – precisely because there is no “normal” adult. The inability of the specialist to anticipate the side-effects of their treatments eventually traps patients in the medical system as the treatment of side-effects creates further side-effects until the patient runs out of financial resources.

From the perspective of hypnotherapy, however, it is the first thread (the evolution of care with age) that is most important – and specifically to those of us seeking to serve the senior population. Aronson draws upon her clinical experience to illustrate the shifting goals of aging patients. To distinguish them, she proposes that we consider the stages of senior, old, elderly, and aged. These are wrapped in life’s third act – elderhood (the first two acts being childhood and adulthood). Aronson’s purpose is to hone our sensitivity to the opportunities and challenges of growing old.

Most of society relates to growing old as the loss of youth. Those visible changes – wrinkled skin, gray hair, and decreased vitality – appear long before we lose our creative potential. Seniors, therefore, are those still seeking opportunities after leaving their adult career. Their unique gifts are discernment, patience, and a surrender of financial ambition that allows them to prioritize options that benefit their community.

Medically the principle concern for the senior is decreased recuperative capacity. Senior illness and injury can trigger a debilitating cascade that speeds decline. This is therefore the stage to begin defining preferences for managing the inevitable decline. Aronson sets the two poles of the spectrum as “breathing at all costs” and non-intervention. Aronson’s illustrations tend to support “comfortable longevity” as the best compromise.

As aging continues activity begins to match the expectations generated by appearance. We become “old.” In planning gatherings and outings, compromises are made for reduced stamina. This transfers to medication – “adult” prescriptions should be screened for new or enhanced side-effects. With conditions that require surgery, discomfort may best be managed with lifestyle changes.

“Old” is also the stage where social changes begin to cascade. This follows naturally as life-long friends relocate and die. While still fairly active, this may be the best time to move to a dedicated retirement community, simplifying lifestyle while developing new friendships. Aronson emphasizes, however, the benefits of multi-generational households – once a necessity but now an overlooked option that enriches the lives of both youngest and eldest family members.

“Elderly” follows when management of medical complaints begins to dominate our days. Aronson dwells on the challenges posed by America’s utilitarian ethic. Cab drivers speed away from elderly fares, and private and public spaces become inhospitable – both physically and socially. Aronson warns that our failure to accommodate the elderly condemns us to suffering in our elderly years and denies us the opportunity to reap the insights gained from their lived experience.

In treating the elderly, Aronson condemns our modern “disease management” system. Essential practical needs are not recognized as medical expenses, creating “penny-wise and pound-foolish” practices that allow minor inconveniences (such as nutritional deficits and hearing loss) to evolve into serious conditions before services are provided. Worse, when those conditions arise, the influence of medical specialists means that the course of treatment often depends on which doctor is available first.

Ultimately, of course, the principle concern is managing the decline of the “aged” to death. Even here, Aronson offers inspirational tales – a bed-ridden grandfather who became tutor to the neighborhood’s school children. She argues for advanced planning and hospice over the isolating and desperate institution of the nursing home.

While I only outline the changes that define the transitions between the stages of elderhood. Aronson’s monumental work draws upon her experience in geriatric practice to illuminate the psychological needs that evolve from reinvention (seniors), to isolation (old) to wellness (elderly), and finally into mortality (aged). While somewhat diluted by her indictment of the medical establishment, Elderhood is rich with insight for those seeking to support each of these distinct communities.

Book Reviews, Relationships

Imaginary Friends

Natural selection (Darwin’s evolution) drives animals toward faster, stronger, and more lethal. Greater specimens act freely, while lesser creatures scrabble in the shadow of death. Imagination changes that picture: lesser creatures still submit, but may observe and plan to turn the tables on their oppressors.

In society, the immediate merits of action and planning are obscured by ritual, rules and rights. The Greek philosophers admired the tyrant – a man capable of driving an entire city toward a common goal. To temper his excesses, the Fathers of the Catholic Church invented the feudal hierarchy: ownership was ceded to the tyrant, but the Church agreed to manage property (including vassals and serfs) only if the tyrant defended the commandments (foremost being “thou shalt not murder”). History tells us that to escape these constraints, the kings established secular universities. It was then left to their vassals to organize parliamentary procedures to reign in the tyrant.

In “Quiet”, Susan Cain dissects the status in America society of the balance between action and planning. As offered by Jung, the preferences carry the labels “extroverted” (for those that prefer action) and “introverted” (for those that plan).

The struggle is intensified by the tendency of individuals to prefer one or the other as a competitive strategy. From the title, you might expect that Cain is partial to introversion, and indeed she uses personal illustrations as she catalogs the costs of America’s deference to extroversion. The projection of ego has been designed into education, work, and social interactions. This allows the aggressive extrovert to monitor and disrupt planning. Cain implies that this is undermining the creativity that is the foundation of vibrant economies. Yet while Cain is sympathetic to the plight of introverts in this culture, she draws a balanced picture of the two types, concluding that they form natural partnerships.

Our personal preference is fundamental to the personality, evident in infancy and persisting through adulthood. The origin of the preference is obscure; Cain spends several chapters surveying the studies that explored the relative impacts of nature (genetics) and nurture (life experience). I concluded that there seems to be a missing factor – perhaps the biochemical milieu during gestation and infancy?

But the studies do illuminate the behaviors that distinguish the extrovert from the introvert. Planning requires information, and thus introverts are “sensitive.” The introvert in unfamiliar surroundings is hypervigilant to the point of exhaustion. This makes them shy of the public performances dominated by extroverts. Conversely, extroverts commit prematurely to goals, a tendency that can drive them to expensive mistakes (Cain references disastrous corporate mergers).

Cain prescribes two paths for strengthening the introvert’s hand. The first is the power of purpose in projecting introverts into public dialog. Cain uses her personal history as one illustration. As a legal advisor, she was terrified of public speaking. While still anxious before presentations, she is stimulated by the worthiness of her mission (coaching introverts to greater influence). Her first recommendation, then, is that introverts seek work that they value.

Using Franklin and Eleanor Roosevelt as examples, Cain’s second path illuminates the power of collaboration. The illustrations in this last section of the book become a little testy, particular in vignettes of group work in school that tend to bullying by the extrovert. But she concludes with vignettes that emphasize the value of allowing each party to lead in their domain of excellence.

Cain’s study is a valuable read for the hypnotherapist, but also sends up a warning flag for the Kappasinian practitioner. Kappas elaborated the categories as “Emotional” and “Physical” types of suggestibility and sexuality. Those distinctions are a powerful aid in therapy, but Cain’s exploration of introversion and extroversion is proof that psychologists are working toward those same insights. While Kappas’ theory is more pervasive – covering learning, communication, intimacy, and child rearing – it’s only a matter of time before those aspects are integrated under Jung’s terminology.