Transformative innovation in healthcare by British Holistic Medical Association

Volume 15

Issue 1

Spring 2018

JOURNAL OF

holistic healthcare Re-imagining healthcare

Innovation or transformation? Time to ditch health centres Prescribe community not pharmacy Curing plus healing Triggering self-transformation Spiritual staff renewal Empowering the dying Reconnecting with nature Levering lifestyle change Fun with therapeutic playlists

Plus â&#x20AC;˘ Research â&#x20AC;˘ Reviews

Transformative innovation in healthcare

JOURNAL OF

holistic healthcare

Contents

ISSN 1743-9493

Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Published by

Update . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

British Holistic Medical Association West Barn, Chewton Keynsham BRISTOL BS31 2SR journal@bhma.org www.bhma.org

Shifting the pattern . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Reg. Charity No. 289459

Changing the world one community at a time – the growth of an idea and the arrival of the orchids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Editor-in-chief

William House

David Peters petersd@westminster.ac.uk

Bill Sharpe

Unleashing health communities – stop building health centres . . . . . 7 Dan Hopewell

Integrating the art of healing with the science of curing . . . . . . . . . . . 14 Paul Dieppe, Sara L Warber and Emmylou Rahtz

Editorial Board Ian Henghes Dr William House (Chair) Dr Mari Kovandzic Professor David Peters Dr Thuli Whitehouse Dr Antonia Wrigley

The lost art of being with death. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Hermione Elliott

Nature as therapy Is nature-connection the antidote to the stresses and impacts of contemporary life? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Pat Fleming

Production editor Edwina Rowling edwina.rowling@gmail.com

Advertising The journal of holistic healthcare has a strong online circulation both nationally and internationally with thousands of page views every month. The journal is available in hard copy and online. To advertise email Edwina.rowling@gmail.com Products and services offered by advertisers in these pages are not necessarily endorsed by the BHMA.

Design

Transformative innovations for health A gathering of change-makers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Darkness, life-compassion and the seeds of transformation Notes and results from the front line of The Healing Shift Enquiry . . . . . . . 28 David Reilly

Making (sacred) space for staff renewal and transformation . . . . . . . 36 Rev Stephen Wright

Lifestyle medicine education – an answer to chronic disease? . . . . . 40 John Sykes

Music, medical school and curating wellbeing . . . . . . . . . . . . . . . . . . . . . 44 Jayne Garner William House . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

www.karenhobden.com

Research. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Cover illustration Helena Maxwell, www.inkythinking.com

Reviews. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Printing Spinnaker Print Ltd

Volume 15 ● Issue 1 Spring 2018

Unless otherwise stated, material is copyright BHMA and reproduction for educational, non-profit purposes is welcomed. However we do ask that you credit the journal. With this exception no part of this publication may be reproduced in any form or by any other means – graphically, electronically, or mechanically, including photocopying, recording, taping or information storage and retrieval systems – without the prior written permission from the British Holistic Medical Association. Every effort is made to ensure the accuracy of material published in the Journal of Holistic Healthcare. However, the publishers will not be liable for any inaccuracies. The views expressed by contributors are not necessarily those of the editor or publisher. 1

Editorial Creating the future we want Throughout the developed world an over-reliance on a reductionist, dualistic roadmap has driven healthcare systems into a three-headed crisis of cost, care and commitment. Now even the best-resourced systems are struggling to treat ‘lifestyle diseases’ and the long-term multiple problems of an ageing population. And, while levels of poor mental health rise, particularly among the young, under-resourced social care systems are buckling under the strain. None of this is likely to change for the better in the foreseeable future. When sustaining innovations work, they can make a failing system cheaper, faster, safer, more efficient. But if these temporary fixes only do more of what they have always done, they will only deliver what they have always delivered. This would be fine if, faced as they are with relentless demand, what healthcare systems are doing was actually working. But with austerity savings already robbing staff of the time and the humanity that good care demands, and with professional commitment rapidly flagging, errors piling up and staff burning out, the system’s precarious sustainability may soon hit a tipping point. Do we need only to pump more money into ‘the system’; to tinker with the way we do medicine, innovating to patch it up even though we know it to be in terminal decline? We might even lever in innovations to shake it up; though such disruptive innovations typically have at best only a short-term impact or get bolted on to mainstream delivery to help it sustain the status quo; or after a short pilot phase get ejected. There was a time for instance when many of us saw in complementary therapies, alternative ways of thinking about illness and the possibility of triggering wellbeing. Though we might still value these approaches, few who work in the NHS any longer view them as vehicles for the sort of system-wide innovation the healthcare crisis urgently demands. As it bites harder, the notion of having to rethink healthcare, and find ways of triggering wellbeing, are no longer seen as radical. But, as Graham Leicester says in his book (reviewed in this issue, page 51) ‘only transformative innovation can deliver a fundamental shift towards new patterns of viability in tune with our aspirations for the future’. This begs the question of what sort of future we are aspiring to; because the future we imagine will affect how we innovate, and how we innovate will shape the future. And indeed complementary therapies might be signposts to medicine’s future if they signify elements the mainstream lacks. If so it would be a future where society will support healthy ways of life and empower self-care, where care will be as important in healthcare as cure,

David Peters Editor-in-Chief

where medicine will promote resilience, and work with a fuller understanding of the body-mind and of humankind’s ancient relatedness to the other-than-human world. Ivan Illyich (1975) insisted that medicine must recognise its limits, for in its current form it is no more sustainable than is our industrial-consumer society, predicated as it is on limitless growth. If these entangled worldviews are now running into the buffers of the biosphere’s very real limits, then we must have in mind a much bigger idea about transformation, and a wider vision of the kind of future we want. It has been said (by William Gibson whose 1984 science fiction novel Neuromancer predicted the internet and virtual reality a decade before the web took off) that ‘the future is already here – it’s just not evenly distributed’. In November 2017 the BHMA and the Scientific and Medical Network held a conference hosted by the Centre for Resilience at the University of Westminster to bring together innovators whose projects may embody such fragments of the future. This future will depend on how we participate in creating the ‘Third Horizon’ (or fail to). What supports this journey or gets in the way was the subject of Bill Sharpe’s keynote. Dan Hopewell from Bromley by Bow Centre calls for a radical move away from our current ways of thinking about primary care. William House illustrates another, new kind of local empowerment. Paul Dieppe, Sara L Warber and Emmylou Rahtz share their research into healing and, on parallel tracks David Reilly and Stephen Wright expand our horizons through their encounters with profound shifts in self-experience and what can happen to mind and body when they occur. Hermione Elliott has found that such shifts can come about in attitudes to dying too – for an individual but also across a whole community. (You will be left wondering how such changes of heart and mind could affect medicine’s current assumptions about preserving life at all costs). Pat Fleming, in her article on eco-therapies, reminds us that though humankind may pretend it is not subject to the eternal cycle of birth and death, Nature is always available to help us reconnect. Finally in this innovations issue of JHH John Sykes provides us with some practical ways forward for managing chronic disease through lifestyle medicine. And in her lighthearted tailpiece Liverpool medical school’s Jayne Garner reminds us that medicine and medical school should sometimes make space for fun and music. After all, how will we create a better world if we don’t hear the music of time and surf the waves of change? It’s up to us. Illyich I (1975) Limits to Medicine. New York, NY: Pantheon Books.

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Volume 15 Issue 1 Spring 2018

UPDATE

Wounded Healer conference

Big bucks for CAM research

The full programme is now out for the two-day International Practitioner Health Summit 2018: The Wounded Healer on 4–5 October 2018 in London. It is aimed at doctors, nurses, pharmacists, allied health practitioners, dentists, counsellors and researchers in the field of practitioner health. The 10-year anniversary conference of the NHS Practitioner Health Programme will bring together the academic, clinical and experiential aspects of physician and practitioner health with a particular focus on mental health.

Here’s why the traction for integrative medicine is so much stronger in the US. In March 2018 Congress passed a federal budget for the fiscal year 2017/18 that includes $142,184,000 for the National Center for Complementary and Integrative Health (NCCIH). Congress established the centre to research the value and safety of complementary and integrative health interventions in improving health and healthcare. Recent research included Tai Chi for fibromyalgia patients; music for aging patients and cognitive decline; and plant-based meds for depression treatment. European researchers may well gaze in envy at what’s been possible in the US!

11th European Congress for Integrative Medicine Medical members might be interested in attending the 11th European Congress for Integrative Medicine, ‘The Future of Comprehensive Patient Care’. It will be held in Ljubljana, Slovenia, on 21–23 September 2018. The congress aims to ‘promote health and develop integrated and sustainable treatment for acute and chronic diseases’. The focus appears to be very much on non-mainstream treatments and traditional healing systems. www.ecim2018-slovenia.org

2018 International Congress on Integrative Medicine and Health This international congress expects to attract 1,200 participants. It will showcase original scientific research and the growth of integrative care in mainstream US healthcare. By the look of the programme the orientation will be evidence-heavy and driven by a concern to address mainstream effectiveness gaps – mental health, chronic pain, prescription drug addiction. The topics seem more mainstream than those of the European Congress for Integrative Medicine (see above) – acupuncture, nutrition, probiotics, mind-body medicine. May 8–11 2018. https://internationalcongress.imconsortium.org/program_ schedule.cfm

Soil, soul, society Those can-do Americans are at it again! The Regenerative Health Institute is joining with the Rodale Institute and the Plantrician Project with the aim of bringing about a global partnership to promote ‘true health, rather than disease-based, care… to train doctors and healthcare professionals that food is medicine and promote a predominantly whole food, organic, plant-based lifestyle’. The BHMA is looking to link up with this initiative. Interested readers will find inspiration by watching

Compassionate Frome project Local GP Helen Kingston set up the Compassionate Frome project in 2013 because too many of her patients were not being helped by medicalising and medicating their health problems. A directory of agencies and community groups (created with the help of the NHS group Health Connections Mendip and the town council) revealed many opportunities for ‘social prescribing’ and showed where new groups were needed for people with particular conditions. ‘Health connectors’ were employed to help people plan their care and voluntary ‘community connectors’ helped patients find the support they needed. Provisional results reported in the magazine Resurgence & Ecologist show that when isolated people with health problems are supported like this, emergency admissions to hospital fall spectacularly. Over the three years of the study, Somerset emergency hospital admissions rose by 29%, but in Frome they fell by 17%. As Julian Abel, consultant physician and lead author of the draft paper put it, ‘No other interventions on record have reduced emergency admissions across a population’. www.theguardian.com/commentisfree/2018/feb/21/town-cureillness-community-frome-somerset-isolation?CMP=share_btn_tw

National social prescribing conference The Compassionate Frome project shows the power and impact of the social prescribing effect. Yet medical students and junior doctors know very little about it. In February 2018 the College of Medicine and the Social Prescribing Network UK, in collaboration with the Royal College of General Practitioners and NHS England, held the first national social prescribing conference for medical students and junior doctors. Interest is growing fast. As one delegate said: ‘At medical school we were taught about the social determinants of health but not that we can change them. Now I know we can.’

https://www.youtube.com/watch?v=12gMp1SEvb8

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Volume 15 Issue 1 Spring 2018

INNOVATING TO T RANSFOR M

Shifting the pattern Bill Sharpe Independent researcher in science, technology and society; Visiting Professor, Digital Cultures Research Centre, University of the West of England

At the end of 2017 the Scientific and Medical Network and the BHMA, in collaboration with the Centre for Resilience at the University of Westminster, convened a meeting of change-makers to explore transformative innovations in health. Bill Sharpe introduced the Three Horizons approach to exploring transformative change: from the established patterns of the first horizon, to emerging visions in the third, via transitional innovations in the second (for a full description see JHH 12.1). Other talks gave inspiring instances of third horizon visions, and practice on the ground, but also saw how difficult it is to shift the bigger system. There is a sense that too many of us are working below the level where our actions resonate with the wider system. How could our fragments of the future make a bigger difference? Bill Sharpe provides some thoughts on this and how Three Horizons practice might be used to help us bring about wider change.

For over 30 years I’ve been involved in finding ways to think about the future, first as a research manager in the computer industry, and for the last 15 years working independently as a futures practitioner across all sorts of areas from sustainable transport to the arts and the future of healthcare. The Three Horizons practice has grown from my work with the International Futures Forum (IFF), which seeks to foster practical hope and wise initiative in the most complex issues facing our society.

The foundational practice of using three horizons is seeing everything in patterns. What this means is that we look at the world as patterns of activity that we all sustain and reproduce by taking part in them. Every day we get up and go about our business, typically doing things in much the same way as we did yesterday, and expecting to do the same tomorrow. We all rely on many patterns of life staying much the same, and expect them to be put right if something goes wrong – if a storm brings down the power lines someone comes out and fixes them. Visionaries look at the familiar, stable pattern and see its flaws, and set about bringing a new pattern into existence. From their point of view this will be a ‘better’ pattern, but we might not all agree, and even if we do, there is a lot of investment in the current way of doing things that creates huge inertia against change. So, if we are setting out to bring a new pattern into existence we have to take a wide-angle view of everything that holds the current pattern in place, and what has to change for it to be transformed. Here are six things that I find helpful to explore with people when using Three Horizons to develop their approach to transformative innovation.

Questions to explore Is there a way that society manages innovation of the sort we want to do? One of the most helpful things that Three Horizon mapping reveals is the

difference between sustaining and transformative innovation. In the first horizon there will typically be plenty of sustaining innovation going on, making the existing pattern function better, whatever ‘better’ means in its own first horizon terms, whether that is better fossil fuel energy systems, better antibiotics, or better weapons. Transformative innovation brings into being things that the first horizon pattern would just not do – such as the shift to renewable energy from fossil fuels, for example. As we explore our area of concern there are broadly two situations that are revealed by a Three Horizons mapping exercise, distinguished by whether or not we have arranged society to support the process of transformative innovation. For example, in democracies we have invented a social system that is generally able to accommodate change in policy, and the constitution within which policy is made, without the need for collapse and renewal of the system of governance itself. In earlier times, and still in other parts of the world, we are familiar with societal change requiring civil war, revolution, collapse or some other discontinuous change in the institutions of governance themselves. Similarly in market economies, we structure the three horizons in such a way that both sustaining and transformative change is enabled: we have the established companies in the first horizon that we expect to provide some stability, innovators funded by venture capital in the second horizon trying out new ideas, and third

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INNOVATING TO TRANSFORM Shifting the pattern

horizon research in universities that opens up new territory and prepares the ground for what Schumpeter called ‘creative destruction’ in which the new sweeps away the old – the way the www. has swept away many familiar ways of doing things. Many of our social systems, such as education and health, are set up to prioritise stability and consistency over renewal. This means that while sustaining innovation can be achieved and is actively supported, it is very much harder to bring about transformative change to a new third horizon. In tackling this, one response is to import market-based innovation into the system, but this of course brings many other problems. The challenge is to develop approaches to transformative change that can be used appropriate to the situation. The growing interest in the theory and practice of ‘systems change’, including my IFF colleagues’ work on developing a robust infrastructure to support transformative innovation, provides some encouragement for the future.

What pre-determined factors are creating conditions for change? Within the third horizon we need to distinguish those things that can be known from those that are inherently uncertain or ambiguous; and what we can influence from what we can’t. Paradoxically, the further out we look the more certain some things become. Like snow that falls in the mountains in winter and will surely flow as floodwater to the valleys in summer, there are emerging realities that lie beyond our control that are part of the landscape of the future to which we will have to adapt. In futures work these are given the name ‘predetermined factors’. Finding them is an important step in framing transformative action so that we work with the grain of change. For example, the spread of digital technology into the printing industry has played the role of a predetermined factor for a couple of decades now and continues to

restructure more and more areas. Demographic changes are another powerful factor, with ageing populations driving change throughout health and social care, while pervasive access to online health information is dramatically shifting our relationship with health professionals. We are most likely to be successful in bringing about change when we can align ourselves with powerful predetermined factors that surround our area of concern and configure them to the vision we are championing.

Who configures the current pattern, and are they going to be the ones to drive the change? A societal pattern of life is held in place by three underlying behaviours: producing, using, and governing. These roles can be combined in one person or spread out across society. In my home I cook the meal, eat it, and maintain the ‘rules’ of what to eat and not to eat and how much to spend on it. This behaviour is embedded in patterns at local, national, and international levels in which these roles are played by food producers, consumer behaviour, and rules on food production, trade deals and so on. Transformative innovation has to encompass all three of these behaviours and any one of them may be the origin of, or major barrier to, change. The fate of GM food illustrated this, with producers championing change, resisted by consumers, with governments caught between. Some changes can be instigated by user behaviour and activism that engages governance – like gender rights – but others cannot happen without sustained innovation from producers supported by governance – the shift to electric vehicles for example. Bottom up innovation can be successful by operating on the margins of the existing system, engaging as little as possible with the first horizon mainstream producers and governance, recruiting users into a new pattern. This is the classic model of ‘disruptive innovation’ – finding new users for a new approach, offering something quite different, building up momentum until you are able to challenge the status quo.

Can we configure new resources for what we want to do? It is easiest for new patterns to get going when they harness resources that are not captured by the existing system. The web opened up a whole field of fresh ways to do things that fuelled the dotcom boom as entrepreneurial ventures rushed into the unoccupied second horizon space. This boom was followed by bust as many of these ventures failed, but out of that time have come the new

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INNOVATING TO TRANSFORM Shifting the pattern

dominant players such as Amazon, Google, Facebook, Apple and many others that have restructured old industries. It can be very creative to think about the third horizon in terms of what sort of abundance is being configured, and who is taking on the role of producer. The success of social media is in large part because it aligned with our desire to communicate and sustain relationships – a desire that seems to expand to fill the available space, just as our desire to travel fills the roads. It can be particularly difficult to pioneer change that harnesses our own role as producers but does not align with significant market opportunities – this is illustrated for example by the challenge of shifting people out of cars to walk and cycle.

Is there momentum building for change, and who might be the prime movers to configure a new regime? It is very noticeable when you facilitate a three horizon conversation whether you are getting lots of examples of third horizon visions and second horizon innovations. If people quickly list lots of second horizon initiatives they know about and third horizon ‘pockets of the future in the present’ it means that change is under way on a broad front and the question then becomes which vision of the third horizon will prevail, and who are the prime movers who will shape it. By contrast, in some three horizon sessions we hear an aspirational vision of a better world, but very few examples or evidence of visionaries and entrepreneurs attempting to bring such a vision about. Between these two extremes a common situation is that there is quite a lot of visionary action creating pockets of the future, but little sign of broader momentum in the system. First horizon systems can tolerate a lot of innovation around the margins without changing. If there are no major pre-determined factors putting pressure on the first horizon system, or opening up opportunities in the third, then we cannot expect visions to get much traction for change.

Can we convene the future? Turning from analysis to action the question to ask ourselves as innovators is whether we can assemble enough of the third horizon pattern we aspire to that it can grow and attract resources. If our ambition is purely local we may be able to survive within the dominant social first horizon and become a pocket of the future. But if we want to shift the whole system then we will need to enrol and mobilise the community of producers, users and governance in such a way that they can eventually take over resources from the first horizon. This convening of the future will go through stages, where first we stand apart from the first horizon, not allowing it to prevent our

innovation. Then we have to start enrolling the players who can grow a complete pattern, and then we have to mobilise the change that will shift resources from the first horizon into the third, which itself will then become the dominant, stable first horizon pattern.

Where are we in healthcare? I have been around many discussions about healthcare using Three Horizons, and my colleagues in the International Futures Forum have written up our experience in this area in detail (IFF, 2018), but I am not an expert in health and my comments are those of an outsider. The first horizon pattern of healthcare faces many challenges but also has a very strong system of sustaining innovation. New discoveries open up ever more, and ever more expensive, ways to treat a widening set of health conditions, and bring them within the existing model of treatment. The first horizon is not going to lose momentum in the near future, despite the many challenges it faces. Innovation will therefore have to get going around the margins of the existing system and build up its own momentum in areas where it can bring something really new into existence. Attempts to bring about transformative change within the system will typically only be tolerated until they really challenge for resources. All around the world there are many pockets of the future in the present that are promising examples of such really new approaches that could grow in scale and scope. There is a strong resonance with emerging need as we see the growing epidemics of chronic life conditions for which the conventional approach has no solution. Many of the technology trends that reinforce the existing system can also empower new models of provision, bringing people together to support their own flourishing in new ways. At least in the UK, the routes to change therefore are about transformative innovation management, looking for those visionary leaders in the system who are suffering from the emerging failures of the first horizon and can create space for the new to grow. What we have learned in the IFF is that to get started the first horizon has not just to say ‘no’ – it has to create a space in which the new system can get going at a small level to test itself out. Then it needs time to complete a design of all the elements of producing, using and governing. And then it is ready to grow, and the first horizon needs to say ‘yes’ and start to provide real resources. The leadership to achieve this is different to first horizon leadership, and relies on the capacity to manage the dilemma between sustaining the first horizon – we cannot allow the existing system of care to collapse – while navigating the pathway to the third. IFF, 2018 (in press) SHINE: Changing the Culture of Care. Fife: International Futures Forum.

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Volume 15 Issue 1 Spring 2018

HEALT HY COMMU NIT Y

Unleashing health communities – stop building health centres Dan Hopewell Director of Knowledge & Innovation, Bromley by Bow Centre @HopewellDan

Today the Bromley by Bow Centre is an internationally acclaimed organisation that has developed a distinctive response to the complex issues facing a community with very high levels of health inequality and deprivation. Its pioneering model integrates primary care with an exceptionally comprehensive range of services that engages the community and focuses on improving the wider economic and social determinants of health, alongside high quality clinical services. The mission of the charity is to enable people to be well and live life to the full in a vibrant resourceful community.

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Volume 15 Issue 1 Spring 2018

My first-hand understanding of the transformative power of community agency came through 15 years in Cuba and Nicaragua painting murals and developing community arts programmes. Working with communities through the medium of public art, I was privileged to participate in societies overcoming legacies of disempowerment and underdevelopment to create development approaches that most improve the lives of those who were most marginalised. Arriving at the Bromley by Bow Centre in 1999 I was immediately struck by the similarities of understanding, that how one does things is the key to the outcomes that people and communities are whole, and require coherent, holistic, integrated approaches. Through 18 years at the Bromley by Bow Centre I have been variously: arts tutor, Director of Learning, Director of Services, Director of Strategy and now Director of Knowledge and Innovation, leading its School of Integrated Solutions. The school carries out research and evaluation programmes, supports ongoing innovation and shares knowledge in the UK and across the globe.

Social determinants of health Professor Sir Michael Marmot published his seminal report ‘Fair Society Healthy Lives’ in 2010. It was a comprehensive review of the causes of health outcomes and contained a damning indictment of the health inequalities prevalent in many of our most deprived communities in the UK. One of the key contentions of the Marmot Review, and one that has been continually affirmed ever since, is that positive health outcomes are significantly more influenced by social and economic determinants than by clinical determinants. Indeed, the conclusion of the report and the subsequent work of Professor Marmot’s team at the Institute of Health Equity at UCL, broadly suggests that our health and wellbeing is up to 90% driven by social and economic determinants and by as little as 10% by clinical factors.

