Men's Health by British Holistic Medical Association

Volume 14 • Issue 3

Autumn 2017

JOURNAL OF

holistic healthcare Re-imagining healthcare

Men and distress Male-friendly mental health services The mid-life call of the soul The men’s shed movement How HIV changed society On becoming the men we have been waiting for Testosterone and the metabolic syndrome Prostatic disease and lifestyle A mindful man in the NHS Research Reviews

Men’s health

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.

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

Men and distress: the final frontier?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Reg. Charity No. 289459

David Peters and Damien Ridge

Men’s mental health: why are we are trying to change masculinity rather than create male-friendly services? . . . . . . . . . . . . . . . 9 Martin Seager

Men’s work, mid-life and the call of the soul . . . . . . . . . . . . . . . . . . . . . . . 12

Editor-in-chief David Peters petersd@westminster.ac.uk

William Ayot

‘For a New Father’. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Poem by John O’Donohue

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

The Somerdale Men’s Shed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Production editor

On becoming the men we have been waiting for . . . . . . . . . . . . . . . . . . 23

Edwina Rowling edwina.rowling@gmail.com

Mac Macartney

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.

Advertising rates ¼ page £260 ½ page £460 Full page £800 Rates exclude origination. To advertise email Edwina.rowling@gmail.com Products and services offered by advertisers in these pages are not necessarily endorsed by the BHMA.

Design www.karenhobden.com Cover illustration Lizzie Tree for the Atlas Mens’ Service at Victoria Health Centre

Printing Spinnaker Print Ltd

Volume 14 ● Issue 3 Autumn 2017

Penny Shrubb

The shock of HIV has changed us and society . . . . . . . . . . . . . . . . . . . . . . 20 James House

Testosterone and the metabolic syndrome – links and solutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Peter Foley

Prostatic disease – an opportunity for better health? . . . . . . . . . . . . . . . 34 Simon Mills

Stress-reduction or stress-immersion? Mindfulness practice and the full catastrophe of working in the NHS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Robert Marx

How to help Harry Friend or foe? The scientific and the scientistic in the fog of the frontline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 David Zigmond William House . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Research. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Reviews. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

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 Male violence: nature and culture A meltdown of old norms is stirring dark suspicions about maleness and men’s place in the world. Men commit most of the world’s murders and most often the victims are their partners or former partners. Are these men ‘naturally’ violent? If we over-biologise gender differences, men are testosterone-driven aliens and women hormonally compelled babymakers. Societies woven around these assumptions split humankind along gendered faultlines so men hold the power. The notion that men are wired for aggression and women are programmed for nurturing offspring only serves to keep this obsolete show on the road. Men dominated labour markets and ruled over production and government when women were economically dependent and work was physical. But these bastions of maleness are crumbling in a post-industrial information age, and women are in the ascendant. Do men feel surplus to requirements now that women control their fertility, get pregnant independently and rear children alone? An enfeebled patriarchy is making waves and pushing back: could domestic violence, terrorism, sexual harassment and child abuse be the death throes of a sick and redundant masculinity? We are not held hostage by our genes as much as we are by the stories we tell. Let’s dump stories that force a political wedge between the sexes; we are one humanity. Yet there are many differences in the ways we become ‘en-minded’ and embodied: each one of us is an all too brief expression of evolution, ancestry, mind and culture, emergent in a particular place and time. Sociologists play down biological factors, imagining human nature as painted on a blank canvas in childrearing and culture. But the canvas is not blank; humans are biological beings, who share their potential for violence with other primates. The human prefrontal cortex makes self-awareness possible, but evolution hung on to what had worked before – the limbic brain. Its mammalian emotion systems trigger fast, effective emergency action in the wild: we respond to threat when we feel anger and fear, seek food, shelter, or mates because of hunger or desire. Then, once we feel safe enough or full enough, the threat circuits are supposed to turn off. But now the things that threaten us are hard to pin down, and highly subjective. We see the world through how we feel, yet can we feel ‘safe enough or full enough’ in a world shot through with deprivation, where background ‘threats’ are unremitting and subliminal, and where the media keeps hitting our hate and desire buttons?

David Peters Editor

These imaginal impulses keep the limbic system churning. And when powerful emotions stir up, they get acted out unless consciously noticed and tolerated. The limits of tolerance are set early on in life: secure attachment lays the neural foundations for emotion-processing in the infant brain; insecure attachment and persistent stress enlarge the amygdala – the brain’s smoke alarm for threat – so that limbic rage and fear are on a hair trigger. Small wonder that men living in brutish conditions – especially if they have experienced childhood trauma or too little love and security – are likely to run amok. Yet men as well as women have nurturing instincts: we are wired for empathy, and for tending and befriending, not just for strife and striving. Yet under ‘threat’, when life is harsh and society austere, mercy will be in short supply in someone with no sense of the ‘remembered safety’ needed for tolerating extreme emotion. Danger, despair or desperation turn off our other limbic circuits for kindness, care and co-operation. In his masterly exploration of the roots of contemporary male insecurity Anthony Clare (2000) calls for ‘the taboo on tenderness’ to be lifted from men, in the ways boys are reared and educated, but also in the way men can increasingly see their maleness reflected in their ability to be kind, to care and love. ‘We spend money on killing machines and wonder why our youngsters are so aggressive. We insist our children, from the earliest years, familiarise themselves with the intricacies of human biology, yet ensure they learn little or nothing of psychology until their own personalities are distorted beyond correction. And, rather than acknowledge the neglect we have shown towards structures such as marriage and family life, we resort to undermining their importance in the sum of human health and happiness.’ The present time feels like a tipping point, and the biology of human nature won’t change in a hurry. So the culture will have to respond to our urgent need to tackle deprivation, condemn violence and live with respect for difference. Evolution, now impelled by a resonance between Earth’s crisis and masculinity’s precarious predicament, depends on social and political action. It’s a synchronicity that invites compassion for ancient wounds and a reconciliation with the suffering Earth. Many are waking up, sensing their vulnerability and interdependence as precious and significant. To these men and women we dedicate this issue of the JHH. Clare A (2000) On men on men: masculinity in crisis. London: Chatto & Windus.

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UPDATE

Two-day foundation course on integrated medicine

Eden Project Eco-Psychology Conference

The College of Medicine is still taking bookings for its third two-day foundation course on integrated medicine, which will take place on 16/17 November 2017 at the iconic Dumfries House in Ayrshire. The course will be an introduction to integrated health and care including lifestyle approaches, social prescribing, mind/body therapies, and the mainstream complementary therapies. It is open to all clinicians but should be particularly helpful for GPs and nurses interested in looking beyond the conventional biomedical box. Spaces are limited and the previous courses in London and Bristol were fully booked.

Transpersonal Narratives in Eco-Psychology proposes that caring for the natural world of which we are an integral part is critical for our survival and our emotional wellbeing. The programme rests on the premise that alongside the damage being done to the biosphere our psychological, social and spiritual health is being harmed. How then can we strengthen our capacity as practitioners and activists to counter these intertwining downward spirals? In this context, the three-day meeting will be looking at spiritual traditions as well as psychological insights that support such capacity, and asking how such insights can support and deepen psychotherapy.

https://collegeofmedicine.org.uk/events/#!event-list

Friday 24 to Sunday 26 November 2017, Eden Project, Cornwall

A new UK Diploma in Integrated Medicine Bristol’s Portland Centre for Integrative Medicine is developing a centre of excellence for IM. The centre offers a range of holistic healthcare therapies and services designed to support health and wellbeing. As part of its aim to transform healthcare the centre launched a new two-year diploma in IM at the Penny Brohn Centre in October. Nine doctors have already joined the course which is led by Dr Elizabeth Thompson and the education team at the Portland Centre. For more information see http://portlandcentrehealthcare.co.uk/diploma-for-integrative-medicine

BHMA/SMN gathering of change-makers Transformative Innovations for Health is a BHMA conference in collaboration with the Scientific and Medical Network. This gathering of change-makers will be on Saturday 18 November 2017 at the University of Westminster. The BHMA AGM will follow at 6pm. Please book online if possible at www.scimednet.org (and click on events), otherwise email info@scimednet.org or download the programme from BHMA website.

Medical teachers symposium This second symposium for medical teachers brought together colleagues from many of the UK’s medical schools. The working conference, designed to address the challenges of 21st century medical education was opened by a panel of activist medical students. Updates followed on research into medics’ wellbeing, and the challenges of culture change. Posters, round-table discussions and presentations gave innovators in student support and education many opportunities to explore and share an exhilarating mix of new ideas and ways forward. A report on the event is expected in December. Look out for notifications on the Centre for Resilience website www.centreforresilience.co.uk

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www.confer.uk.com/eco-psychology.html

The NHS clinical commissioners recommending homeopathy prescribing ban Homeopathic remedies cost the NHS just £92,412 in 2016. Though they are hardly prescribed in the NHS, they are among several treatments the commissioners will stop the NHS offering. Others include chondroitin and glucosamine (costing the NHS £444,535) herbal remedies (£100,009), and omega-3 fatty acids (£6.3 million). The latest (positive) evidence for chondroitin for knee osteoarthritis is flagged up on the research page of this issue of JHH. The commissioners claim homeopathy effects are mere placebo, but even so might they still be good value treatment for certain conditions? Ted Kaptchuk at Harvard recently found that despite having been explicitly informed they were getting a ‘sugar pill’ without active medication, patients with IBS symptoms given these ‘open-label’ placebos experienced a dramatic and significant improvement compared with those given nothing at all. Kaptchuk suggests placebos can work for conditions defined by subjective symptoms like pain, nausea, or fatigue but can’t do much to change objective tests (eg to reduce cholesterol) or cure a disease such as cancer. Kaptchuk says, ‘People can still get a placebo response, even though they know they are on a placebo’. ‘You don’t need deception or concealment for many conditions to get a significant and meaningful placebo effect.’ www.theguardian.com/lifeandstyle/2017/jul/21/a-misuse-of-scarcefunds-nhs-to-end-prescription-of-homeopathic-remedies https://www.health.harvard.edu/blog/placebo-can-work-even-knowplacebo-201607079926

MEN AND DISTRESS

Men and distress: the final frontier? David Peters Editor-in-chief, JHH

Damien Ridge Psychotherapist and social scientist

I started exploring groupwork back in the 1970s when humanistic psychology landed in London from California. As I get older I find I’m increasingly interested in my relationships with men and especially in the conversations and fellowship that I have know arise in men’s circles. There’s an honesty in them and a shared vulnerability that can feel very powerful, meaningful, and I would even say timeless. What I have learned through them about my own gifts and wounds has made me want to widen men’s access to these circles. David Peters

in distress; a service inside the

I am a psychotherapist and social scientist, currently Professor of Health Studies and Head of Psychology, at the University of Westminster, London. My special interest is patient experience and mental health. I have published over 90 academic papers. I first began to flesh out what recovery from depression entailed for patients when I was with the Health Experiences Research Group (HERG) at the University of Oxford. In my work, I variously explore people's experiences of mental health. For example, I examine how the stories people tell about themselves can help them take control of their condition to recover; how men use heroic stories of overcoming depression to negotiate a potentially feminising condition; and how the issues of authenticity and legitimacy are key to understanding how employees with depression respond to the challenges they face.

NHS to which GPs could refer

Damien Ridge

In 2013 Damien Ridge and David Peters worked together to pilot a new kind of service. They aimed to provide something upstream for men

men whose emotional wellbeing was causing concern, but who didn’t have an actual mental illness. The service, which was named ‘Atlas’, offered men acupuncture (they saw this as a way of helping with the sorts of physical symptoms men sometimes present with when they are upset) and the chance to talk about their thoughts and feelings with a counsellor. Atlas was shortlisted for an annual BMJ award in 2015.

DP: Damien tell us about your research focus. DR: It’s research about gender and mental health in general and particularly depression (Ridge, Emslie and White 2011; Ridge et al, 2015; Ridge and Ziebland 2006). I’m a trustee at CALM (www.thecalmzone.net), the male suicide prevention charity. I’m very interested in men getting better access to therapy. Traditionally, its been accepted that talking, and talking about your feelings specifically, and that being vulnerable, are wrong for men. It’s been said that therapy feels feminising to men. But I think things are changing and men are more and more open to exploring emotion and vulnerability, and that when they are in distress more men are open to therapy as a way forward. At some point (I don’t know what

age it was for you) boys suddenly start getting all these messages that it’s not OK to cry, or to show vulnerability, and that it’s time to close up and shut up; as we say now, to ‘man up’. Vulnerability goes underground then, but it is still there, it is still an important part of human growth. It becomes culturally OK for men to be angry, but not to express ‘weakness’ from that point on. So there’s a hidden rulebook. DP: Actually not so hidden. Anger becomes a kind of default mode. Perhaps even a way of keeping a lid on what lies deeper down: sadness, fear maybe. DR: We men go through this change, which is like a hidden rite of passage. Whereas in other cultures the threshold into ‘manhood’ is recognised, consciously organised, and

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MEN AND DISTRESS Men and distress: the final frontier?

celebrated. The crossing over is more structured, often more ritualised. But in our culture it’s obscure and unspoken. We start conforming to these rules but without being able to acknowledge and reflect on them for what they are, and what they may be doing to us. DP: Is it just a stereotype that girls from a very early age are more interested in feelings and tend to talk to one another about them? There is some research to confirm this. Whereas boys are more likely to fixate on objects like sticks and guns. There is intense and quite politicised debate over whether this is nature or nurture. Probably both, while we live in a culture of blue onesies for boy babies and pink for girls; offer them different toys; talk to them differently. DR: It’s the socialisation men undergo. Ordinarily, we think that masculinity is something owned by men, but actually it’s owned and reinforced by society through messages coming from society, a society invested in certain assumptions about masculinity, rather than in what men are or might authentically be. All societies have have their own stories about masculinity and what it should look like, and whether or not we know it, we all have an investment in these stories, and they shape our expectations. For example, some men when they’ve experienced being vulnerable in a relationship, say they feel they’ve been ridiculed or looked down upon by their partner, or by others. It’s as if they feel that men letting their emotional guard down means they lose face or status as men. If this kind of reinforcing of men’s insecurity is something real. Instead of blaming men for their inauthenticity and associated problems, it’s the whole social system and its dynamics that we need to focus on when we talk of masculinity. DP: So we shouldn’t blame men for the downsides of masculinity? DR: Well, we are all responsible for our behaviours. But perhaps we need to be more understanding. Men are understandable, arent they? In fact, at some level, men know they are playing the ‘masculinity game’. They can reflect on what they are doing, if you give them a safe space to do so. DP: And our culture apparently values most those aspects of masculinity to do with competitiveness and warriorhood and strength. DR: Sometimes I wonder if that’s because we are still largely a militaristic society, that still needs men to prepare for war; that socialises men to cut off from their feelings, in a society that cuts off from men. Think about the disproportionate levels of male suicide. This ought to be a much bigger issue for public debate than it is. CALM does great work in raising awareness, but still too few people have empathised with the unspoken anguish men go

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through, and what it is that stops them seeking help, and drives them to take their own lives. And though suicide is the biggest killer of young men we still don’t treat the effects of these problems seriously enough, let alone their root causes. DP: Nowadays it’s a major killer of middle-aged men too. So what’s going on, do you think? Why do men kill themselves in larger numbers than women do? DR: Good question. In medical school we were told it’s because men find more violent and effective ways to kill themselves. But I feel it’s more complicated than the official explanation; that it’s to do with the kinds of complex socialisation we are talking about; a mix of internal and societal self-reinforcing and damaging messages about masculinity. The struggle for authenticity. The shame men feel in being vulnerable. It’s not just about means. Men are implicitly trained not to talk about being upset. So these unacceptable feeling can get to become very big in their minds. Problems that might have been resolved by sharing them, by realising that others (especially other men) also experience the same things – for example despair, failure, weakness – become insurmountable when left to fester. This distorted and toxic way of thinking takes over, and suicide comes to look like a solution. DP: Yet to talk about feelings, and especially dark feelings, you need a language. And if you have little experience of sharing your emotional life, it won’t be easy to articulate what is happening, and so seek help until it’s too late. DR: I think so, but sometimes I worry that we oversimplify it. I think for people to be more aware of male suicide and talk more openly about it is really important. And for men to feel encouraged to talk about distress is a truly important message. And I think the message is getting through because for whatever reason, in the latest statistics male suicide has decreased somewhat. Perhaps this is because men are beginning to feel they have more permission to be open and to be listened to. Historically, the research shows that men are also changing; younger generations of men are much more touchy-feely (Anderson and McCormack, 2014). But the other side of the equation is that the quality of the listening to men is also important. For example, if someone wants to talk about their distress, but the person they turn to is unable or unwilling to listen, then there is a problem for men. Of course it’s obviously very uncomfortable for someone to talk about pain and suicide, but hearing about these feelings is also bound to stir up really uncomfortable feelings in the person hearing about it. Even some helping professionals are uncomfortable with a man who is crying or otherwise in distress, let alone friends.

MEN AND DISTRESS Men and distress: the final frontier?

DP: So just talking about feelings of despair and anxiety or rage with a friend may not be so easy if, after all, friends aren’t necessarily ready for that kind of conversation? DR: Nor may family be. And it’s understandable that people will have an investment, even an agenda, in a relationship as they have known it, and this kind of shift in the relationship can feel threatening, and this is likely to get in the way of just listening. So we need to talk about distressed men, and promote quality listening and the empathy it calls for. This is probably the next phase of suicide prevention. I think we’ve been successful in promoting the idea that people should be able to talk about their distress; that the days of stiff upper lips are over. It’s a great thing that the young royals have been so very vocal about this, and open about their own struggles. But the corollary of greater emotional openess is to begin growing the necessary receptiveness, and to enable the quality of these conversations and the skill of being open to hearing really uncomfortable material. I think that’s probably where we need to focus more efforts in the future. DP: For instance the kind of training the Samaritans provide? The way they train their amazing volunteers to listen, and not to try to fix. These volunteers are taught to sit and listen to some truly harrowing stuff. And it’s being heard, isn’t it, that seems to make a difference? DR: I think so. So, for example, a listener may feel compelled to rush in with solutions, because it’s so very human to want to lessen pain. But for the person who just needs to get something off their chest it is not helpful if the other feels compelled to advise, or in some magical way try to fix ‘the problem’. It takes some effort or even training to realise that it’s OK just to listen; that this is what will help. Also, to show empathy but not by saying ‘oh I know what you’re going through’. That’s not empathy. Empathy might be more like acknowledging your authentic feelings as a listener: ‘I can’t imagine what it must be like for you right now, but I can try to understand if you give me a chance’. These skills can be learned and it’s possible to teach people simply to be there and to listen. Just a three-minute look at the YouTube clip by Brené Brown can help people better grasp the concept of empathy (www.youtube.com/watch?v=1Evwgu369Jw). DP: I fear that is verging on being counter-cultural in the current NHS, where counselling/psychotherapy is turning into cognitive behavioural therapy (CBT). Which, if you’re in deep distress may be very far from what you need in order to unload dark and difficult to articulate thoughts and feelings. DR: Yes, for some people CBT can be helpful of course. But for people – particularly men I think – with

problems that have built up from early life, and which they have never been able to speak about, will that kind of six-week approach meet their (perhaps unspoken but deep) need to connect and relate to another? Nor is it going to be fixed in six sessions. I understand that the NHS has limited resources, but relationships are largely the cause of our emotional problems, and relationships are an important key to resolving them. So we need approaches other than CBT to be available. DP: Approaches other than traditional counselling too, of course. That’s why we set up the Atlas men’s project as an NHS service in the Victoria Medical Centre. This was piloting a new model for a more man-friendly approach. DR: Men in distress often present to GPs with physical symptoms – sleep problems, tension, so we offered men the choice of counselling and/or acupuncture. But actually many chose the counselling option or moved on to counselling after they had begun talking more openly with the acupuncturist. And they could have up to 12 treatments; potentially even a few more if needed. It was a very successful pilot but it had to stop when funding ended two years ago (Cheshire, Peters and Ridge, 2016). Now the GPs are starting it up again because they found it so useful and it proved so popular with men. There’s a need for an ‘Atlas Two’ model, because men want to choose what suits them, not just CBT nor necessarily even the kind of counselling that so many GP practices used to have in-house. DP: What is a GP who is faced with an upset man to do? He isn’t necessarily acutely depressed or overtly suicidal, but he’s having difficult with hurtful feelings he doesn’t know how to share. He possibly feels shame and guilt about these feelings. The GP listens but doesn’t know quite where to turn to get this man appropriate help. What do they have to offer: anti-depressants, CBT, referal to a psychiatrist? DR: Of course, the NHS is an increasingly resourcelimited system and this man doesn’t necessarily need anti-depressants, nor perhaps to be told how to get his thoughts and feelings fixed with CBT. He might turn to a friend or a partner or a colleague, but they may feel that hearing his distress made them uncomfortable themselves. These situations are difficult knots in communication especially if the relationship with the partner or friend or family or work colleagues is in some way part of the problem. Anyone who is going to listen would first have to notice that this was a difficult conversation to be having. DP: It would help if they were able to be aware of their own reactions and knew how to calm down their own emotion systems. Which I suppose is one way of describing what a good psychotherapist trains to do.

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Volume 14 Issue 3 Autumn 2017

MEN AND DISTRESS Men and distress: the final frontier?