Yet despite this evidence little mainstream health policy seems to take the findings of the Marmot Review and turn them into a new and radical approach to how we both define health and wellbeing and how we create and deliver provision in communities that more effectively promotes them. As Professor Marmot himself asks, ‘why treat patients and send them back to the conditions that made them sick?’ It feels like our attention has been deliberately drawn into an important, but nonetheless constrained, conversation about the integrating of health and social care. It seems to be that this narrowly defined ‘health and social care debate’ has had two consequences: • First, it has enabled the principal focus to remain on how the public and statutory systems talk to each other. Not exclusively, but largely. There is a constant flow of earnest initiatives that propose the pooling

HEALTHY COMMUNITY Unleashing health communities – stop building health centres

of health and social care budgets and structures and forcing a new way of working. This seems to keep the thinking away from a more radical debate. • Second, the ‘health and social care debate’ has kept us away from the conclusions of the Marmot Review, including the fundamental questions which inextricably link health and wellbeing outcomes with their economic and social determinants. It resists the awkward question about how we unshackle the central control of health and health creation and unleash it out into communities.

The story of a real person The Bromley by Bow journey and the model we have developed has been heavily influenced by the life and sad death of a young East End mother who died of cancer over 20 years ago. She died in tragic circumstances. Her name was Jean. She was a single mum with two kids and she had two brothers that she looked after and elderly parents who needed a lot of support. There were two sides to Jean’s story.

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The key to this different approach lies in creating centres of health and wellbeing in our communities

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The first was that she fell through all the nets of statutory provision that she, and we, reasonably expect to be there for us. The health system didn’t work for Jean. The social care system didn’t work for Jean or for her family. In short, everything that could go wrong went wrong. Jean was badly let down by the state. But the other side of Jean’s story was much more life-affirming. Just as the state was busy letting Jean down something very interesting, and very normal and human, happened. Suddenly there was a rota for going to the launderette and doing her washing; people were going off to Tesco to get her shopping; Jean was inundated with offers of help…‘I’ll come in and look after the kids for you this afternoon’…‘let me sort out dinner for your mum and dad’… ‘let me know when you’re going to the doctors and I’ll come with you’…‘let me speak to the housing office about that repair that needs doing’. Jean was being cared for. But she wasn’t being cared for by professionals, but by young mums like her. Women who were as vulnerable as she was. She was being cared for by the community, in the community. She was having the social determinants of her health addressed. Some months later there was an enquiry at the Royal London Hospital into the circumstances of Jean’s death. That, in turn, led to the building of the first healthy living centre in Britain at Bromley by Bow. This was the first health centre in Britain to be owned by the patients and

rented to the doctors. Something had shifted in who owned health in that community.

A more radical approach is needed The experience at Bromley by Bow suggests the need for a more radical approach in our health planning and less control from the centre of government and public agencies. We need radical community-based solutions that don’t just focus on the symptoms of disease, but focus on the wider economic and social determinants of health. Public Health England is at the vanguard in the battle to build healthy communities. And its leadership is very clear that the key to healthier communities is empowering communities to achieve change.

Broadening our definitions of health The key to this different approach lies in creating centres of health and wellbeing in our communities that address the full range of health determinants. These will differ from place to place. It will be different in leafy Richmond to inner city Moss Side. That’s why we need to resource health at local levels and in doing so, fully embrace every model of delivery that is likely to promote wellbeing, as well as narrowly defined clinical health. If we have a broad definition of health then we will also need to have a broad definition of what communitybased approaches look like, in terms of buildings, open spaces and partnerships. They might not look like health centres. They might be owned by patients. Clinical health may just a small percentage of what goes on inside them. They might be drive by communities and not by the NHS, or local authorities. We need to have a big purpose in our pursuit of a healthy community. We all know it’s possible to be diseasefree, but have a poor sense of happiness or wellbeing. It’s also possible to be clinically very ill, yet have a positive sense of wellbeing. We start to really address the big health questions when we broaden our understanding of what we mean by ‘health’. That’s when we really start to be radical.

Stop building health centres Today the Bromley by Bow Centre offers a vast array of services to its local community. They stretch from conventional healthcare for local residents to opportunities to set up your own business; from support with tackling your credit card debts to becoming a stained glass artist; from learning to read and write to getting a job for the first time or a helping hand up the career ladder. The centre’s School of Integrated Solutions hosts thousands of visitors every year who come to learn from its experience and who want to see the model in action first-hand. Many of these people are leaders of health systems from the across the UK and globally. Recently, in

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Volume 15 Issue 1 Spring 2018

HEALTHY COMMUNITY Unleashing health communities – stop building health centres

one of our seminars a Darzi fellow asked: ‘What do you think we learn from the Bromley by Bow Centre’s experience about how we should build health centres in the future?’ The answer was very simple: ‘Don’t build health centres!’ This is not an argument that denigrates clinical health. On the contrary it positions it within a broad range of services that drive wellbeing in communities, by creating a locally blended offer, where doctors sit alongside others – including a wide range of non-clinical professionals, patients and local residents – in order to provide what people need. It encourages the design of high quality clinical spaces, but enables them to be owned by communities in buildings that are accessible and fully integrated. Not in a ‘them and us’ culture (which sadly still prevails across much of the health and social care system) but in a fully holistic and integrated culture.

Unleashing healthy communities And, of course, creating buildings which act as ‘centres of the community’ not just ‘health centres’ makes sense for so many other reasons, not least financial reasons. The people who operate successful department stores, like John Lewis, will tell you that the idea of a well-run shop where you can offer a whole range of products, makes

complete sense for the customer and complete financial sense for the business. You can ‘capture the customer’ and have the opportunity, in the convenience of one place, to offer myriad products and services. This is the same principle in integrated holistic centres where health is about life and living, not just disease and illness. It’s about sweating our community assets and ensuring that one investment in a new set of buildings creates benefits and savings across a whole range of Whitehall departments, not just the Department of Health. Popular myths would have us believe that there are very few avowed disciples of the silo approach left. Yet in many parts of Whitehall and the health system it seems to remain the prevailing culture despite a nod toward the integration of health and social care. But that is such a small part of the story that the Marmot Review pointed us to. We need much more of the full service department store. It has to focus on an approach where we stop building health centres and start building centres in communities; places that really address all of the factors that determine wellbeing. And in so doing, we will start to create a way of working which liberates the health system to dance with a whole range of services that can combine to empower individuals. And ultimately create new and healthier communities.

Integrative Medicine Diploma Are you a statutorily registered healthcare professional who would like to know more about integrative medicine and how it might transform your clinical practice? This two-year Diploma in Integrative Medicine offers knowledge and skills around holistic healthcare and consulting, complementary and lifestyle approaches including an understanding of social prescribing methods. With online and face-to-face learning and an emphasis on critical analysis, this course will enable you to reconnect enthusiastically to your professional life and support patients in the prevention and management of long-term conditions. Apply now for the October 2018 intake. Deadline for applications 1st September 2018. Bursaries are available. Join us on our next open clinical day on Friday 11th of May 2018 at Engineers’ House. The topic for the day is 'New options for managing musculoskeletal and gut health using an integrative model of care'. Our Autumn open clinical day is on Friday 5th October, in collaboration with Penny Brohn UK, ‘New options for managing cancer using an integrative model of care’.

Contact Patti Aberhart for more information on both these open clinical days and for diploma enquiries: patti.aberhart@portlandcentrehealthcare.co.uk.

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Volume 15 Issue 1 Spring 2018

SO CIAL PR ESCR IBING

Changing the world one community at a time – the growth of an idea and the arrival of the orchids William House Chair, BHMA trustees

This is a story of a triple transformation. Two of them are well under way and the other is just getting going. Of course, transformations never finish, and it’s hard to pinpoint exactly when they start, but we like to flatter ourselves into thinking that we help bring them about! The first is a transformation of me, about finding my own power and about creating a set of conditions that help other people to find theirs.They can then undertake the second transformation, of a small town in the direction of health creation.The third transformation, to a wildlife garden, is a mirror for the human changes around it.

This article is partly autobiographical, so I will just say that my practice of medicine, my role in the BHMA and my approach to community development have all been strongly influenced by my interest in the creative arts. I owe this to my late parents and to my wife and our children who have all valued creativity and inspired me in their own unique ways.

‘The world is never starved for want of wonders, but for want of wonder’. GK Chesterton

I will start my story six years ago, though like all good stories it really started long before. On February 20 2012 I sat with a group of good people around Sheila’s dining room table. Sheila is one of those wonderful people who dedicate themselves to their community. My admiration, even awe, comes from my own inability to be like her, though we do share one quality: we never give up! Sheila had been working with her community for 30 years, while I had been preparing for this moment of sitting around her table, for a mere 14 – but more of that later. There were four of us round the table; the others were Andrew, an Anglican clergyman from South Africa but now working with our local parish, and Christina, another dedicated community worker involved with launching a small community centre in a deprived part of the town. As for me, I had just retired after 32 years as a GP, nearly all of it serving our small predominantly middle class commuter town, Keynsham, between Bath and Bristol in south west England. There are many like it, but they are all unique

and require unique solutions; just like people. I had undergone my own transformation from a tall, thin and geeky, just 18-year-old, starting at medical school, keen on art, motor mechanics and science; to a rather stooped and bald 64-year-old, enraged by political folly, NHS managerial and strategic ineptitude and widespread failure of imagination. By 2012 I had somehow managed to sublimate my anger into a passion for change, vaguely formed at first. But crucially I knew this: the patients, many of whom I had known through the lens of suffering and medical ritual for 27 years and had grown to love, they will be the agents of change. A key outlet and influence since settling into general practice was behind the converted barn to which we moved in 1987: a large plot, lately the concrete farmyard, converted by the developer into waste ground with rubble and opportunistic and aggressive ‘weeds’. This was to be our wildlife garden – more on this later. *** So this is a story of three transformations: my personal one, the transformation of the waste

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SOCIAL PRESCRIBING Changing the world one community at a time – the growth of an idea and the arrival of the orchids

ground, and the transformation that Sheila, Christina, Andrew and I (and now very many others) are striving towards. I am doing this because only the ordinary people have the power to achieve the depth and scale of change that our culture requires. But surely, you may say, the power sits with our government and our parliament through our elected representatives! Think again! These things are too important and much too difficult to be left to the politicians. ‘Never doubt that a small group of concerned citizens can change the world. Indeed, it is the only thing that ever has.’ Margaret Mead, cultural anthropologist

For a long time I had not believed what Margaret Wheatley and many other writers had been saying. But neither could I understand why our society seemed unable to address, or even admit to, many of the obvious societal causes of ill health which wreak havoc in all communities, poor and rich. As GPs, we were required to diagnose and provide remedies for disease. We were not required to ask awkward questions. When we did, the managerial response was to ignore both the question and the questioner. By 1997, 16 years after joining the practice, I could take it no longer. I took an expensive option: a fivemonth sabbatical leave from the practice. With the help of Bristol University’s newly appointed professor of ethics in medicine, Alastair Campbell, I began my transformation. The professor gave me a reading list. The first book was After Virtue by Alasdair McIntyre. I was daunted! Being a very slow reader I had never developed the reading habit. But this had to change. At the age of 50 I started to read – slowly, diligently, painstakingly, always making notes as I went along. At first it was mostly philosophy, then expanded ever wider into science, creative arts, theology, economics, human ecology and much besides. I found myself writing reflections in the form of a novel with a GP as the central character, and the critical, sometimes mocking, voice of the philosopher whispering in his ear. It was liberating and fun! At the end of the five months I returned to work full of excitement and inspiration. It was as if I had been half blind and could now see. I was like a young child again, wanting to tell everyone about my discoveries. But all the people reacted just like my own parents had, they did not want to listen: too tired, too busy, too difficult. So I searched for the centre of power so I could influence and persuade, even becoming a GP commissioner in practice-based commissioning days. But as Bertrand Russell famously said: From any particular perspective, the locus of power is always somewhere else. Over the next 10 years I found ways of coping. I continued to read and make my notes. I abandoned the writing of the novel and turned instead to the more convivial writing of stage plays, some finished, a few produced. I also worked with one of the practice nurses to create and conduct small research projects within the practice often

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connected to the creative arts (Ferguson et al, 2012). At home was my artist wife, Poppy, our two teenage children, dogs and a wildlife garden. My family gave me meaning and love, but at first, the garden was seemingly unconnected to medicine and health – more an obligation to do something with the large plot of mud, stones and weeds that came with the house. But my reading showed me the central role of nature in understanding the human predicament – more on this later too. So I survived. The family was blossoming, I loved my work with patients, the research was inspiring, but still I was weighed down by the increasing stupidity of the system and the worry that by propping up a failing culture we were harming all our prospects for the future. Then in 2006 everything changed. I received a phone call from the delightful and lively Annie Banbury from the local public health department. She was wanting to involve GP practices in public health work. In a flash, I knew what should be done – social prescribing (SP). This was an almost unknown term in those days but there had been a small SP scheme in Keynsham in the late 1990s which sadly folded. Soon I found myself, after 25 years as a GP in the town, for the very first time meeting with people involved in community development – surely a measure of the professional isolation of the medical fraternity. For me, it was a revelation! This project culminated in 2009 with an important publication on social prescribing (Brandling and House, 2009). By then I had retired from my partnership at the practice and spent a couple of years as a commissioner, experiencing first-hand the obscure and paralytic topdown processes of NHS decision-making. So I was astonished when, on 6 November 2009, the practicebased commissioning board (I was hanging in there as a member) invited me to ‘do something about health and wellbeing in the community’. There was even some funding for a while. I jumped at this challenge. I would use it to set up my own organisation and it would work

SOCIAL PRESCRIBING Changing the world one community at a time – the growth of an idea and the arrival of the orchids

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My reading showed me the central role of nature in understanding the human predicament

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It was shortly after writing this article that I realised that these plans were about creating a nurturing environment and how similar this was to the gardening for wildlife I had been doing for 25 years! Wildlife gardening involves creating a setting in which both humans and wild things can thrive. I had included five different habitats (meadow, hedgerow, pond/wetland, woodland and human – lawn, flower borders, vegetable patch, orchard – of course, the wildlife occupies all of it!) to attract a diversity of wild plants and creatures. Gradually, they were finding us, settling in and thriving. The garden was acting as a single ecosystem. Would a similar approach work with a community of 15,000 people and growing? My 2010 article became a blueprint for action, a new strategy for wellbeing and self-reliance (House, 2010). *** So I now return to Sheila’s house, but we have fastforwarded to March 2018. Our little group of four has grown to eight. We now welcome Alastair, retired diplomat and head-hunter, who is passionate about sustainable living; Sarah, once a doctor and now photographer, is strong on creativity and social media; Kathleen is

committed to engaging with the local authority; and Mike is an Anglican priest with a remit for community engagement and (crucially) experienced in fundraising and business. The organisation that the group leads is now called Keynsham Action Network (KAN) (www.keynshamactionnetwork.co.uk). ‘Keynsham Action Network is an experiment. We want to see if this mostly middle class town can come alive. We are doing this because the world needs people who have come alive.’ Inspired by a quotation from Howard Thurman (Bailie, 1996)

So, how has it been going since that fateful meeting in 2012? KAN’s role is a cross between social prescribing and so-called ‘asset based community development’ (ABCD). But like so many labels, this misses the deeper truth essential to people ‘coming alive’. The transformative process requires a central place for the uniqueness of both the individual and the place. Fulfilled people become assets to the place but this is incidental to the personal experience of a new sense of belonging, of being ‘known’, recognised, valued, of feeling they matter. These experiences emerge from human interactions concerning shared values and aspirations. This needs community networks that give every person an opportunity to connect. Social media can act as signposts but not destinations. They do not substitute for the human smile, the touch, the recognition, the token of kindness. So if we think of social networks as the circulatory system of the community, it needs to be kindness, generosity, tolerance, shared enthusiasm and not least, imagination, that flows around those arteries.

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I recognised that communities are each unique and the desire and approach to change must emerge from within

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directly with the community and would empower the people so they had less use for the state. My reading had shown me the potential power of a community and that SP was only a first step. I recognised that communities, just like the human beings that comprise them, are each unique and the desire and approach to change must emerge from within. It is vital that the actions taken are what the people want and not what outsiders think is good for them. Being more technical about this, a complex systems approach emphasises the importance, not only of the community’s history, but also the interactions between community members within interwoven community networks. This ranges from a nod and smile of recognition when passing in the street, to shared activities and thoughtful conversations. All of these contribute to a sense of belonging and of being ‘known’. This helps life to have meaning for the individual, but more widely, these connections generate human energy and establish the culture and values of the community in a dynamic way. Crucially, it helps people to care – about themselves, about one another, and about their environment. The built environment must facilitate opportunities for all of this. I tried to capture some of these ideas and other thoughts in an article published in the JHH (House, 2010).

We do this by inspiring, encouraging and supporting both individuals and groups. We aim to foster a nurturing and nourishing environment within which the people interact and find their own wonder. Gradually social norms change. The website (www.keynshamactionnetwork.co.uk) gives some idea of the range of our initiatives. So what has happened since that natal gathering in February 2012? Perhaps the most noticeable change in the town has been the spirit of collaboration between organisations. Keynsham was previously known as a place with much voluntary action going on, but little sense of connection or coherence. Now it is normal for the many clubs and organisations to work together rather than compete with one another. This is exemplified by the very successful ‘Live Simply’ project (http://live-simply.co.uk/ what-were-about). This started in 2012 with a group of

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SOCIAL PRESCRIBING Changing the world one community at a time – the growth of an idea and the arrival of the orchids

church members approaching us for help in promoting sustainability. The response was to support them in putting on public events in Keynsham with international speakers on sustainability-related issues, often linked with Keynsham Music Festival. The most recent event in December 2017 featured Patrick Holden, Founding Director and Chief Executive of the Sustainable Food Trust. This was a collaborative event led by Live Simply with nine other local organisations. Among the many other speakers in the past six years were the ‘reverential ecologist’ Satish Kumar, and the Scottish human ecologist and activist Alastair McIntosh. Check the website (http://live-simply.co.uk) for other activities and events over the years. Live Simply is now a very successful independent organisation at the centre of a growing sustainability movement.

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The most noticeable change in the town has been the spirit of collaboration between organisations

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The vibrancy of community organisations and networks sets the scene for KAN’s most fundamental task: to connect the people. This goes beyond enabling individuals to feel that we belong and that we matter, it is ultimately about caring for ourselves, for one another and for our environment. This is not only dependent on the extent of the person-to-person networks, but crucially on the quality of the interactions. To enhance this quality of interactions, we previously tried an approach based on doorstep conversations but, for several reasons, this was not feasible. We just launched another approach called ‘Good Conversations’. This has emerged from a collaboration with members of the Fife Shine project and the International Futures Forum (IFF) both based in Fife, Scotland (Hannah, 2014). As I write we have just held our first training day for the Good Conversation skills, funded by the St Monica Trust. This was attended by a wide range of local professionals involved in health and social care (including two GPs), together with both volunteers and employees in local voluntary organisations. There is much excitement around this.

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Finally, I return to the garden. In the Summer of 2017 four pyramidal orchids appeared for the first time in different sites across the garden. The seeds probably floated over the wall from the little churchyard next door – a meaningful connection perhaps? They had probably been in our garden soil for years, waiting for the right conditions. Wild orchids will grow only if the soil contains a certain fungal mycelium – a network to feed them. Without this, the microscopic seeds simply lay dormant, like so many humans who have become disconnected from life, from the caring and generosity that nourishes human connection. So the world is deprived of the beautiful orchid and the wondrous gifts that so many humans would have to offer. Now, like the orchids, they are beginning to emerge from the darkness in response to ‘…a patient and increasingly skillful love-making that [persuades] the land to flourish (Hawkes, 1951; Kellert, 1993). ‘[The] most important ecological processes are prominently manifest at the bottom of biological food chains.’ Kellert, 1993 Bailie G (1996) Violence unveiled. New York, NY: Crossroad Publishing Company. Brandling J, House W (2009) Social prescribing in general practice. BJGP 59(563): 454–456. Cooper DE (2018) Mystery and the way of the garden. Resurgence No. 306: 20–24. Ferguson P, House W, Nettelfield P (2012) We are not human beings in medicine any more, JHH 9(2): 38–44. Hannah M (2014) The patterning of hope, JHH 11(2): 7–11 (especially The Fife Shine Project p9). Hawkes J (1951) A land. New York, NY: Random House. House W (2010) The community and the chocolate factory. JHH 7(1): 20–23. Kellert SR (1993) The biological basis for human values of nature. In: Kellert SR and Wilson EO (eds) The biophilia hypothesis. Washington DC: Island Press, p47.

Useful reading Alinsky S (1971) Rules for Radicals. New York, NY: Random House. Capra F (1996) The Web of Life: A New Scientific Understanding of Living Systems. London: Harper Collins. Freire P (1970) Pedagogy of the Oppressed. New York, NY: Continuum. Illich I (1973) Tools for Conviviality. London: Harper and Row. McIntosh A (2008) Rekindling Community: Connecting People, Environment and Spirituality (Schumacher Briefings). Totnes: Green Books. McIntosh A (2001) Soil and Soul: People versus Corporate Power. London: Aurum Press.

INT EGRATING HEALING

Integrating the art of healing with the science of curing Paul Dieppe University of Exeter Medical School

with

Sara L Warber University of Exeter Medical School; University of Michigan Medical School

Emmylou Rahtz University of Exeter Medical School

I am a doctor who has had two different medical careers – the first in academic rheumatology, where my special interest was in osteoarthritis; the second in health services research, where I became particularly interested in placebo and nocebo responses. I have always ‘known’ that there was more to good medicine than the application of materialistic science alone, and have believed that human caring is a crucial part of helping others when they are sick. I am currently emeritus professor of health and wellbeing at the University of Exeter Medical School, where I am able to pursue my longstanding passion, by doing research on healing, in collaboration with a multidisciplinary team of colleagues based in several different countries. Paul Dieppe

Introduction The biomedical science of curing diseases needs to be balanced by the art of promoting healing. We have asked members of the public what healing means to them. Based on the findings, and on other current research we are undertaking, we suggest that key elements to the facilitation of a healing response include: 1) caring, loving human interactions, 2) feeling safe, 3) connecting with other living things and with the natural environment, and 4) creativity.

The theme of this issue of the Journal is Transforming innovations for health. In our view, an important transformation that needs to take place is the (re)introduction of a culture of healing illness, alongside the pursuit of curing disease. Healthcare in the West has become totally dominated by biomedicine, with its rigid, reductionist, materialistic approach to the prevention or cure of disease. This paradigm has, of course, been startlingly successful in many ways: eradicating some infectious diseases, controlling others, developing effective therapies for many disorders, and transforming people’s lives through fantastic surgical achievements such as hip replacement or cataract removal. But there remains much illness, suffering (and disease) left over; indeed medicine’s effective interventions often save lives, but leave people damaged, distressed and in desperate need of caring and healing. Modern biomedicine pays relatively little attention to illness, will have nothing to do with healing, and has

no answers for the suffering that comes from societal problems such as loneliness, loss of identity, loss of meaning in life, and alienation. As Rachel Naomi Remen (2010) has said: ‘We thought we could cure everything, but it turns out we can only cure a small amount of human suffering. The rest of it needs to be healed. And that is different’.