DR: Agreed. So you might have to notice your own discomfort and hold your tongue. And just to try and convey back you are hearing, and caring about what’s being said; expressing empathy just by reflecting back their underlying feeling, rather than focusing on the detail: ‘… what you’re going through sounds really tough’ or ‘….it sounds like you are so frustrated’ or ‘…it sounds like you are in such despair right now’. Or whatever you feel they’re trying to convey, but absolutely without trying to offer a solution. DP: Do we professionalise caring and medicalise discomfort and suffering too much? The fact is human beings do get into very unhappy places and always have. Which is why evolution has hard-wired us for empathy with other human beings. The men of our species survived not simply through strength but at least as much because they were able to tend and befriend others; perhaps other men especially. Empathy is part of our nature; it’s why we so easily pick up on another person’s emotions. And that is something important to know. And so rather than find ourselves caught up in a negative way by the distress someone is expressing, we could all learn better ways of being there for our fellow man and woman. DR: I think so. And fortunately, this is something that can be learnt. DP: I don’t see our upbringing as giving us a language or a context for talking about emotion though. If men were more able to sit with one another’s feelings I think that would be, on many levels, a revolutionary shift. DR: Interiority…the last frontier! Men together exploring their inner space. DP: To boldly go… DR: Well, it is courageous, isn’t it? And no wonder men are confused when society at large is messaging us not to show vulnerability, while the ‘new man’ on the other hand is expected to be sensitive. We need to be finding ways to incorporate a different notion of sensitivity and strength into our notions of masculinity. ‘What doesn’t kill you will make you stronger’ is a cliché but there is much truth to it when it comes to being vulnerable. DP: It does imply deeper and different kinds of strength though. DR: Just being able to accept the presence of unpleasant feelings can be helpful in itself. On its own this can lead to change and transformation. Feeling bad isn’t wrong and the tortuous tactics we use to avoid feeling bad just invite more suffering in the end. But as you can’t know this without going there, it’s a real leap of faith for men to take. Male psychotherapy clients may not be willing to go there initially at least.

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And of course it’s a lot to take on when you’re already feeling feeling rubbish about yourself. DP: Most men, if they go anywhere to be heard, will turn to their GP. DR: Yes, the GP is often a crucial first port of call. And some GPs will be more receptive to men’s mental health issues than others (and we know from our research that quite a few will be struggling with their own depression or burnout) (Cheshire et al, 2017). From a psychotherapist’s perspective, a man who is depressed is likely to be highly self-critical, his anger turned inward, and if the encounter doesn’t work he may blame himself, or he may feel abandoned. So being heard in a way that is not critical is vital for men, as (hidden) hypersensitivity is the other side of more traditional masculinity. If the professional can supply and model a more nurturing voice that will be a fine start, whether or not they have particular skills to help a man reframe his experiences in a less critical way. DP: It would be a wise and experienced GP who would be able to do that. DR: Some people do have wise friends, mates that they can turn to, particularly mates who have experienced distress of their own and come through it. At work, a man might find a colleague or a boss who understands because they’ve been through something similar. So for example in some research we’ve done, we found that men will talk about anti-depressants with colleagues who have also taken them. Talking about anti-depressants can be a less threatening way for men to start talking more openly about distress. After all, nowadays so many people have taken anti-depressants or are on them. So this can be a way of getting real about depression, of being honest about how we feel. But depression isn’t always seen as being legitimate: the ‘pull your socks up’ attitude is still very much around. It is difficult to talk about one’s depression if there is a whiff of cynicism about the condition. DP: But as it’s such a widespread problem, finding ways to be honest about it in the workplace – perhaps through people who’ve been through it – would be an important step. DR: And if friends can’t help, people can go online and find support. There’s a CALM webchat area where men don’t even have to talk to someone, they can just type into a forum. Or they can talk to somebody on a phone helpline. There are lots of online support groups that people can turn to these days. So a man who wants to maintain anonymity can still talk about his problems that way. And, although these days there seem to be far fewer counsellors available in primary care, we shouldn’t dismiss CBT for some people. Obviously it can help, particularly for men

MEN AND DISTRESS Men and distress: the final frontier?

who are solution-focused and want something that appeals to their rationality. DP: I know from my involvement with counselling and counsellors (my wife is one!), that the majority by far of people who train as counsellors are women. And I think most of their clients are women. I know two men who trained as counsellors and in both cases they had been the only men in their course. I think a bare majority of GPs are now women. So with women being so prominent in family medicine and counselling services, a man in distress is more likely to end up talking to a woman than with another man. Do you have any thoughts about that? DR: It depends on their preference: some men want to see women, but some men are going to have problems with relating to women, aren’t they? So you do need to have a mixture, which is what we provided in Atlas; people had a choice of male or female acupuncturists and counsellors. And if we are serious about designing more man-friendly mental health services we ought to ask whether there may be things that only another man can understand experientially. Obviously, for instance, some men might be embarrassed to talk about sexual issues with a woman, and might feel more comfortable with a man. On the other hand, some men might feel competitive or threatened by having to talk to another man. So I think the choice has to be there. Even here in our psychology department, most of the students coming in are women, so we’re asking ourselves how can we make psychology more appealing to men? Do we, for example, need to go out to schools and encourage men to come and do psychology degrees? Do we need to have a module on male psychology? DP: Is that yet another indicator that the mind and the emotions are viewed as feminine territory? I know you and I feel this blinkered approach to their inner life is at the heart of men’s emotional difficulties. I certainly suspect that men’s inability to tolerate emotions such as sadness or anger is what leads them into acting them out as violence and addiction. But whether it really matters if men are saddled with this assumption remains an underresearched question. Yet if we are right then what’s to be done about redeeming this stunted view of masculinity? How indeed to rehabilitate emotions so that men may come to see them as something valuable? I’m very interested in finding new ways

for men to talk to other men about them, because my own experience has convinced me that men’s groups properly held and led with care have a huge amount to offer; and not just to individual men, but potentially to the culture as a whole. DR: Yes, you and I have thought about reworking the Atlas model so that some of the men who benefit from a programme could be trained as facilitators, and become the seed for peer-led groups. Apart from any other considerations this could (as long as group leaders and participants were well-selected) be acceptable to men and potentially cost-effective too. DP: That’s right, but without these circles having to be typical talk therapy groups; perhaps drawing instead more on the many lessons learned in different corners of the ‘men’s movement’: the work with military veterans, young offenders, and in prison workshops especially in the US. But I know there’s good work being done over here too in some tough estates by the Band of Brothers that grew out of the Mankind Project (https://mankindproject.co.uk). I believe their group structure draws on traditional Native American tribal circles. That’s not as whacky as it might sound if, as many suspect, some indigenous cultures have held on to practical ways of dealing with the male psyche’s obvious problems. Another significant driver for a new story is Robert Bly’s narrative about men’s emotion-life – that side-byside (rather than in the female face-to-face fashion) – men can explore their vulnerability and allow themselves to tolerate emotions like sadness and despair. This reframes the journey into emotional intelligence as something courageous, heroic even! Anderson E, McCormack M (2015) Cuddling and spooning: heteromasculinity and homosocial tactility among student-athletes. Men and Masculinities 18(2): 214–230. Cheshire A, Peters D, Ridge D (2016) How do we improve men’s mental health via primary care? An evaluation of the Atlas Men’s Well-being Pilot Programme for stressed/distressed men. BMC Family Practice 17(1):1–11. Cheshire A, Ridge D, Hughes J, Peters D, Panagioti M, Simon C, Lewith G (2017) Influences on GP coping and resilience: a qualitative study in primary care. British Journal of General Practice 67(659): e428–e436 Ridge D, Emslie C, and White A (2011) Understanding how men experience, express and cope with mental distress: Where to next? Sociology of Health & Illness 33(1):145–59. Ridge D, Kokanovic R, Broom A, Kirkpatrick S, Anderson C, Tanner C (2015) ‘My dirty little habit’: Patient constructions of antidepressant use and the “crisis” of legitimacy. Social Science & Medicine 146:53–61. Ridge D, Ziebland S (2006) ‘The old me could never have done that’: how people give meaning to recovery following depression. Qual Health Res 16(8):1038–53.

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MALE-FRIENDLY SERVICES

Men’s mental health: why are we are trying to change masculinity rather than create male-friendly services? Martin Seager Consultant clinical psychologist; adult psychotherapist

‘Open up vs. man up’ is a double-bind that men in our society face, and this is in danger of perpetuating

It wasn’t until I was in my mid 40s having worked as a clinical psychologist and psychotherapist in the NHS for nearly 20 years that I got struck by men’s issues and how invisible they are. I had been working with men and women for all this time but had only really thought about gender issues as applying to women. What triggered my awakening was a male clinical psychology trainee coming up to me in desperation after one of my lectures at UEL where he was the only male among the 30 or so doctoral students in the room. Suddenly I realised that psychology was not a man’s world and then I came to realise that in many areas of life men also can suffer for their gender. Once I started looking around at issues such as suicide, life expectancy, homelessness, addiction, parenthood, imprisonment, educational performance and deaths in the workplace, I began to see that men too have a gender that places particular burdens upon them. From that time I have become passionate in all my work, more recently in the voluntary sector, researching and shedding light on men’s gender issues and developing new ways of reaching and helping men.

rather than resolving their health problems, both mental and physical. By trying to change the male gender itself rather than meet the gendered needs of men, our society is in danger of stigmatising and shaming men and boys more than helping them. I explain this double-bind as a mixture of bad science, political correctness and disregarded evolutionary gender differences.

The injunctions for men to open up and man up constitute a double-bind, which results in a state of affairs as bad for the women and children who share their lives, as for the men in our society. It is a mixture of bad science, political correctness and disregarded evolutionary gender differences. I argue that until we can separate the science and the humanity from the politics and the prejudice, we are unlikely to improve the wellbeing of men considerably and may even in some ways worsen it. I end by showing positive examples of how men and boys can be genuinely helped by those few services that do get it right by tailoring their approach to the needs of men rather than trying to tell men to change their masculinity.

Double-bind – message 1 (explicit): open up! The notion that men should ‘open up’ about their problems, vulnerabilities

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and emotions is now a mainstream policy and an unquestioned piece of public health thinking. The call upon men to ‘open up’ is pervasive. Implicit in this idea is the assumption that masculinity is somehow emotionally illiterate, repressed or deficient. This message also carries with it the implicit assumption that, by not ‘opening up’, men are somehow to blame for their own troubles and distress. The help is out there if only they would seek it, but they don’t. They are too stubborn, ‘traditionally masculine’ and even ‘macho’ for their own good. This viewpoint is hard to challenge in public and to do so is often to invite ridicule and contempt. Of course, even if it were true that men and boys were emotionally deficient we would still have to ask two big scientific questions: (a) why should this be the case when most childcare is still carried out by adult females? And (b) why should we criticise men or any group for a deficiency? Shouldn’t we

MALE-FRIENDLY SERVICES Men’s mental health: why are we are trying to change masculinity rather than create male-friendly services?

be trying to empathise with their problems and adapting our services to take account of any deficiency?

Double-bind – message 2 (implicit): man up! In contrast to the first message, the second is much louder though perhaps less explicitly voiced. However, our true attitudes to the male gender must surely be evidenced primarily by the actions we take and the services we provide for vulnerable men. If we truly believed that male vulnerability was an important thing, then society would surely provide the services to meet this need. But when we take a look around we find: • 97% of deaths in the UK workplace are male and there is no policy that addresses this – men are doing the bulk of the dangerous and heavy manual jobs without gender recognition1 • 99% of combat deaths are male and this is accepted as the norm • nearly 80% of suicides are male but there are almost no male-specific suicide or mental health services2 • 85% of rough sleepers are male but street homelessness is not seen as a gender issue • male life expectancy is significantly less than female but there is no major initiative to address this as a gender inequality issue • funding in specifically male cancers and other health problems is significantly less3 • 95% of prisoners are male and most have severe or significant mental health problems but their living conditions are neglectful of mental wellbeing and little thought is given to their rights and needs as fathers or the needs of their children to have fathering • there are almost no specific services for male victims of domestic abuse although, even allowing for underreporting, they still make up 30–40% of the total4 • male victims of atrocities are overlooked (eg the boys who were burned to death in Nigeria by Boko Haram when the girls were kidnapped got no press coverage5) • perinatal services, employment law and the family courts on the whole do not acknowledge that fathers have equal feelings for or value to their children • in the UK women are now over a third more likely than men to go to university – there is no national policy or strategy to close this gap.

In summary so far There is a paradox or double-bind in that while we chide men for not ‘opening up’ and seeking help we have arranged our society in such a way that we deny male emotionality, vulnerability and victimhood. The reality is that men and boys will listen more to the actions of

society than its words, rather as we all will judge politicians by their deeds more than their rhetoric. In terms of our actions as a society we clearly have less empathy for the male of the species. We might be saying we care but our actions show we don’t mean it. This gender differential in compassion has been called the gender empathy gap6, male gender blindness or the elephant in the room of gender.

How do we explain the male gender empathy gap? Once we remove our blinkers enough to ask this question it is not too hard to answer. Starting from an evolutionary perspective there is clearly a male archetype which myself and colleagues7 have distilled into what we have called the three ancient rules of masculinity: 1. Be a fighter and a winner. 2. Be a provider and a protector. 3. Retain mastery and self-control. Much of male behaviour can be explained and predicted using these three simple rules, most notably male risktaking and the male reluctance to seek help. These behaviours make sense once we recognise that the male archetype is to protect and provide for others, not to seek protection for the protector. The theory that male behaviour is merely a social stereotype, on the other hand, does not fit the evidence of universal differences across all cultures in these respects. If male behaviour was a stereotype then it would be hard to explain scientifically why the same universal pattern of risk-taking in men is found across all cultures and at all points in history. This is in essence an evolutionary ‘women and children first’ pattern which persists to this very day. In addition to evolutionary factors, we have a mainstream socio-political narrative that assumes a picture of female inequality and disadvantage coupled with male privilege and power. This means that the very idea of male inequalities and disadvantages becomes almost unthinkable and certainly unsayable. This applies even to our history where, for example, we somehow forget (even in 2017 at the centenary of World War 1, 1914–18) the thousands of young working class men who also had no suffrage but were compelled by virtue of their gender to sacrifice their very lives for our freedom and protection. In the same period of history (1912) the chances of survival as a man travelling first class on the Titanic were lower than those of a woman travelling third class. This is because the role of the male has always been to protect and rescue. On the Titanic 97% of women travelling first class were saved and all the children who were travelling first or second class (100%). On the other hand, less than 10% of men travelling second class survived. Our very survival as adults has always been intimately connected with our gender. This is rarely factored in to gender equality discussions or policies.

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MALE-FRIENDLY SERVICES Men’s mental health: why are we are trying to change masculinity rather than create male-friendly services?

Is masculinity toxic or just our attitudes to it? Beyond even a lack of empathy, there is now a prevalent view that masculinity is a bad thing and should be somehow reformed, redefined or fixed. In terms of modern socio-political attitudes in the western world, masculinity has become stigmatised at least in the liberal middle class as something dangerous and toxic even though the science (facts and statistics) tells a very different story, that humanity continues to rely on working class masculinity to provide infrastructure, protection and security. In May 2016 I took part in the first debate on masculinity ever held at the Cambridge Union8. However, the very title of the motion being debated (‘This house believes that masculinity is damaging for everyone!’) evidenced that UK society has reached a sad point where masculinity, far from being celebrated or even appreciated, is now firmly ‘in the dock’. It seems that the worst abuses of physical, sexual or political power by some highly damaged or over-privileged men has been generalised to the whole of malekind. We have confused the extreme and the bad with the norm. The most damaging men (including sex offenders and crazy dictators), while being in a significant minority, have come to be seen as typifying the dangers of the whole male gender rather than as examples of what can go wrong when male human beings are damaged.

So what is the right approach to helping men? If society is to authentically help men and therefore help itself, one thing for certain is that it needs to change not men, but its own attitudes to men and masculinity. How are we to help any client group without empathy for them? A better theory is that men are not emotionally deficient or illiterate but differently literate. It should hardly be surprising that there are some important sex and gender differences in the way human beings process and respond to emotions and distress. In all other spheres of life (ethnicity, age, culture, religion, disability) we celebrate difference and take account of differences when trying to help people. When it comes to gender, our society seems to be trying to deny any difference, while at the same time paradoxically stigmatising masculinity. However, where services have tried to adapt to men rather than trying to make men change, the results are very promising. In particular, services (for example CALM9, Men’s Sheds10) seem to work where they do the following:

• honour male banter and male vocabulary as attempts to make connections rather than seeing these as defensive and emotionally avoidant • allow more space for non-verbal communication and activities that can be a bridge to verbal communication • use male culture, camaraderie and male team spirit. In essence successful approaches to men honour male archetypes rather than undermining them – for example a service that encourages men to seek help as a way of taking action and taking control (going with the archetype) alongside other men will be more successful than one that encourages men to get in touch with their internal vulnerabilities (going against the archetype). Similarly, a service that went against the female archetype (‘beauty doesn’t matter’) would be much less successful than one that went with it (‘many different body shapes can be beautiful’).

One brief illustration In 2014 at Central London Samaritans I helped deliver a project called Man Talk where rather than focusing on how men talk we simply addressed how volunteers were listening. We simply ran a series of workshops and training events that exposed our volunteers (80% female) to male culture and male issues, for example blues music and female actors trying male roles in Shakespeare’s Julius Caesar. After a year we took a simple quantitative measure of the length of phone calls with men and found that this had increased significantly (based on a large sample of 1,000 calls).

Conclusion The simple message based on science and humanity is this: if we stop trying to change how men talk but change how we listen, and if we stop seeing male behaviour as a stereotype and start respecting the male archetype, we will all get a lot further. In other words, if we develop a male-friendly approach, men will actually respond. 1

www.inside-man.co.uk/2015/03/03/97-employees-die-work-men2009-2014-figures

www.bps.org.uk/system/files/user-files/Division%20of%20Clinical% 20Psychology/public/Gender%20-%20Final.pdf

www.bbc.co.uk/news/health-20875488

www.theguardian.com/society/2010/sep/05/men-victimsdomestic-violence

www.mediaite.com/online/why-did-kidnapping-girls-but-notburning-boys-alive-wake-media-up-to-boko-haram

www.newmalestudies.com/OJS/index.php/nms/article/view/227

• are not constrained by a traditional feminised11 counselling model based on direct face to face emotional exploration

http://newmalestudies.com/OJS/index.php/nms/article/view/151/154

www.youtube.com/watch?v=wc8h2Nd5uHg&t=3139s

• focus more on telling your story than directly exploring feelings

www.thecalmzone.net

10 http://menssheds.org.uk 11 https://thepsychologist.bps.org.uk/volume-27/edition-6/are-mentalhealth-services-inherently-feminised

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MID-LIFE OPENING

Men’s work, mid-life and the call of the soul William Ayot Poet, playwright and ritualist

The growing sense of a gender in crisis is raising

My first love was poetry though I spent many years writing theatre. In the 1990s, I started using poems to explore men’s issues and I’ve since facilitated men’s groups in rehab, organised large-scale men’s gatherings, and led rites of passage. My writing includes the play Bengal Lancer, three collections of poetry, and the prose book, Re-enchanting the Forest: Meaningful Ritual in a Secular World. This year, I was commissioned by the Steelworkers Union of Port Talbot to write a poem commemorating their relationship with the burns unit at the Moriston Hospital. Working with these resigned yet defiant men, and seeing my words cut into a powerful steel sculpture was among the most moving experiences of my working life.

curiousity about men’s groups and men’s work and the men’s movement. The unifying theme here is one of transformation: how to move forward at a point in life when the way you have come to understand your maleness no longer works. When Vietnam vets returned, often traumatised

Imagine a circle of men, mostly strangers. They’ve been together for about 24 hours now and, while they’ve come to accept that their life isn’t actually in danger, they are still wary of each other. For the most part, their experience of other men is founded on their boyhood experience of constant competition, shaming and the ever-present threat of violence. For about an hour, they’ve been edging towards a truth that’s been hanging in the air between them. One of the leaders of this men’s work retreat – for that’s what it is – picks up a book of poetry and begins to read…

and dismembered and disfigured, they faced rejection and some selfhatred. It was in the 1980s that these men began gathering in groups to heal and embrace a new kind of masculinity.

Counting the marigolds The fist came out of nowhere. He was nine years old and running up the garden path, excited as only a boy can be when he sees his father coming home. Daddy, Daddy. I scored a goal! It caught him right on the button. Something split and he could taste the metal in his blood before he hit the ground.

He was staring at a bed of marigolds, concentrating, counting leaves and petals, when his father picked him up and looked him in the eye. I must have told you a dozen times, he slurred. Never leave yourself open. When such a poem is read to a group of men, a silence descends that speaks of generations of fathers and sons. The fathers, often desperate to armour-up their boys in a cruel world; the son’s grieving the loss of their dad to a thousand kinds of absence, or nursing the age-old ache of betrayal. Such silences may stretch into a kind of timelessness – only to be broken by a sob, or a low growl that speaks of a vast web of masculine woundedness that has toxified the world for some hundreds of years. Sometimes, in moments like this, a man looks round the circle and sees the grief in other men’s eyes. For the first time, he realises that he is not alone, and takes his first step on the lifelong journey to wholeness. After many years he can come to a place in his life where other men no longer threaten, irk or terrify

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MID-LIFE OPENING Men’s work, mid-life and the call of the soul

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Gathering together, reading poems, telling stories and evolving initiatory rituals that helped them to heal and come home, they opened the door to a genuinely new kind of masculinity.