What is healing? Within biomedicine the term healing is used to describe the repair of wounds and tissue damage, such as skin healing over, or the healing of a fractured bone. In complementary and alternative medicine (CAM) the term is used much more widely, and can be a verb, a noun or an adjective (Levin 2017; Hufford 2017). The word comes from the old English ‘healan’ which means wholeness, and CAM practitioners often use it to denote the achievement of wholeness of mind body and soul. Academics who have studied the subject use a variety of concepts, such as ‘from feeling ill to wellness’ (Kirmayer, 2004); ‘a process of restoration of the whole person and

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INTEGRATING HEALING Integrating the art of healing with the science of curing

transcendence of suffering’ (Egnew, 2005), and ‘healing as the remainder – when other things have all been done, but there is still suffering and the need for care’ (Frank, 2014).

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The individual has the ability to self-heal, and such self-healing can be activated in different ways

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As part of our research into the nature of healing, we have asked members of the public in the UK, as well as healthcare professionals, what they think healing is. We have used innovative visual methodology, asking people to draw pictures in response to the question ‘what does the word healing mean to you?’, and asking them to describe what they are drawing and why (Rahtz et al, 2018). While some people described wound healing, most had a much wider and more nuanced concept of the meaning of healing. Three main themes emerged: 1) Healing comes from a great external force, exemplified by illustrations of the sun; 2) Healing comes from interactions with other people, whether medical professionals, CAM practitioners, healers or others; and 3) Healing comes from within – the individual has the ability to self-heal, and such self-healing can be activated in different ways, including communing with nature. People described practices and inner states that could help achieve healing. Some people depicted more than one model, demonstrating the inter-linkages between the models, and some described the outcome of healing (wholeness) rather than the process. Examples of the illustrations, using crayons to illustrate what healing means to them, are shown in Figures 1, 2 and 3. From our research, and literature work we conclude that healing is not a ‘thing’ that can be defined, dissected and described by reductionist science alone, rather it is a process, and an individual experience of beneficial change that may be attributed to many different things. Healing is like ‘love’ – it is something you experience and feel, but something that is hard to define or put into words. And love and caring are key facilitators of healing.

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Figure 1: Many participants tried to draw some representation of energy flow into the body, or energy fields around it, as their concept of what healing was about, as in this illustration.

Figure 2: Nature was a common theme in pictures drawn in response to the question ‘What does the word healing mean to you?’ This participant talked of the importance of growth, as well as being in touch with the natural world (including its animals), and of energy from above, while drawing this picture.

INTEGRATING HEALING Integrating the art of healing with the science of curing

Caring and loving kindness for others can, according to the healers and members of the public we have been working with, facilitate a healing response. We need to consider what other factors are important to see our way forward to the development of a healing culture within modern health care, to achieve transformative change. Based on our recent research (Rahtz et al, 2018; Dieppe et al, 2015; Goldingay et al, 2014; Greville-Harris and Dieppe, 2015; Warber et al, 2015; Rahtz et al, 2017; Scott et al, 2017; Warber et al, 2004), we would like to highlight three other factors: • safety • connectivity • creativity.

The importance of feeling safe Everyone knows that humans are hard-wired for the flight or fight response; what is less well known is that we are also hard-wired for the opposite response (the safety or nurturing response), and that each of these reactions is linked to our communication centres and our ability to interact with each other (Porges, 2007, 2003 ). The safety or nurturing response is essential to help us look after our young babies, and work in teams as well as individuals, but in addition, if we feel safe we are to be able to interact well, hear each other, and share our feelings. Conversely, if we are afraid, we cannot hear what others say well, we do not express ourselves well with voice or facial expression and, therefore, cannot interact properly. We must feel safe if we are to have a successful interaction with another, and allow self-healing to be activated. So healthcare professionals and their patients need to feel safe when they meet. And the creation of a feeling of safety depends on the context and environments in which we meet, as well as our communication skills. How often, in modern biomedical consultations, we wonder, do both professional and patient feel entirely safe? And how much time do we spend thinking about the environments in which we work, and whether they will help us all feel safe or not?

Connectivity We cannot connect with each other, or with our environment, unless we feel safe. And making meaningful connections seems to be critical to the activation of healing (Warber et al, 2004). We have investigated both long healing journeys (Scott et al, 2017) and sudden healing transformations (Rahtz et al, 2017) and in each case both healers and ‘healees’ have stressed the importance of connections with other people, and with animals and the natural world. Many people mention metaphysical as well as physical connections: connecting with God, or with some metaphysical source of energy or love. This accords with the new emerging science of ‘non-locality’ and universal consciousness (Dossey, 2015; Neppe et al, 2015; Currivan, 2017) which suggest that we

may all be part of an interconnected universe, in which consciousness is the primary essence, and that we might therefore have the ability to transcend the normal confines of our physical bodies, and make profound connections outside of ourselves – this may be the most important means of facilitating healing (Dossey, 2016). How often do healthcare professionals deeply connect with their clients, as equal human beings, simply ‘being with’ them and sharing their suffering? How could this quite different skill be taught as a part of ‘communication skills’ curriculum?

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If we feel safe we are to be able to interact well, hear each other, and share our feelings

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Some other facilitators of healing

Creativity Humans need to be creative and to express their creativity to thrive and flourish (Swindells et al, 2013). The importance of arts and crafts in healthcare, and their ability to help us heal, has recently been highlighted in the UK by the All Party Parliamentary Group on Arts and Health’s Report (2017). Creative practices, along with other forms of healing intervention are often used in the care of the dying, when medicine accepts that it can no longer cure a disease or prolong life, but we believe that these practices should be used more widely in helping chronic disease as well. How often do healthcare providers consider the possibility of social prescribing and signposting to creative group activities or time communing with the natural world for individual health and wellbeing? How can we make this a major part of our thinking?

Conclusion: we can combine the art of healing with the science of curing On the basis of the empirical research we have undertaken with healthcare professionals, healers and members of the general public, we conclude that healing is quite different from curing, and that most people recognise the need to combine the art of healing illness with the science of curing disease. To do this, we believe there needs to be a change in the culture of modern healthcare, which tends to arrogantly dismiss anything that is not based on materialism and reductionist science. Simple changes can help, such as paying attention to the environments in which we practice health care, and the behaviours of its practitioners, to try to ensure that everyone feels as safe as possible. And we need to recognise that making a profound connection with another human being, leading to a reframing of the meaning of life, is one of the most

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INTEGRATING HEALING Integrating the art of healing with the science of curing

important abilities we have to help activate their healing potential. We should also take account of the spirituality of our clients, their religious beliefs, if any, and understanding of how the world works, without censure. Encouraging people to be creative, and to enjoy nature are other important avenues to self-healing. Medicine also needs to be less tied into commercial interests that lead to the invention of new ‘diseases’ and the use of drugs and devices, in place of the recognition of illness, which could be relieved by healing. For people to heal they need to feel safe, to make sense of the world and find meaning for any illness or disease, to be able to make meaningful, deep connections with others, to relate to the natural world around them, and to have the space to express their natural creativity and real ‘self ’, and therefore to flourish. Acknowledgments: PD and ER would like to acknowledge the financial and intellectual support of The Institute of Integrative Health, Baltimore, USA (TIIH.org), and we also wish to thank all those who participated in the research reported here. Rachel Naomi Remen (2010)https://onbeing.org/programs/ rachel-naomi-remen-listening-generously All Party Parliamentary Report (2017) Creative Health: The arts for health and wellbeing. Available at: www.artshealthandwellbeing.org.uk/ appg-inquiry (accessed 12 March 2018). Currivan J (2017) The cosmic hologram: In-formation at the centre of creation. Rochester, VT: Inner Traditions. Dieppe P, Roe C, Warber SL (2015) Caring and healing in health care: the evidence base. Int J Nurs Stud 52: 1539–41. Dossey L (2016) Telecebo: beyond placebo to an expanded concept of healing. Explore 12: 1–21.

Dossey L (2015) Nonlocal mind: a (fairly) brief history of the term. Explore 11: 89–101. Egnew T R (2005) The meaning of healing: transcending suffering. Ann Fam Med 3: 255–262. Frank A (2014) Healing. In: Encyclopaedia of Bioethics, 4th ed. New York, NY: Macmillan Reference. Goldingay S, Dieppe P, Farias M (2014) ‘And the pain just disappeared into insignificance’: the healing response in Lourdes – performance, psychology and caring. Int Rev Psychiatry 26: 15–23. Greville-Harris M, Dieppe P (2105) Bad is more powerful than good: the nocebo response in medical consultations. Am J Med 128: 126–9. Hufford D (2017) The profound importance of language in cultural dynamics. Explore 13; 263–4. Kirmayer LJ (2004) The cultural diversity of healing: meaning, metaphor and mechanism. Brit Med Bull 69: 33–48. Levin J (2017) What is healing: reflections on diagnostic criteria, nosology and etiology. Explore 13: 244–256. Neppe VM, Close ER (2015) The concept of relative non-locality: theoretical implications in consciousness research. Explore 11: 102–117. Porges SW (2007). The polyvagal perspective. Biol Psychol 74(2): 116–43. Porges SW (2003) Social engagement and attachment: a phylogenetic perspective. Ann N Y Acad Sci 1008: 31–47. Rahtz E, Bonnell S, Goldingay S, Warber S, Dieppe P (2017) Transformational changes in health status: a qualitative exploration of healing moments. Explore 13: 298–305. Rahtz E, Warber SL, Dieppe P (in press) Understanding public perceptions of healing, an arts based qualitative study. Scott JG, Warber SL, Dieppe P, Jones D, Stange KC (2017) Healing journey: a qualitative analysis of the healing experiences of Americans suffering from trauma and illness. BMJ Open 7(8): e016771. Swindells R, Lawthom R, Rowley K, Siddiquee A, Kilroy A, Kagan C (2013) Eudaimonic well-being and community arts participation. Perspect Public Health 133(1): 60–5. Warber SL, Bruyere RL, Weintrub K, Dieppe P (2015) A consideration of the perspectives of healing practitioners on research into energy healing. Glob Adv Health Med 4 (suppl): 72–8. Warber SL, Cornelio D, Straugh J, Kile G (2004) Biofield energy healing from the inside. J Altern Complement Med 10: 1107–13.

College of Medicine Foundation Course in Integrated Health Thursday 5th–Friday 6th July 2018 • Penny Brohn Centre, Bristol A two-day course led by Professor David Peters and Dr Michael Dixon giving a practical introduction to integrated health and care.

Open to all clinicians and therapists, and of particular interest to GPs and nurses who want to look beyond the conventional biomedical box.

The course qualifies for CPD hours and can also provide the first stage towards a Fellowship of the College.

What is included?

The course will include skills for use in clinical practice, including sessions on lifestyle approaches, social prescribing, mind/body therapies and herbal medicine, and how to begin to integrate these skills into your everyday clinical practice.

£350 for the two-day course (including lunch and refreshments). Concessionary rate (£250) for College of Medicine members. College membership is available to all from as little as £10 – www.collegeofmedicine.org.uk Programme details and booking for all College of Medicine events are on the Events page at www.collegeofmedicine.org.uk

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Volume 15 Issue 1 Spring 2018

NATU RAL DYING

The lost art of being with death Hermione Elliott Director, Living Well Dying Well

Natural death and dying appears to have been lost to the interventionist experts. Dying has become medicalised, despite initiatives such as Living Well Dying Well. We have become unskilled at being round death, which is after all a natural process. Change, however, is being pioneered.

It dawned on me many years ago that fundamentally I am a midwife. Yes, as a former nurse and midwife I delivered many babies, but for a large chunk of my career I worked with people facing ill-health, using the crisis of illness as a means for deep personal change – giving birth to a new way of being. Now in the latter stages of my career I find myself educating and facilitating others to engage with death. This has had many unforeseen consequences, not least that in looking death in the eye, people find a new connection with life – however long or short that turns out to be. I continue to be passionate about the need to reskill society, for community engagement and the deprofessionalisation of death. I hope that instead of the battleground we seem to inhabit presently, in time many more people will be able experience the process of being with death in all its power, awe and rawness, not as a failure but honoured as the summation of a life.

In the time that Living Well Dying Well has been operating, we have seen growing interest in the subject of death and dying, perhaps led by the mainstream media who regularly cover the subject with human interest stories and issue-led features and commentary. Alongside this, community and grassroots initiatives and a new sense of empowerment – the right to choose – are changing the landscape in ways that exceeded our hopes. Yet in contrast there has been an unsettling development in the way health professionals deal with people who are dying. It seems ordinary ‘natural’ dying – the gradual decline into death as a natural consequence of life, requiring simple compassionate ‘comfort care’ – is less and less the norm. Nor, as dying has become more medicalised in a system where intervention is on the increase, is death seen as a significant, profound and spiritual transition. These two trends are clearly at odds with the flourishing of public interest in ‘natural’ dying.

How can we do death differently? In setting up Living Well Dying Well seven years ago I was looking to build

a different vision of how we approach death and dying. I believed in pioneering ways to do this and could visualise a better future although on first ‘take’ it looked to be totally incompatible with the current reality. So when Bill Sharpe presented the Change and the Three Horizons Model at the Transformative Innovations for Health gathering last November it was a great relief to discover that I mainly operate from a Horizon 3 (transformative future paradigm) position. Bill’s presentation helped me understand some of the struggles I had encountered when my Horizon 3 had come up against Horizon 2 (innovation) and/or Horizon 1 (business as usual) thinking. I wish I had known then what I know now. But thank you anyway, Bill!

What was the vision for doing death differently? When I wrote about the end of life doula role and training in this journal seven years ago (Elliott, 2011), the aspiration was not to create another layer of health or social care service, but rather to recognise that ordinary people within our communities value

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NATURAL DYING The lost art of being with death

(Elliott, 2011)

As a society, we have become so unskilled at being around death, so having the companionship of someone who isn’t afraid of the territory is tremendously reassuring; not another specialist, but someone who is informed, feels comfortable with the unknown, and is willing to walk alongside and be of support in whatever way is needed.

What changes have we seen? I would like to be able to write that the climate had radically changed over the last seven years. Yes, on the one hand death is ‘out there’ much more, thanks to the media and to some of the notable initiatives highlighted below. However, there is still considerable aversion to facing up the inevitability of death. Sadly too, inappropriate medical intervention continues to be carried out on frail and elderly people, which begs the question ‘who are we doing this for’?

The change we would like to see A group of elder-care specialist doctors in North Wales recently began a public campaign: #havetheconversation – highlighting the need for patients to be protected from the over-use of cardiopulmonary resuscitation (CPR). They point out: ‘as the law currently stands in the UK, you do need to ‘opt in’ to a peaceful death. I love the language in their flyer: ‘Don’t leave it too late to tell your doctor you want an “I want to die in my own bed” form.’ As these geriatricians point out, ‘CPR is not a treatment for ordinary dying’. And yet many people have told me of their experiences of crash teams in hospitals, or paramedics in the home and in nursing homes swinging into action, administering CPR to frail, elderly and terminally ill people, as a routine response to ordinary death. CPR is a brutal procedure, yet it is now considered the normal thing to do even when faced with such vulnerability. This is a mystifying development, and one based on assumptions that we really have to confront. A Nursing and Midwifery Council disciplinary hearing last year demonstrated how badly we have lost perspective.

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Don’t leave it too late to tell your doctor you want an “I want to die in my own bed” form

She received a 24-month caution. But did she truly deserve such a blot on her record for giving what most people would consider to have been sensitive end-of-life care? In the blog entries following a Nursing Times article one contributor suggested that certifying and verifying death are not same and that any layperson would have correctly identified the resident as dead. It seems the NMC has created a precedent that implies nurses should start CPR on clinically dead patients and keep going until paramedics arrive. So we must take seriously that ‘as the law currently stands in the UK, you do need to opt in to a peaceful death’.

The power of choice and community The most significant change has come about through individual and community initiatives, and this is where I hold out most hope for lasting change. A growing movement is now raising awareness, encouraging us to think about death, make choices and have clear plans for it. The Dying Matters network has facilitated the activities of many organisations like Living Well Dying Well to be part of this network (www.dyingmatters.org).

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CPR is a brutal procedure, yet it is now considered the normal thing to do even when faced with such vulnerability

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‘The role of a doula is a non-medical one. Think back only two or three generations when there was always someone (generally a woman) in the neighbourhood, who was called in by families to help out at a death – she was often the same woman who was summoned to help with birth. When we lost this role, death gradually became removed from everyday life and hence our relationship with it. Doulas do not replace medical or nursing expertise, but rather, they add a missing layer, acting as an expert family member, a mentor or facilitator and a source of information or guidance.’

An experienced nurse who had been called to see an elderly nursing home resident found her ‘waxy, yellow and almost cold…not breathing’. So, having checked that ‘there was no pulse or vital signs of life’, she considered the resident to have already died. However, the NMC view was that as no Do Not Resuscitate Order was in place and the resident’s death was unexpected, this nurse had been under a professional obligation to attempt CPR and to call for emergency assistance. The nurse agreed that she had been acting outside of her competence on the occasion in question because she was not qualified to certify death (Ford, 2017).

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relationship and have the capacity and willingness to offer support to people who are dying.

The rise of death cafes is a beautiful example of a spontaneous grassroots initiative. Pioneered by Jon Underwood in the UK, it has spread worldwide to 52 countries. Many of our doulas are active in setting up and hosting these events (http://deathcafe.com).

NATURAL DYING The lost art of being with death

Three doulas in Todmorden instigated The Pushing Up Daisies Festival. This west Yorkshire event demonstrated how well community engagement, with kindness and creativity at its heart, can bring people together in a powerful and meaningful way. The festival created lasting connections and has built a communal feeling of confidence, resilience and a shared understanding of many aspects relating to death and dying (www.pushingupdaisies.org). The Compassionate Neighbours project initiated by St Joseph’s Hospice has done much to mobilise the goodwill of people volunteering in the community. This project created a network of trained people who offer their time, companionship and support to people living in their community who are coping with serious illness old age and terminal illness people (www.stjh.org.uk/neighbours). As it has turned out Living Well Dying Well doulas have discovered they have a much bigger educational role than we first imagined. We often hear: ‘We didn’t know we were allowed to do that’. This could be related to refusing treatment, making choices about dying at home, or having the body remain at home after death. In response, many of our doulas have chosen to specialise, offering support to people to make their choices known through a Living Will or Advance Decision. We recognise this as a priority especially when, as we see above, the onus is on the individual to opt out from treatments they may not want, which prolong but do not necessarily enhance life (www.lwdwtraining.uk/contact-us). The Compassionate Frome project launched in 2013, though not specifically related to death and dying, provides even more evidence of the power of community. George Monbiot (Monbiot, 2018), writing in the Guardian recently, highlights how local GP Helen Kingston ‘… kept encountering patients who seemed defeated by the medicalisation of their lives: treated as if they were a cluster of symptoms rather than a human being who happened to have health problems’. The project supported health connectors employed to help people plan their care, and community connectors who helped people find the support they needed: anything from handling debt or housing problems, to joining choirs, lunch clubs, exercise groups or writing workshops. ‘…while across the whole of Somerset emergency hospital admissions rose by 29% during the three years of the study, in Frome they fell by 17%. Julian Abel, a consultant physician in palliative care and lead author of the draft paper, remarks: “No other interventions on record have reduced emergency admissions across a population.” Helen Kingston reports that patients who once asked, “What are you going to do about my problem?” now tell her, “This is what I’m thinking of doing next.” They are, in other words, no longer a set of symptoms, but people with agency.’

The vision continues Let’s consider that ‘when faced with a terminal illness, medical professionals, who know the limits of modern medicine, often opt out of life-prolonging treatment. An American doctor explains why the best death can be the least medicated – and the art of dying peacefully, at home’ (Murray, 2012). Why would our patients not want the same? ‘Agency’ is powerful, and as health professionals who aspire to recognise our patients as self-determining, we need only to see them as human beings like ourselves. It comes back to simplicity: how would I feel; what would I want? If am at the centre of my own life – in my case this includes my spiritual journey, the joy of sharing with my husband, my friends, my colleagues and my community – then if at all possible, right up until the moment it ends, I want to preserve the integrity and quality of this life. Through all its challenges and ups and downs, my identity, values and the very smallest things have importance and meaning. If I become too vulnerable to assert myself, I want to know there will be someone else – partner, friend, doctor, doula – who will do everything they can to uphold my wishes, so that I can let go into the journey. I want to know I will be given comfort care and be supported therapeutically so that I am not distracted by symptoms, from the task at hand. I believe most of us feel the same and would like this wholeness to be reflected in their dying. As doulas our contribution to change and our primary aim is to be available as companions to be fully present and responsive in supporting the journey of the person who is dying, and those who care about them; most importantly to facilitate them in making choices and upholding their right to have them respected. As citizens, change will require us to have conversations in our families, to make sure we insist on honest discussions with health practitioners, and recognise that making a Living Will or Advance Plan is as important as writing a legal will. Though this really isn’t such a radical innovative vision, the current culture around death and dying is not yet amenable to it. If we want to see change, and take dying out of the hands of interventionist experts, each one of us will have to reset our compass and make absolutely sure that it points unequivocally towards having a peaceful death. Elliott, H (2011) Moving beyond the medical model. Journal of holistic healthcare 8(1) pp 27–30. Ford, S (2017) Nurse handed caution for not carrying out CPR on ‘clearly dead patient’. Nursing Times, 7 March. Monbiot, G (2018) The town that’s found a potent cure for illness – community. The Guardian, 21 February. Murray, K (2012) How doctors choose to die. The Guardian, 8 February.

(Monbiot, 2018)

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Volume 15 Issue 1 Spring 2018

ECOTHER APY

Nature as therapy: Is nature-connection the antidote to the stresses and impacts of contemporary life? Pat Fleming Group leader, educator, conservation botanist

We lead increasingly indoor, digitally dependent lives – according to the WHO we are now an ‘urban species’ and the change has been rapid. Nature connection therapies have a range of benefits which help with this dislocation from the outside. Such therapies range from simply ‘being’ outside to bushcraft and forest bathing. We all benefit from a connection with the natural environment and ecotherapy can help with a range of health issues.

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I live by the river Dart on Dartmoor, and teach nature connection and emotional wellbeing to educators at nearby Schumacher College. I also run a public wild-planted conservation garden at Princetown beside the main National Park Visitor Centre. I firmly believe that immersion in natural and wild places, combined with sensory and imaginative engagement, reflective practice and hands-on activities offers immense health, social and spirit/soul benefits. This article is a broad sweep examination of how nature connection is being practiced in the UK and beyond, summarising evidencebased impacts from a current worldwide wave of good quality wide-ranging research.

‘Ecotherapy: how nature makes us happier, healthier and more creative – this is a major principle of human life, now supported by evidence in biology, psychology and medicine.’ Evolutionary biologist EO Wilson

‘Nature: a place where birds fly around uncooked!’ Oscar Wilde

I started in mental health work as a psychological counsellor and therapeutic groupwork leader, and wanted to understand some of the bigger forces at play affecting our human health. I have worked for nearly four decades exploring, developing and offering various forms of nature-based therapies, in particular deep ecology, emotional resilience work and immersive work in wild and natural settings. I have seen how nature-connection practices can help participants unlock negative behavioural and thinking patterns, and can assist in reframing and resolving deep anxieties. It has been heartening to participate in and witness how these therapies enable personal insights and awakenings. When this happens it can lead to an increased sense of wellbeing, greater inner freedom, more energy, stability and confidence; not to mention

delight and joy in being alive! A recent burst of research interest in nature connection is now providing evidence to back up my impression (Richardson et al, 2016). These benefits can even be evoked in an indoor space: researchers have shown that simply projecting images of wild natural spaces accompanied by recorded birdsong helps us relax, feel more peaceful, less concerned and anxious. These artificial sights and sounds benefit our mood and concentration too, but I prefer to take people outside. Under a blue day or night sky in natural, wilder spaces as we engage all our senses there arises a more powerful awareness of humankind as a part of nature.

Hard-wired for nature Our human evolutionary journey began way back in deep time: 10 billion years after the universe, biological life emerged some four or five billion years ago. I have found that deep time exercises can help us delve back, to reach with our body and imagination all the way back to the Big Bang, 14 or more billion years ago. This has helped me get a felt sense of how the natural world has shaped human life and health. In deep ecology workshops, this universe story (Swimme, 1994) of how the universe

ECOTHERAPY Nature as therapy

emerged and evolved from the singularity can help us appreciate the forces, processes and materials that form us. In deep ecology workshops we seek ecological remembering through movement, sound and improvisation. A kind of therapeutic reconnection may unfold as we explore our beginning as single cell organisms, moving through early invertebrate life-forms, feeling into our fish bodies and senses, reptilian then amphibian bodies. Passing on from mammal-body we ultimately arrive as homo sapiens. Our newish species evolved some 1.8 million years ago from our more primitive hominid Australopithecus ancestors who dwelt in Africa’s Rift Valley (with some Neanderthal genes mixing in along the way), to become relatively hairless upright bipeds sporting large brains with especially well-developed frontal cortexes, enabling excellent problem-solving and manipulation skills, use of tools, language and communication leading to more complex social culture. All of these capacities evolved as we lived for hundreds of thousands of years as hunter-gathers within the natural settings of savannahs, steppe grasslands, forests, margins of rivers, coasts and lakes. Our domestication of animals and development of land-based agricultural practices of the Neolithic period occurred in relatively ‘shallow’ time, beginning some 12,000 or so years ago. We gradually settled into a more sedentary lifestyle living in early villages. Over a few thousand years we started to urbanise into increasingly denser, more organised populations. In evolutionary terms, this is a small blink in time.

Dislocation from the outdoors In 2008, the World Health Organization reported that we have officially become an urban species. As of February 2018 the world human population is 7.6 billion, more than 50% of whom live in urban environments leading

increasingly digitally dependent indoor lives. These are quite sudden changes even on the timescale of relatively new species like ours. Homo sapiens evolved in wild and natural habitats, so how will these changes impact our bodies, our nervous systems, our minds, and world’s once diverse cultures? If as WHO (setting the bar rather high!) defines it, health is ‘a complete state of physical mental and social well-being, and not merely an absence of disease or infirmity’, it would be very surprising indeed if this rapid, radical lifestyle shift did not add to the stresses and ills of modern life: to social isolation, anxiety and depression, obesity and diabetes, pollution-related diseases; also to the health effects of poverty, urban slums, poor social conditions and mass migrations. It seems there is an epidemic dislocation from the outdoors. George MacKerron, an economist researcher at University of Sussex running the ‘Mappiness app’ study, examining human happiness, notes: ‘study participants (over three million) are significantly happier outdoors in green or natural habitats than they are in urban environments’. His study (MacKerron , 2013) also found that people spend 93% of their time either indoors or in vehicles.

Nature connection research In a century when so many of more of us will be cut off from the natural world we need to understand the part that intentional nature-reconnection might play. Over the past 20 years or so, a wave of research worldwide has tried to address this question. A useful overview of this work is The Nature Fix by Florence Williams, and a National Geographic article This is your Brain on Nature (see resources section) (www.youtube.com/watch?v=BiXrRKyrfA). Both sources have a lot to say about how nature engagement is beneficial to human health: • increased physical health – eg lower blood pressure, reduced obesity, improved immune system • enhanced emotional and cognitive health • improved recovery from depression, anxiety and stress • reduced social isolation and improved communication skills • enhanced sensory and aesthetic awareness, and ability to self-direct • increased sensitivity to one’s own wellbeing.

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ECOTHERAPY Nature as therapy

Nature engagement The best forms of nature engagement for each individual or group will very much depend on life habits, choices and issues (work, family, housing, local environment, communities, illness etc) which in turn affect people’s wellbeing perspectives. I have known nature-based therapies help address mental health issues even where conventional therapies have failed. While working with an urban community organic gardening project we were joined by an Iraq War veteran suffering PTSD. She could hardly speak or socialise, but through gardening, and especially by learning bee-keeping, she recovered her mental wellbeing, eventually regaining self-confidence and the ability to speak again. In time she was employed as the project’s wildlife officer which meant giving public talks and teaching about wildlife.

Nature-based therapies Ecopsychology focuses on our connection with the natural environment. In traditional psychology, the ‘psyche’ is considered in isolation from its natural environment. Ecopsychologists seeing this split between mind and nature as being at the heart of our current ecological crisis, address this through therapeutic practices. Over the past 40 years ‘eco’ or nature-based therapies have been developing worldwide. In various ways they all offer practical ways to immerse ourselves safely in sensory experiences of the natural world, and to pay attention to what is experienced. Ecotherapy can take place in ‘natural’ green and blue spaces (coastal, woodlands, national parks, mountains, landscapes) or in designed environments (parks, gardens, urban green space, therapeutic environments.) Ecopsychology practices aim to encourage an individual to experience a deeper connection with nature, or with each other in a group and with a wider sense of self.

Natural and wild spaces Types of ecotherapy within natural spaces include: • green gym activities outdoors – walking, making and repairing, cycling, Tai Chi, unstructured time in nature • forest and seashore schools • environmental education organisations offering guided walks, nature connection, wild camps, bushcraft training • wild nature connection courses and camps – including vision quests, solo trips in nature, deep ecology, medicine walks, deep nature dives, wilderness spirit work • forest bathing therapy (shinrin yoku) – a Japanese practice based on ancient Shinto and Buddhist practices. It involves spending time in natural or semi-natural woodlands, cultivating a range of sensory experiences, also strolling and breathing exercises.

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The physiological differences documented by Japanese researchers show that people who have spent time forest bathing for extended periods, have lower concentrations of cortisol, lower pulse rate, lower blood pressure, greater parasympathetic nerve activity, and lower sympathetic nerve activity than in city environments (Hansen et al, 2017).

Designed and managed therapeutic green spaces When people are ill, the quality of space around them can help them recover. Perhaps the opposite is also true. Knowing that gardens can nourish the human spirit, an international movement of landscape and garden designers are incorporating health and wellbeing principles into their public gardens and green spaces. Particular examples can be found in spinal injury specialist units such as Horatio’s Project at Stoke Mandeville (www.horatiosgarden.org.uk/horatios-garden/stokemandeville/the-design), dementia care homes (Learning through Landscapes– www.biglotteryfund.org.uk/globalcontent/press-releases/uk-wide/010216_uk_ai_learninglandscapes), cancer support centres such as the Penny Brohn Centre in Bristol, in the USA’s PTSD farms for combat veterans (www.wtvm.com/story/32504178/ga-farmprovides-alternative-healing-for-vets-with-ptsd), and in the UK charity Farms for City Children (http://farmsforcitychildren.org). Designed green therapeutic spaces and ecotherapy projects include: • horticultural therapy in community gardens, orchards, city and rural farms. The range of projects work with special needs children, families and adults including ADHD and autism, sufferers of PTSD, depression, anxiety, post-accident and post-operative conditions, dementia • therapeutic hospital and hospice gardens • public gardens offering silent reflective spaces • medicinal herb and apothecary gardens/woodlands • botanical and other public gardens where there are sensory gardens (eg for blind people). Healing green space design encourage meaningful creative activity and stimulation through social interaction, manual and physical activity that lead to task satisfaction, and reduce social isolation, anxiety and depression, and increase personal confidence, self-worth and wellbeing.

Peaceful beautiful places Botanic gardens, arboreta and National Trust gardens provide accessible green spaces where nature and beauty are managed. Peaceful public places such as these are nodes in a wonderful UK wide network. City farms and community gardens in schools are important urban green therapeutic spaces. More than 200 farms and more than 1,000 community gardens provide nature-connection

ECOTHERAPY Nature as therapy

with the earth beneath your feet. This mindful embodied work helps us to remember who we really are – deeply connected participants in the web of life. Nature connection invites us to experience a much wider and more ancient sense of self and belonging. ‘Everybody needs beauty as well as bread, places to play in and pray in, where nature may heal and give strength to body and soul.’ John Muir, naturalist and mountaineer (1838–1914) Hansen M, Kobayashi H, Park S-A, Song C (2017) Shinrin-Yoku (forest bathing) and nature therapy: a state-of-the-art review. Int J Environ Res Public Health 14(8): 851.

havens where people of all ages learn about growing vegetables, prepare (sometimes wild and foraged) food together, and share community meals, hold local fresh food sales, learn about bee-keeping and local wildlife. Silent Spaces is a recent movement which aims to provide quiet public places. They are often within larger gardens, where everyone is asked to switch off their mobiles, stop talking and respect a quiet area for personal reflection, prayer and meditation. It is heartening that these therapies, projects and practices are now being taken more seriously by the mainstream. Partnerships are developing between regional health services and national parks. Where I live in Devon, the Naturally Healthy project has been running for more than three years in Dartmoor and Exmoor national parks. It has brought together GP practices, local authorities, Exeter and Plymouth universities, Natural England and Public Health England. The pilot study is showing encouraging results including practical suggestions for ‘green prescriptions’. The Naturally Healthy Report is now available online (http://valuing-nature.net/news/naturallyhealthy-report-now-available).

In conclusion Nature connection therapies are being shown as making us healthier, more creative, more empathic and more likely to engage with the world and with each other. For those who would like to experience a deeper level of wild nature engagement, also to meet others involved in ecotherapy work, research and training, there is a list of resources at the end of this article. Essentially nature connection work is simple: get outside into a more natural setting (even a garden) and open your senses. Notice the wind in your hair and on your skin; really feel the cold, or the warmth of sunlight and see the colours entering your eyes; look afresh at natural forms; be aware of how the air enters your nostrils, how gravity pulls on your body; make a stronger contact

MacKerron G (2013) Happiness is greater in natural environments. Global Environmental Change 23(5). Richardson M, McEwan K, Maratos F, Sheffield D (2016) [Online] Joy and calm: how an evolutionary functional model of affect regulation informs positive emotions in. nature. Evolutionary Psychological Science. doi 10.1007/s40806-016-0065-5.

Resources for ecotherapy, re-connecting with nature, green healthcare Websites www.natureandforesttherapy.org Resources, research and training in forest bathing and forest therapy. Good health benefits research. www.changeinnature.org Offers immersive courses – deep nature dives, creative retreats and mindfulness in nature. www.dartmoor.gov.uk/enjoy-dartmoor/outdoor-activities/ naturally healthy Report on National Parks collaborative research with Public Health England and local authorities on green health initiatives, also offering a practitioner’s ‘Wellbeing in nature’ toolkit. www.chalfontdesign.com Prof Giles Chalfont – therapeutic green spaces and support for dementia (University of Lancaster’s Centre for Ageing Research). Resources include Dementia Green Care Handbook. www.ecopsychology.org.uk UK network of ecologically-based psychotherapists and movement therapists. Also courses, resources, events. www.farmsforcitychildren.org ‘Outside the classroom’ immersion for children in the countryside, farming, nature and food. www.farmgarden.org.uk UK-wide network of urban-based local community farms and gardens teaching healthy lifestyles and wellbeing, with handson contact with plants and animals. Good resources and research evidence on mental health benefits.

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ECOTHERAPY Nature as therapy

www.findingnature.org.uk Nature connections research blog by researcher Dr Miles Richardson at University of Derby. www.forestschoolassociation.org Natural learning in woodlands. Offers UK network of forest schools, trainers resources and local groups. www.horatiosgarden.org.uk Charity which designs and installs therapeutic garden spaces beside spinal injury units around UK. www.infom.org Japanese-based with good resources (publications, articles) on forest bathing practice. www.johnmuirtrust.org Offering training and experiential wild nature connection, offers John Muir Award. Educational resources and conservation lobbying and practices. www.lghn.org.uk UK network of horticulturalists and garden designers interested in health, wellbeing and green-space therapeutics. www.derby.ac.uk/science/research/centres-groups/ psychological/groups/nature-connectedness Based at University of Derby. Research reports. Host of Nature Connections conference series. www.rhs.org.uk Educational resources on benefits of gardens, horticultural and green therapies, including Phd students research. Published ‘RHS Health and Horticulture Charter.’ https://silentspace.org.uk National UK network of gardens and green spaces offering silent areas and/or silent time periods. www.schumachercollege.org.uk Courses include re-wilding, discovering our indigeny, deep ecology, cosmos and holistic science. www.thrive.org.uk Social and therapeutic horticulture centres, training, resources.

www.wildwise.co.uk Offers ‘Call of the Wild’ deeper immersion course, family and children’s camps, bushcraft training, rites of passage, re-wilding events.

Publications The nature fix – why nature makes us happier, healthier and more creative. Florence Williams (2017) This is your brain on nature. National Geographic (2016) www.nationalgeographic.com/magazine/2016/01/ call-to-wild Ecotherapy: healing with nature in mind. Linda Buzzell and Craig Chalquist (eds) (2009). Ecotherapy – theory, research and practice. Martin Jordan and Joe Hinds (eds) (2016). The last child in the woods: saving our children from nature-deficit disorder. Richard Louv (2010). Review of nature-based interventions for mental health care. Natural England (2016).

Events 20 June Nature Connections- interdisciplinary conference at University of Derby. www.lotc.org.uk/nature-connections2018-4th-interdisciplinary-conference. 22–25 June Wild Nature and the Human Soul. Lake District residential organised by Wildrites. See website above. 5–8 July Edge of the Wild. Ecopsychology Gathering at Green and Away, Worcester. Organised by the Ecopsychology Network. See website above.

www.wildrites.uk Psychosynthesis-based workshops on wild nature and the human soul, vision quests, medicine walks.

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TRANSFORMATIVE INNOVATIONS

Transformative innovations for he On November 18 2017 the BHMA held a conference in collaboration with the Scientific and Medical Network. Hosted by The University of Westminster’s Centre for Resilience, the meeting brought change-makers together to celebrate the future they are working to create. 20th century medicine has focused on smaller and smaller parts with astonishing success: triumphant in infections, deficiency diseases, with surgical excisions and transplants, intensive care and anaesthetics. But the precision of medical science is unraveling as 21st century medicine is forced to confront whole person (indeed whole society) problems: chronic degenerative and inflammatory diseases, stress-, environment- and lifestyle-mediated diseases, addictions and psychological disorders.

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TRANSFORMATIVE INNOVATIONS

alth: a gathering of change-makers Bio-technical single-solution approaches won’t cure them. If, as sci-fi author William Gibson once said, the future is already with us but unevenly distributed, the multitude of possibilities include some we would like to live in but many that we would not. Since the choices we are making now will re-shape the world, where might we find seeds of desirable new paradigms for healthcare? We brought some notable change-makers together to celebrate the future they are working to create. The graphic record below, of what proved to be a very stimulating conference, was crafted as the day unfolded by Helena Maxwell from Inky Thinking. www.inkythinking.com

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THE TR ANSFO R MING SHIFT

Darkness, life-compassion and the seeds of transformation Notes and results from the front line of The Healing Shift Enquiry David Reilly Director, TheWEL programmes and The Healing Shift Enquiry

This article is from the keynote speech given at the Transformative Innovations for Health:

I’ve centred the four decades of my career as a doctor on studying our life’s ability to heal itself. I remain a student. These notes are a work in progress. Impacted by its over mechanised ways, I almost left medical school in fourth year, but I stayed on vowing to be part of change – at least within myself. And I had a dream that one day we would talk not just about diseases and treatments, but about our human healing capacity – and that this would create a different focus for the world of medicine and health. This focus has now been posited as the basis of a new ‘fifth wave’ of public health. But be it in me or you, dreams are not enough, and caution is needed to not just shoot off after a ‘good idea’ without clear evidence – or another dead-end wave is generated. A new vision – a ‘third horizon’* – must be rooted in first-principle evidence of clear effect, proof that this path leads to real transformation. That’s the path that calls me.

a gathering of changemakers conference (see pages 26--27).What is the human healing response? How might it be enhanced? David Reilly reports from the front line.

* (The Three Horizons Model: H1 is the current predicament and the maps we use to navigate it; H3 is what will come to replace it. H2 are new paths that will bridge us from H1 to H3 [Sharpe, 2013])

The blank slide: darkness Can I begin with my most important image. See Figure 1. It’s a blank. What do you see when you look into, not at, this darkness? If this is the darkness in your own life,

what do you see, how do you react as you look into it? A common perception is a form of abyss, or a trap. What feelings does this raise in you? For many it may be stuff like fear, despair, entrapment, hopelessness. Many of us have had such dark experiences, and some never return.

Figure 1

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THE TRANSFORMING SHIFT Darkness, life-compassion and the seeds of transformation

Now swap the image. What if you see this darkness as an enemy? This is the way we often see our diseases, or our suffering, or lack of wellbeing. What state does that image generate in you? How does your body feel as it meets this enemy? Making ready to fight, warfare? How does this differ from the abyss? Let’s change the image once more. What if this is a blank canvas in a dark room, waiting for the light of dawn, and the creation of a new image? Do you feel the difference within you? Your physiology, and so your health and wellbeing, follows as the servant of these image-generated states – created by your shift in interpretive (if often reflex) perception of the very same darkness. In rats injected with tumour and then subjected to electric shocks, ‘only 27% of the rats receiving inescapable shock rejected the tumor whereas 63% of the rats receiving escapable shock and 54% of the rats receiving no shock rejected the tumor’ (Visintainer et al, 1982). This is how a state of helplessness contrasts with one of empowerment. A sense of travelling a road out of darkness seems to enhance health even more than dark’s absence.

The seed I now see the darkness of human suffering as soil, soil containing seeds waiting to germinate. So viewed, the world is different. So viewed, the work to be done spontaneously reshapes. The dark and the cold are the very things that seeds need to germinate. Our suffering, our darkness, primes us for transformation, and calls out strengths that would otherwise remain dormant. So viewed, suffering is not the enemy. It is seen as the precondition, and the call for change – from the friend of our life. It’s normal to suffer – as it is to age, get sick and die. That’s why we need compassion as our deeper response to the human predicament.

The gardener So – what now? I think we need to study gardening – human gardening. In 2012 Russian scientists reported that they had germinated seeds found in the Siberian permafrost, buried by an ice-age squirrel over 30,000 years ago. Later they blossomed with a unique form to their flowers (see Figure 2). (Yashina et al, 2012). Life wants out. It awaits the conditions, then it will emerge. It does not argue or resist. Sometimes it can repair the body, at times it can restore spirit. This universally applicable truth is powerful knowledge for someone who is labouring under the burden of suffering or illness. It is a powerful foundation for planning human caring and endeavour.

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Figure 2

Mapping the human healing response If you stress or damage an organism its inherent drive is to bounce back, or if overwhelmed, go to seed. We need a direct study of this ‘healing response’ in humans (Reilly, 2001). Let’s be curious about this capacity for growth and healing, and consider the conditions that block it or help set it free. Perhaps growth, healing, and creativity are water we can draw from the same well. To study healing is not to measure an object, it is an inherent drive, but its behaviours and fruits can be readily mapped. There’s something unconditionally generous about life’s processes. If a plant has drooping leaves, and you water it after a period of neglect, it doesn’t object, it responds. How come? As I shifted from a map dominated by bringing ‘interventions’ and treatments, to one that worked to release inherent strength – the results transformed. And I transformed – from Descarte’s apprentice watch repairer, into a student of human gardening. Life heals. You cut yourself, it heals; you break your heart, it works to reclaim your wholeness; a whole continent is devastated: one hundred million people

THE TRANSFORMING SHIFT Darkness, life-compassion and the seeds of transformation

killed in 20th century wars and yet there’s an unstoppable movement back towards order and peace. So when I use the word ‘life’ here, I don’t mean the life situations we all have – they just cycle: if it’s up it will be going down, and if it’s down, and you hold out through the storm, it will be back up one day. No, what I am calling life here is that which beats your heart. This life is the carer’s greatest ally, the suffering person’s hope. Who knows what life ‘is’? Our science can study, describe, define, discern mechanisms and manipulate it – but we still don’t know what it is. Fortunately, plants know how to grow. Gardeners don’t make the plant grow, and don’t have to know how it grows, they just learn how to support it. In the pain clinic where I worked for 10 years seeing people the clinic had failed to help, eventually the only prerequisite clinical sign I sought was that my patient’s heart was beating. That was enough. Because life wants out, it wants to be free. Life is stronger and bigger than we are. So, in a sense, learning not to take one’s suffering and recovery personally can be very helpful. Don’t take yourself so personally. Take care of your life. Just these perceptions in themselves proved to be a medicine – before any dialogue or work took place.

Our predicament – our first horizon – our epidemics Why bother with all this? If the ‘plant’ of your life is struggling, you are not alone. Post-industrial societies are struggling. Our children are succumbing earlier and earlier to the new epidemics. A young girl in Scotland now has more than a 40% chance of significant psychological distress by the age of 15 (Sweeting et al, 2009). And the science is now clear that chronic distress translates into more disease and earlier death (Russ et al, 2012). Children born in the century before 1970 had a 2–3% chance of becoming obese adults – this has since increased tenfold (Harcombe, 2010). Life-style related diabetes now affect 1 in 11 of humanity and 5–7% of the UK – and even at 5% this is using up 10% of the whole NHS budget (www.diabetes.co.uk/cost-of-diabetes.html). And it is going to get worse. It is now being diagnosed in primary schools, and in preschool children tipping dialogue into terms of ‘tragedy’ and ‘disaster’ (Diabetes.co.uk, 2015). Some affected as teenagers are coming to their amputations in their 20s. It’s already worse in other parts of the world – for example, in Qatar the type II diabetes rate is 26%.

Figure 3: The four great waves of public health, now showing diminishing returns

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THE TRANSFORMING SHIFT Darkness, life-compassion and the seeds of transformation

Note that many degenerative diseases and cancers are happening younger and younger – which belies talk of the epidemics being a result of ‘medical success’ of people living longer. It seems we – public, patients, staff, policymakers – don’t adequately understand how to flourish in the modern world. So we lean more heavily on our old maps, increasing our prescribing, extending our waiting times. We are improving management of course: by harder work, better targets, better drugs, efficiency measures – but, this is not transforming our predicament, only containing, mitigating, palliating this darkness. Our interventions, based on the four great waves of public health of the last two centuries (Figure 3), are now delivering diminishing returns. Personally or collectively, our old maps ‘worked’ for us in another time – and so we may cling to them even when times have changed. On a larger scale, our maps built empires, industrial revolutions, the modern world – no wonder we believe them now even as we hit the impasse. At their core these four waves rely on experts and their powers to intervene. Now these ‘fix-it’ ways are not working in the modern epidemics – you can’t just ‘fix’ diabetes, anxiety, depression, obesity, chronic pain, chronic inflammation, chronic fatigue, and more. We need a new wave of innovation, and a new guiding map for a change of era (Reilly, 2013b; Hanlon et al, 2011a, 2011b, 2012). Do we see this yet? Do we ‘get’ it yet? We have many ways to defend our old maps, and use up a mass of resources and human endeavour and care trying to hold up that first horizon. Currently around 40% of the population have long-term conditions. What will be the tipping point till it is common understanding that drugs and surgery and stern words are not enough – for a person in pain, for a people in pain.