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Among the early leaders of what came to be called the men’s movement – and there were many – was the American poet Robert Bly. For some years he had been touring the US college circuit, reading his poems and probing the naïve underbelly of American masculinity. His conclusions shook a generation out of its ‘nice’, resentful torpor. He and his colleagues, including the archetypal psychologist James Hillman, mythologist Michael Meade and an expanding group of shamans, Jungians, and other specialists, challenged men on both sides of the Atlantic to look at themselves, their wounds, and their ways of relating to other men – and women. Their imaginative use of myth, poetry and ritual, connected with men at a very deep level. There was drumming, chanting and intimate sharing; there were midnight rituals and walks in the woods; and the mythopoetic men’s movement (later the expressive men’s movement) came into being. So too was the image of the touchy-feely, platitudinous, tree-hugger, of a thousand skits and disparaging articles. In the UK as elsewhere, men’s natural reaction to this unwelcome ridicule and suspicion was to circle the wagons and withdraw – a mistake I believe, which led to a broad assumption that Bly and his friends were no more than right-wing reactionaries and anti-feminists, which couldn’t have been further from the truth. In fact, Bly was perceived in America as a ‘pinko’, a virtual communist. He was among the first artists to hand back a prize in protest at the war in

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Vietnam, and happily espoused the thought and writings of feminists, female thinkers and artists, founding the Great Goddess Conference with the Jungian thinker Marion Woodman. But in the UK the damage was done, and the notion of men’s work as foolish, self-indulgent and reactionary was firmly established. So, in spite of all this, what was it that appealed to men in such numbers? And does it still have a place in a world that has changed so radically in the last 30 years? The classic format of a men’s work event at the outset, was to gather 100 or more men at some out-of-season camp or centre, which served as a place of learning, instant community, and liminal space (for rituals).1 Usually things began with some ragged drumming before each session and settled into three days of intimate sharing and descent, held together by an archetypal story from the ancient word-hoard of world mythology. By the end of a long weekend, the drumming was tighter and packed with energy, while the story had evolved into a ritual that closely followed the journey of the myth’s hero and the inner process begun in the imaginations of the participants. The last morning usually involved a period of assimilation, the confirmation of lifelong bonds and friendships forged during the events of the weekend. Men came away – as their women folk often attested – lighter, more open and better able to deal with the multiple stresses of relationship, family, work and society. It made their lives better. It worked.

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Men came away lighter, more open and better able to deal with the multiple stresses of relationship, family, work and society.

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him; where some of them have become closer than family, having helped him to cleanse his wounds, own his own darker side, and discover his lost potential. I know this is so. I wrote the poem. I led the workshop. Men’s work originally came out of work being done in the United States, during the 1980s, to support Vietnam vets, who at the time were still largely despised and rejected by the countrymen they had gone to war to ‘defend’. Gathering together, reading poems, telling stories and evolving initiatory rituals that helped them to heal and come home, they opened the door to a genuinely new kind of masculinity. The work was fierce in its demand for authenticity and accountability, groundbreaking in its openness, sharing and expression, and ultimately a life-changing – not to mention life-saving – experience for men from Seattle to Sydney, Sidcup to South Africa.

Bly’s basic format gave birth to a hundred variants as men gathered all over the west, to meet, explore and in many cases do some genuine healing. Indigenous rituals, rites of passage, and vision quests were mounted. There were weekend workshops and seminars at camps and country retreats. Psychotherapists opened facilitated men’s groups from Stroud to San Antonio, while, in other areas, men worked with gangs and troubled youth, or became activists and ecologists, helping others to return to the land. Many developed an inner life, or found a spiritual path that beckoned to them and deepened their existence. Still others saw an entire way of being; of learning and belonging, of ritualising and teaching, of finding an identity and redeeming something that had been tarnished and lost. Perhaps the greatest and most lasting outcome of the men’s work of the 1990s was the proliferation of ritual men’s groups which Bly untiringly advocated. Groups of

MID-LIFE OPENING Men’s work, mid-life and the call of the soul

And then the tide went out… Over time, the original teachers explored new ideas, or found their way back to their first loves of poetry, psychology and writing. Their ‘disciples’, those who had organised, supported and promoted the work, found themselves moving into careers where the skills they had developed in men’s work were readily transferable – into public service, social activism, or corporate work (working in the belly of the beast, as more than one colleague put it). As for the participants, some men seemed to think that, having attended a few weekends, they had been initiated into manhood, and that they had effectively ‘done their work’. Others, in their men’s groups and bringing up families, worked conscientiously to instill their values into their sons and the boys they mentored or taught. The media sought other demons, and moved on. There were still bands of men who gathered to do good work. The Mankind Project, for instance, ran initiatory programmes that sought to change the world ‘one man at a time’. Mandorla, picking up the baton from Everyman, and Wild Dance Events ran residential weekends in Snowdonia, and brave individuals occasionally set up conferences to explore masculinity or various male-related issues. The work survived in rehab centres and youth programmes; and in public sector initiatives to support and challenge violent men, but as far as the general public were concerned, Bly’s old dictum had seemingly come to pass – ‘the energy had left the wine’.

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In a way, it’s no surprise that reaction has set in and that laddism, Trumpism, sexual dysfunction and male suicide are on the increase.

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That said, the underlying need has not gone away. With the arrival of internet pornography, climate change, globalisation, and mass migration, not to mention the accompanying evils of social upheaval and authoritarian politics, men are under even more pressure than their fathers were 30 years ago. Not only are they carrying the

age-old, if self-imposed, imperative to provide, in a world where fewer and fewer of us have access to the kind of wealth that cushions the top 1%; they are also forced into trying to square the new-age circle that demands they be caring, sharing modern men. In a way, it’s no surprise that reaction has set in and that laddism, Trumpism, sexual dysfunction and male suicide are on the increase. Even without these threats to wellbeing, there comes a point in a man’s life when the world around him – the world of computers and work, of lawnmowers and power tools – loses its savour. Usually he’s in his mid 40s, sometimes older, though it’s increasingly happening to younger men these days. Firstly, he begins to think with his dick. He buys a Harley, or a Morgan, or a pair of leather trousers. Sometimes he starts an impossible love affair, or ‘inexplicably’ goes cruising in the park. Alternatively, he takes up bungie-jumping or the violin – or he walks out of his job, or ends his tired marriage. Workmates, neighbours and abandoned wives tend to call this the mid-life crisis but it’s something much older and much, much deeper. It’s also a thing we might expect, given the proscribed and limited, even desperate lives that many men lead these days. Our natural tendency to pathologise anything in this area leaves us, I’m sure, with a choice of syndromes and psychological conditions – but the simple fact is, it’s the man’s soul that is calling. The poets of the Middle East, and some of the 20th century west, were only too aware of the soul’s erratic yet enticing ways. They knew for instance that the soul couldn’t count, that it was wayward and demanding. Above all they understood that the soul – or the psyche if we must – was insatiably curious, that it just wanted to experience things. Imagine you’ve come across a button, a bright red button with a little plaque screwed into the counter-top saying something like ‘Don’t press this button’ or better yet, ‘Under no circumstances whatsoever are you permitted to press this important, serious and potentially very destructive button’. Well, your soul, which, of course, never learned to read anyway, will be fascinated by such a bright and shiny button. I mean… it’s red isn’t it? No doubt your soul will hover over the button for a while, but you know what’s going to happen. It’s going to say, ‘I wonder what happens if you do this!’ It’s going to put its mythic finger on the button, and… Kaboom!... Suddenly you’re in the divorce court, or a genito-urinary medicine clinic (or maybe both), and you’re wondering why you never had the balls to wear those Hawaiian shirts that you coveted way back when – and wouldn’t it be fantastic to drive across America to see your old girlfriend, or paint the house turquoise and take up the mandolin…

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…men’s work provides a way of getting present and becoming whole again.

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seven or eight seemed to work the best, meeting every fortnight or so. With drumming (always the psycho-active drumming to open things up) and poems, and sharing at an ever-deepening level. Some of these groups have lasted for decades, and have seen men through devastating events such as divorce, the deaths of parents and children, even the deaths of members of the group. They have provided solace and support, abiding friendship, and a profound sense of belonging in an unpredictable world. The benefits to health and wellbeing were incalculable.

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MID-LIFE OPENING Men’s work, mid-life and the call of the soul

…one’s first arrival at a men’s conference or workshop is a time for acute nervousness.

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Taken together, men’s work in its various forms offers a way for guys who’ve hit the wall – of alienation, depression, self-loathing, or simple failure – to ‘unpack their stuff ’ in a safe yet exhilarating way. In a circle of men, you see yourself reflected. Your shadow – be it your grandiosity, your flakiness, or your nit-picking pedantry –

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can be challenged without recourse to rage or violence. And when the rage surfaces, you can be held, until the grief comes, and with it the healing. As in the example above, one’s first arrival at a men’s conference or workshop – like a first day at school, or boot camp – is a time for acute nervousness. As the mythologist Michael Meade used to say, ‘A man at his first men’s conference asks himself two questions – is someone gonna get killed? And is it gonna be me?’ What follows, however, is invariably an inspiring surprise, as the instinctive care and fundamental decency of the men around you becomes apparent. In a male world of mistrust and violence, men’s work offers something reassuringly benign, wholesome and masculine. And the tide is finally turning. Books are addressing the subject once again, and documentaries are highlighting the hidden successes of men’s work (see The Work, an inspiring documentary following three men through a men’s work intervention led by inmates at Folsom Prison, California). Most importantly, men are turning up at workshops like the one mentioned above. They are nervous and wary but open to new ideas and seeking the composure and self-assurance that they’ve seen in other men.

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Men are open to new ideas and seeking the composure and self-assurance that they’ve seen in other men.

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And this is where men’s work is more necessary than ever – because it addresses alienation directly, and manages not to pathologise – because it deals with the soul. In a world of increasing alienation, where more and more men – black, white, gay or straight – feel detached and unhappy, where suicide is now the biggest killer of men under fifty (see www.mentalhealth.org.uk/a-to-z/s/ suicide), men’s work provides a way of getting present and becoming whole again. Alienation makes men restless and prone to distraction. It feeds our addictions and magnifies our need to compete. We yearn to be successful, to have the money that makes us feel like we belong, that we have arrived, that we are okay. And, of course, it never works, we can never quite shake off the fundamental malaise. Plenty is no shield and distraction can’t keep it at bay. We are fragmented, apart. We are cast out. We are alone – and on a lonely Friday night with your wife denying you access to the kids – it can kill you. Just when the soul is prompting a man to press the red button, men’s work, by speaking the language of the soul – using poetry, story and ritual – brings him to a place where his wildness is acknowledged, where his grief and rage are embraced, and where his shadow – the deep black bag that holds his darkest secrets – is not only acceptable but welcome. And it works. You read an article or a book and you overcome your fear. You go to a workshop or a talk and you make a decision that changes your life for the better. Thereafter, of course, it can be hell. You spend weeks, howling at the moon or floundering around at the bottom of the well of grief. You lose friends and home and family, materially you can lose everything (I certainly did) but in time you get somewhere, and your life begins to pick up momentum. Surrounded by other men who are searching and striving like yourself, your soul gets fed and you sense the healing. At its best, it is a time of immense enrichment and spiritual deepening, an opening to all the things that constitute the great mysteries of life. Towards the end there’s an acceptance of oneself, one’s failures and petty victories. And other people start to notice the difference. They seek you out and show you respect.

Having been through that opening weekend of nerves and massive relief myself, I have reaped the benefits of men’s work in a hundred ways. I’ve experienced lifechanging rituals on a men’s rites of passage retreat. I’ve been shepherded through vision quests, and taken part in workshops on a dozen aspects of the male experience. I no longer feel threatened in the presence of other men and I’m not afraid to speak my truth to a roomful of guys who don’t agree with me. I’ve found my true path in life, and a very real sense of belonging. Above all, there are men all over the UK, and abroad, that I know I can call on in case of need. Men who know me in my frailty, who have seen me in the extremities of grief and anger, confusion and callousness. What’s more, they know I’m there for them too – and short of going off to war with a man, or climbing Mount Everest, you can only get that from men’s work. Ayot, W (2013) Counting the marigolds. From The Inheritance. Glastonbury: P.S. Avalon. 1 Following anthropologist, Arnold Van Gennep’s principals, laid down in his book Rites of Passage, men’s work events usually involved three fundamental stages: Separation, Ordeal or Transformation, and Return.

For a New Father John O’Donohue As the shimmer of dawn transforms the night Into a blush of color futured with delight, The eyes of your new child awaken in you A brightness that surprises your life. Since the first stir of its secret becoming, The echo of your child has lived inside you, Strengthening through all its night of forming Into a sure pulse of fostering music. How quietly and gently that embryo-echo Can womb in the bone of a man And foster across the distance to the mother A shadow-shelter around this fragile voyage. Now as you behold your infant, you know That this child has come from you and to you; You feel the full force of a father's desire To protect and shelter. Perhaps for the first time, There awakens in you A sense of your own mortality. May your heart rest in the grace of the gift And you sense how you have been called Inside the dream of this new destiny. May you be gentle and loving, Clear and sure. May you trust in the unseen providence That has chosen you all to be a family. May you stand sure on our ground And know that every grace you need Will unfold before you Like all the mornings of your life.

From: Benedictus: A Book of Blessings by John O’Donohue Reprinted with kind permission from the John O'Donohue Literary Estate

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MEN’S SHEDS

The Somerdale Men’s Shed Penny Shrubb Aquaterra Operations Director

Having worked in the leisure industry for more than 25 years I have seen various approaches to encourage people to become more active to improve their general health and wellbeing. Yet in the UK, two-thirds of our population still remain inactive. It has been my personal mission throughout my career to focus on the inactive and those who are more vulnerable in the community, looking at the correlation between social interaction and health and wellbeing. Building someone’s confidence and getting them involved in regular activities that may not fit the mainstream ideal is far more rewarding than getting people to join a class or gym.

Introduction ‘A Men's Shed is a larger version of the typical man’s shed in the garden – a place where he feels at home and pursues practical interests with a high degree of autonomy. Members share the tools they need to work on projects of their own choosing at their own pace and in a safe, friendly and inclusive venue. They are places of … community projects, of purpose, achievement and social interaction.’ (http://menssheds.org.uk). The Somerdale Men’s Shed project is also at the heart of a health and wellbeing project.

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Finding the right balance between physical activity and social interaction outside of mainstream norms is often difficult. However, a current project I have initiated that blends these two requirements perfectly is the Somerdale Men’s Shed programme. Health and wellbeing is not simply about how fit we feel. It is also about our state of mind and the things that make us feel positive about life. Connecting with other people and finding something that makes us feel needed and useful creates that positivity. It is that element of the human condition that drives me and it is why I felt that a men’s shed, with its ability to be a place of leisure that provides practical pastimes within a social atmosphere, was an ideal vehicle to address the issues of inactivity and social isolation. The word ‘shed’ conjures up pictures of a ramshackle, dilapidated outbuilding used to dump stuff that might be useful one day. But a shed can also be an organised place of calm, an escape from the hurly burly of the week, a place to potter and reflect. And to some degree that is exactly what the men’s shed provides – ‘… a larger version of the typical man’s shed in the garden – a place where he feels at home and pursues practical interests with a high degree of autonomy’. This is how a men’s

Volume 14 Issue 3 Autumn 2017

shed is described by the UK Men’s Sheds Association (UK MSA). Their description continues: A men’s shed offers this to a group of such men where members share the tools and resources they need to work on projects of their own choosing at their own pace and in a safe, friendly and inclusive venue. They are places of skill-sharing and informal learning, of individual pursuits and community projects, of purpose, achievement and social interaction. A place of leisure where men come together to work. The men’s shed idea started in Australia in the 1990s. It seems to have taken off particularly after the publication in 2015 of The Men’s Shed Movement: The Company of Men, by Professor Barry Golding of the Federation University of Australia. This book became the definitive account of men’s sheds in Australia. He described the movement as ‘being like the tributaries of a river that rose in different places but came together to create a powerful river of considerable force’. The men’s shed movement has now spread to the USA, Canada and the UK. At the time of writing, there are 432 men’s sheds registered with the UK Men’s Sheds Association

MEN’S SHEDS Developing the Somerdale Men’s Shed

Developing the Somerdale Men’s Shed Our men’s shed at Somerdale in Keynsham, near Bristol, is ‘in development’. The website of the UK Men’s Sheds Association has a wealth of information, including how to start a men’s shed. As the website says: ‘Men’s sheds are currently opening at a rate of 1 to 2 a week. This fact reassures us all that there will be guys in your community who will want to join a shed…’ They identify finding and affording premises as the most common obstacles. We are lucky at Somerdale because we have an available building, which also happens to have an interesting history. Somerdale is the site of the old Cadbury’s (previously Fry’s) chocolate factory built in the early 1930s and famously closed in 2011 amidst national uproar. Later the factory was bought by St Monica Trust for conversion to accommodation for older people, together with various social and business facilities (including a GP surgery). The social and sports facilities are in keeping with the Quaker ethic of the Fry and Cadbury families. The old Fry Club sports pavilion has been replaced by the new Somerdale Pavilion with a range of leisure facilities (operated by Aquaterra, a registered health and wellbeing charity). This leaves the nearby disused changing rooms (housed in a large shed) crying out for a new purpose. So what better purpose than to give some of the local men (and perhaps women) a new purpose? We see the creation of our Somerdale shed as an extension of our ‘Step Out Move On’ project, a nonmedical referral option for social and physical activities to improve the health and wellbeing of people who are isolated, vulnerable in some other way, or perhaps with long-term conditions. When something happens to us, we have three choices in life. We can either let it define us, let it destroy us or we can let it strengthen us. At the Somerdale Pavilion we want to help people to ‘step out and move on’. We can’t guarantee it will get easier but we will help make people stronger. Sometimes the smallest step in the right direction ends up being the biggest step of your life. The first step to getting anywhere is deciding you are not willing to stay where you are. The Scottish Men’s Shed Association reports that ‘most men, when stuck at home for any length of time, whether due to accident, illness, retirement or redundancy, become less and less inclined to go out of the house and take part in leisure activities. As a result they start to eat less healthily and subsequently their health suffers. Depression is another problem. Due to the lack of interaction with work colleagues, friends and even their neighbours, they become more withdrawn, so they end up at the local surgery where the inevitable tablets are dispensed and so they start the downward spiral’.

We speak to so many men visiting the Somerdale Pavilion who have no meaningful purpose in life, and no enjoyment in mainstream exercise, yet they can all tell us a story about what they have made over the years. So we are now supporting a group of local men to create something that will become more than a useful social facility for males.’

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The first step to getting anywhere is deciding you are not willing to stay where you are.

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and a further 118 known to be in development. These have an estimated membership of over 10,000 men.

The project aims to increase social interaction and participation in community life, getting men involved in their community, involved in something they can see as productive and worthwhile. We know that lack of purpose is an important contributor to poor health, particularly in men and in older people. Data presented by the Men’s Health Forum shows that 73% of adults who ‘go missing’ and 87% of rough sleepers are men. Men are three times as likely to report frequent drug use than women and three times more likely to be alcohol dependent. Men have measurably lower access to the social support of friends, relatives and community; finally, more than three-quarters of people who kill themselves are men. Many (but not all) users of men’s sheds across the country are older people. So a hard-hitting report published in 2006 by Age Concern (now Age UK) and the Mental Health Foundation, Promoting Mental Health and Wellbeing in Later Life, is relevant to men’s sheds. It identifies five main areas that influence mental health and wellbeing in later life: • Discrimination against older people is widespread in our society. Those who also experience mental health problems are doubly disadvantaged. Many aspects of growing older predispose to being discriminated against. • Participation in meaningful activity – the lack of this is a pervasive problem in our society, particularly affecting older men. Only half of all retired people say they wanted to stop working and over a third say they felt forced to stop. • Relationships are fundamental to health at all ages. Through dispersal of families, the death of friends and siblings, the loss of regular employment and the difficulties in making new friends, older people are particularly vulnerable to the loss of relationships that nurture. • Physical health and mental health are closely related. Physical ill-health and disability are the most consistent factors relating to depression in later life. Poor mobility clearly aggravates loneliness and low self-esteem and vice versa.

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MEN’S SHEDS Developing the Somerdale Men’s Shed

• Poverty and poor mental health are also closely related: each aggravates the other. Both make social exclusion more likely, but meeting socially and having a network of friends makes it easier to escape from poverty. This all links with the now familiar Five Ways to Wellbeing developed by the New Economics Foundation: • connect – with others • be active – making use of what Somerdale Pavilion has to offer • take notice – be aware of what there is out there • keep learning – learn new things, set yourself a challenge • give – volunteer, join a community group. Men’s sheds generally can and do provide support in all of these areas. For the last 200 years or so, women have been primarily identified as 'homemakers', even when they have been engaged in paid work outside the home. Women have snatched moments and places to unleash their own creativity, while dealing with the demands of everyday domestic and working lives. Nevertheless, in this context, the shed has been a sanctuary for men to 'retreat' to or for women to be 'banned' from. Thus the shed has never been known as a space for women. It has been seen as a non-domestic male space for male activities– absolute privacy away from the female domain! However, a survey undertaken by the UK MSA in June 2015 showed that ‘a third of sheds now involve women. But there is still much debate about the wisdom of this. Clare Colley, from the Canberra Times 2016, reported the prospect of allowing women to join one of Canberra's largest men's sheds divided the group as it was felt that being in a male-only environment, where it's just men, makes it easier for some guys to talk about some of the issues that may be affecting them. However there are a growing number of women who use sheds for a variety of purposes. It has always been Aquaterra’s aim to support men and women’s health and wellbeing, so the vision of the Somerdale Shed is one of inclusivity. Yet to ensure we break down as many barriers as we can we recognise that a varied programme of male only, women only, and mixed sessions may be needed. We also hoped that there will be inter-generational sessions where local schools, scouts and guides, grandchildren and relatives will be invited along in a bid to break down barriers and build meaningful community relationships between the young and older residents within the community. The Somerdale Shed building is currently in the process of being renovated by a committed and passionate team of ‘shedders’ who have been recruited from

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the community through local media and word of mouth. With support from Aquaterra through the start-up process, the recruitment and the application for grant funding for the refurbishment, they have been given the autonomy to create a flexible space that can be used for a wide variety of projects. The shedders meet regularly to discuss the key milestones of the refurbishment and how they want it to operate, look and feel. Their vision is to restore the external façade, in keeping with its original design, rewire electrics, restore water supplies, knock down partition walls to create a flexible workshop, a clean room for photography and crafts, storage areas and a small kitchenette. As the project progresses the shedders would like to develop the outside areas to create planting beds and grow-your-own produce. The aim of the Somerdale shed is to be self-sustainable once the refurbishment has been completed. A nominal fee will be required per session to cover utilities, refreshments and use of resources. We hope that crafts will be made, furniture recycled and items repaired on site and sold, with all profits being ploughed back into the project. Local companies and educational establishments have already been in contact requesting help to build flower boxes and a children’s play area. This all helps to build stronger links with the local community. The Somerdale shed project will provide a physical building where its members can decide on the type of practical things they would like to work on. Experience from elsewhere suggests that men’s sheds will attract people who have skills in many different areas – carpentry, electrics, gardening, soldering, general repairs, mechanics – often rekindling skills that may have been dormant for many years. However, there are no specific requirements. Individuals make their own contribution, whether that’s a particular skill or simply conversation, tea and coffee-making or providing entertainment. One Somerdale shed member, 86 years old, simply entertains the others with his magic and jokes. The overall aim is not so much the output of making and mending, but rather to promote wellbeing and to engender a sense of fun and belonging.

HIV IN THE U K

The shock of HIV has changed us and society James House Documentary director

As a non-medic, my knowledge of healthcare (such as it is) has been gleaned through filming in the NHS, as a patient, and as the son of committed, lifelong GP William House. Recently I directed Epidemic: When Britain Fought AIDS for Channel 4, a film that told the story of the early years of the AIDS epidemic in this country and the (successful) fight to get central government to take action. The experience of making that film inspired this article.

The AIDS epidemic, perhaps particularly in the UK, changed society’s attitudes for ever. Gay men suddenly became visible, and conversations about sex and sexuality were increasingly unavoidable. Over time, rejection changed to sympathy and eventually a certain kind of solidarity. A brief 35 years later we have marriage equality. The speed of social change has been immense but for the gay community – and others – life is still lived in a precarious balance.

As a documentary director working in television you don’t always get to make programmes you have a personal connection to. With tenacity and a degree of luck you can manoeuvre yourself towards things you feel are worthwhile, and you find ways of caring about them. But it doesn’t always feel personal. So, as a gay man, when I was approached by a production company with some seed funding from the Wellcome Trust to develop a film about the early years of the AIDS epidemic in the UK I leapt at the opportunity. Three years later, and scheduled to coincide with the 50th anniversary of the partial decriminalisation of male homosexuality in England and Wales, Epidemic: When Britain Fought AIDS went out on Channel 4. I was born in 1981 – a year before the first case of AIDS was recorded in the UK. In 1996 when combined anti-retroviral therapy first became available (people called it ‘the Lazarus effect’ – patients literally got up and walked) I was only 15. Treatment improved dramatically from that point onwards. Given, then, that I dodged the most horrific years of the epidemic by accident of birth, why did I want to make this film? Until now I hadn’t asked myself that question. In writing this piece I’ve done so for the first time. The answer is surprisingly conflicted.

On the one hand there’s celebration. As a teenager and young adult, despite the fact that I had little explicit knowledge of the AIDS epidemic or queer history (it doesn’t tend to be taught in schools) I had a vague feeling of indebtedness to the gay rights activists who’d come before me. I sensed that the rights and freedoms I could enjoy – to be honest about my sexuality and, from 2004, to have a relationship acknowledged by law – were thanks to their brave work. At the same time, even decades after decriminalisation, the world I grew up in was quite clearly far from accepting towards gay people. At school and with family, homosexuality felt like a taboo. When, infrequently, it was discussed it was ‘them’ doing it, not ‘us’. And ‘they’ were odd creatures. I wasn’t ‘out’ at school, but I was frequently bullied with the word ‘gay’ (or worse) for being more effeminate than the other boys. ‘Gay’ was – and often still is – a term of abuse in the playground. Talking to gay friends today I know my experiences were not unusual. Contradictory feelings, then. I wanted to celebrate progress I wouldn’t care nearly so much about had I not been politicised by my experiences as a gay teenager in the ‘90s! I felt that in making a film about the AIDS epidemic I could acknowledge what I wouldn’t dispute have been massive steps forward, while at the same time hammering

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HIV IN THE UK The shock of HIV has changed us and society

I had a vague feeling of indebtedness to the gay rights activists who’d come before me.

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Rupert Whitaker’s is the earliest of many stories whose brutality shocked and moved me. By summer 1982, and a student at Durham University, he’d been in a relationship with the charismatic Terrence Higgins for a year. When Higgins collapsed at the London nightclub, Heaven, and was rushed into hospital with a mysterious illness, Whitaker’s life was turned upside down. Higgins, like other early AIDS patients, was kept in isolation – a technique called ‘barrier nursing’. Whitaker was allowed to see him only through a glass window. Physicians would not consult Whitaker about his partner’s condition. In a world where gay relationships were considered unacceptable by the mainstream – and where equal marriage was unimaginable – partners had no rights. When Higgins died in July 1982, doctors refused to tell Whitaker the cause of death. Instead, they advised him to read the autopsy report, soon to be published in a medical journal. Whitaker’s grief at losing his partner was compounded by the feeling of being completely disregarded. His relationship – his love – didn’t matter. In the eyes of the medical establishment he didn’t even exist. Unfortunately, stories like Whitaker’s aren’t hard to come by. Jonathan Blake, one of Britain’s longest surviving AIDS patients, told me that when he was first admitted to hospital it was no surprise that he got ushered into a side room. Even in 1982 – before the hysteria set in – gay men were treated as ‘other’. Soon, with the epidemic in the United States gathering pace, reports of the ‘gay plague’ became more common in the news in Britain. LGBT activist Lisa Power – a determined, passionate woman who has developed a dark sense of humour (one senses out of necessity) – told me, ‘It was the perfect mix. Strange kinds of sex, strange kinds of people, a disease that nobody could cure. You couldn’t make up a better plot for fear if you tried’. Then she remembered, ‘oh and junkies too! And sex workers! All the bad people…’ Like the disease, the story went viral. According to many of the doctors I interviewed, the news reports had a direct impact on patients’ experiences in hospital. Ian Weller, who began his career as a liver specialist at the Royal Free Hospital, London, is a gentle, caring, softlyspoken man. He told a story that had evidently etched itself onto his mind and is now irrevocably in mine. He

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was sitting on a patient’s bed talking to him – in a side room. The door opened and he saw a tray of food slide along the floor towards the bed. Then the door slammed shut again. He later discovered it was a staff member scared to enter the room of an AIDS patient. Weller described to me nights where he wouldn’t get home until the early hours of the morning because they’d struggled for hours to find an undertaker to take the bodies away. Weller was just one of a trio of courageous, progressive medics I was lucky enough to interview for the film. In 1982 Michael Adler was a professor of what was then called genito-urinary medicine at the Middlesex Hospital in London. He told me: ‘I would like to say about myself, “Oh yes, that’s really exciting, I’m going to get in there and I’m going to help”. It wasn’t like that, actually. I mean, we just happened to be there, and it came and found us!’ Adler was being modest. In the early years there was

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When Higgins died in July 1982, doctors refused to tell [his partner] the cause of death.

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home the wrongs of the recent past lest they happen again. How far, then, have we come? How different is the world of 2017 to 1997 when I turned 16, or the early ’80s when AIDS arrived in Britain? My answers here are unapologetically personal.

no specialism for AIDS or HIV – HIV hadn’t been discovered, and at the very beginning the disease was called GRID, Gay Related Immune Deficiency. So doctors whose specialisms made them helpful in its treatment were lumbered with it. People like Adler, Weller and Tony Pinching, then an immunologist at St Mary’s Hospital, didn’t have to throw themselves in as wholeheartedly as they did. Certainly at the beginning, it didn’t make them popular with their institutions. A doctor I met during research told me his clinical director pulled him to one side and said: ‘You know these people coming into the hospital are rather unpleasant, they’re all infected. I would discourage you from having them in here, it’s giving this hospital a bad name.’ Along with others of their peers, these doctors joined the patients in battle. Holed up inside the wards, and facing a common enemy outside, something very special began to happen. All the doctors I interviewed talked about a flattening of the relationship between the doctor and the patient. They were dealing with young people on the brink of death, surrounded by an increasingly politicised community. Sometimes, particularly in the early days, the patients had read thoroughly the few reports coming out of the US, and they knew more than the doctors. Tony Pinching began to well up when he talked about his patients’ generosity in the early years. ‘These were people with life expectancies of nine months or so, and they were telling us everything they could so we could put it into the scientific machine and learn more about this disease… These were ordinary people doing extraordinary things.’ It’s worth noting that the common enemy they were battling seemed to combine both the disease and the

HIV IN THE UK The shock of HIV has changed us and society

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As medical expertise grew, the traditional hierarchy began to re-emerge…

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The thrusting together of patients and doctors during the early years of the epidemic serves as a microcosm for what happened in the country as a whole. By making gay men visible, society had to come to terms with their existence. Rupert Whitaker – now a prominent psychiatrist, immunologist and specialist in HIV and AIDS – gets the last word in my film, and he puts it better than I could. ‘My view is that if we hadn’t had AIDS we wouldn’t have marriage equality today… I think that one of the reasons that we have marriage equality, is because we are seen as people who love each other. That we can have actual real relationships, and those relationships are now recognised. So, if, for instance, I had a partner now who was dying in hospital, I would be his next of kin, I would be his family.’ He’s right. The social change over the 35 years since Rupert lost his partner Terry has been immense. How far, then, do we still have to go? As a sexually active gay man living in 21st century London I know to go for an STI test every three to six months. When I do, I receive exemplary service from the very gay-friendly Dean Street Express, a clinic in Soho that provides outreach services, too, in the local bars and gyms. It’s a mechanised system – a computerised check-in with touch-screen monitors – and you’re seen by a clinician who’s often pushed for time. But they’re friendly and non-judgemental. You get asked questions such as, ‘Are you into, fisting, barebacking, chemsex etc.’ This is a scenario where straight-talking about gay sex serves a clear public health benefit. It would have been unimaginable 30 years ago. As a sidenote, I often think that my gay male friends are far better informed about the risks of STIs – and what can be done to prevent them – than the straight ones. In

fact, I can’t remember a straight friend telling me they’ve been for an STI test. But as a middle class man working in the media in London I live a comparatively charmed life. Dean Street is wonderful, and unique in the UK. I would imagine a routine STI test in many places elsewhere in the country would be an obstacle course of awkwardness and judgement. Friends tell me stories about going to the GP with a rash, and on saying they’re gay being sent for an STI test – regardless of the fact they insist they’re in a monogamous relationship with a healthy partner. Perhaps the GP is following protocol, but it’s easy to come away with the feeling of being mistrusted, or of being judged.

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Given that we will always be in the minority, it’s possible there will always be work to do.

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homophobic attitudes it brought to the surface. I have wondered since whether this dynamic – engaged, politicised patients and respectful medics working together – could be created outside the battlefield. Either way, in this instance it didn’t last all that long. As medical expertise grew, the traditional hierarchy began to re-emerge – although on both sides, lives and perspectives had changed.

And even in London in 2017, in the days of equal marriage and relatively frequent and positive representation of LGBT people on television, I don’t think things are okay. I can’t walk down the street holding hands with another man without fear of being called a ‘batty boy’ or worse. Regularly (every few months) I’ve been abused on the street. Not everyone experiences this. It’s more likely to happen if you show affection in public, and if you look less masculine. It’s about gender policing as much as sexuality. In fact, homophobic abuse is often directed towards straight people who don’t fit the mould. Perhaps non-traditional gender presentation is now a bigger taboo than non-traditional sexuality. A trans woman I spoke to recently said she felt that for her community things are roughly where they were for gay men 30 years ago. When it comes to LGBT people in Britain, then, our situation is varied, complicated and hangs in a delicate balance. Things are so much better, but there is work still to do. And given that we will always be in the minority, it’s possible there will always be work to do. Which is why I felt strongly I wanted to end my film with a call to continued action from someone who speaks for another minority entirely, Martin Luther King: ‘Our lives begin to end the day we become silent about things that matter.’ In this article I’ve talked about one ‘thing’ that matters – the shifting position of LGBT people over the last 30 or so years. There are many other ‘things’ that matter, and it’s time to make some noise about them too.

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LEADER SHIP

On becoming the men we have been waiting for Mac Macartney Founder, Embercombe

Power and domination are not masculine values. Nor are love and co-operation feminine ones. Both maleness and femaleness are fully engaged in all of these, yet men and women tend to express them differently. Men, that is real men, know how to love, and they deeply understand the necessity and virtue of co-operation. How can men step into gendered maturity in a balanced way and why it is important to do so for the sake of the world and one’s own mental health?

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Over a period of 20 years I was mentored by a group of indigenous Native American elders. During this training and ever since, I have attempted to bring two worlds together – an ancient world-view that emphasises relationship, interdependence, and reverence for life with the significant challenges and opportunities of the 21st century.

‘The world is changing’, said my mother, ‘and a good thing too’, she added with some feeling. She had been regaling me with a conversation that she had experienced with a group of her elderly friends. It had left her frustrated and irritated. It seems they had been treading familiar ground on the theme of ‘things were different (better) in our day’ and my mother’s efforts to derail the predictable drift of their tense and fearful conversation had failed. It is indeed changing, and whether for better or worse it will continue to change, probably accelerating as it does so. At Embercombe, our centre in Devon, we are witness to the impact of these changes as people from all sectors of society and of all ages share the kaleidoscope of stories that have brought them through our gates. People come for many reasons. Some arrive on the back of a crisis, some are bored, some look for meaning and purpose, some seek distraction, and some are following a trail and we are the next staging post. All carry questions, hurts, triumphs, joys, sadness, fears, and hopes. Many of our visitors bring questions around identity, belonging, authenticity, and what it means to be a human being. Some, of course, are men and some remind me of the young man I was, floundering to find my way in a society that made no sense to me. I got into

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all kinds of difficulty and came close to what my mother’s friends might have called ‘a sticky end’. I was a young man blessed and challenged with many of the fixations, desires, naivety and fantasies commonly associated with my age and gender. I was physically powerful, possessed boundless energy, a fertile imagination, carefully disguised low self-esteem and a secret longing to make my mark on the world. Nothing that I could see around me was likely to yield the adventures I longed for and with the exception of a schoolteacher who was rumoured to have once worked as a lumberjack in the far north of Canada, there was not a single man I knew whose life looked better than servitude to repetition, sameness and predictability. My own father died when I was in my very early 20s. I admired and respected him but as the only son of three who had failed to achieve academically, I believed myself stupid and incapable of walking in his steps. We all have different stories and we all have different challenges even if they are often versions of the same thing. I now view my early failures as blessings that encouraged me to walk a path less travelled. The boy-child that I was yearned to see honour and nobility in his life. I now understand that like the fox cub or the young of most animal species I was exploring

LEADERSHIP On becoming the men we have been waiting for

and practising the adult I was yet to become when I played, wrestled, and quarrelled my way through those early years. A woman friend wrote to me a few months ago wearily and anxiously commenting on her young son’s obsession with weapons, fighting, and winning. Recognising myself I wrote these words to her. ‘I was armed to the teeth all my childhood, loved pirates, fur trappers, soldiers of all kinds, battle, and extracting information from sullen, obstinate prisoners (my younger brother usually). Although I wouldn’t wish the trials I subjected my parents to on anyone, I do now understand that I was working out all kinds of complicated things about, power, self-esteem, honour, bravery and cowardice, and so on. Perhaps it’s best to express and explore these things in play than internalise and hide them. I do not doubt that Louis will be a very wonderful, principled man, and no doubt shed a little light on this troubled world.’ In all sectors of our society men are finding old certainties softening and collapsing. Institutions and customs that once propped up ideas of manhood are toppling or at least shaken and are no longer imbued with unquestioning self-confidence. Patriarchy, and the beliefs and practices resulting from it, have cost women and our earth dear. Like all who are frightened, many men have and still are lashing back at the tide of change women continue to launch as they strive to redress centuries of exclusion and disenfranchisement. A great turning1 is under way and like all such processes the old will resist the new until the inevitable overwhelms that whose day has passed. These words of the Hopi Nation elders offer the only sound advice I know of when faced with such challenges. There is a river flowing now very fast. It is so great and swift that there are those who will be afraid. They will try to hold on to the shore. They will feel like they are being torn apart, and they will suffer greatly. Know the river has its destination. The elders say we must let go of the shore, push off toward the middle of The river, keep our eyes open, and our heads above the water. See who is there with you and celebrate. The elders, Hopi Nation, Oraibi, Arizona. 2000 CE

There are, of course, countless men who desire to support this change and are doing so in small and great ways, but as old prejudices are dismantled new questions arise and with this, confusion, disorientation, and inertia. Another woman friend sent me a letter that I felt sent us plunging into another cul de sac when she appeared to equate kindness, compassion, gentleness and peacefulness with women and competitiveness, aggression, and intolerance with men. It’s not difficult to see why I

don’t believe that this is either true or helpful. How, for instance, would our male children grow into adulthood if they were raised, loved, and educated to embrace values and behaviours that incorporate those attributes commonly associated with women while also exploring positive expressions of traditional male attributes? This is what I wrote in response. ‘I write the following because this topic is an important enquiry for me. I am a man and I am very happy to be a man. After all, creation made me a man, and I have no reason to doubt her wisdom in this. Being a man, I wish to express this essence as potently as I am able, while knowing, as I do, that I still don’t really know what it means. So – a few thoughts and feelings. I have written the words below as if “I know” but I do not. I am simply a man who for the last 40 years has worked to find self-love. Not at the expense of anyone else, but because I believe that from this place I can discover qualities I aspire towards such as compassion, gentleness, kindness. Even love. Together with this, I find myself to be a particular kind of man. I can be kind and I can be cruel. I can be peaceful and I have a potential for violence. I am cooperative, yet I am also competitive. I like my fierce aspect, just as I like my vulnerable self. As a human being, and as a man, I have pledged myself to the re-balancing of our Earth – beginning and continuing with me, yet externally in the world as well. The re-turning of the sacred feminine into balance with the sacred masculine is an imperative that with or without our human co-operation, is happening. We are some way on a cycle and, thankfully, the wheel is still turning. But do we know the essence of feminine and masculine energy? I somehow doubt it. It seems to me that it is unfolding, and that every step is a revelation. I quite enjoy not knowing, and intuitively I distrust the certainty that so many so often express in defining the difference. I do not think that power and domination are masculine values. Neither do I think that love and cooperation are feminine values. It seems to me that both masculine and feminine are fully engaged in all of these, yet have a tendency to express them in ways particular to the masculine or the feminine. Men, that is real men, know how to love, and they deeply understand the necessity and virtue of cooperation. If we want to explore power, domination, and all similar energies, we have only to look at astrology’s Pluto to discover a description of this vast shadowed under-world. Yet Pluto exists

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LEADERSHIP On becoming the men we have been waiting for

within the astrological charts of men and women. As does Venus. Men are from Mars, and Women from Venus always was just a catchy book title, not an expression of cosmological truth. Even if it did sell millions. The cruel and savage assault of patriarchy upon our world, felt most painfully by women, girls, and all aspects of our natural world, did not come about because men are essentially power-driven, but because they seduced themselves into a sick and self-destructive baby-fantasy that substituted the terrifying uncertainty of ignorance and fear for the certainty of control and domination. And from this grew the inevitable degrading march that now threatens the life-systems of our Earth. Once taken root it just grew and grew. Two thousand years ago, in Britain, women were war chiefs, tribal chiefs, spiritual chiefs, political chiefs, mothers and everything else. Boudica and Cartimandua were just two for whom we have names. In war they sharpened swords, hewed and hacked along with their men comrades. As tribal chiefs they did everything that such people do – men or women. In Britain it was the Romans who brought with them the belief that women holding power was a perversion of natural law. Now, our ideas of what is feminine and masculine seem so ponderously fixated on New Age ideas of good and bad, spiritual and materialistic, that we seem stuck in the mud of our cultural bias, and unverified hand-me-down wisdom. I don’t think it helps. The truly equal and peaceful society we work for will come about when men are parented into their true adult, away from the stupid and dangerous posturing of the bully, and women in turn assume their most powerful, potent, and confident embodiment of the feminine. Love will belong as much to one as it will to the other, because this is the underlying truth. Alongside which, no doubt the other generally less well thought of human attributes such as competitiveness, jealousy, greed and general nastiness, will perhaps be equally shared between the sexes. Much to everyone’s relief. It feels very important to me that men and particularly young men succeed in locating an understanding of manhood that encourages the positive human attributes relevant to all genders while also allowing elbow room for those whose energy and drive pushes at the boundaries of whatever might be considered normal. We are not all the same and we should avoid the futility of trying to be. Wholeness is the onward journey, sponsored by parenting, teaching, and mentorship that encourages our unique gifts to flourish and ripen. A young man dear to me has always dreamed of becoming a soldier. His parents opposed it for years only yielding when it became clear that he would not submit to their will. Now he trains with a special forces regiment. The question for me is not whether he should or should not be a soldier but rather, what kind of soldier will he be? During the first few years after I arrived at Embercombe I was still being mentored by a group of