The journey of change Yet, here, trapped in the darkness of our First Horizon, with so many heroically ‘keeping the lights on’, it’s hard to see that our maps, our thinking and structures won’t free us. Often we keep going in our lives pushing harder through our predicament, our suffering – until we break down. That, as that old but still true cliché says, is often the point of breakthrough. So, truth is, the sooner we have our breakdowns the better… then the cry is heard – calling for that third horizon, that different way, and so leading us into our next cycle of the ‘hero’s journey’ of change. This sequence, this pattern in human affairs, is like a fractal, it is ‘scale independent’ – it applies in our personal world, or our collective world. As carers – of ourselves and others – coming to understand these components of a journey of change is critically helpful. But where to begin? It must be from right here. When overwhelmed our imagination can freeze – and we can’t see a road out to freedom. First, we need to know, to remember, or be reminded, that healing is possible and waiting. Then, we look for inspiration, real examples of successful changes, however small-scale. We breath that in

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– inspire – and we are sparked, catalysed, germinated. Let’s look at inspirational transformation in action in other epidemics – in Glasgow in the 19th century. More than 10,000 people died in that city as the periodic cholera swept through. Contemporary care palliated, but could did not stop the onslaught. Then, someone dreamt of change. They envisaged bringing a clean water supply into the city. How do we respond to dreamers when they describe a new horizon to us, as we tackle our predicaments in what we tell them is ‘the real world’? The idea was rejected for years by many people including those with vested interests like water companies, landowners and even the admiralty: it would ‘bankrupt us, poison us, can’t be done, it won’t work, it’s technically too difficult...’. Note today’s parallels here to big business conflicts over ‘clean food’ rather than clean water. Sometimes darkness has to deepen before we are able to really question our current maps and envisage our release. It took decades of controversy before the clean water of Loch Katrine flowed into the city from a project as ambitious in its day as the moon landing. In the 1866 epidemic Glasgow escaped almost unscathed, with only 53 deaths compared with more than 4,000 in the 1848–49 epidemic (BBC, 2014; McCombes, 2010). Today analogous epidemics are killing more than cholera ever did. Can we dream a world where our children will be spared in today’s epidemics? If not, we are trapped in the darkness by our own poverty of vision. What would be our equivalent ‘clean water’ to transform our current populations health? That was the quest behind the Fifth Wave of Public Health project and the AfterNow work it spawned. Your dream may be critical to us.

The shift Maybe each generation is called afresh to learn about these cycles of darkness and response. We are left clues and buried maps by our predecessors in the substance of much of our narratives, myths and stories, and our wisdom traditions – as explored so well for us by Joseph Campbell (Campbell, 2008). But these words of guidance, their framing, may fail to transmit these truths adequately to a new generation. I dare to wonder if a focus on engaging with healing capacity was placed more centrally in our learning, our science, its generational transmission would strengthen. The journey of change builds on our awareness of where we are – and so any suffering needs acknowledging not diverted, drugged, distracted. Acceptance deepens – it is how it is, not as we would wish it to be. This is not resignation, it is honest turning towards the pain. We come to see our suffering as a call of change and not an enemy. We realise that the diminishing returns of our current ways (H1) are signs that the future cannot be only be based on the maps that built our current world view. We get beyond attacking the old maps – recognising ways they were effective in their day, keeping what is good still.

THE TRANSFORMING SHIFT Darkness, life-compassion and the seeds of transformation

We seek the core understanding that will build the new maps we need. These foundations make us ready, primed, to find inspiration and so rediscover our inherent hope. With such activation comes action. A caution: as we explore new ways, we often must walk off the confines of the current evidence-based maps – so we need be wary of firing off second horizon innovations that lack practice-based proof of transformative effect. People in need are vulnerable – they may buy any promise of a ‘quick fix’. Fashion is everywhere, even if the clothes are intellectual or managerial, or whatever. Much personal or large scale ‘innovation’ ends up being about doing the old better map, propping up old ways, rather than charting a better new path. What direction to travel? I found to avoid a wasted journey, return to a core principle: point the compass at life itself. Ask ‘does this create the conditions that allow life to emerge, does this serve life?’. If it does, and you improve the gardening, something creative, something healing will happen. You won’t know what it’s going to be – and be ready for it not corresponding to your five-year goal, your target weight or your academic or financial dreams. This not-knowing is called adventure. To explore this for yourself, or with others, maybe try the following reflective enquiry. It’s a simple sequence I’ve found can catalyse perceptual shift, and so generate new maps. It uses images to circumvent the current maps and egoic-self. At its core is an activation of a change of heart – and this is aided by using images of dependent life in need of care – like a plant, a child, a pet.

Life-compassion dialogue Taking account of any suffering or strain… eyes closed if this helps, in a quiet reflective way – let an image or idea come in response to these questions: ‘If you were plant what shape are you in?’ Let an image come to mind that reflects this and take notice. Now ask: ‘What does this plant need, what is it calling for?’ Let a quiet voice or a feeling come through. If it comes in metaphor – like ‘light’ or ‘water’… then ask what that would be at a practical level in my life, my day to day living. Now, sitting with this image of your life; ask… ‘Whose plant it? Who is responsible for it? Who is the gardener?’ Yes, only you. It’s no one else’s job. No one else can do this for you, eat for you, sleep for you, nurture your life… Give yourself a score out of 10 for your self-gardening. Could it be better? Life-compassion dialogue from www.thewel.org

The healing shift enquiry I became a student of survival; then of recovery; then of flourishing. As I discovered the limits of current orthodoxy, I also found that complementary medicine is not it – it

lacks awareness of public health and is still basically an expert/fix-it model. Both systems have value, neither are providing the transformative components we need to face our chronic disease epidemics. I came to stop looking for treatment systems and adopted ‘first principle’ working. My clinical field studies involved working with people who had experienced recovery either through their own efforts, and/or through any effects of our consultations together. I studied this with them directly, working outwards from there, ‘reverse engineering’. Avoiding ideas, fantasies, speculation, theory, philosophy as best I could, I tried to understand something of how these people had survived. Sometimes I’d ask ‘How come you’re not dead?’ It’s a provocative question, so be sensitive about the timing! But at the right moment it can reveal a lot about what has been keeping them going and how they had got through. I’d also ask for their teaching if something we had done together was effective. I was also learning from my own life and the people close to me. As I watched people recover and transform their lives in the middle of the epidemics, they were like poppies on a battlefield and somehow I felt they were holding answers, if only I could hear them well enough. I remember one of my formative conversations with a woman in the early 1980s – it held the essence that would later seed the ‘fifth wave’ ideas. We held a first consultation together in the pain clinic. She had run the gamut of drugs and procedures but was still struggling. She was wondering about the gamut of alternative medicine. We were exploring my nascent efforts at what I’d later call a therapeutic consultation. At the end of what I knew to be an important meeting for her, I asked her: ‘In view of our meeting, how would you feel if I didn’t prescribe anything?’ It seems simple now, but then it ran counter to my training and medicine’s maps to ‘do something’. She was delighted. ‘That would be great, people just seem to always want to do things to me, or have me take drugs.’ When she came back four weeks later, she described a transformative experience to me. She was different. There were radical shifts in her whole health, her whole world, her whole wellbeing. In addition, the negative impact of her pain was meaningfully reduced. I realised that if I had prescribed something (orthodox or otherwise), she and I would be having a conversation about what a fantastic medicine that was, and I’d be asking the kind of questions practitioners ask about – how quickly it had acted, what had the treatment done at first, how it developed then, and had it worn off yet, and should we repeat it: a health intervention conversation that has been repeated billions of times around the planet. She helped move me off this territory, to accept that this outcome was entirely due to what had happened between us – and thus within her. I had seen this ‘healing response’ as I called it before, but always interwoven with and so attributed to an intervention or its placebo effect. Now I had to confront this capacity directly, creatively. In studying this I could refocus and supplement the usual practitioner’s questions unfettered. I could ask, ‘Did you

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THE TRANSFORMING SHIFT Darkness, life-compassion and the seeds of transformation

Carol’s pre-three-month interview: • Depression every year for the last 36 years, as troughs in an overall pretty miserable existence. • Anti-depressants on a seasonal basis. • Periods – unable to leave the house for nine months. • Anxious all the time, ‘fear’ is a central theme in her life. • Panic attacks ➟ urinary incontinence and vomiting. • Paranoia and self-loathing also feature. • Not many people know her suffering, she can put on a face. I know that had I met this person before the mid-1980s I would have had a very heart-sinking feeling. Now, I know she has transformative potential, not through faith, but because of simple, practical experience. I know the seed may be buried in the permafrost under ten feet of concrete, and I know this may be a five-year job, and a very stormy job at that. But I know she can shift. When she came back three months after entering the programme, the PhD researcher who re-interviewed her noted ‘an absolute shift in her manner… a deep transformation… a changed awareness and ways of being with herself ’.

Carol – interviewed after the course +3 months: Carol described how every dimension of her life had changed and she was off all drugs. In her own words, ‘[It’s] Totally different. The whole way I look and see things and feel things… I keep pinching myself that I’m not dreaming all this… I’m not afraid anymore… this confidence is coming from inside it’s not just a phase… I’m myself now, I’m quite happy with who I am.’ I’m healing, I see myself as healing. This is just a personal thing, I’ve seen myself with like an open wound that’s never healing, and now I can see it’s closing down you know it’s like you know how if you’ve got a scar it’s open, so now this is closing in, its healing, that’s how I feel. It’s not open anymore’. +12 months: ‘I have to say this, this is the first year, since I was 20, that I never had to take anti-depressants or St John’s Wort or something like that for my mood swings, because I have suffered from depression all my adult life’.

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When the shift happens and the seed germinates the effects ring through the whole organism: different dimensions that practitioners didn’t even know about begin to reorganise. I’m still amazed by this – by my old maps it’s not supposed to happen, especially after so many years, nor so quickly. This doesn’t happen all the time of course, but as an explorer, once I had seen it, I now knew it could happen. It was experiences like this that led me to more formal study and research. The research team’s results show that Carol’s results echo the group averages, as does a series of in-depth case studies and qualitative work. Our main research work also used the six measures shown in Carol’s results in Figure 4, tracked prospectively with some randomised wait list groups. The results showed clinically important and statistically significant improvements in all six measures, across the whole time period. This confirmed the years of course assessments, and the pilot research results (Higgin et al, 2009), and the retrospective tracking. The same was true of our quantitive measures. Fasting insulin levels are a sensitive measure of movement towards diabetic risk, and in our study cohort of 125 people just less than half were actual or suspected pre-diabetics. After the course, half of those with raised insulins had improved, and one in three of those in a ‘pre-diabetic’ category moved out of category, persisting at nine months. (Reilly, 2013a, Reilly et al, 2013a; Reilly et al, 2013b).

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When the shift happens and the seed germinates the effects ring through the whole organism

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know you had this in you? How did you achieve this?’ (Note the empowering new anchors this brings). ‘Why do you think this happened; why did it not happen before; was there anything that we did that helped? What does it need now?’ And so on. Let’s look at this action. This next example is from a research depth-study of a healing response. The researchers called this woman Carol. She was a healthcare staff member in her early 50s who joined our wellness enhancing learning programme in the Highlands after 36 years of absolute misery and suffering. The programme (TheWEL) was designed to model what had been learned from the one-to-one studies of supporting healing responses into a group situation.

What are we dealing with here? Rich questions arise. How can we now learn better to catalyse such germination, engage it and foster it effectively? How can we best measure its effects? What might its determining conditions be? What are its limits? Can it be taught? Can it be scaled up? There is clearly more going on than the important elements of inspiration or motivation or willpower. One core dimension is a deep shift in perception, with a resultant reconnection to capacities. In time, this entails a physical shift in the embedded patterns of mind. The subconscious maps or mindsets we navigate our lives by become physical: the more you think a thought or hold a view or map your world a certain way, the more the brain myelinates these pathways and insulates them. These are the sorts of map that drive your car when you’re not thinking about it. And they drive your inner and outer life. When you shift the map, the journey changes automatically, it has to. Then what about our own maps?

THE TRANSFORMING SHIFT Darkness, life-compassion and the seeds of transformation

the shift we aimed for, and the one people described, was in compassion towards their life, rather than ‘self ’ compassion – and this life-compassion cascades nurture with its intrinsic respect for life. Not that people would necessarily articulate things this way – indeed they often struggled to find words to describe the shift, even saying ‘I don’t know what happened, but things have changed’.

Figure 4: Carol’s questionnaire results as a percentage maximum of attainable score on measure yourself medical outcome profile; outcome related to impact on daily living; fatigue impact scale; self-compassion scale; psychological wellbeing scale, and the patient enablement instrument.

The practitioner shift Our colleagues are dropping on the battlefield, burning out in increasing numbers. As the relevance of self-care and self-compassion for health practitioners became clearer to me, in 2010 I stared running the original patient groups just for the staff – The StaffWEL. The staff often seemed as unwell as their patients or clients. Why is that? Are we saying, ‘Okay plant, I won’t be watering you because I’ve got everyone else’s plants to water’? Whatever the mixed causes, we need to confront this neglect: would you treat a dog the way you treat yourself? I’d bet you wouldn’t dehydrate it, feed it the junk you feed yourself, or the alcohol, or subject it to the self-attacking voice in your head, or the stress you put yourself through, or starve it of exercise or activity, or play, or downtime or calmness or sleep. Go find these maps – mostly now subconscious – that drive this life-neglecting way of living. Then enter the journey to shift them.

Life-compassion What works is an activation of a self-sustaining transformation of self-care. In turn, a key here is nurturinginstinct – a given wisdom in us all. In turn, this is automatically mobilised by compassion – another given, but often neglected, capacity. In our staff and patient groups we found measures of self-compassion rose significantly over the nine months. But the self we are talking about here isn’t the egoic self. More accurately

‘The vision of this plant, instead of someone saying, right, you’ve got to look after yourself, we all know that. The visual element of the plant sitting…I thought… oh my God, my roots are all dry. I’m not grounded and my petals are all faded. But gosh, that really worked for me.’ WEL patient participant, 2012

We experience the world as we see it. We can see your life-predicament, our darkness, in flight or fight mode, as an enemy and we shrink or attack accordingly; or, we can see it as a plant with drooping leaves crying out for the nourishment only the keeper of that life can bring. This transformation of our perception of suffering involves a shift towards a felt sense of a larger, truer, deeper self: a realisation that I am not the waves, I am the ocean. Call that what you will, but watch out for the web of labels. When a human being experiences that movement, something very profound happens, and we have seen how directly accessible that shift can be when circumstances are right, triggering transformative process. Wisdom traditions, spiritual and religious teachings have emphasised this, but all too often they distort the story so that the shift seems distant, externally mediated, unattainable. But I believe it’s actually robust, ever-present and natural. It is after all only a reconnecting to what we might call the wellspring: the pre-existing and fundamental characteristics of life itself – repair, growth and flourishing – with the natural fruits of joy, peace, creativity, spontaneity, loving, openness, connectivity. Yet when we speak of such things, and even though these traditions have a thousand ways of talking about them, we actually enter a territory where language fails. Perhaps the great task of our time is to reclaim this realm in a secular context, and so retrieve the wisdom that lives in all of us and rediscover these instinctively available and naturally inherent capacities.

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The fifth wave

Acknowledgements

The idea and metaphor of a needed fifth wave to meet the new public health challenges was seeded by the Public Health Institute of Scotland headed by Professor of Public Health Phil Hanlon. Andrew Lyon led country-wide learning journeys of an enquiry group seeking inspiration. They concluded that the capacities that Carol modelled contained the essence of a new way (Hanlon et al, 2011a). ‘How can we take what we’ve just seen and scale it to a level of a nation?’ This was the bold visionary question that Phil Hanlon asked me in 1999 after meeting one of my patients who had shown a healing response similar to Carol’s. This wonderful question is akin in scale to the dream of Loch Katrine’s water supply. You know, the rock they had to get through to create those 19th century tunnels was so hard at times they advanced only a meter in a month. Phil’s question was part of my inspiration to ask if we could inch-advance into the solution of the epidemics by testing if the effects of this wellness-enhancement-learning approach evident in oneto-one work could be catalysed in a group setting – and so TheWEL was born in 2004. More than 3,000 patients and staff have completed this – and the research has said yes, this can work well in both primary care and secondary care. Now, TheWEL Charity with a sister charity Community Renewal will pilot a facilitated version in community settings. In the big scheme of things this is just a trickle of clear water but it shows the potential for profound personal transformation is there waiting to be mined. Government-backed initiatives have picked up some of the themes of the enquiry – compassion was placed in the NHS quality strategy (The Scottish Government, 2010), and the birth of the ALLIANCE organisation seeded an emphasising on the power of people with long-term conditions to change the course of their own lives (Douglas-Scott et al, 2008). The risk here is of these second horizon initiatives being absorbed into the old ways of our first horizon. Increasing the flow and impact of these fifth wave ways and changes could take a long time to affect the epidemics, but the direction we can travel is clear. Coupling traditional forms of actions to clean up the air and food and environmental toxicity, combined with fifth wave orientation and action over the next 20 or 30 years could bring these epidemics to a halt. If it can become an embedded norm to ask what they can do to help release innate capacity and healing, this can spiral out from the individual to touch families, communities and nations. What if the whole medical toolkit became servant not master of this vision? Imagine what would happen if we placed the capacity for innate healing movement and change, of repair and growth, and so flourishing at the centre of our vision and so into the design of our services and our science? Transformative change would grow as people like Carol lead us out of this dark era.

To Carol and my thousand other teachers, to all my colleagues on the Healing Shift Enquiry and WEL programmes – too numerous to list – but some mentioned below as authors in the references.

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www.thehealingshift.org; www.thewel.org; www.afternow.co.uk BBC (2014) The rise of Glasgow urban growth in Victorian Scotland (cholera epidemics). Available at: bbc.co.uk/history/scottishhistory/ victorian/features_victorian_urban.shtml (accessed 12 March 2018). Campbell J (2008) The hero with a thousand faces. The Collected Works of Joseph Campbell. Ovato, CA: New World Library. Diabetes.co.uk (2015) Five Scottish children diagnosed with type 2 diabetes. Available at: www.diabetes.co.uk/news/ 2015/jan/five-scottish-children-diagnosed-with-type-2-diabetes-97211814.html (accessed 12 March 2018). Douglas-Scott S, Donaldson A (2008) Gaun yersel: the self management strategy for long term conditions in Scotland. Edinburgh: The Scottish Government. Available at: www.alliance-scotland.org.uk/ blog/resources/gaun-yersel/ (accessed 12 March 2018). Hanlon P, Carlisle S, Hannah M, Lyon A, Reilly D (2012) A perspective on the future public health practitioner. Perspect Public Health 132(5): 235–239. Hanlon P, Carlisle S, Hannah M, Reilly D, Lyon A (2011a) Making the case for a ‘fifth wave’ in public health. Public Health 125(1): 30–36. Hanlon P, Carlisle S, Hannah M, Lyon A, Reilly D (2011b) Learning our way into the future public health: a proposition. Journal of Public Health 33(3): 335–342. Harcombe Z (2010) The obesity epidemic: What caused it? How can we stop it? York: Columbus Publishing. Higgin M, Reilly D, Mercer S, Hopkins D (2009) Evaluation report of the pilot phases of the wellness enhancement learning programme for patients with chronic fatigue syndrome CFS-ME. Available at: www.thewel.org results (accessed 12 March 2018). McCombes A (2010) Loch Katrine; a triumph of community values over private greed. The 150th anniversary of the greatest public health achievement of its day. Available at: http://eastdunbartonshiressp. blogspot.co.uk/2010/01/loch-katrine-triumph-of-community.html (accessed 12 March 2018). Reilly D (2013a) The healing shift enquiry – creating a shift in healthcare. Journal of holistic healthcare 10(1): 9–14. Reilly D (2013b) We need a new vision to meet the new challenges of our times. Journal of holistic healthcare 10(1): 4. Reilly D, Banks A, Clark C, Krawczyk C, Lyon A, Quinn P, Smith F (2013a) Water from TheWEL: The healing shift enquiry – seeding a shift towards a health culture in an ill(ness) environment. Initial Learning from a StaffWEL – Wellness Enhancement Learning – programme. Paper presented at the The Scottish School of Primary Care 2013 Annual Conference, Inverness. Available at: www.sspc.ac.uk/images/PDFs/large/DReilly.pdf (accessed 12 March 2018). Reilly D, Banks A, Clark C, Krawczyk C, Lyon A, Quinn P, Smith F (2013b) The Healing Shift Enquiry: creating a shift in health care. Annual Report. Reilly D (2001) Enhancing human healing. BMJ 322(7279): 120–121. Russ TC, Stamatakis E, Hamer M, Starr JM, Kivimäki M, Batty GD (2012) Association between psychological distress and mortality: individual participant pooled analysis of 10 prospective cohort studies. BMJ 345: e4933. Sharpe B (2013) Three horizons: the patterning of hope. Charmouth: Triarchy Press. Sweeting H, Young R, West P (2009) GHQ increases among Scottish 15-yearolds 1987–2006. Soc Psychiatry Psychiatr Epidemiol 44(7): 579–586. The Scottish Government (2010) The Healthcare Quality Strategy for NHS Scotland. NHS Scotland Quality Strategy – putting people at the heart of our NHS. Edinburgh: The Scottish Government. Visintainer MA, Volpicelli JR, Seligman ME (1982) Tumor rejection in rats after inescapable or escapable shock. Science 216(4544): 437–439. Yashina S, Gubin S, Maksimovich S, Yashina A, Gakhova E, Gilichinsky D (2012) Regeneration of whole fertile plants from 30,000-y-old fruit tissue buried in Siberian permafrost. Proc Natl Acad Sci USA, 109(10): 4008–4013.

STAFF RENEWAL

Making (sacred) space for staff renewal and transformation Rev Stephen Wright Visiting Professor and Honorary Fellow, University of Cumbria; Spiritual Director, the Sacred Space Foundation

This is an edited version of

My interest in spirituality and wellbeing is personal and not merely academic. I had what was by any measure a ‘successful’ career in nursing and academia and picked up lots of glittering prizes along the way. A plunge into a series of ‘awakenings’ 35 years ago took (dragged) me in a different direction, helped along the way by the gifts of some very wise teachers of high repute. Since that time, among other things, I have sought to integrate a deepening of this awareness in life, both personal and professional. The latter has taken me, or at least the me-who-I-think-I-am, in new directions of writing and research on the theme of spirituality and health, facilitating retreats, working as a spiritual director and setting up a charity/retreat centre with Jean Sayre-Adams (www.sacredspace.org.uk). I work with others providing development programmes, specifically for health care professionals, unifying spiritual teachings and practice with the cultivation of compassionate action and leadership.

a talk given recently at the joint SMN/BHMA conference

Levels of identity

on Transformative

‘Is there a God?’ ‘Why is this happening to me?’ ‘What do I do with my life?’ These are the everyday questions that surface in the process of Spiritual Direction. A less common, but more important, question is: ‘Who is asking the question?’ Through deeper enquiry, we may begin to realise that who we think we are is not necessarily who we really are. All spiritual traditions nudge us into questioning assumptions about what it is to be ‘me’. Our level of awareness of ‘me’ determines the way we are in the world. Between the shores of the ego and the ocean of the soul there are many planes of consciousness. So, if we are talking about changing the way healthcare is organised, we must be clear not only about what needs to change but who it is that wants to change and why. Intention is all. Form follows consciousness. In the clarification of the motive through the ‘ground of our beseeching’, to paraphrase T S Eliot (1944), we are

Innovations in Healthcare. It draws on and distils a lifetime of professional and spiritual practice.

more likely to produce wholesome changes if they have come from the wholesomeness of our Essence as opposed to, say, the product of our ego attachments and agendas. Inner awakening to a deeper truth of self must precede the forms we create. All kinds of drives, conscious and unconscious, determine the form that emerges. In a culture where ‘we’ should be in charge, make things happen and succeed, surrender into other perceptions of self is anathema. I sat with my teacher Ram Dass, long ago and we explored these ideas, how the ego gets in the way, wants to ‘do’ everything. He offered as a precept, ‘I do nothing, and nothing is left undone’. It took me years to ‘get’ that. When we act from the plane of ego consciousness we stamp our will, however benevolently intended, upon the world. Things we want to change are contaminated and corrupted by our desire to fix people and things according to our image. When ‘we’ let go of doing and serve ‘The Will’ not ‘our will’ the results are very different. A story here might be helpful.