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Native American teachers and healers. Throughout the 16 years I had been trained and mentored by them they had made it very clear that they expected their investment in me to yield dividends. Any sign that I might not reciprocate in this manner prompted the possibility of an abrupt termination to my training. The outcome they hoped for was that I would make a commitment to vigorously share the gifts and knowledge that my life experience, talents, privileges, and education had bestowed on me. Their reasoning and its communication were both clear and forthright. ‘You are part of the 1% of humans upon which has been heaped rights, freedoms, and privileges that few others around this world enjoy. You have never known hunger, thirst, extreme cold or extreme heat. You sleep safe in your bed each night and an array of choices has been laid before you. With all this bounty and all this good fortune, curiously, you seem surprisingly dissatisfied, almost ungrateful. You stand on the shoulders of countless others who fought for your future. There is no meaning in a human being’s life that turns away from the responsibility of serving life. What child is it that would not honour those whose love, care, and courage, nurtured his young life? During the same period of time my education was supplemented with tutorials that my Native American friends believed had been sadly missing from my schooling and university education. For example, the misogyny that lay unnoticed by most in our laws, social culture, religion and attitudes; the manner in which history is manipulated by those whose avarice is assisted by the ignorance of others; how language and the roots of words can yield insight and unearth deliberate obfuscation; how fear and ignorance can foster acts of terrible cruelty, especially when manipulated by those seeking power over others. Every step along the way of my prolonged learning journey with these teachers took me closer to an understanding that I had been born at a critical juncture in my species’ history and the history of the earth. Epiphany followed epiphany, each one part of a deepening realisation of the catastrophic inevitability that results when hubris, ignorance, cleverness, creativity and disconnection from nature combine. When our collective egoism was unfettered from the restraints that a sense of the sacred encourages, we became truly dangerous – understanding that might does not bestow right. Over time we have created laws that attempt to mediate the excesses of those who wield power, but we have not done the same in relation to our species and all those others who share the earth with us. Only very recently has the concept of earth rights, animal rights, life rights, begun to take hold and gain traction.2 We need men to become comfortable in their skins as men, but primarily as people; people who recognise that

LEADERSHIP On becoming the men we have been waiting for

humanity has undergone some kind of rite of passage and that now we are challenged to demonstrate that we have the courage and the intelligence to learn from our past mistakes and successes. While it may not be so in the future we still need men and women to make babies, and although an exclusively binary world is tedious and misleading, a prevailing design principle extant in the natural world is the joining and separating pathway of two great powers, the feminine and the masculine, the egg and the sperm, Wakan and Sequan, goddess and god. As we continue to unravel the complex questions accompanying gender, rights, responsibilities, and our species’ role here on earth, one thing is clear to me. It is imperative that as people of all genders we lift our heads above the noise and busyness of everyday human preoccupations and see what is happening to this beautiful planet we call home.

I wish to be a man of integrity and courage and I have choices to make that will determine whether my wish is realised. It is my responsibility to determine the man I am and am yet to be. Meanwhile my seven-month old son looks on and no doubt places his trust in me to protect him and stay loyal to the promise I made when he and his mother and my older son stand together as a family. This I will do, but since I have the ability and the resources I will do more than this. I will consider my family to be an ever-increasing circle that radiates outwards and has the capability to cross oceans and continents. This is our strength, kinship with the wider family of all things and all people, in relationship with the entire human and more-than-human world. Connected, compassionate, aware and actively engaged. 1

Joanna Macy www.joannamacyfilm.org

The Earth Charter http://earthcharter.org/discover/the-earthcharter/; Ecocide http://eradicatingecocide.com

Physician, heal thyself THE NEED FOR DOCTORS TO CARE FOR THEIR OWN HEALTH IS FINALLY RECOGNISED ‘Physician heal thyself’ was one of the founding principles of the British Holistic Medical Association in 1983. Thirty-four years later the contemporary interpretation of this has finally been incorporated into the Declaration of Geneva – effectively the modern-day Hippocratic Oath. By voting unanimously for this amendment, The World Medical Association (WMA) has finally recognised the importance of doctor wellbeing. The declaration will now include this statement: ‘I WILL ATTEND TO my own health, wellbeing, and abilities in order to provide care of the highest standard.’ The Declaration of Geneva is one of the WMA’s oldest policies to safeguard the ethical principles of the medical profession. There have been only very few and careful revisions over many decades.

Previously, the declaration did not include the need for doctors to take care of their own health and wellbeing. However, increasing workload and occupational stress have taken their toll on doctors’ health and on their ability to provide care of the highest standard. It has also affected recruitment for some high pressure frontline roles such as general practice and accident and emergency medicine. This final recognition is very welcome. The new clause reflects not only the humanity of physicians, but also the role that physician self-care can play in improving patient care. It acknowledges that looking after ourselves is critical to providing the highest quality care.

This Journal of Holistic Healthcare has published many articles relevant to this subject. Visit https://bhma.org/page/3/?s=physician+self-care for a preview of our new website search facility using this subject. Members will soon be able to search and download articles free (non-members will need to pay).

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Volume 14 Issue 3 Autumn 2017

METABOLIC SYNDRO ME

Testosterone and the metabolic syndrome – links and solutions Peter Foley GP

With a global epidemic in obesity, time is of the essence to make lasting improvements to patient care. Unsurprisingly, the rate of metabolic syndrome is also rising. Links are being made between low levels of testosterone and an increased risk of metabolic syndrome among men. While there has been a role for the administration of synthetic testosterone, a more holistic approach, whereby patients improve their diet and limit their physical inactivity, can also lead to improved health and reverse the metabolic syndrome. The holistic approach can improve compliance, adherence and lead to lasting change.

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Having trained in the Peninsula College of Medicine and Dentistry, I pursued a career in general practice while also studying for an MSc in Sports and Exercise Medicine through the University of Bath. I have a passion for the promotion of lifestyle medicine, witness my instagram account (@drpeterjfoley. I write for the world’s largest low-carb website dietdoctor.com and am also on the advisory board for diabetes.co.uk. My MSc research is focused on the role of nutrition and exercise in pre-diabetes.

We are living in a time of worsening global health through a surge in modifiable illness. With reduced levels of daily physical activity and diets high in refined carbohydrate, we are seeing a rise in the rate of metabolic syndrome (MetS) among men globally. The role of testosterone remains crucial for men’s health, and we are continuing to learn more about the links between testosterone and MetS.

Testosterone Introduction Testosterone, the primary male sex hormone, is a naturally occurring androgen, produced in both the testes and adrenal glands, with anabolic and virilising effects, stimulating and controlling the development and maintenance of male characteristics in vertebrates by binding to androgen receptors. Women also produce testosterone, however to a much lesser extent.

Symptoms Symptoms of reduced testosterone include decreased libido and sexual function, fatigue, muscle weakness and memory impairment. With such symptoms, clinicians can often overlook testosterone and focus on more

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common causes such as diabetes, depression or medication side-effects.

Physiology Many studies have shown age-related cross-sectional declines in total and/or Free Testosterone (FT) levels in men (Harman et al, 2001). Correlation studies have shown that visceral fat increases with age, with an inverse correlation between the amount of visceral fat and plasma insulin with levels of testosterone and sexhormone binding globulin (SHBG) (Kupelian et al, 2006). Approximately 50% of men in their 80s will have testosterone levels in the hypogonadal range. Correlation studies cannot distinguish between cause and effect relationships between whether low testosterone induces visceral fat deposition or whether a large visceral fat deposit leads to low testosterone levels. Prospective studies have confirmed that lower endogenous androgens predict central adiposity in men (Rosmond et al, 2003) and that these low testosterone levels are significantly inversely associated with levels of blood pressure, fasting plasma glucose, triglycerides, and body mass index and positively correlated with HDL-cholesterol (Zmuda et al, 1997). A five-year follow- up study of Swedish men

METABOLIC SYNDROME Testosterone and the metabolic syndrome – links and solutions

indicated that elevated plasma cortisol and low testosterone were prospectively associated with increased incidence of cardiovascular-related events and Type 2 Diabetes Mellitus (T2DM) (Rosmond et al, 2003). The extent to which the decline of FT is the result of the ageing process as opposed to chronic illness, medication use and other age-related factors remains controversial. There are several reasons to believe that adiposity is a significant factor in lowering levels of testosterone, which can be seen in men as young as 40 (Goncharov et al, 2009). Increased adiposity, with its associated hyperinsulinism, suppresses SHBG synthesis, and reduces levels of circulating FT (Eckel et al, 2005). Testosterone has been found to inhibit triglyceride uptake and lipoprotein lipase activity and cause a rapid turnover of triglycerides in abdominal adipose tissue (Martin et al, 1996). Furthermore, insulin (Pitteloug et al, 2005) and leptin (Isidori et al,1999) have a suppressive impact on testicular steroidogenesis (Stamler et al, 1976). The role of testosterone on insulin sensitivity was further investigated, where acute androgen deprivation resulted in reduced insulin sensitivity among young men (Yiamalas et al, 2007) and strongly impaired the glycaemic control of men with T2DM (Haidar et al, 2007).

The metabolic syndrome The metabolic syndrome (MetS) is a constellation of metabolic risk factors (including hypertension, dyslipidaemia, abdominal obesity and impaired glucose metabolism), which is associated with a twofold increased risk of cardiovascular disease (CVD) (Ford, 2005), and an even higher risk of T2DM (Grundy, 2008). The prevalence of MetS increases with age and is higher in men (RegitzZagrosek, 2006), with MetS-associated risks varying according to sex (Boden-Albala et al, 2008), where women have a stronger risk factor for developing CVD (Takahashi et al, 2007). Since the first formalised definition of MetS by the World Health Organization in 1998 (Alberti, 1998), there has been considerable disagreement over the terminology and diagnostic criteria used, with differing views from

several scientific bodies. These include the International Diabetes Federation, the World Health Organization, the American Heart Association/National Heart, Lung and Blood Institute and the European Cardiovascular Society (Alberti, 2009). Furthermore, there is further controversy over whether MetS is a true syndrome or a mixture of unrelated phenotypes (Alberti, 2009). This has understandably led to confusion among practitioners. However in 2009, a consensus agreement was reached to unify the approach in defining MetS worldwide (see Figure 1).

The obesity epidemic More than half of Europeans are now either overweight or obese (Tuomilehto and Schwartz, 2010), with alarming trends also seen in children (Health and Social Care Information Centre, 2013). Physical inactivity (6%) and obesity (5%) are now recognised as some of the leading causes of global mortality (WHO, 2011). In the United States, 63% of men and 55% of women are classified as being overweight, with 22% having a BMI of more than 30kg/m2 (Ogden et al, 2006). Approximately 80% of obese adults suffer from at least one, and 40% from two or more, of the diseases associated with obesity, such as T2DM, hypertension, cardiovascular disease, gallbladder disease, cancers, and arthritis (Janssen and Mark, 2007). A large number of cross-sectional studies have established a relationship between abdominal obesity and MetS (Carr and Brunzell, 2004). Testosterone has also been identified as being inversely related to abnormal waist circumference, raised C-reactive protein (CRP) levels, and dyslipidemia (Crysohoou et al, 2013). Often people who have features of MetS also manifest a prothrombotic and proinflammatory state (Alberti, 2009). The mechanisms underlying the contribution of abdominal obesity and insulin resistance to metabolic risk factors is not fully understood (Alberti, 2009), however lipid levels, raised BMI, and raised inflammatory and insulin marker levels seem to explain the relationship, suggesting a potential mediating effect. This finding may support a research hypothesis relating serum testosterone with cardiovascular disease (Crysohoou et al, 2013).

Figure 1: Diagnosis of metabolic syndrome 3 out of 5 required for diagnosis: • Hypertension

(Systolic >130 diastolic >85 or drug treatment)

• Dyslipidemia – High triglycerides – Low high-density lipoprotein cholesterol)

(>1.7mmol/L) (<1.0mmol/L men, >1.3mmol/L women)

• Impaired fasting BM

(>100mg/dL/5.6mmol/L)

• Central obesity*

(Population and country specific)

*Not an obligatory component, but useful as a preliminary screening tool. No single cut-off for diagnosis, with further work needed to establish usefulness in diagnosis. (Alberti et al, 2009)

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METABOLIC SYNDROME Testosterone and the metabolic syndrome – links and solutions

Relationship between testosterone and METs Previous studies have suggested a role for sex hormones in the development of MetS, with androgen-deprivation therapy in prostate cancer patients (Shahani et al, 2008), and total testosterone levels in hypogonadal men (Chubb et al, 2008) being associated with the development of the condition. MetS and its individual components are also common in hyperandrogenic conditions in women, including polycystic ovary syndrome (PCOS) (Ehrmann et al, 2006). Low sex hormone binding globulin levels have been observed in both men and women with MetS (Maggio et al, 2007). However, little is known about possible sex differences in this association. The Ikaria Study, which researched the diet and lifestyle of Greek people over the age of 80 on the island of Ikaria, suggested a mediating effect of testosterone on the prediction of having MetS (Crysohoou et al, 2013). Inhabitants of this island were four times as likely to reach 90 than their American counterparts.

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A holistic approach is to address both nutrition and physical activity to improve testosterone production and sensitivity.

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A systematic review and meta-analysis of crosssectional studies indicated that testosterone levels were significantly lower in men with type 2 diabetes, and men with higher testosterone levels (range 449.6 –605.2 ng/dL) had a 42% lower risk of developing T2DM (Ding et al, 2006). Numerous studies have also found inverse associations between the severity of features of the MetS and plasma testosterone (Kaplan et al, 2006), which can be consistent across race and ethic groups (Kupelian et al, 2008). Furthermore, an inverse relationship has been found in men between testosterone and diabetes (Saad and Gooren, 2009), where those with diabetes have lower testosterone levels (Stanwort and Jones, 2009) Longitudinal studies have revealed epidemiological evidence that low testosterone levels are independent risk factors for the development of both MetS and T2DM (Triash et al, 2009) and also cerebrovascular events (Yeap et al, 2009). Furthermore, to further clarify the causal nature of the observed associations, more large-scale longitudinal studies are required, particularly in women. Therefore, additional tools, such as Mendelian randomisation studies and intervention studies, are needed to establish true causation. (Brand et al, 2011)

Testosterone replacement The traditional view among physicians was that the administration of testosterone can lead to an increased

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risk of malignancy and voidal symptoms among elderly men. Several follow-up studies of men receiving testosterone treatment (Calof et al, 2005) have failed to demonstrate an exacerbation of voiding symptoms due to benign prostatic hyperplasia, with complications such as urinary retention in therapy groups similar to those receiving placebo. There is also no convincing evidence that testosterone is a main factor in the development of prostate cancer in elderly men (Morgentaler, 2009). Guidelines for monitoring have been developed which, if rigorously applied, render testosterone administration to elderly men an acceptably safe therapy in men without a history of prostate carcinoma or without evidence of harboring a prostate carcinoma (Wang et al, 2008). A meta-analysis found that testosterone treatment in older men compared to placebo was not associated with a significantly higher risk of detection of prostate cancer, although the frequency of prostate biopsies was much higher in the testosterone- treated group than in the placebo group (Calof et al, 2005). While there may be a role for administering testosterone for some patients, a more holistic approach is to address both nutrition and physical activity levels in order to improve testosterone production and sensitivity.

The role of exercise for MetS In 2011, the UK Chief Medical Officer released the Start Active, Stay Active campaign to promote physical activity among the general population. Current exercise guidelines recommend either 75 minutes of vigorous intensity or 150 minutes of moderate intensity per week, or a combination of both. Several physical activity programmes have been produced throughout the UK, including Sport and exercise medicine – a fresh approach, which are designed for physicians and patients to further understand the importance of physical activity for health. Exercise has been proven to significantly improve blood glucose control, reduce cardiovascular risk factors, contribute to a reduction in waist circumference and prevent the progression to T2DM (Knowler et al, 2002). This is due in part to heightened control of satiety hormones (insulin, leptin, adiponectin, glucagon-like peptie and cholecystokinin) which is linked to healthy testosterone levels. Structured exercise interventions have been shown to improve HbA1c in patients with T2DM, independent of body weight with a linear relationship of higher intensity levels being associated with larger reductions (Boule et al 2003). This was also identified in patients with hypertension (Colbery et al, 2010). There is also compelling evidence that regular exercise is effective in the primary prevention of several other chronic diseases, including ischaemic heart disease (RR 40%), stroke (RR 27%), colon cancer (RR 25%), and breast cancer (24%). Exercise promotion can include simple light aerobic programmes to more intense resistant and high intensity

METABOLIC SYNDROME Testosterone and the metabolic syndrome – links and solutions

interval exercising (HIIE). Physicians should consider patient age and previous activity levels when recommending an exercise regimen (Bax et al, 2007). Provided there are no contra-indications, patients with diabetes would benefit from a programme which consists of several exercise modalities (Colberg et al, 2010). While the evidence base lacks large trial results, there is no evidence of harm including cardiovascular events during exercise, and/or a worsening of diabetes and/or blood pressure levels by dynamic resistance exercise regiments. There is a strong argument for the promotion of limiting daily physical inactivity, irrespective of level of intensity.

Aerobic training Most exercise protocols designed to promote weight loss have previously focused on regular light aerobic training (three times a week) which have resulted in negligible weight loss (Wu et al, 2009). However, aerobic training is known to improve glycaemic control in the diabetic population (Snowling and Hopkins, 2006). A meta-analysis of endurance training included 72 trials which identified a median training time of 40 minutes, 3 times a week over 16 weeks of a moderate intensity (60% of heart rate reserve). Significant reductions were seen in resting blood pressure (-3.0/-2.4 mmHg), with more significant reductions seen in the hypertensive participants (-6.9/-4.9 mmHg). These trials did not observe the effects of specific training frequency, intensity or mode on blood pressure however (Fagard and Cornelissen, 2007).

Dynamic resistance training Resistance training includes activities where physical effort is applied against opposing forces with the use of large muscle movements. Progressive resistance exercise programmes have been found to significantly improve insulin sensitivity in individuals with T2DM at a similar or greater impact as observed with aerobic activities (Cauza et al, 2005). One meta-analysis included 25 trials of differing resistance intervention programmes and revealed net mean reductions in blood pressure of -2.7/-2.9 mmHg (Cornelissen et al, 2011) The precise mechanisms by which resistance training can improve blood pressure are unclear, although several physiological changes are proposed in the literature: • improvements and chanes in endothelial function (Casey et al, 2007) • changes in arterial compliance (Rakobowchuk et al, 2005) • changes in sympathetic activity (Carter et al, 2003) • changes in cardiac heart rate variability (Collier et al, 2009) • changes in arterial elasticity and aortic wave reflections (Cortez-Cooper et al, 2009).

High intensity interval exercise (HIIE) Early research on HIIE has produced preliminary evidence that it can lead to modest reductions in subcutaneous and

abdominal fat, with greater reductions in those with T2DM. Regular HIIE (three sessions a week) has also been shown to significantly increase both aerobic and anaerobic fitness while also significantly lowering insulin resistance, resulting in an increase in skeletal muscle capacity for fatty acid oxidation and glycolytic enzyme content (Boutcher, 2011). There is growing evidence for the positive impact of high-intensity interval exercise (HIIE) on weight reduction for overweight individuals (Boucher, 2011). HIIE protocols can vary, but they typically involve an all-out intensity exercise followed by a period of either very low intensity or rest. Most commonly, cycle-sprints are performed on static cycle ergometers at an intensity in excess of 90% of maximal oxygen uptake (V 02 max). Subjects have included adolescents, young men and women, older adults and a selection of patient groups (Boucher, 2011). The most used protocol is the Wingate test, which consists of 30 seconds of all-out cycle-sprints followed by several minutes of very low intensity cycling (Gibalaand and Mcgee, 2008). This protocol amounts to just three to four minutes of exercise a session, with sessions being performed three times a week. Most of our insight into the skeletal muscle adaptation to HIIE has been achieved through this protocol (Gibalaand and McGee, 2008). Hormonal response has been shown to be significantly elevated after the WIngate sprints, which include catacholamines, cortisol and growth hormones (Vincent et al, 2004). Chronic responses include increased aerobic and anaerobic fitness, skeletal muscle adaptations and decreased fasting insulin and insulin resistance. As this protocol is particularly challenging, participants need to be highly motivated to tolerate the accompanying discomfort, thus this is unlikely to be suitable for most sedantary and overweight individuals. Less intensive protocols have been established, which include an 8 second sprint followed by a 12 second recovery for a 20 minute period (Trapp et al, 2008). It is hoped that these less intense protocols may be more readily adopted by those with a lower fitness baseline. When measured (Boucher et al, 2010), HIIE has had positive impact on insulin sensitivity, subcutaneous fat, abdominal trunk fat, BMI, waist circumference and VO2 max. Studies included had an average intervention length of 10 weeks. As yet, the mechanisms underlying the positive impact of HIIE remain unclear, but may include HIIE-induced fat oxidation during and after oxygen and appetite suppression.

My approach Lifestyle behaviour change is considered the most difficult part of diabetes management, with GPs often providing generic advice for exercise (Avery et al, 2016). In general, primary care physicians are knowledgeable about the underlying physiological mechanisms of T2DM, but often experience difficulty when communicating this information to patients (Avery et al, 2016). The most

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METABOLIC SYNDROME Testosterone and the metabolic syndrome – links and solutions

common barrier which I am faced with is what I refer to as the diet and exercise paradigm. ‘I don’t have the time’ and ‘I eat a healthy diet’. By exploring what patients feel a healthy diet is, I often find that there is a very high intake of refined carbohydrate along with alcohol…a recipe for poor mental, cardiovascular, digestive and metabolic health (Lustig, 2016).

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Simple suggestions can give patients realistic physical activity measures without the dreaded lycra or gym membership.

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As a young GP with a passion for holistic care, I enjoy supporting patients in making positive impacts on their health through a variety of lifestyle interventions. Through several motivational interview techniques, I try to sensitively explore patient concerns regarding health and weight. From my experience, I find that patients are often very willing to share their concerns regarding weight and lifestyle when done in a sensitive way. By using SMART goals (specific, measurable, achievable, realistic, timebound) and a SWOT analyses (strengths, weaknesses, opportunities, threats), I aim to develop positive and proactive lifestyle plans for patients to explore. Ultimately, this is a patient-driven intervention, so by targeting patient-centred issues, we can improve adherence and engagement. By exploring exercise solutions, often simple suggestions such as limiting daily inactivity can give patients realistic and non-threatening physical activity measures to strive for, without the dreaded lycra or gym membership. Pre-exercise counselling can often be a helpful way to encourage an increase in physical activity. By identifying patients’ previous level of sporting involvement, we can identify suitable programmes to follow. This can range from a simple ‘couch to 5km’ for the more novice exercisers to sports fans using sports commentary to accompany their exercise training; where they would previously sit and watch a game, they could simply exercise for the first half of a game for example.

Dietary measures The current globally accepted dietary guidelines support a low saturated fat and high carbohydrate diet, with some national guidelines suggesting a 60% intake of carbohydrates (Noakes and Windt, 2016). The flawed science behind this message has resulted in an increase in consumption of junk food, low in fat, high in refined carbohydrates and polyunsaturated vegetable oils (Credit Suisse, 2015). Most current diets are calorie-based, with the UK Clinical Practice Research Datalink from 2004–2014 revealing that the probability of gaining a normal weight through the current dietary guidelines being 1:167, equating a failure rate of more than 99% (Fildes et al, 2015).

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Dietary fat has been targeted for many years, which is reflected in current nutritional guidelines (Credit Suisse, 2015). This is in the absence of supporting evidence from randomised control trials (Harcombe et al, 2015). This also led to an increase in consumption of omega-6 vegetable oils, which has previously been found to increase mortality rates when compared with saturated fat ingestion in a double-blinded study (The Minnesota Coronary Experiment) involving 9,432 participants 45 years ago (Ramsden et al, 2016). Diets low in fat have also been linked with lower levels of testosterone in men (Sharp and Pearson, 2010). In my clinical practice I tend to favour a low carbohydrate and high fat (LCHF) approach, with an emphasis on eating cruciferous vegetables while avoiding baked and refined carbohydrates. I support patients with an ad lib LCHF nutritional plan. LCHF diets have been found to be as good as low fat diets in several meta-analyses (Phelan et al, 2009; Johnson et al, 2014). I have found that patients report increased satiety and lower levels of perceived hunger as alluded to in the literature (Noakes and Windt, 2016). With a clear message supporting the consumption of nutrient-dense food, patients can have increased satiety levels with an overall decrease in energy intake, resulting in a negative energy balance, leading to weight loss without perceived hunger (Noakes and Windt, 2016). The approach is very consistent – unprocessed cruciferous vegetables, raw nuts and seeds, eggs, fish, unprocessed animal meat and natural plant oils (Noakes and Windt, 2016). LCHF diets have been found to have several metabolic advantages over low fat diets, including improved T2DM, obesity and MetS (Feinman et al, 2015). This has been challenged in several inpatient studies measuring low carb v high carb diets (Hall et al, 2016) and energy-restricting low carb, low fat diets (Hall et al, 2015). Both patient groups were found to have equal weight loss which appears to dismiss the specific metabolic advantages of an LCHF approach, however this was not performed in free-living subjects, which failed to allow for patient choice or flexibility. My current experience is that I have had more success with LCHF patients than those who have continued with the low-fat approach. LCHF diets are now being considered as first-line treatments for T2DM (Schofield et al, 2016), however there needs to be a shift away from unhelpful and inaccurate guidelines which target certain food groups to an emphasis on food quality and source rather than targeting macronutrients.

Conclusion With a growing global obesity epidemic, there needs to be a change in how we approach this crisis in primary care. Through the promotion of more holistic care, I feel that we can promote patient empowerment and encourage more healthy lifestyle choices. By using a variety of motivational interviewing techniques, I find that patient

METABOLIC SYNDROME Testosterone and the metabolic syndrome – links and solutions

adherence and compliance is improved and my best outcomes to date are from those patients who are adopting simple daily improvements over a sustained period of time. Through limiting both physical inactivity and limiting the intake of refined carbohydrates, my male patients continue to improve their health, evident through both clinic and laboratory measurements and also through improved mood, concentration and masculinity! Alberti K, Zimmet P (1998) Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: diagnosis and classification of diabetes mellitus provisional report of a WHO consultation. Diabet Med 15: 539–53. Alberti KG, Eckel RH, Grundy SM et al (2009) Harmonizing the metabolic syndrome: a joint interim statement of the international diabetes federation task force on epidemiology and prevention; national heart, lung, and blood institute; American heart association; world heart federation; international atherosclerosis society; and international association for the study of obesity. Circulation 120(16): 1640–1645. Avery L, Flynn D, van Wersch A (2012) Changing physical activity behavior in type 2 diabetes. A systematic review and meta-analysis of behavioral interventions. Diabetes Care 35(12): 2681–89. Bax JJ, Young LH, Frye RL, Bonow RO, Steinberg HO, Barrett EJ (2007) Screening for coronary artery disease in patients with diabetes. Diabetes Care 30(10): 2729–36.

Collier S, Kanaley J, Cahart R Jr, et al (2009) Cardiac autonomic function and baroreflex changes following 4 weeks of resistance versus aerobic training in individuals with pre-hypertension. Acta Physiol (Oxf)195: 339–48. Cortez-Cooper M, DeVan A, Anton M, et al (2005) Effects of high intensity resistance training on arterial stiffness and wave reflection in women. Am J Hypertens 18: 930–4. Credit Suisse (2015) Fat: the new health paradigm. Available at: http://publications.credit-suisse.com/tasks/render/file/index.cfm? fileid=919B088F-CBDF-C311-855036815DD5985A (accessed 10 September 2017). Crysohoou C, Panagiotakos D, Pitsavos C, et al (2013) Low testosterone levels are associated with metabolic syndrome, in elderly men: the role of body weight, lipids, insulin resistance and inflammation; the Ikaria study. RDS 10(1): 27–38. Ding EL, Song Y, Malik VS, Liu S (2006) Sex differences of endogenous sex hormones and risk of type 2 diabetes: a systematic review and meta-analysis. JAMA 295(11) pp 1288–1299. Eckel R, Grundy S, Zimmet P (2005) The metabolic syndrome. The Lancet 365(9468): 1415–1428. Ehrmann D, Liljenquist D, Kasza K, et al (2006) Prevalence and predictors of the metabolic syndrome in women with polycystic ovary syndrome. J Clin Endocrinol Metab 91 pp 48–53. Fagard R, Cornelissen V (2007) Effect of exercise on blood pressure control in hypertensive patients. Eur J Cardiovasc Prev Rehabil 14 pp12–7.

Boden-Albala B, Sacco R, Lee H et al (2008) Metabolic syndrome and ischemic stroke risk: Northern Manhattan Study. Stroke 39: 30–35.

Feinman R, Pogozelski W, Astrup A, et al (2015) Dietary carbohydrate restriction as the first approach in diabetes management: critical review and evidence base. Nutrition 31: 1–13.

Boule N, Haddad E, Kenny G, et al (2001) Effects of exercise on glycemic control and body mass in type 2 diabetes mellitus: a meta-analysis of controlled clinical trials. JAMA 286: 1218–27.

Ford E (2005) Prevalence of the metabolic syndrome defined by the international diabetes federation among adults in the US. Diabetes Care 28(11) pp 2745–2749.

Boule N, Kenny G, Haddad E, Wells G, Sigal R (2003) Meta-analysis of the effect of structured exercise training on cardiorespiratory fitness in type 2 diabetes mellitus. Diabetologia 46: 1071–81.

Gibalaand M, McGee S (2008) Metabolic adaptations to short-term high-intensity interval training: a little pain for a lot of gain? Exercise and Sport Sciences Reviews 36(2): 58–63.

Boutcher S (2011) High-intensity intermittent exercise and fat loss. The Journal of Obesity [online] doi: 10.1155/2011/868305.

Goncharov N, Katsya G, Chagina N, et al (2009) Testosterone and obesity in men under the age of 40 years. Andrologia 41(2): 76–83.

Calof OM, Singh AB, Lee ML et al (2005) Adverse events associated with testosterone replacement in middle-aged and older men: a meta-analysis of randomized, placebo-controlled trials. Journals of Gerontology 60(11): 1451–1457.

Grundy S (2008) Metabolic syndrome pandemic. Arterioscler Thromb Vasc Biol 28: 629–36.

Carr MC, Brunzell JD (2004) Abdominal obesity and dyslipidemia in the metabolic syndrome: importance of type 2 diabetes and familial combined hyperlipidemia in coronary artery disease risk. Journal of Clinical Endocrinology and Metabolism 89(6): 2601–2607. Carter JR, Ray C, Downs E, et al (2003) Strength training reduces arterial blood pressure but not sympathetic neural activity in young normotensive subjects. J Appl Physiol 94: 2212–2216. Casey DP, Beck DT, Braith RW (2007) Progressive resistance training without volume increases does not alter arterial stiffness and aortic wave reflection. Exp Biol Med 232 pp1228–35. Cauza E, Hanusch-Enserer U, Strasser B, et al (2005) The relative benefits of endurance and strength training on the metabolic factors and muscle function of people with type 2 diabetes mellitus. Arch Phys Med Rehabil 86: 1527–33. Chubb S, Hyde Z, Almeida OP, et al (2008) Lower sex hormone-binding globulin is more strongly associated with metabolic syndrome than lower total testosterone in older men: the Health in Men Study. Eur J Endocrinol 158: 785–92. Colberg SR, Sigal R, Fernhall B, et al (2010) Exercise and type 2 diabetes: the American College of Sports Medicine and the American Diabetes Association: joint position statement executive summary. Diabetes Care 33: 2692–6. Cornelissen VA, Fagard R, Coeckelberghs E, et al (2011) Impact of resistance training on blood pressure and other cardiovascular risk factors: a meta-analysis of randomized, controlled trials. Hypertension 58: 950–8.

Haidar A, Yassin A, Saad F, Shabsigh R (2007) Effects of androgen deprivation on glycaemic control and on cardiovascular biochemical risk factors in men with advanced prostate cancer with diabetes. Aging Male 10(4): 189–196. Hall K, Bemis T, Brychta R, et al (2015) Calorie for calorie, dietary fat restriction results in more body fat loss than carbohydrate restriction in people with obesity. Cell Metab 22(3): 427–436. Hall KD, Gortmaker S, Lott M, Wang YC (2016) From calories to weight change in children and adults: the state of the science. Durham, NC: Healthy Eating Research, Robert Wood Johnson Foundation. Health & Social Care Information Centre (2016) Statistics on obesity, physical activity and diet. Leeds: Health and Social Care Information Centre. Harcombe Z, Baker JS, Cooper SM, et al (2015) Evidence from randomised controlled trials did not support the introduction of dietary fat guidelines in 1977 and 1983: a systematic review and meta-analysis. Open Heart 2 e000196. Harman S, Metter EJ, Tobin JD, et al (2001) Longitudinal effects of aging on serum total and free testosterone levels in healthy men. Baltimore Longitudinal Study of Aging. The Journal of Endocrinolgy and Metabolism 86(2): 724–31. Isidori A, Caprio M, Strollo F et al (1999) Leptin and androgens in male obesity: evidence for leptin contribution to reduced androgen levels. Journal of Clinical Endocrinology and Metabolism 84(10): 3673–3680. Janssen I, Mark AE (2007) Elevated body mass index and mortality risk in the elderly. Obesity Reviews 8(1): 41–59. Johnson V, Binnie M, Barlow K, et al (2014) Red meats: time for a paradigm shift in dietary advice. Meat Sci 98: 445–51.

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Kaplan SA, Meehan AG, Shah A (2006) The age related decrease in testosterone is significantly exacerbated in obese men with the metabolic syndrome. What are the Implications for the relatively high incidence of erectile dysfunction observed in these men? The Journal of Urology 176(4) pp1524–1528. Knowler W, Barrett-Conner E, Fowler S, et al (2002) Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 346: 393–403. Kupelian V, Page S, Araujo A, et al (2006) Low sex hormone-binding globulin, total testosterone, and symptomatic androgen deficiency are associated with development of the metabolic syndrome in nonobese men. Journal of Clinincal Endocrinolgy and Metabolism 91: 843–50.

Schofield G, Henderson G, Thornley S, et al (2016) Very low-carbohydrate diets in the management of diabetes revisited. NZ Med J 129: 67–73. Shahani S, Braga-Basaria M, Basaria S (2008) Androgen deprivation therapy in prostate cancer and metabolic risk for atherosclerosis. J Clin Endocrinol Metab 93: 2042–49. Snowling NJ, Hopkins WG (2006) Effects of different modes of exercise training on glucose control and risk factors for complications in type 2 diabetic patients: a meta-analysis. Diabetes Care 29 (11): 518–2527. Stamler J, Stamler R, Riedlinger W, et al (1976) Hypertension screening of 1 million Americans. Community Hypertension Evaluation Clinic (CHEC) program, 1973 through 1975. JAMA 235(21) pp 2299–2306.

Lustig RH (2016) Sickeningly sweet: does sugar cause type 2 diabetes? Yes. Canadian Journal of Diabetes 40: 282–286.

Stanworth RD, Jones TH (2009) Testosterone in obesity, metabolic syndrome and type 2 diabetes. Frontiers of Hormone Research 37: 74–90.

Maggio M, Lauretani F, Ceda G, et al (2007) Association of hormonal dysregulation with metabolic syndrome in older women: data from the InCHIANTI study. Am J Physiol Endocrinol Metab 292 E353–58.

Takahashi K, Bokura H, Kobayashi S, et al (2007) Metabolic syndrome increases the risk of ischemic stroke in women. Intern Med 46: 643–48.

Marin P, Lo n L, Andersson B, et al (1996) Assimilation of triglycerides in subcutaneous and intraabdominal adipose tissues in vivo in men: effects of testosterone. Journal of Clinical Endocrinology and Metabolism 81(3) pp1018–1022, 1996. Morgentaler A (2009) Rapidly shifting concepts regarding andro-gens and prostate cancer. The Scientific World Journal 9: 685–690. Noakes T, Windt J (2016) Evidence that supports the prescription of low-carbohydrate high-fat diets: a narrative review. British Journal of Sports Medicine 51: 133–139. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM (2006) Prevalence of overweight and obesity in the United States, 1999–2004. JAMA 295(13): 1549–1555. Pitteloud N, Hardin M, Dwyer A, et al (2005) Increasing insulin resistance is associated with a decrease in Leydig cell testosterone secretion in men. Journal of Clinical Endocrinology and Metabolism 90(5): 2636–26. Phelan S, Liu T, Gorin A (2009) What distinguishes weight-loss maintainers from the treatment-seeking obese? Analysis of environmental, behavioral, and psychosocial variables in diverse populations. Ann Behav Med 38(2): 94–104.

Traish AM, Saad F, Guay A (2009) The dark side of testosterone deficiency: II. Type 2 diabetes and insulin resistance. Journal of Andrology 30(1): 23–32. Trapp E, Chisholm D, Freund J, et al (2008) The effects of highintensity intermittent exercise training on fat loss and fasting insulin levels of young women. International Journal of Obesity 32(4): 684–691. Tuomilehto J, Lindstrom J, Eriksson JG et al (2001) Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. New England Journal of Medicine 344(18): 1343–50. Vincent S, Berthon P, Zouhal H, et al (2004) Plasma glucose, insulin and catecholamine responses to a Wingate test in physically active women and men. European Journal of Applied Physiology 91(1): 15–21. Wang C, Nieschlag E, Swerdloff R, et al (2008) Investigation, treatment and monitoring of late-onset hypogonadism in males: ISA, ISSAM, EAU, EAA and ASA recommendations. European Journal of Endocrinology 159(5): 507–514. Wu T, Gao X, Chen M, et al (2009) Long-term effectiveness of dietplus-exercise intervention vs. diet-only interventions for weight loss: a meta-analysis: obesity management. Obesity Reviews 10(3): 313–323.

Rakobowchuk M, McGowan C, de Groot P, et al (2005) Endothelial function of young healthy males following whole body resistance training. J Appl Physiol 98: 2185–2190.

Yeap BB, Hyde Z, Almeida OP, et al (2009) Lower testosterone levels predict incident stroke and transient ischemic attack in older men. Journal of Clinical Endocrinology and Metabolism 94(7): 2353–2359.

Ramsden CE, Zamaora D, Majchrzak-Hong S, et al (2016) Re-evaluation of the traditional diet-heart hypothesis: analysis of recovered data from Minnesota Coronary Experiment (1968–73). BMJ 352: i1246.

Yialamas M, Dwyer A, Hanley E, et al (2007) Acute sex steroid withdrawal reduces insulin sensitivity in healthy men with idiopathic hypogo-nadotropic hypogonadism. Journal of Clinical Endocrinology and Metabolism 92(11): 4254–4259.

Regitz-Zagrosek V, Lehmkuhl E, Weickert M (2006) Gender differences in the metabolic syndrome and their role for cardiovascular disease. Clin Res Cardiol 95: 136–47. Rosmond R, Wallerius S, Wanger P, et al (2003) A 5-year follow-up study of disease incidence in men with an abnormal hormone pattern. Journal of Internal Medicine 254(4): 386–390.

Zmuda J, Cauley J, Kriska A, et al (1997) Longitudinal relation between endogenous testosterone and cardiovascular disease risk factors in middle-aged men: a 13-year follow-up of former multiple risk factor intervention trial participants. American Journal of Epidemiology 146(8): 609–617.

Saad F, Gooren L (2009) The role of testosterone in the metabolic syndrome: a review. Journal of Steroid Biochemistry and Molecular Biology 114(1–2): 40–43.

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LIFEST YLE

Prostatic disease â&#x20AC;&#x201C; an opportunity for better health? Simon Mills Herbal practitioner

Benign prostate disease becomes more common as men age. Not so long ago, the balance of research

Sixteen years ago, as a moderately prominent herbal practitioner, I published a paper for the Journal of the Royal Society of Medicine on natural approaches to the management of prostatic disease that predicted that plant constituents like beta-sitosterols and remedies like saw palmetto would become valuable adjuncts to treatment and that there was more herbal promise of this sort to come. Since then the evidence base has moved on considerably and the case for saw palmetto has been particularly dented. So by the time Kerry Bone and I updated our herbal textbook, Principles and Practice of Phytotherapy there was a substantial shift in emphasis. What we thought was the future had turned into the past. So now what is a man now to do? For many, prostatic problems can be the first big health fear. Here we look at how natural approaches can both help the three main chronic prostatic conditions and then actually unlock wider benefits for a healthy life.

evidence suggested that the herb saw palmetto could shrink benign enlarged prostate gland. However, the consensus view appears to be shifting against its efficacy in prostatic conditions. Nonetheless, lifestyle changes may have powerful positive effects on this and other prostate disorders. And in addition such improvements are likely to benefit other conditions associated with ageing.