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STAFF RENEWAL Making (sacred) space for staff renewal and transformation

The dance of life Maysie (not her real name) was close to death, 90, emaciated and terribly sad. The student nurse and I were helping her off the commode. Maysie put both her arms around my chest to steady herself while the nurse wiped her bottom. She said, ‘Oh it’s years since I’ve had my arms around a man and a man’s arms around me’. I suddenly lurched into a memory of my mother, and how when I was a child we would go to the Tower Ballroom in Blackpool. I told her this, and how my mum taught me to dance with her by having me stand on her feet and off we would waltz. Maysie said, ‘I loved to dance, at the tower too and do you remember Reginald Dixon on the organ?’ And I said I did, and would she like to dance now and she said yes and the next thing you know I had pushed my feet beneath hers, gripped her gown behind her and waltzed through the screens out into the ward with me singing like a rusty Sinatra and Maysie humming along as I held onto her feather-light frame. We returned breathless to the bed, passing the ward manager who looked aghast. Maysie and I were laughing like kids. I placed her back in bed, brought her some roses from the garden. The gobsmacked student gasped, ‘Where did you learn to do that? It wasn’t in the module!’ Maysie died three days later, still smiling. It was of course nothing special, like any nurse, I have my tales to tell of moments such as this one when the barriers fall away; moments of freedom when heart, mind, body and spirit conjoin in the flow of caring so that healing happens. In this little vignette the student and I had broken a lot of rules… the intimacy, the risk assessment process, flowers on the ward. It takes certain qualities to run those risks: courage and confidence rooted in wisdom and experience (and perhaps a certain fearlessness). In the trajectory from novice to expert, we acquire the connoisseurship, the ‘nous’, to be able safely to go with the flow of the healing stream, and to encourage others to do likewise.

Humanising the system In risk-averse health services like our own, technically rich yet spiritually impoverished, my colleagues and I work daily with practitioners in their struggle to humanise the system. For some the effort is costly, exhaustion leading to quitting, burnout or indifference – the consequences of which we saw recently at Mid-Staffordshire NHS Trust or Winterbourne View and in other regular reports of uncaring, not to say cruel staff. If we accept, as Martin (1984) proposed in his seminal study Hospitals in Trouble, that uncaring psychopathic staff are rare, then most are ordinary people doing the best they can while lacking adequate education, leadership, resources and support. In such circumstances indifference is really a defence mechanism in the face of overwhelming physical and emotional labour Burnout, the spiritual crisis that follows when we just can’t take it any

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more, is all too common (Wright, 2010). An occupational therapist at our first Spirituality and Health conference (Durham, 1996) illuminated this point. She cried out, ‘How can I go back when my heart and soul are not welcome there?’ Working in dis-spiriting, dis-connected and dis-easing environments can crush the essence of what it is to be human. Attention has more recently been paid in healthcare to developing leadership and staff support. These are all to the good, but sometimes these policies may be ways of staying in denial of the fact that the roots of high levels of patient complaints, clinical errors and staff attrition rates can be traced back to simply not having enough people and resources to do the job properly. However, even when support and staffing are good, compassion and healing can still fall short; things still go awry. I have participated in six enquiries where care has failed. In one, a superbly equipped and staffed hospice, patients still experienced neglect and staff were bullied. All kinds of unconscious phenomena feed into relationships at work that have nothing to do with material resources. In this example, a failure to address the fear of death and dying among the care staff (Speck, 2003) lead to an inclination to be seduced by their own mythology, delusions reinforced by signals such as, ‘Oh how wonderful you are to be able to do this work, I couldn’t’. The stereotype of hospice workers as martyred carers battling against the odds goes unchallenged, with dire consequences for patients and staff. Holistic care needs far more than the right resources to do the job. A highly energised senior NHS executive I met thought ‘all this spiritual stuff ’ was ‘too touchy feely’, irrelevant to ‘getting the patients through the system’. That last production line phrase was telling. I replied, ‘But what the hell is healthcare if it’s not touchy feely?’ The conversation dried up. Five years later she asked to come into retreat after the NHS trust that employed her sank into ‘special measures’.

The infiltration of modern individualism Much of modern western healthcare has subtly and sometimes not so subtly bought into the values of neoliberalism. With its roots in Nietzschean ‘ubermenschen’ and ‘Gott is tot’ (Nietzsche, 1891) 20th century eugenics and Darwinian survival of the fittest, this ideology has permeated almost every level of our culture and has rippled through the political discourse from the economics of Hayek and the ideologies of Ayn Rand and onwards into Thatcherism, Reaganism and, latterly, Trumpism. It is a fundamental denial of the truth that we are not just human beings but also human belongings. Rampant individualism, as an irrefutable ‘given’ has colonised our values and infected every part of our culture. It denies the truth that we are at our best when connected, collaborative and cooperative, living lives in community of shared responsibility.

STAFF RENEWAL Making (sacred) space for staff renewal and transformation

This world-view has even crept into the spiritual life. For example, in the past year I have worked with (or been a patient in!) 27 English and Scottish NHS trusts which have set up mindfulness programmes for staff, in an effort to reduce sickness, absenteeism, burnout and attrition. Like motherhood and apple pie, building awareness, resilience and opening us up to greater compassion through mindfulness would seem self-evidently good. So, what’s to complain about? First of all, the implementation of some mindfulness programmes buys into the zeitgeist that ‘it’s all down to you’ – that whatever is going wrong in society, personal life and work is the result of your own moral, biological, psychological or spiritual weaknesses that with a bit of (mindful) work, you can put right. (If you can’t, it’s your fault). Thus, stressed people get asked, ‘What’s wrong with you?’ rather than, ‘What’s wrong with the circumstances that have made you stressed?’ Lonely people get asked, ‘Why can’t you make friends’ rather than ‘What’s going on that has atomised neighbourliness?’ Impoverished people get asked, ‘Why don’t you get a job’ rather than, ‘Why have so many jobs become insecure drudge paying shit wages?’ The responsibilities (and costs) of making sure the workplace or society is a healthy place to be will be bypassed if employers, governments and societies are allowed to get away with dumping the problem on individual failings. Too many of the resilience building/mindfulness website and self-help tools are breath-taking in their lack of attention to these organisational responsibilities. Despite the efforts to secularise it, can mindfulness really be divorced from its underlying Buddhist philosophy, not least what a necessary questioning of what ‘mind’ is? Is a profound spiritual practice debased when reduced to a stress reduction technique? I was at a meeting some years ago with the Dalai Lama. He said, ‘Why do you all want to learn Buddhism, you have all you need already here?’ The rich tradition of the contemplative way, for example, with the same attendant health benefits and cultivation of loving awareness is already here. The different philosophical roots of this tradition also hold the possibility that there is ‘Something Other’ available to help us… we are not on our own (Wright, 2017). The Buddha said, ‘Suffering is’ and that its roots were in attachment to things or to persons or to ideas of self. Another perspective is possible, that suffering occurs only on one plane of consciousness and that it may have meaning and purpose. Therefore attachment may not be the issue, rather detachment from our Source. Reconnection with this – our deepest Self – offers a different perspective and set of responses to the challenge of what it is to be human.

Heartfullness At the Sacred Space Foundation our approach rests on what we have called ‘heartfullness’ – an awakening to full awareness through inner exploration. It enables people to let go of trying to do compassion and instead simply to learn to be it. For we carry its infinite source already

within the very heart of our being. Could it be possible then, that integrating deep spiritual practice, spirituality, into staff development and support programmes would assist the emergence of greater compassion? Could dismantling unhealthy and limiting constructs of selfsupport more holistic care? Spiritual practices and insights do not have to be segregated to the meditation room, the retreat or the religious house. Despite the scepticism we might expect from hard-pressed NHS managers, some 25 have now asked us to bring our programmes to them. Such personal transformation invariably requires processes such as inner enquiry over a long term and a deep shaking of the tectonic plates of the psyche in order to unleash the real ‘I am’ from the ‘I-that-I-think-I-am’. Such liberation is not about personal gratification, pacification or creating a saccharin, fluffy, feel-good existence. Rather, the intention is to nurture an interior realisation and fullfilment that liberates us into deeper engagement with life and work; but from a place of profound awareness of our true nature. An awareness that is not detached, disengaged, aloof witnessing of the human condition, but bursts with compassion for the healing of it and inspires a healthy-boundaried, nonattached willingness to participate. It is a call to leave the self and come Home to the Self, from which our path of service arises, awakening the heart to revolutionary compassionate action in the swampy lowlands of ordinary reality….in the worlds of the prophet [Micah 6:8] …to ‘act justly, love mercy and walk humbly with God’… whatever we experience that to be.

The void within This demands nothing less than transformation out of limited perceptions of self and the story of life as we currently live it. It requires the writing of a new story where we are the hand and the pen and the paper. In the words of TS Eliot (1944) – it requires ‘a condition of complete simplicity costing not less than everything’. This to many, perhaps most, is scary stuff. Little wonder we have lots of drugs to keep us addicted and away from it. In the first week of November 2017, a police raid in Toronto netted 42kg of carfentanil, a powerful opioid, normally used to knock out elephants, but which when mixed with heroin delivers a knock-out but deadly ‘high’ for people. Half a world away, it was Single’s Day in China and the on-line shopping giant Alibaba saw more than 160 billion Yuan (£20 billion) kerchinging through its tills in the planet’s biggest ever one-day shopping spree. These events are connected. Sartre (1943) wrote of the ‘God shaped hole’ in our consciousness – an empty space longing to be fulfilled with meaning, purpose and connection, the very stuff of spirituality and what it is to be human. For millennia and across cultures God/s quenched this spiritual thirst in various forms. But now in a life uprooted from what Tillich (2000) called ‘the ground of being’, locked into ordinary reality without connection to ‘something other’, we seek other gods to fill the void.

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STAFF RENEWAL Making (sacred) space for staff renewal and transformation

Few of them are healthy: drink, drugs, TV, sex, shopping, power-grabbing, career chasing, status seeking. All these painkillers offer only temporary respite. Like the insatiable hungry ghosts of the Buddhist tradition with their bloated bodies and tiny mouths they demand more and more. All are ultimately destructives to ourselves and the Earth. The fear-full undercurrent lurking in us all as we touch that emptiness within, bereft of the numinous, makes us sick. It drives a relentless anxiety in the human condition that, if for example, it compromises our immune system makes it more likely we will develop one or more of a whole raft of illnesses from cardio-vascular disease to cancer (Wright and Sayre-Adams, 2008).

The 4 Fs It’s no accident therefore that fear is diminished, and thus our health and happiness improved, when we have four other Fs in our lives. On all scales and from the big picture of much recent research, we are more likely to be happy and healthy if we have: Faith (not necessarily in a God, but simply having faith in something that gives meaning to life. For most people it is some perception of the divine, but it could equally be politics, philosophy or, for that matter sport!) Fellowship – family, friends, community – relationships that shelter us from loneliness. Loneliness has been shown to undermine health – although it may be not so much the loneliness per se as the underlying anxiety if provokes. Fulfilling work – bringing meaning, purpose, rewards to life. Free giving – volunteering, parenting, opportunities to help and express compassion without expectation of reward. Our programme at Sacred Space, going back more than three decades, grew out of both the scientific and the spiritual truths of the consequences of disconnection from each other and ourselves. The early teachings we pursued in the healing arts extended to support for health care staff as we noticed that course participants sought more than skills in healing. They wanted, often desperately, healing for themselves. Out of that our ‘heartfullness’ ideas grew (see https://youtu.be/YUMBKXjgEN0).

Inner work and the quality of relationships Despite the reservations of the hard-pressed manager, inner work for individuals and achieving organisational goals are not mutually exclusive. The transformation of self-perception among carers can unleash benefits for the organisation – fewer staff problems and better responses from patients. Getting the relationships right in the first place seems to save money down the line with less staff sickness and fewer patient complaints, for example. The focus of our work is twofold. Drawing on spiritual practices from the contemplative tradition, a lineage to

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which I am blessed to belong, we help individuals in our retreat facilities while also outreaching to groups in workplaces. The practices include spiritual direction, mentoring, deep silence, guided imagery, reflection, Enneagram insights, labyrinth walking, meditation and so on. When working with groups we use venues that are aesthetically pleasing, in nature, well away from the workplace, sometimes residential and lasting a week as well as short time out/retreat days. Isolation from mobile and wifi signals helps (the anxiety arising in some under such circumstance is itself full of rich teachings about attachment!) Participants report many benefits, but often find it painful and frightening too. When we begin to engage with the dismantling of ‘who-I-think-I-am’ to discover the ‘I am’, that letting go of attachments to roles and identities can be confusing and hurtful. Confronting the essential emptiness of personality can take us to the edge of the abyss. ‘If I’m not this’ (doctor, nurse, mother, friend, sister, taxpayer…) ‘Then who am I – nothing?’ Contemplative practices help people move from fear to liberation in ‘I am.’ – full stop, no accretions needed. There is joy in the realisation that being nothing and no-thing are not the same. I conclude with the story of Irene, a course participant and NHS support worker. She arrived armed with her multipacks of cola and stashes of chocolate and ciggys. Her bad education, crushed and angry persona, dysfunctional upbringing and home life was soon revealed and she spent the first part of the programme barely able to stay in the room. However, she stuck with it. In the final session everyone was speaking of their revelations and the impact of discovering their I am-ness. She exclaimed, ‘Well if you’re ‘I am’ and I’m ‘I am’, then we’re all the same aren’t we?’ Recognising our mutual I-am-ness is the stuff of connection and the fount of compassion in action. That’s what we are called to do, as Forster (2012) suggests, ‘only connect’ – with the Essence of who we really are and through that connect with others and the All-that-is, whatever we experience that to be. That is the truth that sets us free. It is where ‘human love will be seen at its height’. This connection is not somewhere else. It is here. Now. Always. In the Wizard of Oz, Dorothy cries, ‘I want to go home!’ ‘But you are home, Dorothy’, replies the good witch, ‘All you have to do is wake up!’ Eliot TS (1944) The four quartets. London: Harcourt Brace Jovanovich. Forster EM (1910) Howards end. Empire. London: Penguin. Martin J (1984) Hospitals in trouble. Blackwell London. Nietzsche F(1891) (T Commmon trans 2016) Thus spake Zarathustra. London: Createspace. Sartre J-P (1943) (R Eyre trans 2003) Being and nothingness. London: Routledge. Speck P (2003) Working with dying people. In: Obholzer A, Roberts V (eds) The unconscious at work. London: Brunner-Routledge. Tillich P (2000) The courage to be. Yale, CT: Yale University Press. Wright S (2017) Coming home. Penrith: SSP. Wright S (2010) Burnout – a spiritual crisis on the way home. Penrith: SSP. Wright S, Sayre-Adams J (2008) Sacred space: right relationship and spirituality in healthcare. Penrith: SSP.

LIFEST YLE MEDICINE

Lifestyle medicine education – an answer to chronic disease? John Sykes GP

It is thought that lifestyle issues cost our NHS around £11 billion a year, yet healthcare professionals often receive very little teaching on how to optimise a patient’s lifestyle behaviours for better health. Lifestyle medicine involves targeting root causes of disease by trying to optimise a patient’s activity levels, nutrition, sleep, mechanisms of de-stressing as well as ensuring patients are engaged in a community with strong support networks. This piece focuses on some of the teaching I have organised to GPs, medical students and healthcare professionals on lifestyle medicine and how you can get involved in this growing field.

I am a GP working in the NHS who is passionate about integrating lifestyle medicine into primary care and beyond, by enhancing student and professional education. I work as a GP in Bath and I am one of the directors of the British Society of Lifestyle Medicine. I have organised several teaching events for GPs and medical students on lifestyle medicine including the inaugural RCGP Lifestyle Medicine Conference, which won the Vibrant Faculty Award 2017 in Severn. I am looking forward to a career in which I can combine my passion for general practice and lifestyle medicine.

Current situation The World Health Organization (WHO) in 2010 found that two-thirds of all death worldwide was due to noncommunicable disease, most of which are caused by poor lifestyle choices including tobacco use, unhealthy diet, insufficient physical activity and harmful alcohol intake. In April 2015, Margaret Chan, the director of WHO, stated that ‘non communicable diseases have overtaken infectious diseases as the biggest killers worldwide’ (Chan, 2015). It is now estimated that lifestyle-related conditions cost our NHS around £11 billion a year with the combined cost to the NHS and is expected to rise exponentially in the next few decades (Hughes, 2016). It is widely acknowledged that chronic disease has become a major issue for the NHS and for healthcare systems all over the world. Most specific disease guidelines include a first stage of management in which giving ‘lifestyle advice’ or encouraging ‘behaviour change’ is the initial recommended step. Despite this being first-line management for many chronic conditions it is not an area many practitioners feel confident giving advice in. A recent questionnaire

based study in the British Journal of General Practice examined GPs knowledge and confidence in giving advice to patients on physical activity. This revealed that only 20% of responders were broadly aware of national guidelines of physical activity for the population and only 43% were ‘somewhat’ confident of raising the issue of physical activity with a patient (Chatterjee, 2017). Despite the fact that brief advice for physical activity has a number needed to treat of 12, which is 10 times less than smoking, it has been shown that 72% of GPs do not speak to their patients about becoming more active (Brooks, 2016; Macmillan Cancer Support, 2016). This is probably a reflection of the lack of teaching in this area. We are taught how to advise patients on which drugs to use, when to use them, which dose and what effects to see when taking them. It is fair to say many healthcare practitioners do not receive the same level of training on how to give advice to patients on physical activity, diet or other lifestyle behaviours.

What is lifestyle medicine? Many of our traditional medical treatments only serve to reduce

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LIFESTYLE MEDICINE Lifestyle medicine education – an answer to chronic disease?

Figure 1

symptoms or ‘manage’ risk factors of a condition or disease. Lifestyle medicine aims to actually target the root cause of the problem by looking at upstream determinants of disease that occurred to lead to the medical chronic condition. In attempting to correct the disease-causing process, lifestyle medicine has the potential to actually reverse the disease or put the condition into remission. Understanding and acknowledging physical, emotional, environmental and social determinants of disease is essential to identify these causes. The determinants of disease can be categorised into three levels (see Figure 1). There are the ‘upstream’ eterminants, such as the environment, which can in turn be divided into the macro- and micro-environment. Politics, economics, social, cultural and physical factors all contribute to environment. Next are the ‘mid-stream’ determinants which include stress, anxiety, low mood, drugs and alcohol, poor sleep, poor relationships and inequality. Issues in this group commonly lead to poor habits in the next group of determinants of disease called the ‘downstream’ determinants. These include nutrition, inactivity, smoking, limited sun exposure and pollution. Upstream determinants of disease are currently managed by public health but the mid-stream and downstream determinants currently have no formal place in our medical model. It could be strongly argued that this is where lifestyle medicine could have an enormous impact. Lifestyle medicine involves the use of evidence-based lifestyle therapeutic approaches focusing predominantly on a whole-food and plant-based diet, increasing activity and movement, reducing sedentary behaviour, bettering sleep habits, stress management and relaxation therapy, alcohol moderation and tobacco cessation and other nondrug forms of treatment in order to prevent, treat and reverse the lifestyle-related disease. Although many components of lifestyle medicine exist, I find it easiest to look at it within five key areas (see Figure 2).

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1. 2. 3. 4. 5.

Activity Relaxation Sleep Nutrition Community

Figure 2

Lifestyle medicine advocates a multidisciplinary, multisystem approach to the chronic disease problem, seeking to involve a varied team who can best educate and inform on these important lifestyle issues. By giving relevant experts a platform to teach we can spread information on ways to improve lifestyle and health. For example, learning about nutrition from nutrition experts, learning about relaxing from meditation experts and sleep from sleep experts.

Why lifestyle medicine? Most healthcare professionals entered the profession as they wanted to help their patients become and stay healthy with the main outcome that they go on to live happier lives. Unfortunately the current medical model

LIFESTYLE MEDICINE Lifestyle medicine education – an answer to chronic disease?

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Most specific disease guidelines include a first stage of management in which giving lifestyle advice is the initial recommended step

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Regardless of the reasoning there is no doubt that the current medical model is struggling. The prevalence of chronic disease continues to rise, accompanied by an unsustainable financial cost to the NHS. Alongside this, levels of career dissatisfaction within the medical profession continue to rise, pushing increasing numbers of healthcare professionals into early retirement, ‘burnout’ or career change. A different approach is needed: one that focuses on addressing the root cause of the problem; one that inspires practitioners as they are able to prevent, reverse and cure chronic disease. No medical professional gets much satisfaction from starting a diabetic drug medication and reducing a HbA1c from 64 to 58. However, think of the level of satisfaction and pride associated with having the tools to help a patient reverse their condition and in doing so improve energy levels, happiness and general vastly improve their quality of life. It is important to recognise that consultation techniques are key to helping patients make changes in their lifestyle. Motivational interviewing methods are essential for assessing motivation to change and confidence in making that change. It can also identify concerns, fears and barriers, which are important to address before attempting to make a change. By understanding the evidence around lifestyle medicine and by employing motivational interviewing techniques, healthcare practitioners may utilise lifestyle medicine to revolutionise patient care. Lifestyle medicine may also have the power to revitalise a workforce whose deep desire is still to care holistically for patients and allow them to live healthier and happier lives.

Obstacles to lifestyle medicine? The only way in which healthcare professionals will gain confidence in lifestyle medicine is if they are taught the information regarding the evidence base of the subject as well as the tools to allow them to help patients make

lifestyle changes such as motivational interviewing. Unfortunately, there is very little teaching on lifestyle medicine or behaviour change in undergraduate or postgraduate education. Without the knowledge and the tools, it is very difficult to implement lifestyle medicine. This may explain to some extent the limited success most practitioners experience and why many are demoralised by the concept of trying to encourage their patients to change their behaviours.