Benign prostatic hyperplasia Benign prostatic hyperplasia (BPH) is a progressive, benign growth of the prostate gland that gradually narrows the urethra leading to obstruction of the flow of urine. Urine remaining in the bladder stagnates, leaving the patient vulnerable to infections, bladder stones and kidney damage. Complicating many cases of BPH therefore is a linked range of lower urinary tract symptoms (LUTS). However, there is no exact correlation between the size of the prostate and the degree of LUTS, suggesting that other factors are involved. Various theories have been proposed to explain BPH itself. Recent evidence downplays androgens, both testosterone and dihydrotestosterone; their role is now said to be permissive. A higher oestrogen/testosterone ratio could be a causative hormonal factor, and increased peripheral conversion of testosterone to oestradiol by aromatase could be at play (Roehrborn, 2008). There is, however,

a strong link between BPH and chronic prostatitis (Sciarra, 2008) and one theory has proposed that BPH is an immune-mediated inflammatory disease caused by auto-immunity or possibly infection (Kramer, 2007). Another theory proposes that higher circulating insulin stimulates prostate growth, hence linking BPH to insulin resistance (Vikram, 2010), and an association with obesity has also been observed (Parsons, 2009). The sympathetic overactivity linked to obesity, metabolic syndrome and hypertension may specifically increase the risk of manifesting LUTS (Moul, 2010; Sarma, 2009). LUTS and metabolic syndrome have been shown to be comorbid, as has LUTS and erectile dysfunction. Improving testosterone can help symptoms of LUTS (Yassin, 2008) and inflammation may also play a role (insulin resistance is a pro-inflammatory condition); elevated serum C-reactive protein correlates well with severity of LUTS (Sarma, 2009). Increased levels of physical activity have been associated with a decreased

ÂŠ Journal of holistic healthcare

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LIFESTYLE Prostatic disease – an opportunity for better health?

risk of BPH and LUTS in several large studies (Parsons, 2007; Sea, 2009). A low fat, low animal protein diet appears to be protective, modest alcohol consumption may protect against BPH, but it might increase LUTS (Parsons, 2009). High glycaemic foods appear to contribute to risk (Parsons, 2007; Ranjan, 2006), whereas consumption of fruit and vegetables appear protective (Barnard, 2009). It would seem likely that following a low-inflammatory diet replacing sugars and processed foods with vegetables, fruits and fish will be helpful in containing BPH. In earlier times the association of the symptoms of prostatic enlargement with ageing led to the inevitable use of rejuvenating male tonics and promoters of male potency. Given the primal demand for such agents, it is not surprising that they feature in most traditions. There are obvious stimulants such as cola (Cola nitida) and yohimbe (Pausinystalia yohimbe) used in male virility ceremonies in west Africa, as well as more modest euphorics such as the central American plant damiana (Turnera aphrodisiaca) and the Asian ginseng (Panax ginseng). Although all have traditionally been used for BPH none has systematically been tested. The most notable remedy from the southern USA is saw palmetto (Serenoa serrulata), also initially used as a male tonic. However, the consensus view appears to be shifting against its efficacy in prostatic conditions. Positive 1998 and 2002 Cochrane reviews (Wilt, 2002) have been supplanted by a negative 2009 revision, which suggested that in a total of 26 studies there was no benefit above placebo (Tacklind, 2009) and a major robust clinical study showed no benefits in BPH (Barry, 2011). As well as saw palmetto urologists in Germany have widely prescribed nettle root (Urtica dioica) and pumpkin seed (Curcurbita pepo) for early symptoms of benign prostatic hyperplasia (Bombardelli, 1997). Pumpkin seed remains a good source of useful zinc and there is consistent evidence in double blind controlled studies in favour of nettle root (Safarinejad, 2005).

Chronic prostatitis Unlike acute prostatitis overt infections are rarely involved in the painful and debilitating chronic disorder. It can affect up to 15% of men at some stage in their lives and between 2% and 10% of adult men suffer from prostatitis at any given time. Chronic prostatitis may be associated with an increased risk of prostate cancer as well as BPH (Krieger, 2004). The main symptoms of chronic prostatitis are chronic genito-urinary pain or discomfort, with or without difficulties on urination. There is no known effective conventional treatment. Antibiotics are rarely effective. Feedback from patients is that prolonged sitting or riding a pushbike can make the condition worse, which suggests that poor circulation in the pelvic cavity is a factor. Many also complain that their pain flares up when they drink alcohol. Stress appears to be another factor (Mehik, 2001).

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From the published research, chronic inflammation possibly linked to an auto-immune reaction is identified as an important factor. Men with chronic prostatitis have signs of significant inflammation in biopsy tissue, with T cells apparently driving this reaction (John, 2001). Professional herbal approaches to this condition are likely to combine traditional male remedies like saw palmetto and damiana with echinacea, and urinary antiseptics such as buchu and the Ayurvedic herb varuna (Crataeva nurvala). A wider recourse to inflammatory modulators like tumeric, fish oils and boswellia may be helpful and any exercise that increases circulation to and from the pelvic cacity is recommended.

Prostate cancer Older men are at increased risk of prostate cancer (PC), especially those with a family history and/or with a higher prostate specific antigen (PSA) level (Kell, 2010). The risk is low in Asia, but when Japanese men move to the US their risk increases (Patel, 2009). Infection and inflammation (prostatitis) also appear to be causative factors. Many men with PC also have prostatitis on biopsy and regular use of anti-inflammatory drugs lowers risk of developing PC. The role of androgens is unclear and controversial; 5-alpha reductase inhibitors may prevent the condition, but their value in studies might result from improved screening (Jacobs, 2005). The phenomenon of ‘watchful waiting’ (active surveillance) for men with intermediate PSA and/or Gleason score readings provides an opportunity for conservative natural management of men with low-grade PC. Plants that reduce NF-kappaB transcription can be considered for downregulating inflammatory pathways (Aggarwal, 2004) and here are promising research data for culinary items like rosemary, turmeric, ginger, green tea, and oregano (Capodice, 2009). Red wine, but not alcohol, has been linked to a significantly lower risk of PC (Schoonen, 2005). Grape seed extract inhibited advanced human prostate tumour growth (Singh, 2004). There is also promising research on phyto-oestrogens such as isoflavones. Linseeds (30 gm a day) for an average of 30 days prior to surgery significantly reduced cellular proliferation rates in a controlled trial involving 161 men with PC (Demark-Wahnefried, 2008). There were no changes in testosterone or PSA. Metabolites of the linseed lignans (such as enterolactone) inhibit PC cell growth in vitro (McCann, 2008) and isoflavones appear to concentrate in prostate tissue after supplementation (Gardner, 2009). There is good evidence from a metaanalysis of 14 epidemiological studies that soya foods will lower the risk of PC by around 26%. Non-fermented sources of soya such as tofu or soya milk showed a higher degree of protection than fermented soya products such as miso (Yan, 2009). Dean Ornish’s research team in the US has looked at the impact of diet in PC patients. In the first study a very

LIFESTYLE Prostatic disease – an opportunity for better health?

low-fat vegan diet (12% dietary fat) plus supplements (soya, vitamin E, fish oil, selenium and vitamin C), exercise and stress management was compared to controls. PSA declined 4% over 12 months versus a 6% rise in the control arm. At follow-up two years later, 13 men in the control group had progressed to PC treatment versus just two in the intervention group. A second study with similar intervention examined prostate biopsies after three months. A low GI, moderate fat diet in four men for six weeks found favourable gene expression changes after radical prostatectomy compared with controls (Freedland, 2009; Van Patten, 2008). In conclusion, prostatic disease need not be seen as a mysterious and untreatable series of conditions. Each may respond to basic health measures. If the shock of the diagnosis leads to a shift in lifestyle it may even help prevent other problems of ageing. Aggarwal BB (2004) Nuclear factor-kappaB: the enemy within. Cancer Cell 6(3): 203–208. Barnard RJ, Aronson WJ (2009) Benign prostatic hyperplasia: does lifestyle play a role? Phys Sportsmed 37(4): 141–146. Barry MJ, Meleth S, Lee JY, et al (2011) Effect of increasing doses of saw palmetto extract on lower urinary tract symptoms: a randomized trial. Complementary and Alternative Medicine for Urological Symptoms (CAMUS) Study Group. JAMA 306(12):1344–51. Bombardelli E, Morazzoni P (1997) Cucurbita pepo L. Fitoterapia 68(4): 291–302. Bone K, Mills S (2013) Principles and practice of phytotherapy; 2nd Edition. Edinburgh: Churchill Livingstone. Capodice JL, Gorroochurn P, Cammack S, et al (2009) Zyflamend in men with high-grade prostatic intraepithelial neoplasia: results of a phase I clinical trial. J Soc Integr Oncol 7(2): 43–51. Demark-Wahnefried W, Polascik TJ, George SL, et al (2008) Flaxseed supplementation (not dietary fat restriction) reduces prostate cancer proliferation rates in men presurgery. Cancer Epidemiol Biomarkers Prev 17(12): 3577–3587. Freedland SJ, Aronson WJ (2009) Dietary intervention strategies to modulate prostate cancer risk and prognosis. Curr Opin Urol 19(3): 263–267. Gardner CD, Oelrich B, Liu JP, et al (2009) Prostatic soy isoflavone concentrations exceed serum levels after dietary supplementation. Prostate 69(7): 719–726. Jacobs EJ, Rodriguez C, Mondul AM, et al (2005) A large cohort study of aspirin and other nonsteroidal anti-inflammatory drugs and prostate cancer incidence. J Natl Cancer Inst 97(13): 975–980. John H, Barghorn A, Funke G, et al (2001) Noninflammatory chronic pelvic pain syndrome: immunological study in blood, ejaculate and prostate tissue. Eur Urol 39(1): 72–78. Kell JS (2010) Prostate-specific antigen tests and prostate cancer screening: an update for primary care physicians. Can J Urol 17 (Suppl 1): 18–25. Kramer G, Mitteregger D, Marberger M (2007) Is benign prostatic hyperplasia (BPH) an immune inflammatory disease? Eur Urol 51(5): 1202–1216. Krieger JN (2004) Classification, epidemiology and implications of chronic prostatitis in North America, Europe and Asia. Minerva Urol Nefrol 56(2): 99–107.

Mehik A, Hellstrom P, Sarpola A, et al (2001) Fears, sexual disturbances and personality features in men with prostatitis: a population-based cross-sectional study in Finland. BJU Int 88(1): g35–38. Mills S (2001) Benign prostatic disease: herbal approaches. In Boyd J and Hamilton-Stewart P (eds) Key advances in the effective management of benign prostatic disease. London: Royal Society of Medicine. Moul S, McVary KT (2010) Lower urinary tract symptoms, obesity and the metabolic syndrome. Curr Opin Urol 20(1): 7–12. Parsons JK, Im R (2009) Alcohol consumption is associated with a decreased risk of benign prostatic hyperplasia. J Urol 182(4): 1463–1468. Parsons JK, Sarma AV, McVary K, et al (2009) Obesity and benign prostatic hyperplasia: clinical connections, emerging etiological paradigms and future directions. J Urol 182(6 Suppl): S27–S31. Parsons JK (2007) Modifiable risk factors for benign prostatic hyperplasia and lower urinary tract symptoms: new approaches to old problems. J Urol 178(2): 395–401. Patel AR, Klein EA (2009) Risk factors for prostate cancer. Nat Clin Pract Urology 6(2): 87–95. Ranjan P, Dalela D, Sankhwar, SN (2006) Diet and benign prostatic hyperplasia: implications for prevention. Urology 68(3): 470–476. Roehrbornb CG (2008). Pathology of benign prostatic hyperplasia. Int J Impot Res 20(Suppl 3): S11–S18. Safarinejad MR (2005) Urtica dioica for treatment of benign prostatic hyperplasia: a prospective, randomized, double-blind, placebocontrolled, crossover study. J Herbal Pharmacother 5(4): 1–11. Sarma AV, Kellogg Parsons J (2009) Diabetes and benign prostatic hyperplasia: emerging clinical connections. Curr Urol Rep 10(4): 267–275. Sarma AV, Parsons JK, McVary K, et al (2009) Diabetes and benign prostatic hyperplasia/lower urinary tract symptoms-what do we know? J Urol 182(6 Suppl): S32–S37. Schoonen WM, Salinas CA, Kiemeney LALM, et al (2005) Alcohol consumption and risk of prostate cancer in middle-aged men. Int J Cancer 113(1): 133–140. Sciarra A, Mariotti G, Salciccia S, et al (2008) Prostate growth and inflammation. J Steroid Biochem Mol Biol 108(3–5): 254–260. Sea J, Poon KS, McVary K (2009) Review of exercise and the risk of benign prostatic hyperplasia. Phys Sportsmed 37(4): 75–83. Singh RP, Tyagi AK, Dhanalakshmi S, et al (2004) Grape seed extract inhibits advanced human prostate tumor growth and angiogenesis and upregulates insulin-like growth factor binding protein-3. Int J Cancer 108(5): 733–740. Tacklind J, MacDonald R, Rutks I, Wilt TJ (2009) Serenoa repens for benign prostatic hyperplasia. Cochrane Database Syst Rev CD001423. Van Patten CL, de Boer JG, Tomlinson Guns ES (2008) Diet and dietary supplement intervention trials for the prevention of prostate cancer recurrence: a review of the randomized controlled trial evidence. J Urol 180(6): 2314–2322. Vikram A, Jena G, Ramarao P (2010) Insulin-resistance and benign prostatic hyperplasia: the connection. Eur J Pharmacol 641(2–3): 75–81. Wilt T, Ishani A, MacDonald R (2002) Serenoa repens for benign prostatic hyperplasia. Cochrane Database Syst Rev CD001423. Yan L, Spitznagel EL (2009) Soy consumption and prostate cancer risk in men: a revisit of a meta-analysis. Am J Clin Nutr 89(4): 1155–1163. Yassin AA, El-Sakka AI, Saad F, et al (2008) Lower urinary-tract symptoms and testosterone in elderly men. World J Urol 26(4): 359–364.

McCann MJ, Gill CI, Linton T, et al (2008) Enterolactone restricts the proliferation of the LNCaP human prostate cancer cell line in vitro. Mol Nutr Food Res 52(5): 567–580.

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Stress-reduction or stress-immersion? Mindfulness practice and the full catastrophe of working in the NHS Robert Marx Consultant clinical psychologist and mindfulness teacher

Many who work in the NHS

I have been running mindfulness groups for staff in my NHS trust for more than 10 years and one of my responsibilities at work is to ensure the safety and quality of mindfulness provision to patients and staff. In the time I have been teaching, mindfulness has undergone a huge shift in public awareness and its effectiveness has been charted in an explosion of research. At the same time, the NHS has become an ever more stressful place to work. While mindfulness has been one helpful response to that stress, its provision raises significant questions about both the integrity of the mindfulness approach and the real causes of workplace stress.

are facing unmanageable levels of workload and stress-related problems. We hear a lot about the use of mindfulness as a psychological therapy, of how it has come to be widespread in the NHS, as well as some concerns about its over-application and the challenges of quality control. This article from a very experienced mindfulness teacher working with NHS staff explores these questions, the realities of NHS staff stress and the limits of applied mindfulness in an overstretched system.

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Introduction ‘What can we do for you today?’ asks my GP. ‘I’ve been getting headaches’, I venture. My GP starts to look at the screen in front of her. Although this GP doesn’t seem to remember me each time I show up in her surgery, I like her: she gives her patients additional time and seems to genuinely want to help. She takes my blood pressure; she asks me about my job and we talk about the stress of working in the NHS as we generally do when I see her. She sympathises with the workload until she hears how many hours a week I work, which is apparently paltry compared to how many she works. She tells me she can’t keep up this pressure much longer. ‘You’re a clinical psychologist aren’t you?’ ‘Yes.’ I reply. Back to the screen. ‘Are you depressed?’ she asks. ‘No, I don’t think so.’ ‘But you are anxious’ she returns. ‘Maybe Amitriptyline would help.’ ‘Fill these out.’

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She gives me the PHQ-9 and GAD-7 – forms which I give to some of my patients. I know the forms well so scan them and recognise I would fall well below clinical levels on both. ‘I really don’t think...’ I begin. ‘Have you read this?’ she asks triumphantly. She thumps down a well-turned copy of Don’t sweat the small stuff by Richard Carlson on the space between us. ‘Read some of it now’, she gestures, pointing to the book and returning to the screen. ‘Go on.’ I tell her that she gave this to me to read last time I came to see her. While she looks at the screen, I flick past the chapter entitled ‘Let Others Be “Right” Most of the Time’ and settle on ‘Become more patient’ but realise I am too irritated to take anything in. ‘It’s a fantastic book,’ she says. ‘I recommend it to a lot of my patients.’ Pause. ‘How often do you actually stop and do nothing in a day?’ she picks up. ‘Well, I meditate every day.’ I reply. Actually, I teach mindfulness and stress management to staff.

ON THE FRONTLINE 1 Stress-reduction or stress-immersion? Mindfulness practice and the full catastrophe of working in the NHS

‘Mmm...sometimes those doing the teaching find it the hardest to put into practise’, she comments, looking away again. Another pause, more awkward this time. ‘Look up this website’, she says and gives me the paper freshly emerging from her printer. ‘It’s got some really useful techniques for managing stress. Come back and see me any time.’ I can’t imagine how any GP could have meaningfully responded to the systemic complexity of which my headaches were one symptom in seven or so minutes. After the GP, I saw a range of other clinical specialists about the headaches, many of whom told me work stress was a component and many of whom suggested having a lunch break and taking up mindfulness practice. Like many of my NHS colleagues, I realised I was stressed. According to a 2016 Guardian survey of NHS staff, 43% of NHS healthcare workers surveyed identified feeling unreasonably stressed at work ‘most’ or ‘all of the time’ (Johnson, 2016). The NHS has higher sickness absence rates than any other large public sector organisation, with 3.4% of worker hours lost to sickness in 2013 (ONS, 2014). Sickness absence costs the NHS £2.4 billion a year, accounting for around 2.5% of the entire NHS budget (NHS England, 2015). NHS Employers (2016) estimates 30% of this sickness time is caused by stress. And the response from managers and clinicians who want to help, but who do not want to focus on the totally inadequate resources available to do the job, can feel like a message of individual responsibility. If only I could learn not to sweat the small stuff, and do a bit more mindfulness, I’d be well on my way.

Individuals and organisations This potentially pernicious locating of the problem in the individual appeals to us healthcare professionals. Doctors, who are trained to have an aversion to not knowing or not being able to fix, can keep treating an individual who offers the promise of being categorisable and fixable. Psychological therapists, who often rely on the idea that individuals contribute to the patterns that cause distress, can continue to ‘help’ individuals to think or act differently. Managers, who tend to dislike pessimistic critiques of services for which they are responsible, can isolate rotten apples rather than consider the rather hopeless-sounding prospect of rotten barrels or rotten barrel-makers. Even we as NHS staff may buy into the notion that it is about us because we mostly do not like to be perceived as ‘weak’, and tend to think it is down to us to cope better and to keep soldiering on. Much more credit is given to individuals who are seen to be ‘getting on with it’ than ‘moaning about the system’. As long as we are not on our knees, we can avoid feeling powerless if the powerlessness is located in the individual and we mobilise to ‘empower’ her. However, staff in the 2016 Guardian survey of NHS workers (Johnson, 2016) did not identify a lack of

individual qualities, such as mindfulness or resilience, as the problem. They cited increasing workloads, cuts to the health service, unreasonable expectations and long working hours as causes of their stress. We are currently in the midst of the biggest sustained fall in NHS spending in any period since 1951. Once adjusted for inflation that is specific to the NHS, the real increase in funding is just 0.2% per year – well below the 3.7% growth rate that the UK health service has been used to in the past (RCP, 2016). Mental health trusts have seen a £150 million reduction in funding over the last four years (Today, 2017). At the same time that NHS funding is getting tighter, demand for NHS services and costs for new medical treatments are increasing, and other cutbacks that impact the NHS have been deepening – for example a £4.6 billion reduction in local authority social care budgets since 2011 (a net budget cut of 31%) (Butler, 2016). The Red Cross recently described the NHS as facing a ‘humanitarian crisis’ (Campbell et al, 2017). According to Chris Hopson, NHS Provider’s Chief Executive, ‘the NHS is increasingly failing to do the job it wants to do and the public needs it to do, through no fault of its own’ (cited by Campbell, 2016). The NHS is an increasingly unworkable system that relies on the goodwill of staff who accept overwork as the price to pay for survival, and that is innately stressful.

Fixing with compassion, resilience and mindfulness In a post-Francis culture, we hear repeatedly about the need for NHS staff to be caring and compassionate (eg DH and NHS Commissioning Board, 2012). More recently, this has broadened to include the need for staff to be ‘resilient’ as well as compassionate (eg NHS England, 2017). Often mindfulness is cited as one of the tools that would help to support greater individual compassion and/or resilience or simply be another ‘skill’ that could in itself help manage staff stress (eg NHS England, 2014). Indeed, there is robust evidence that mindfulness can have positive effects on staff stress and self-compassion in the workplace (Good, 2015). The Mindful Nation report (MAPPG, 2015) produced by the All Party Parliamentary Group on Mindfulness summarised the research that ‘suggests that employees…in a range of other settings who practise mindfulness have less emotional exhaustion, better work-life balance and better job performance ratings.’ Sussex Partnership is an example of an NHS Trust that has embraced mindfulness, with two mindfulness trainings, 5–10 staff mindfulness groups a year, 40 trained mindfulness teachers in different clinical services and a comprehensive programme of mindfulness research. It is clear this mindfulness-based work is making a real positive difference to people’s lives. One well received innovation has been a new session that mindfulness teachers deliver as part of our induction day for all new staff called ‘Taking care of ourselves and each other’. The first time I delivered the session, I enthusiastically and naively invited the staff

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group to suggest ways they managed stress. An already irate new manager quickly told me where I could put my ‘compassion’. He told me that rather than mindfulness and compassion practices, what he needed was for his manager to stop giving him unfeasible amounts of work to do and employ more staff. He could take all the lunch breaks in the world, but after each lunch break, there would simply be an additional hour of work that he would then have to do at home that evening or early before his colleagues arrived the next morning. Therefore, his no doubt calming lunch break, infused with a delightful mindful breathing space, was simply storing up more work for him to do at times when his family would have preferred he was giving them his full attention. I was stumped. I could only agree with him. And on every subsequent occasion when I led that session, I made sure I began by saying that stress was endemic to the NHS and that although some mindfulness practices may make a helpful difference, as indeed they do for me, they were akin to making a boat to help survive the ocean of stress, and would by no means remove the ocean or necessarily get you to dry land. I now make sure to emphasise that if, despite their best efforts at taking care of themselves, using mindfulness or any other approach, they found themselves regularly drenched by this ocean, that it wasn’t their fault. That seemed to me the most honest and compassionate thing I could say. The Mindful Nation report (MAPPG, 2015) states that: While it seems that mindfulness can offer real benefits for reducing stress and absenteeism, it is important to emphasise that as an isolated intervention it cannot fix dysfunctional organisations. Mindfulness will only realise its full potential when it is part of a well-designed organisational culture which takes employee wellbeing seriously.