Teaching to medical students If healthcare professionals do not have lifestyle medicine integrated into their practice from the start of their training then it makes it difficult to change habits later on in their careers. This supports the idea of integrating lifestyle medicine teaching and motivational interviewing into the undergraduate curriculum for all healthcare professionals. I have been involved in implementing a Prevention Medicine Day at Bristol University. This day is a central study day for 3rd year medical students. It originally started as a half-day teaching on nutrition but has developed over the last four years into full day teaching on lifestyle medicine. The day involves a mixture of lectures, workshops and role plays as well as practical demonstrations in which food is prepared by cooking experts. The idea of lifestyle medicine is introduced, as well as specific teaching on physical activity, diet, motivational interviewing and a brief look at the environmental aspect of the issues associated with lifestyle medicine such as the food environment and the cost of food. The day involves one tutor for every 12 students, with around 200 students attending in total. The tutors are all junior doctors or full-time doctors with a keen interest in lifestyle medicine.

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Think of the level of satisfaction associated with having the tools to help a patient reverse their condition, improve energy levels and happiness

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often does not push towards these desirable outcomes. There are many reasons for this. It could be argued that the focus on symptoms and markers of disease is so strong that the ‘wood is not seen for the trees’ and the root causes are ignored. Time pressures can be to blame as well as the multiple targets continually set for healthcare professionals leaving little time for addressing underlying causes.

These days have generated a great interest in lifestyle medicine from both students and tutors who have taken part in the day and has led to the development of student selected studies at Bristol University that focus on components of lifestyle medicine such as diet. The day is currently being developed into a set program with support from the British Society of Lifestyle Medicine which can be repeated at other medical schools to spread the message further of lifestyle medicine to other medical schools in the country.

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LIFESTYLE MEDICINE Lifestyle medicine education – an answer to chronic disease?

Although this is just a start, the event will hopefully spark more enthusiasm from doctors and students at these various medical schools to drive lifestyle medicine into the undergraduate curriculums in all medical schools. Once this has been achieved then hopefully this sort of teaching will spread to other healthcare professional degrees and courses.

Teaching to GPs Lifestyle medicine is useful to all practitioners. One obvious group of healthcare practitioners who can have significant impact are those in primary care. Although the idea of a family doctor is not what it used to be, there is still continuity with a GP that one does not get with many other healthcare professionals. For this reason, I was keen to target GP teaching sessions. I was lucky enough to work for public health in Wiltshire during my GP training and in that time I taught on the subject of physical activity to more than 15 GP practices as well as to regional teaching groups of GPs in Bath and Wiltshire.

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Unfortunately, there is very little teaching on lifestyle medicine or behaviour change in undergraduate or postgraduate education

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As part of my role as the Leadership Scholar for Severn Deanery in my last year as a trainee I decided to set up a conference on several aspects of lifestyle medicine for GPs and GP trainees. I was fortunate to get several very well respected speakers to talk including Dr William Bird, Dr Ali Khavandi, Dr Rupy Aujla and Dr Zoe Williams. This conference included information on several aspects of lifestyle medicine, including physical activity workouts with a local personal trainer, food demonstration by Dr Rupy Aujla and a panel discussion with all the guest speakers and the opportunity for delegates to ask questions around lifestyle medicine. It also included specific teaching on motivational interviewing by Dr Tim Anstiss, the founder of the Academy for Health Coaching, who taught specific methods to help practitioners help patients change their habits. The day was a sell out and the feedback proved delegates’ enthusiasm for the subject. The conference was put forward for the RCGP Vibrant Faculty Award for South West. Due to the success of this event, funding was given for a second lifestyle medicine conference in Bristol which focused on practitioner health. This conference involved lots of practical workshops including several different types of workouts from yoga to high intensity interval training to jogging to a gentle walk. Separate sessions on meditation and mindfulness were taught by a mindfulness

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expert from London called Michael James Wong and gave delegates the chance to meditate and zone out from their busy schedules. Many admitted they had not practiced this for many years and couldn’t believe how relaxing and enjoyable they found it. Workshops were also organised specifically looking at diet myths, looking at the science behind low carb diets and what diet is best implicated for heart health. The day received some very positive feedback and there are already plans in place for another conference to hopefully reach more GPs and practitioners in primary care and beyond.

What’s next? I feel lifestyle medicine is a game changer as it has the chance to transform patients’ lives but also transform practitioners work to become more enjoyable and fulfilling. One thing that was clear during all these teaching events and conferences was the vast enthusiasm for this subject. Both students and health care practitioners that have attended the different sessions have all given formal and formative feedback expressing their delight at how they enjoyed learning more about this subject and they wished for more training of similar nature. Thanks to the British Society of Lifestyle Medicine, it appears that several more of these events will appear, with events planned in Leeds and Cardiff in the next few months. The annual British Society of Lifestyle Medicine Conference is happening on the 23rd June 2018 in Edinburgh and already has a fantastic line-up of speakers. The society is also running the International Board of Lifestyle Medicine diploma on 11th August 2018. This society is barely a year old and now has more than 200 members with a great vision to inspire the UK to be healthier through lifestyle medicine. If you are interested in this subject, learning more or want to get involved with the British Society of Lifestyle Medicine then please do get in touch via the website. Brooks J (2016 )Promoting physical activity: the general practice agenda. Br J Gen Pract 66(650): 454–455. Chan M (2015) WHO Director-General addresses the place of noncommuicable diseases in strategies and agendas. Available at: www.who.int/dg/speeches/2015/ncd-development-cooperation/en/ (accessed 15 March 2018). Chatterjee R, Chapman T, Brannan M, Varney J (2017) GPs’ knowledge, use and confidence in national physical activity and health guidelines and tools: a questionnaire-based survey of general practice in England. Br J Gen Pract 67 (663): e668-e675. Hughes D (2016) Illnesses associated with lifestyle cost the NHS £11bn. BBC news online. Available at: www.bbc.co.uk/news/health37451773 (accessed 15 March 2018). Macmillan Cancer Support (2016) Move more – physical activity the underrated ‘wonder drug’. Available at: https://be.macmillan.org.uk/be/ p-19569-move-more-guide.aspx (accessed 15 March 2018). WHO (2010) WH) Global status report on noncommunicable diseases 2010. Available at: www.who.int/nmh/publications/ncd_report_full_en. pdf (accessed 15 March 2018).

MEDIC AL EDUC AT IO N

Music, medical school and curating wellbeing Jayne Garner Lecturer, School of Medicine, University of Liverpool

Undergraduate students face an increasing range of pressures – academic, financial and emotional – as they progress through their education. In particular, medical students face additional issues as they manage a heavy academic workload and the realities of dealing with real life challenges on clinical placement. As part of national Well Being Week, we put together a school playlist to share music and promote wellbeing in a unique way, bringing staff and students together for some creative fun.

I work with undergraduate medical students as a lecturer and as a personal tutor. The increasing pressures on medical students (academic and financial) have resulted in a noticeable rise in mental health and stress-related issues. In addition to support services, it is vital that medical schools develop new and innovative ways to promote wellbeing. We have used music to do this in Liverpool, and created something unique for our students and staff to share.

Why did we do this? Improving student wellbeing is an ongoing challenge for educators. Rising fees, financial insecurity and fast-changing employer expectations place an increased burden on students long before graduation. Course requirements alongside work and personal commitments have resulted in rising mental health problems for those studying in higher education (Gil, 2015). This phenomenon is not confined to the UK. A recent systematic literature review suggests that university students experience substantially higher rates of depression than those found in the general population, concluding that more research on effective interventions for managing student depression is necessary (Ibrahim et al, 2013) An Australian study examined psychological distress in students compared with the general population, finding significantly higher rates of mental health problems among those at university. Predictors of distress included studying full time, financial issues, and being aged between 18–34 and female (Stallman, 2010). These issues particularly affect medical students and doctors. A meta-analysis relating to depressive symptom prevalence among resident physicians estimated 28.8% of this group would encounter symptoms (Mata et al, 2015). It has also been acknowledged in health education

literature that medical students have reported above average issues relating to mental health, a reflection of the stress they face over the duration of an academically tough and emotionally challenging course. A recent national survey of medical students by the British Medical Journal (Billingsley, 2015) found that 30% of respondents had experienced or received treatment for a mental health condition while studying. Furthermore, of these students 80% said the support available to them was either poor or moderately adequate. There is evidence that stigma associated with mental health issues both exists and affects medical students’ willingness to access appropriate support services. A study by Chew-Graham et al (2003) found that medical students worried about seeking help because it could be recorded on their education or employment record and affect their future progress. Hooper et al (2005) found that issues relating to failure, coping, stress, anxiety and depression were perceived to be barriers to a successful career and could be viewed as signs of weakness. Regulatory bodies such as the General Medical Council (GMC) recognise the importance of wellbeing and require effective support mechanisms for medical students. However, the stigma and culture of medicine can perpetuate the myth that seeking help is negative and a sign of personal weakness. These

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MEDICAL EDUCATION Music, medical school and curating wellbeing

entrenched cynical attitudes have been termed the ‘hidden curriculum’ in medicine (Hafferty, 1998), and remain a barrier to fully understanding and adequately addressing good wellbeing for medical students. How to effectively promote wellbeing to sceptical students and ensure that accessing support services is not seen as a sign of failure is a key challenge for medical educators nationally and internationally.

A new medical school curriculum The University of Liverpool implemented a new curriculum in 2014, moving away from problem-based learning to a spiral, integrated system. Several initiatives were introduced alongside this change, including an increased emphasis on the importance of accessing wellbeing support and services. A dedicated team based in the School of Medicine sought to encourage students to speak up about any problems, issues or anxieties they were facing. Given previous evidence on student reluctance to access this kind of support, we promoted the service ensuring that students knew it was confidential and would not appear on their academic record. To develop the wellbeing agenda across the medical school further, we began exploring different approaches to encourage positive wellbeing.

Action for positive wellbeing As part of Well Being Week 2016, we sought to further bring students and staff together in the creation of a shared experience. Using a SurveyMonkey link posted via the school blog and the electronic Well Being Newsletter, we asked students and staff to nominate a song that helped them feel better, and compiled a playlist. We also asked them to complete a brief survey including why they felt their song promoted happiness and wellbeing. As has been identified in previous literature, music and memory link together and by giving this playlist a positive focus, we sought to emphasise the importance of wellbeing. The creation of the playlist also allows ‘sharing’ between staff and students, another important element to enhance student and staff experience. Most importantly, we thought it would be fun.

What happened? In total 11 songs were nominated. One was excluded due to offensive swearwords in the lyrics. For future reference, this did highlight the importance of being specific about what might be classed as unsuitable. Choices varied from current artists such as Drake and Bruno Mars to classics like Curtis Mayfield and The Bee Gees. Interestingly, no Beatles songs were submitted even though we are in Liverpool. In terms of their explanations for their choice of song, answers were very insightful, offering a range of perspectives. Two respondents described how their song had lifted their spirits when life presented challenging situations:

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‘A song that can’t help but make you smile in the face of desperation.’ ‘The lyrics illustrate the rewards of perseverance through a difficult time.’ Another offered further explanation of how their song represented individual freedom of expression, and offered an escape from the oppressive elements of daily routine: ‘Because this song is all about retaining your spirit, the dreamer in you, and not having it stifled by your everyday life.’ Three respondents linked their song to physical expression and dancing; this again offered an opportunity to enhance wellbeing as part of the ‘be active’ agenda specified by MIND: ‘I always listen to this song when I’m a bit moody and it really makes me smile again and also, although a bit sad, dance around my room.’ ‘First because it is so funky, second because you have to dance to it’ ‘Whenever I hear it I just have to get up and dance.’ Nominated songs were seen to find positive aspects in everyday occurrences and help with motivation to complete assignments or simply distracting from the weather: ‘Got me through research and scholarship by keeping me focused.’ ‘A song which celebrates the fact that it’s stopped raining is very important in Liverpool.’ All the responses emphasised the positive influence of music, how it can lift moods, promote positivity and get people enthused and engaged. The survey went on with a request to complete the statement: ‘Music is medicine because…’. The open structure of the question elicited a range of answers. The power of music to provide escapism was mentioned by two respondents: ‘You can lose yourself in its rhythms and melodies and be momentarily transported away.’ ‘It’s escapism.’ Other life improving affirmative reasons regarded a range of emotions that music can invoke, and while the majority of these were very positive, the power of music to cause sadness and tears was also acknowledged: ‘Lyrics can remind you of reasons to be grateful.’ ‘It has the power to change mood.’ ‘It works on every emotion. It can make you cry, reminisce, laugh, feel warm inside.’ A more detailed response further explained the significant impact music could have, relating to important events or simply assisting with the process of relaxing:

MEDICAL EDUCATION Music, medical school and curating wellbeing

‘It touches people’s lives in so many positive ways, whether bringing back happy memories of a special song. Shared experiences at a concert or relaxing at home listening to the radio after a stressful day.’ The final three comments relating to why music is medicine explained the artistry and healing nature inherent to both disciplines: ‘Both can be considered an art form.’ ‘It soothes the soul, nothing else can do that!’ ‘It cures all kinds of stuff.’ The nominated songs compiled into a playlist for students and staff are available at: https://open.spotify.com/user/ drjaynegarner/playlist/0D5wIQN2NNcMNeZgDBvfdr This has been made available on the school blog and played in the foyer of the medical school building.

How does this fit in? There is evidence in healthcare literature linking medicine and music for educational, therapeutic, clinical, cultural and humanism purposes. Investigators have linked music with emotion, memory and therapy as a tool in medical practice (Kobets, 2011) and identified how music, memory and cognition are intrinsically linked (Jancke, 2008). Particular initiatives relating music to medical education offer insight and opportunity. The work of Ortega et al (2011) reported that faculty, staff and students playing together in a band promoted interpersonal relationships, improved communication and gave a level playing field for non-hierarchical feedback between band members. The weekly sessions served to enhance rapport, improve quality of life and enrich medical education. The authors concluded that this model of creating a musical ensemble was transferable to other medical schools and could ultimately improve patient care. Specific focus on the use of music in the teaching of medical humanities was outlined by Newell and Hanes (2003) who emphasised that characteristics such as care, empathy, dignity, compassion and fostering relationships could be emphasised and understood by listening to music. Their eight-session course was seen to be academically valid by participants and potentially a way to assess humanistic qualities in residents and students. Similarly, Modell et al (2009) conducted pilot studies providing first year medical students with a participatory music experience during a human physiology course. This intervention restored emotional wellbeing and reinforced a sense of community in the classroom. McLellan et al (2013) reported a small scale phenomenological study which concluded that music could help medical students appreciate holistically that the state of people’s health (either well or diseased) can be enhanced by a ‘nontechnical’ intervention. Given this range of approaches and evidence linking music and medicine, identifying new ways to merge these

disciplines represents an interesting challenge for the future.

Does this matter? While we cannot claim the playlist has directly affected the wellbeing of medical students, faculty and staff, it has provided a fun opportunity to create a shared experience. The comments from respondents to the playlist have also demonstrated the importance of music to positive wellbeing, something we will continue to champion as we continue to develop support services. The medical school plans to produce new playlists, giving students and staff the opportunity to share new and old music. The playlist will continue to create something original and fun, enhancing wellbeing, improving staff and student experience and creating a shared musical memory. So, YES, it does matter! Billingsley M (2015) More than 80% of medical students with mental health issues feel under-supported, says Student BMJ survey. Studentbmj (online). Available at: http://student.bmj.com/student/ view-article.html?id=sbmj.h4521 (accessed 2 March 2018). Chew-Graham CA, Rogers A, Yassin N (2003) ‘I wouldn’t want it on my CV or their records’: medical students’ experiences of help-seeking for mental health problems. Medical Education, 37(10), pp 873–880. Gil N (2015). Majority of students experience mental health issues says NUS survey. The Guardian, 14 December. Available at: www.theguardian.com/education/2015/dec/14/majority-of-studentsexperience-mental-health-issues-says-nus-survey (accessed 2 March 2018). Hafferty FW (1998) Beyond curriculum reform: confronting medicine’s hidden curriculum. Acad Med, 73(4), pp 403–7. Hooper C, Meakin R, Jones M (2005) Where students go when they are ill: how medical students access health care. Medical Education, 39(6), pp 588–93. Ibrahim AK, Kelly SJ, Adams CE, Glazebrook C (2013) A systematic review of studies of depression prevalence in university students. Journal of Psychiatric Research, 47, pp 391–400. Jancke L (2008) Music, memory and emotion. Journal of Biology 7(21). Kobets AJ (2011) Harmonic medicine: the influence of music over mind and medical practice. Yale Journal of Biology and Medicine, 84, pp 161–167. Mata DA, Ramos MA, Bansal N, Guille C, Di Angelantonio E, Sen S (2015) Prevalaence of depression and depressive symptoms among resident physicians: a systematic review and meta analysis. Journal of the American Medical Association, 314(22), pp 2373–83. McLellan, L, McLachlan E., Perkins L, Dornan T (2013) Music and health. A phenomenological investigation of a medical humanity. Advances in Health Science Education, 18, pp 167–179. Modell HI, DeMiero FG, Rose L (2009) In pursuit of a holistic learning environment: the impact of music in the physiology classroom. Advances in Physiology Education, 33, pp 37–45 Newell GC, Hanes DJ (2003) Listening to music: The case for its use in teaching medical humanities. Academic Medicine, 78, pp 714–719. Ortega R.A, Andreoli MT, Chima RS (2011) Is there a place for music in medical school? Medical Teacher, 33, pp 76–77. Stallman H (2010) Psychological distress in university students: a comparison with general population data. Australian Psychologist, 45(4), pp 249–257.

Acknowledgements Thank you to staff and students at the University of Liverpool School of Medicine for their contribution.

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…and divided we fall William House Retired GP; Chair of the BHMA

For as long as I can remember I have been interested in how the things of the world work. I remember taking my toys apart, spreading the bits across the floor, and then putting them back together again. As I grew older the toys got bigger, culminating with the purchase for £2 of a 1931 Austin 7 car when I was 14. Of course, I took it apart and put it back together – several times – and had fun driving it around the field at the back of our house. Three years later (fresh from passing my driving test) I was interviewed by a consultant surgeon for a place at medical school. I told him all about the car and I was offered a place. The places were hard to get and, of course, his interest in the car told me that taking things to pieces must be the ideal preparation for a medical career! There was nothing in my six years of medical education that prompted me to think otherwise. So, as a newly qualified doctor in 1972 I was plunged into the world of very sick people. Without conscious awareness, my perspective gradually changed over the next 10 to 15 years. Scientific medicine was losing its fascination. I could see that treating sick people as if they were toys or motor vehicles to be dismantled and reassembled often missed the essence of their sickness. But the challenge was (and still is) to develop the compelling holistic concepts and language that makes sense of the deeper human search for meaning, connection and belonging. This is the essential counterweight to the ‘mechanical fault’ model of illness. This was the founding purpose of the BHMA in 1983 and so it remains. But, there is a bigger story. Without this our ‘compelling holistic concepts and language’ are unlikely to find their proper place at the heart of healthcare. In 2002, Canadian medical sociologist Arthur W Frank contributed the opening chapter to Consuming Health – The commodification of health care. As the name suggests, this book is about the interface of healthcare with the ‘political-economic orthodoxy of neoliberalism’ – what he calls the ‘high-intensity market’. Using cosmetic surgery as an obvious example, Frank argues that we now consume healthcare in much the same way that we consume any other ‘commodity’ – clothes, cars, meals out, holidays. Of course, this book was published 16 years ago and ‘medical consumerism’ is now not only well recognised but is even

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more deeply entrenched in mainstream healthcare. ‘Health’ has become a commodity, from over-the-counter purchases such as gym membership, a deep tan from a tropical island or high street salon, to medically contrived treatments – a different shaped nose, different sized breasts. More worryingly, this merges into pills for obesity, pills for depression, pills for high blood pressure. Frank then electrifies his argument with the revelation of fragmentation as the unifying feature of commodification. This calls into question some central tenets of our culture, and at the same time points towards solutions. Frank describes how health opportunities always offer a solution to particular ‘features’ of the human experience – needing to feel good about yourself, having your desired body shape, being happy, having a ‘normal’ blood pressure, a lower cholesterol. It is never about the entirety of you as a person with your own unique character, strengths and ambitions. Why has this fragmentation happened and does it matter? I suggest we have an unholy trinity: the economy’s need for saleable products, the scientist’s need for measurements of the human condition and the medic’s need for diagnoses. They combine to sacrifice our own unique reality, replacing it with the bits that will feed the neoliberal machine. This matters because it subverts our deeper human needs, suppresses the idea of the common good and medicalises society – the DSM-5, the latest (2013) list of mental health diagnoses, runs to 947 pages and more than 300 maladies]. Fortunately, some of the many individuals who have realised all this have contributed to this issue of our journal. I still have the Austin 7. It is no longer a collection of parts, but a treasured possession that carries meaning and connection to memories: of my first date with my wife, Poppy, when she accidently switched off the petrol with her foot; of driving her from London to Hastings and back for a drink; of doing more good for my older male patients than most of my medical ministrations. Just turning up in that car was enough! Frank, Arthur W (2002) What’s wrong with medical consumerism? In: Henderson S and Petersen A (eds) Consuming Health – The commodification of health care. London: Routledge, pp13–30.

Research summaries Thanks to James Hawkins http://goodmedicine.org.uk/goodknowledge

Can MBIs fix our DNA?

Mind the mindfulness hype

We know yoga and meditation make us feel better. Now we are beginning to understand its molecular benefits: how this kind of happiness gets into every cell and changes the way our genetic code builds the cells we are made of. A new review of high-quality studies looks at more than a decade of research into how different mind-body interventions (MBIs) affect gene behaviour. It includes studies of meditation, mindfulness, yoga and Tai Chi. The 18 studies, which featured 846 participants over 11 years, reveal a pattern of molecular changes as a result of MBIs, changes known to benefit our mental and physical health. Stressful events trigger the sympathetic nervous system (SNS) which in turn increases production of nuclear factor kappa B (NF-kB) which regulates how our genes are expressed. NF-kB activates genes to produce proteins called cytokines. Cytokines trigger inflammation at a cellular level. In the wild, in humankind's hunter-gatherer prehistory, or in a modernday situation where injury is likely, short-lived flight and fight are vital threat-avoidance responses, and pro-inflammatory reactions would be useful. But in today's society threats are often more cultural, psychological and persistent; these reactions may not switch off, increasing cancer risk, accelerating ageing processes and undermining mental wellbeing. According to these studies, however, MBIs decrease the production of NF-kB and cytokines, reversing the pro-inflammatory gene expression pattern and so reducing the risk of inflammation-related health problems.

An article in Perspectives on Psychological Science reminds us that mindfulness meditation, once a fringe topic of scientific investigation, is now ‘an occasional replacement for psychotherapy, tool of corporate wellbeing, widely implemented educational practice, and key to building more resilient soldiers’. The article’s sceptical authors, who clearly feel there has been too much misinformation about the benefits, costs, and prospects of mindfulness meditation, point out that the mindfulness movement and the evidence supporting it have not gone uncriticised. They warn that ‘misinformation and poor methodology associated with past studies’ may lead consumers to be harmed, misled, and disappointed. The article discusses the difficulties of defining mindfulness, debates the proper scope of research into mindfulness practices, and the crucial methodological issues involved when interpreting results from investigations of mindfulness. The authors review the present state of mindfulness research, summarising what we do and do not know, and put forward an agenda for further developing ‘contemplative science’. They hope to inform interested scientists, the media and the public, so that harms are minimised and research practices improved.

Buric I et al (2017) What Is the molecular signature of mind–body interventions? A systematic review of gene expression changes induced by meditation and related practices. Frontiers in Immunology, 8, doi 10.3389/fimmu.2017.00670

Is coffee good for us? Researchers tapped into data from 521,330 people enrolled in European Prospective Investigation into Cancer and Nutrition (EPIC). Compared with non-consumers, those men and women who drank the most coffee had statistically significantly lower all-cause mortality, less digestive disease mortality. Women in the coffee group had statistically significant fewer deaths from circulatory disease and cerebrovascular disease. Apart from caffeine, coffee contains several other bioactive substances, including polyphenols, diterpenes, and melanoidins, but in unpredictable amounts and depending on the blend and how it’s roasted and brewed. It’s not yet clear why coffee drinking was associated with reduced risk for death from various causes but this relationship did not vary from country to country. Gunter MJ et al (2017) Coffee drinking and mortality in 10 european countries: A multinational cohort study. Annals of Internal Medicine 167(4): 236–247. doi.org/10.7326/M16-2945

Dam NTV et al (2017) Mind the hype: A critical evaluation and prescriptive agenda for research on mindfulness and meditation. Perspectives on Psychological Science 13(1) 36–61. doi/abs/10.1177/1745691617709589

Nutrition and psychotic illness Diet is increasingly recognised as a factor influencing the onset and outcomes of psychiatric disorders.This systematic review is a useful guide to research on the topic of nutrition in psychosis. People with schizophrenia, even in the early stages of their illness, generally have low quality diets and a wide range of nutritional deficiencies. And, in the first years of psychotic illness, reduced levels of vitamins and polyunsaturated fatty acids are known to be associated with poor outcomes including symptom severity. Research has shown, for example, that some food derived nutrients such as the amino acid N-acetylcysteine can be effective as adjunctive treatment for patients with long-term schizophrenia. The authors conclude there is preliminary evidence for taurine in early psychosis, but that effects of omega 3 and antioxidant vitamins/amino acids are inconsistent, perhaps benefitting patients with high levels of oxidative stress. They recommend that future studies should evaluate multifaceted dietary and supplementation interventions in early psychotic illness. Firth J et al (2018) Adjunctive nutrients in first episode psychosis: A systematic review of efficacy, tolerability and neurobiological mechanisms. Early Interventions in Psychiatry. doi.org/10.1111/eip.12544

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Reviews Anthroposophy and science: an introduction Peter Heusser Peter Lang, 2016 ISBN 978 3 63167 224 2 Anthroposophy and Science is a remarkable state-of-the-art milestone in exploring the relationship of natural science with spiritual science as originally represented by Rudolf Steiner (1861–1925). The book reflects the author’s high standard of scholarship and reviews the latest concepts in physics, chemistry, biology, genetics, medicine, neurobiology, psychology, philosophy of mind or cognitive science, anthropology and epistemology, all in their relationship to anthroposophy. To write an up-to-date overview of one of these fields is a significant task, but to provide a comprehensive overview of them all is a magnificent achievement of a very high order. The reductionist materialistic world view not only characterises conventional natural science, but our current whole world culture and understanding. To penetrate this thinking and really explore alternatives I found exciting and even disturbing. I became aware of how deep this reductionist science sits in my own consciousness, in spite of 50 years’ study of anthroposophy. The fundamental realisation expressed in Steiner’s The Philosophy of Freedom is that world reality meets us through the combination of sense, perception and thought. The modern philosopher Nagel points to the realisation that the world is intelligible and includes human beings with intelligence (Nagel, 2012). So intelligence has double part in existence. The realisation that the universe is lawful and potentially understandable is implicit in ordinary science, so thought and the laws of nature are part of the natural world. Thought itself is not a physical object. Steiner equates thought, intelligence and spirit. In which case we can say that spirit is the foundation of the material world and every layer of existence including the phenomena of life, sentient beings (animals) as well as human beings who think about the world. As the starting point of knowledge (epistemology) is thought and perception; theories of sensory physiology or neuroscience have no primary role in epistemology, as they are themselves the products of thinking and sense perception. Neither can atomic theory be assumed to be a primary reality, (based on nonperceptible atoms) which is often used in science as a basis for rejecting the prime reality of perception. A fundamental and recurring theme of the book is the way Peter Heuser considers the various levels of complexity in the world. He points out that with higher levels of complexity new characteristics and lawfulness

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emerge which would not be predictable from the most complete knowledge of the characteristics of the constituent parts. Indeed many of the characteristics of the parts disappear or are ‘sublated’ in the more complex structure. The simplest physical and chemical example is water, H2O, a combination of hydrogen and oxygen. Detailed knowledge of hydrogen and oxygen, he says, would never lead to a prediction of the characteristics of water and the laws of hydrodynamics. So the qualities of water cannot be reduced to the qualities of its component parts in spite of the fact that without hydrogen and oxygen water could not exist. At a more complex level proteins in living organisms, although composed of a series of amino acids, have characteristics which cannot be extrapolated from knowledge of the amino acids and their sequence. For example, their tertiary structure which is critical to their functioning as enzymes cannot be predicted from the amino acids and their sequence alone. So on the one hand, new properties emerge – the concept of emergence, and on the other the properties of the components

REVIEWS

to a significant degree submerge or are sublated in the qualities of the new structure and its functioning. Historically, as Swiss physician Troxler (1780–1866) (Beethoven’s physician) observed, behind the sense perceptible phenomena of life was a real but not directly perceptible something, behind feelings a real not directly perceptible soul (Seele) and behind human self-conscious thought a real not directly perceptible spirit (Geist). He attempted to sketch out a medical anthropology that would understand development, physiological functions and pathological processes as not simply physical interactions but as the expression of a harmonious or disharmonious interaction of material-physical, bodily-living, soul and spiritual forces in an organ or organ system. He went on to predict that in future a new sense needed to develop, for the reality that stands behind life phenomena and the development of cognition of soul and spirit. He called such cognition anthroposophy as distinct from anthropology. A name which Steiner would subsequently use for his perceptions and researches. Troxler gave an opening address at the opening of the University of Bern where he became the first professor of philosophy. Biographically, I found it interesting that Peter Heusser shared one of the first chairs in integrative medicine with responsibility for the subject of anthroposophic medicine at this same University of Bern. A fundamental perspective of anthroposophic medicine is based on asserting the reality alongside the physical material body (Korper), the living body (Lieb), the soul (Seele) and spirit (Geist). These emergent phenomena are described with reference to other western thinkers. The work is well referenced and points to advances in natural science that make sense of many of Steiner’s puzzling statements as well as the many ways anthroposophy can holistically contextualise and make sense of the findings of natural science. It also provides a rational and philosophical framework that can integrate conventional and complementary approaches to medicine. Dr Michael Evans Nagel T (2012) Mind and cosmos. Why the materialist neo-Darwinian conception of nature is almost certainly false. Oxford: Oxford University Press.

Cultural perspectives on mental wellbeing Natalie Tobert Jessica Kingsley, 2017 978 1 78592 0 844 Natalie Tobert brings to this important topic a depth of knowledge grounded in her anthropological studies of attitudes to health in more traditional societies. She combines this impressive knowledge base with more recent acquaintance with the plight of asylum seekers and other new immigrants who find themselves tangled in our various bureaucracies, in her role of teaching and consultation about cultural competency in health. Tobert argues for a humbler acceptance of plurality; plurality of models of the person; of ideas about illness and health; birth and death; about the very nature of reality itself. She is here tapping into the rich seam of philosophical thought summed up by Foucault’s notion of dominant and subjugated ways of knowing. As she points out, cultural arrogance and imperialism is

ingrained where the West encounters other cultures. However, as the West experiences crisis after crisis, environmental, existential, spiritual and so on, subjugated ways of understanding areas such as mental health and spirituality start to creep in around the edges and threaten that previously unexamined hegemony. The triumph of science and technology in the modern age set the stage for the analytic, reductionist, ‘masculine’ paradigm to claim its dominance as a way of knowing. This successful coup subjugated intuitive, spiritual, non-rational, ‘feminine’ knowledge. However, as Tobert points out, our society is now composed of a rich and complex mixture of cultures from all over the globe, in various states of assimilation and non-assimilation with the elusive ‘host’ culture (she dissects these complexities with precision). The materialist paradigm cannot maintain its dominance in the face of this tide. Where it presumes to maintain it, and medical psychiatry is the relevant example here, it is on increasingly shaky ground. The book starts by embracing a broad compass and the argument is built in a layered fashion. Contrary views are juxtaposed, sometimes with little comment, but the whole builds to a powerful plea for change within mental health. Themes recur within this build up: •

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divergent beliefs erode unexamined assumptions that our cultures’ perspective is the only one: about the body, birth and death, sexual mores to name but a few. Dissolving rigid boundaries, whether of the self or of ideas is a recurrent theme linked to this evidence of the relativism of core notions are examples of cultural u-turns. The status of homosexuality in the West is an example within healthcare, the privileging of care over cure and the importance of communication – which becomes miscommunication where there is lack of cultural competency or openness to difference world views.

By layering these themes with rich, anthropological or clinical examples, the book builds to its climactic argument: the imperative to break the mould of conventional diagnostic, illnessbased, models of mental health in favour of embracing varying approaches to unusual experiences; acknowledging the effects of trauma, adversity and social circumstances on human beings and their adaptation, and an acceptance of multiple, culturally contextual ways of making sense of anomalous experiencing. This includes taking seriously the spiritual framework within which other cultures frequently view mental health difficulties, as do many in our society – for instance the Spiritual Crisis Network (SCN, www.spiritualcrisisnetwork.uk) Seeding just this paradigm shift within mental health has been at the heart of my own effort, through books (Clarke 2008, 2010 – anthropology chapter by Tobert!), through clinical work and service development within the NHS (Araci & Clarke 2017) and national initiatives such as the SCN and the Division of Clinical Psychology’s ‘Beyond Diagnosis Group’. All these build a case for seeing both spiritual experience and psychosis within the broader compass of the existence of two ways of knowing, corresponding to the dominant and subjugated ways of knowing cited earlier. As a psychologist, I explore the roots of these divergent ways of knowing in brain organisation, offering a view of humans as only partially rooted in their individuality, partially composed of relationship, leading to fluidity of the self (Clarke 2008, Clarke and Nicholls 2018). This view offers a science-based foundation for the very plurality that Tobert is championing.

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To conclude, this absorbing and richly varied book draws from varied disciplines and sources of evidence to make a powerful case for a paradigm shift in mental health. Many forces tending in this direction are cited, such as cogent critics of psychiatric medication, Joanna Moncrieff and Robert Whitaker, the anger of the service user movement and the voices calling for the spiritual dimension to be taken seriously, along with rich consideration of the views of non-Western cultures, from personal experience in Britain and India. Above all, the message of the book is hopeful for all of us who find the current orthodoxy stultifying and unjust. The problem is not with science but cultural myopia, and Tobert gives abundant examples of where cultural u-turns had upended such orthodoxies. Isabel Clarke Araci D, Clarke I (2017) Investigating the efficacy of a whole team, psychologically informed, acute mental health service approach. Journal of Mental Health 26: 307–311. Clarke I, Nicholls H (2018) Third wave CBT integration for individuals and teams: comprehend, cope and connect. Abingdon: Routledge. Clarke I (ed.) (2010) Psychosis and spirituality: consolidating the new paradigm. Chichester: Wiley. Clarke I (2008) Madness, mystery and the survival of God. Winchester: ‘O’Books.

Transformative innovation A guide to practice and policy Graham Leicester Triarchy Press, 2016 ISBN 978 1 91119 300 5 This inspiring book was launched in Edinburgh at a reception to mark the 15th anniversary of the International Futures Forum (www.internationalfuturesforum.com) and it represents an excellent summary of many of its key insights into social and learning processes over this period. Transformative innovation represents a ‘fundamental shift towards new patterns of viability in tune with our aspirations for the future.’ This contrasts with sustaining innovation that fixes the existing system and disruptive innovation that shakes it up. Following the introduction, the book consists of six chapters on knowing, imagining, being, doing, enabling and supporting. It outlines 10 characteristics of transformative innovation derived from IFF praxis: balance, in terms of operating in both the old and the new world; inspiring and hopeful; informed by a longer term perspective; pioneering a process rooted in discovery and learning; grounded; personally committed with our full self; responsible; revealing hidden resources; maintaining integrity and coherence of means and end; and maintaining a pioneering spirit even in the face of success. At this point, the reader will find a useful analysis of the evolution of a more adaptable way of providing care and support to old people. One tension is the need to measure outcomes on a short-term scale when the effects are slightly longer term and the project is not yet ready to be scaled. Given our world of boundless collectivity, information overload and rapid change, we need flexible approaches to knowing. Here there are five principles: seeing ourselves as

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subjects and participants in a relational universe, expanding what we consider to be valid knowledge and therefore our context of learning, respecting a dynamic pattern of relationships and the emerging integrity that it brings about, taking a cyclical view of time enabling us to complete and close processes so as to make space for the new, and moving from fragmentation and separation to wholeness and connection – summarised as holism with focus. Then there are the two loops of fear and love, which the reader will find in my account of our Rome meeting. ‘Imagination’ comes next, and here the reader is introduced to what I consider a crucial conceptual tool, the three horizons framework. The first horizon – H1 – represents current dominant systems and business as usual; the second – H2 – is a pattern of transition activities and innovations, some of which may prop up H1, while others enable the transition to the third horizon – H3 – embodying our deeper aspirations for the future. These are represented respectively by the manager, the entrepreneur and a visionary. The beauty of this framework is that it can be used to set up a creative conversation of potential scenarios and patterns without people becoming too attached to a single perspective. H3 provides some imaginative space and may help resolve dilemmas in the present as we seek to attain the best of both worlds. The whole process is encapsulated in one of the ‘prompt cards’ encouraging us to ‘develop a future consciousness to inform the present’ (attractors pull from the future). ‘Being’ involved the human system and its patterns as we seek to embody a transformative response by bringing together what the IFF calls a creative integrity configured around personal commitment and expressing wholeness and relationship. Its principal axes are being and doing and it moves between autonomy and integration, focus and holism, creating a distinctive culture. Social learning is an iterative process involving action and reflection. Importantly, this is not just an abstract technique, but is embodied in learning from experience – hence the learning journey as an essential component of the IFF process. The chapter on ‘doing’ also explains Jim Ewing’s strategies of Impacto and Implemento, which have been used successfully in a school project. This involves a sequence of steps to consider purpose, urgency, destination, success path and commitment, with an emphasis on clarity of purpose that can then be reflected in clarity of communication. ‘Enabling’ entails a compelling vision of the third horizon while ‘supporting’ pioneers trying to implement the process. This also involves a realistic view of policy landscape and new forms of evaluation – how does one flourish in the presence of the old? Finance has its own challenges due to the nature and timing of transformative innovation and the ever-present fact of continuous change and evolving contexts. If these insights resonate with your own challenges, then you might like to consult a further set of resources at www.iffpraxis.com. Finally, we can give ourselves permission to get going, and Graham provides a nice framework for this based originally on Al Gore’s reinventing government programme. The permission slip gives us authority and responsibility to help shift our systems towards an aspirational third horizon vision of the future after we have asked ourselves a series of pertinent questions. If we are able to answer yes, then we don’t need to ask for permission, we just need to do it. Pioneers in every field will find this book a rich resource David Lorimer

JOURNAL OF

holistic healthcare About the BHMA In the heady days of 1983 while the Greenham Common Women’s Camp was being born, a group of doctors formed the British Holistic Medical Association (BHMA). They too were full of idealism. They wanted to halt the relentless slide of mainstream healthcare towards industrialised monoculture. They wanted medicine to understand the world in all its fuzzy complexity, and to embrace health and healing; healing that involves body, mind and spirit. They wanted to free medicine from the grip of old institutions, from over-reliance on drugs and to explore the potential of other therapies. They wanted practitioners to care for themselves, understanding that practitioners who cannot care for their own bodies and feelings will be so much less able to care for others. The motto, ‘Physician heal thyself ’ is a rallying call for the healing of individuals and communities; a reminder to all humankind that we cannot rely on those in power to solve all our problems. And this motto is even more relevant now than it was in 1983. Since then, the BHMA has worked to promote holism in medicine, evolving to embrace new challenges, particularly the over-arching issue of sustainability of vital NHS human and social capital, as well as ecological and economic systems, and to understand how they are intertwined . The BHMA now stands for five linked and overlapping dimensions of holistic healthcare:

marker of good practice through policy, training and good management. We have a historical duty to pay special attention to deprived and excluded groups, especially those who are poor, mentally ill, disabled and elderly. Planning compassionate healthcare organisations calls for social and economic creativity. More literally, the wider use of the arts and artistic therapies can help create more humane healing spaces and may elevate the clinical encounter so that the art of healthcare can take its place alongside appropriately applied medical science.

Integrating complementary therapies Because holistic healthcare is patient-centred and concerned about patient choice, it must be open to the possibility that forms of treatment other than conventional medicine might benefit a patient. It is not unscientific to consider that certain complementary therapies might be integrated into mainstream practice. There is already some evidence to support its use in the care and management of relapsing long-term illness and chronic disease where pharmaceutics have relatively little to offer. A collaborative approach based on mutual respect informed by critical openness and honest evaluation of outcomes should encourage more widespread co-operation between ‘orthodox’ and complementary clinicians.

Sustainability Whole person medicine Whole person healthcare seeks to understand the complex influences – from the genome to the ozone layer – that build up or break down the body–mind: what promotes vitality adaptation and repair, what undermines them? Practitioners are interested not just in the biochemistry and pathology of disease but in the lived body, emotions and beliefs, experiences and relationships, the impact of the family, community and the physical environment. As well as treating illness and disease, whole person medicine aims to create resilience and wellbeing. Its practitioners strive to work compassionately while recognising that they too have limitations and vulnerabilities of their own.

Self-care All practitioners need to be aware that the medical and nursing professions are at higher risk of poor mental health and burnout. Difficult and demanding work, sometimes in toxic organisations, can foster defensive cynicism, ‘presenteeism’ or burnout. Healthcare workers have to understand the origins of health, and must learn to attend to their wellbeing. Certain core skills can help us, yet our resilience will often depend greatly on support from family and colleagues, and on the culture of the organisations in which we work.

Climate change is the biggest threat to the health of human and the other-than-human species on planet Earth. The science is clear enough: what builds health and wellbeing is better diet, more exercise, less loneliness, more access to green spaces, breathing clean air and drinking uncontaminated water. If the seeds of mental ill-health are often planted in an over-stressed childhood, this is less likely in supportive communities where life feels meaningful. Wars are bad for people, and disastrous for the biosphere. In so many ways what is good for the planet is good for people too. Medical science now has very effective ways of rescuing people from end-stage disease. But if healthcare is to become sustainable it must begin to do more than just repair bodies and minds damaged by an unsustainable culture. Holistic healthcare practitioners can help people lead healthier lives, and take the lead in developing more sustainable communities, creating more appropriate models of healthcare, and living more sustainable ways of life. If the earth is to sustain us, inaction is not a choice.

“The Journal of Holistic Healthcare… a great resource for the integration-minded, and what a bargain!” Dr Michael Dixon

Humane care Compassion must become a core value for healthcare and be affirmed and fully supported as an essential

Three issues each year – £48 for full BHMA members. On-line members £25/year including access to all past issues.

Guidelines for Contributors About the journal The Journal of Holistic Healthcare is a UK-based journal focusing on evidence-based holistic practice and the practical implications of holistic health and social care. Our target audience is everyone concerned with developing integrated, humane healthcare services. Our aim is to be useful to anyone who is interested in creative change in the way we think about health, and the way healthcare is practised and organised. Our basic assumption is that holism can improve healthcare outcomes and will often point to costeffective ways of improving health. Holistic healthcare can be understood as a response to our turbulent times, and medicine’s crisis of vision and values; an evolutionary impulse driving individuals and organisation to innovate. But when complex and creative adaptations do occur, these ideas, experiences and social inventions don’t always take root. Though they might be the butterfly wingbeats that could fan the winds of change, even crucial seeds of change may fail to germinate when isolated, unnoticed and lacking the oxygen of publicity or vital political support. Some of these ideas and social inventions have to be rediscovered or reinvented, and thrive once the culture becomes more receptive – or more desperate for solutions. The JHH sees holism as one such idea, a nest of notions whose time has come. So we want the journal to be a channel for publishing ideas and experiences that don’t fit easily into more conventional mainstream journals, because by making them visible, their energy for change becomes available to the system. The journal’s themes include the theory and practice of mind-body medicine; every aspect of whole person care – but especially examples of it in the NHS; patients’ participation in their own healing; inter-professional care and education; integration of CAM and other promising new approaches into mainstream medicine; health worker wellbeing; creating and sustaining good health – at every level from the genome to the ozone layer; environment health and the health politics of the environment; diversity and creativity in healthcare delivery, as well as holistic development in organisations and their management: a necessarily broad remit!

Writing for the journal We intend the journal to be intensely practical; displaying not only research, but also stories about holism in action. Personal viewpoint and theoretical articles are welcome too, providing they can be illuminated by examples of their application. The Journal of Holistic Healthcare is a vehicle for injecting

inspiration into the system: ideas and research that might enable positive change. We realise that there is nothing as practical as a good theory, and we encourage authors to foreground what they have done and their experiences, as well as what they know. Though we don’t always need or want extensive references, we ask authors to refer to research and writing that supports, debates or contextualises the work they are describing, wherever appropriate. We like further reading and website URLs wherever possible. And we like authors to suggest images, photos, quotes, poems, illustrations or cartoons that enrich what they have written about. Because the JHH aims to include both authors’ ideas and their experience we invite authors to submit case studies and examples of successful holistic practice and services, research findings providing evidence for effective holistic practice, debate about new methodologies and commentaries on holistic policy and service developments. Our aim is to be a source of high-quality information about all aspects of holistic practice for anyone interested in holistic health, including policy-makers, practitioners and ‘the public’. We aim to link theory to practice and to be a forum for sharing experiences and the insights of reflective practice. Articles should be accessible and readable, but also challenging. Key articles will link theory and research to practice and policy development. Contributions from the whole spectrum of healthcare disciplines are welcome. The journal is particularly concerned to highlight ways of embedding holistic thinking and practice into health care structures, including primary care organisations, networks and collaborative initiatives.

Original research JHH is a platform for holistic ideas, authentic experiences, and original research. We estimate our regular (and growing) circulation of 700 copies is read by as many as 2000. And, though we don’t yet attract researchers seeking RAE points, we are free to be a voice for the kind of ideas, reports, experiences and social inventions that wouldn’t fit easily into more conventional mainstream journals: small studies, pilots, local reports, surveys and audits, accounts of action research, narratives, dissertation findings (otherwise hidden in the grey literature), pragmatic and qualitative studies and practice evaluations. By publishing them in the JHH, important seeds for change become available to people who need to grow them on. Another advantage of submitting to JHH is the peer feedback to authors, some of which we may include as commentaries on a published paper.

If you would like to submit an article please contact either editor-in chief David Peters on petersd@westminster.ac.uk or editor Edwina Rowling on edwina.rowling@gmail.com. For our full contributors guidelines see www.bhma.org.

Editorial Board Ian Henghes Dr William House (Chair) Dr Mari Kovandzic Professor David Peters Dr Thuli Whitehouse Dr Antonia Wrigley

British Holistic Medical Association West Barn Chewton Keynsham BRISTOL BS31 2SR Email: contactbhma@aol.co.uk www.bhma.org

ISSN 1743-9493 PROMOTING HOLISTIC PRACTICE IN UK HEALTHC ARE