A deeper look at mindfulness practice beyond stress management NHS England (2014) recommends developing ‘the habit of daily mindfulness practices’. I think this is good advice. Developing simple ways of becoming more present can improve our quality of life and reduce stress. However, my own experience of working long-term in the NHS has been that doing these kinds of brief mindfulness exercises, while making a helpful difference to my physiology and reactivity in the moment, simply don’t remove the general sense of overwhelm and stress that comes from working under such unrelenting pressure. This is despite having had a longstanding personal meditation practice which I would consider to have been life-transforming. I do not think this indicates a failure on my part, or a failure on the part of the practice. In my view, any possible sense of failure comes from the mistaken notions that (a) the individual should be able to fix it, which I have responded

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to above and (b) that mindfulness is purely a stressreduction technique – which I would like to address in the remainder of this paper. Although it is now often used as such, stress management is a diversion from the way mindfulness is used as part of path within a Buddhist practice. In the moment of overwhelm and stress, rather than applying mindfulness like a cream to remove stress, the invitation can be to open-heartedly embrace the whole of our experience of life as it is, and work with our tendency to shut down around a huge swathe of our experience that we feel is unwanted. Pema Chodron (1991, p3) wrote that: The point is not to try and change ourselves. Meditation practice isn’t about trying to throw ourselves away and become something better. It’s about befriending who we are already. The ground of practice is you or me or whoever we are right now, just as we are. That’s the ground, that’s what we study, that’s what we come to know with tremendous curiosity and interest. Mindfulness is often presented as something that calms us and centres us. But the deeper meaning of mindfulness is to be present with what is, to come up close to all of what we are experiencing and to hold it with curiosity, patience, kindness and discernment. Given the conditions of many of our working lives, then what is present are the sensations of speed and stress and ‘the central question… is not how we avoid uncertainty and fear but how we relate to discomfort’ (Chodron, 2001, p6). This suggests mindfulness is really about stress immersion, not stress reduction. Rather than aiming to keep our minds protected from stress in our usual neurotic, fear-driven way that seeks always to secure ourselves on safe, comfortable and pleasant dry land, maybe NHS stress can be an invitation to allow others to infringe on our space, to affect and touch us, and so to become more connected. The Tibetan Buddhist practice of Tong Len (Tsoknyi, 2012, p66–68) invites us to breathe in the suffering of others and breathe out what we have that may benefit them. In this way we actively take in stress and offer out stress relief, using this to work on our own obsession with increasing our pleasure and reducing our pain. In so doing, we potentially and paradoxically reduce our own suffering which is seen as having its root in our own selfpreoccupation. If, by contrast, we use mindfulness to try and feel less stressed in the face of overwhelm, then we are simply trying to get somewhere other than where we are in that moment, which is the opposite of mindfulness. As Eckhart Tolle (2001) says, ‘stress is caused by being “here” but wanting to be “there”‘. If you find yourself on a helterskelter, you might as well scream and be in the ride rather than wish all the time it would stop and you could get off when you can’t. Jon Kabat-Zinn (1990, p171) makes this point:

ON THE FRONTLINE 1 Stress-reduction or stress-immersion? Mindfulness practice and the full catastrophe of working in the NHS

It (mindfulness) is not a set of techniques for healing. Healing comes out of the practice itself when it is engaged in as a way of being. Meditation is much less likely to be healing if you are using it as a way of getting somewhere, even to wholeness. From this perspective, you already are whole, so what is the point of trying to become what you already are? When we lead Saturday mindfulness day retreats as part of the eight-week mindfulness-based cognitive therapy courses for patients and staff in our trust, we sometimes include an exercise called crazy walking. This is a take on the more traditional practice of mindful walking in which you walk often extremely slowly without trying to get anywhere but to simply be aware of sensations in the feet or in the body as a whole. The slowness makes it easier to really notice the plethora of minute movements needed to take a single step. Extremely useful as this practice can be, it may give the impression that what we should be doing in our daily life is slowing everything down to such an extent that we can notice, and to some extent control, the detail of our experience. Crazy walking, by contrast, invites the participant to walk fast, often in a crowded room of others also walking fast, as if trying to meet a deadline or catch a departing bus. The challenge then is to bring mindfulness to the experience of speed, stress and disturbance. This exercise, by contrast, emphasises that mindfulness is not about getting to a calm place somewhere other than where we currently are but to learn to be with what we have, which is often uncontrollable. We see how our mind craves to be in control, to fix, to manage, to try and make the world the way we want it to be – which is an endless task that Buddhists call ‘samsara’. Through the repeated noticing of this tendency to want things to be different from how they are, we can start to allow a larger space that can hold the myriad pleasant and unpleasant experiences.

Mindfulness as the path to equanimity and compassion Equanimity What may start to arise in the development of this larger space is the fourth of the Buddhist ‘immeasurables’ – equanimity. This is the aspect of mindfulness that is willing to be with the whole of our experience. Joseph Goldstein (2013, p280) describes it as follows: For most of us, there is a deep conditioning in the mind to try and hold onto what is pleasant and push away what is unpleasant. But it is precisely this conditioning that powers the rollercoaster of hope and fear...conditions are always changing and often out of our control. We don’t have to live defensively in the fear of the unexpected if we accept that anything can happen anytime.

It is equanimity that stops us falling into reactive patterns of trying to hold onto what we like and pushing away what we don’t like, fuelling the oscillating anxiety of hope and fear. If we are able to develop equanimity to be with stress, we may be able to understand it and to tolerate it as an inevitable aspect of the human condition, especially the human condition in the current NHS. This is not an equanimity that is equivalent to asking people to grin and bear it. Although there can be a strength to endurance, a ‘gritting your teeth and getting on with it’ type of stoicism feels tight in the body and is still resisting the experience, holding on for it to get better, so very much still driven by hope and fear. Equanimity in a Buddhist context arises within a worldview that understands the inevitability of suffering together with pleasure, and the limitations on our ability as frail humans to change a lot of it. This acceptance can lead to some sense of humility and gentleness as we become open and receptive to our own vulnerability and that of others around us. The connection with our vulnerability helps us to do what we can to respond helpfully but also to know our limitations: in the Buddhist tradition, compassion is balanced with wisdom and both wings are needed to fly. The opposite extreme of this would be a hubristic and illusory sense of mastery which produces a striving, impatient, self-preoccupied busyness and an intolerance to ourselves and to those around us who cannot keep up – which could be another description of stress.

Compassion This is therefore not an indifferent equanimity. It is an equanimity that can be the centred base from which we can respond compassionately. Our immersion into stress can enable us to connect with the similar experiences of our colleagues, patients and people in general. A mindfulness that can be with our own stress with the intention of knowing deeply the experience that others all around us are having can help build a powerful intention to use our experience to be of benefit not just to ourselves but to our colleagues, patients and the wider community, an intention that is part of what is called ‘relative bodhicitta’ in the Tibetan Buddhist tradition. It is bodhicitta that is at the heart of our own liberation from suffering. The image used for bodhicitta is the lotus flower which has its roots in the mud. The mud is where it gets the nutrients that generate its beauty. The NHS workplace is a context in which the values that still inspire many NHS staff – care and compassion for the distressed regardless of ability to pay – are played out on a daily basis. It is these values that make some sort of sense of the stress that the work causes. This is one of the reasons why convoluted bureaucratic processes, focus on targets and ‘performance’, and ‘restructuring’ that is heedless of networks of working relationships, jar with many NHS staff and often undermine the motivation for doing the work. It is the motivation which is the most important component of the true resilience that enables us to connect to what matters,

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and which thereby repeatedly makes sense of what we do and keeps us human. Mindfulness based stress immersion would not be an easy sell to commissioners and managers who want to know what concrete outcomes they will get from interventions, or to individual staff, who understandably simply want to feel better, just as I did when I went to see my GP. Stress immersion may even be criticised as the high road to burnout in some staff who are already overloaded and desperately need a break. And there is no doubt that finding ways to rest, and to deepen our connection with ourselves are very important. However, research is also showing that it is not compassion that fatigues, and that burnout is actually more linked to ‘empathy fatigue’ than ‘compassion fatigue’. While repeated empathic resonance with others’ pain can lead to empathic distress and emotional exhaustion, compassion, which includes the desire to dispel suffering, not just feel it, strengthens balance and motivation, and helps overcome empathic distress (Ricard, 2013).

Acknowledgements Many thanks to my deeply supportive colleagues and managers at Sussex Partnership, and to Professor Peters, Sarah Marx, James Low, Ed Halliwell, Paul Johanson, Hester O Connor, Damian White, Debbie de Wet, Peter Rock and Taravajra for their helpful comments on earlier drafts of this paper. Butler P (2016) Vulnerable adults at risk as councils face £1bn social care shortfall. The Guardian, 13 July. Available at: www.theguardian.com/ society/2016/jul/13/vulnerable-adult-social-care-risk-england-councilsface-1bn-shortfall (accessed 7 August 2017). Campbell D (2016) NHS chiefs warn that hospitals in England are on the brink of collapse. The Guardian, 11 September. Available at: www.theguardian.com/society/2016/sep/10/hospitals-on-brink-ofcollapse-say-health-chiefs (accessed 11 August 2017). Campbell D, Morris S, Marsh S (2017) NHS faces ‘humanitarian crisis’ as demand rises, British Red Cross warns. The Guardian, 6 January. Available at: www.theguardian.com/society/2017/jan/06/nhs-faceshumanitarian-crisis-rising-demand-british-red-cross (accessed 7 August 2017). Chodron P (2001) The places that scare you. Boston: Shambhala. Chodron P (1991). The wisdom of no escape. Boston: Shambhala.

Conclusion Pressure, demand, and the stress that results from them, has reached unmanageable proportions for many in the NHS. Well-intentioned managers with very limited resources want to support their staff but there are no quick fixes. We rightly seek to help individuals be more mindful, compassionate or resilient but can be reluctant to acknowledge that massive resource limitations that are beyond our power to control cast a dark shadow over individual wellbeing, and will continue to do so until NHS services are properly resourced. We can’t halt a tsunami by learning not to sweat the small stuff. This is not a manifesto of passive resignation. As individuals, we can do something. Mindfulness-based interventions are indisputably effective for many individuals in reducing stress in real and significant ways; for some individuals, they are life-changing. But we all have limits and the serenity prayer (Sifton, 2011, p7) shows us that we need to enquire into what we can do and what we can’t, to explore the line where acceptance starts to constrict and damage us rather than open or teach us, and this can be a fruitful focus of mindfulness practice. Mindfulness can sometimes result in staff realising that what we are participating in through our work is so irremediably harmful to ourselves that we must give it up. But it can also help us to actively keep choosing this stressful work, holding it within a larger experiential and philosophical perspective that allows us to grow and to strengthen the meaning and value orientation of our lives. This full immersion invites the heartfelt embodiment of service and compassion, balanced with an understanding and acceptance of suffering and the limitations on our ability to remove it.

Department of Health and NHS Commissioning Board (2012). Compassion in practice. Nursing, midwifery and care staff our vision and strategy. London: The Stationery Office. Goldstein J (2013) Mindfulness: a practical guide to awakening. Boulder: Sounds True. Good DJ. Liddy CJ, Glomb TM, Bono JE (2015) Contemplating mindfulness at work: an integrative review. Journal of Management 20(10): 1– 29. DOI: 10.1177/0149206315617003 Johnson S (2016) I worry about the long days….I’m so scared of making a mistake.’ The Guardian, 12 February. Kabat-Zinn J (1990) Full catastrophe living: using the wisdom of your body and mind to face stress, pain and illness. New York: Delta. Mindfulness All Party Parliamentary Group (2015) The Mindful Nation Report. London: The Mindfulness Initiative. NHS Employers (2016) Stress management. Available at: www.nhsemployers.org/~/media/Employers/Publications/ Stress%20management.pdf (accessed 7 August 2017). NHS England (2017) Ten high impact actions. Available at: www.england.nhs.uk/wp-content/uploads/2016/03/releas-capcty-6topic-sht-6-2.pdf (accessed 7 August 2017). NHS England (2015) Simon Stevens announces major drive to improve health in NHS workplace. from Available at: www.england.nhs.uk/2015/09/nhs-workplace (accessed 7 August 2017). NHS England (2014) Building and strengthening leadership: leading with compassion. Available at: www.england.nhs.uk/wp-content/ uploads/2014/12/london-nursing-accessible.pdf (accessed 7 August 2017). NHS England (2014) Building and strengthening leadership: leading with compassion. London: The Stationery Office. Office for National Statistics (ONS) (2014) Full report: Sickness absence in the labour market. London: ONS. Ricard M (2013) Empathy fatigue. Available at: www.matthieuricard.org/ en/blog/posts/empathy-fatigue-1 on 11th January 2017 (accessed 7 August 2017). Royal College of Physicians (2016) Underfunded, underdoctored, overstretched: the NHS in 2016. Available at: www.rcplondon.ac.uk/ guidelines-policy/underfunded-underdoctored-overstretched-nhs-2016 (accessed 7 August 2017). Sifton E (2011) The serenity prayer: faith and politics in times of peace and war. London: Norton. Tolle E (2001) The power of now. London: Hodder & Stoughton. Tsoknyi Rinpoche (2012) Open heart, open mind. London: Rider.

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ON THE FRONTLINE 2

How to help Harry Friend or foe? The scientific and the scientistic in the fog of the frontline David Zigmond

How to Help Harry is a true but disguised

I did my basic medical training in the 1960s. Early on I realised that although systematised biomechanical expertise was cardinal to medical practice, it was far from sufficient. This insufficiency largely motivated my subsequent professional decades: I trained and worked in general practice, psychiatry and psychotherapy. My enduring mission has been to define and tend our better balance between otherwise divergent schemata and human sense. Writing and teaching have helped me explore, crystallise and propagate.

description from the frontline of general practice. It depicts the difficult human hinterland that typically lies behind problems we try to speedily despatch with ever-more schemes, algorithms and financial inducements. This tale is – to my mind – a good illustration of how our current type of NHS ‘progress’ has yielded much better technology, but often at the price of our overmanaged emotional illiteracy. Harry’s predicament and response may also be said to be archetypically ‘male’ in our current culture – another opening for speculation.

Standardisation of medical services – increasingly by electronic monitoring, mediation and management – has become equated with ‘best practice’. This seems to offer undeniable practical benefits: clarity, uniformity, reliability and ease of transmission. But does anything get lost? If so, what? how? why? This short exploration draws from authentic situations in primary care: a ‘heartsink patient’, and a problematic professional meeting. Usual conventions of disguise assure discretion. We all want to be healthy. No one wants an unhealthy existence. And the job of government is to help people live healthier lives. Andrew Lansley MP, Secretary of State for Health, 23 January 2012

When you have duly arranged your ‘facts’ in logical order, lo, it is like an oil lamp that you have made, filled and trimmed, but which sheds no light unless you first light it. Saint-Exupéry, The Wisdom of the Sands (1948)

Dr Q inhales Harry’s fatalism involuntarily. It is not just the lingering and residual odours of his staple props – his nicotine and alcohol – but his anguish-laden physiology. This continues to signal Harry’s troubles,

both despite, and because of, his almost unceasing attempts to chemically banish, or at least quell, his morbidly echoing memories, his shame-leeched self-prophecies. Dr Q has come to surmise that such trapped and stultified internal worlds emanate particular kinds of energies and odours: that the physical experience becomes encoded, then signalled – in our sweat, our breath and in myriad thermal and electromagnetic transmissions we are usually unconscious of. He remembers an old designation connoting something similar: the ‘heartsink patient’. Dr Q has learned to be stoic and philosophical: he can look forward to enlivening counterpoint – very different people who energise the room with an aura of faith, trust and optimism. Reflecting on this, he now recalls conversations a couple of decades ago, when there was much talk of personal ‘vibes’: he never explored what scientific research has been done in this area, but his daily experience reminds him with recurring and fresh evidence of its power and centrality. * Harry’s fatalism can be perceived more consciously, too: his trudging gait, the downcast gaze avoidant of the new or the personal, the sagging voice that has not the resolve to complete its message, his clothes and

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ON THE FRONTLINE 2 How to help Harry: Friend or foe? The scientific and the scientistic in the fog of the frontline

hair – clean enough – but habitually tousled, drab and dank. Dr Q has known Harry 15 years, and has witnessed and gleaned the story of Harry’s cumulative desolation. In recent times Harry’s already impoverished self-confidence was dealt a series of grievous blows: a marriage floundering from his difficulties of expression and extension, then foundering on their (his) infertility and poor employment prospects, then finally torpedoed by his wife’s break-out: an affair with an ‘old friend’ – a confident, successful and expansive man whose attractiveness and fertility was soon evidenced by the pregnancy of Harry’s future ex-wife. In earlier times Harry conveyed to Dr Q descriptions and tales from his childhood. Of a father distant, fractious, discontent, hostile and critical. Of a mother softer, but lost in an ocean of melancholy. Her only child, she confided in him when he was old enough to ‘understand’. Of the unhappy basis of her marital bond: the accidental conception of Harry in an untried relationship, ten years earlier. Of her attempts to conjure love through their Christian faith; through another conception soon after Harry – an obstetric disaster which cost mother her newborn, her womb and her future fertility. Harry’s childhood was spent trying to appease, comfort, compensate or placate those who gave him life. He could neither understand nor succeed. Dr Q intuited something of this massive disseminated damage on their first encounter; later meetings confirmed and detailed. Dr Q’s fuller portrait and biography of Harry grew slowly: piecemeal and opportunistically, for Dr Q was always careful not to encourage disclosure more than Harry could bear. Harry developed a reticent and shy trust: Dr Q sensed a flickering, bruised warmth. Dr Q enlisted support. Psychiatrists at the times of Harry’s greatest incapacity, counsellors when he could motivate himself a little more. Harry complied and they provided, at least, periodic containment for Harry and supportive respite for Dr Q. But Harry is a man of few words and little appetite for schematic enquiry: he did not respond to formal attempts at psychotherapy. His desolate view of himself and his world remains undiminished. * Harry does, however, entrust very limited aspects of himself to others. Now in his early middle-years, he has complied with his GP’s practice screening programme. His blood lipids, checked for the first time, are found to be high. Dr Q remembers, too, Harry’s response to the doctor’s gentle enquiry regarding his feelings six months ago: Harry’s father had just died suddenly of a heart attack. Harry had shrugged with a kind of glum defeat: ‘he was never much of a father to me … now he’s not here at all…’. Dr Q was then mindful, not just of Harry’s stunted grief, but of the portents, for Harry, for such a death. His emotional tangle of recent-upon-ancient frustrations and hurts, increasingly swallowed down with self-anaesthetising doses of booze, fags and factory foods augured badly. Now

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with father’s sudden death these portents seemed clearer still: a sharpening prophecy. The practice receptionist’s request for Harry to see Dr Q about his lipids was a standard procedure: ‘to identify, discuss and take action regarding remediable risk factors’. At the end of the last meeting, in the fresh shadow of his father’s death, Dr Q had raised those specific concerns, again. The themes were old: the clarity was new. Harry responded with a rare vein of articulation, caustic and taut: ‘I know your job is about saving lives, doctor, and I’m grateful for your kindness with me, but I’m not sure I have the kind of life that’s worth saving … We can’t all choose our lives and we’ve all got to die some time’. This quiet, courteous coda was undramatic in delivery, but arrestingly bleak in meaning. Dr Q had time only to express benign intent and tell Harry the bridge is always open. * Six months later, as the door opens, Dr Q knows it is Harry, booked in to discuss his lipids. These excess lipids may be the designated problem, but they represent the mere biochemical tip of a vast psycho-spiritual iceberg. Dr Q holds his breath momentarily; he braces himself as he thinks: ‘How to help Harry?’. * Stella has many similar meetings to address: her working days and diary are full. She has a friendly but business-like, diplomatic manner. This is reflected in her attire: trim knee-length navy skirt, cream blouse, discrete pearl earrings – a kind of uniform, smart but not alluring. Dr Q notices she is wearing her NHS Trust ID card around her neck, an emblem not just of how busy she is, but who controls her. This is a managed excursion. Stella, though not herself medically trained, is the emissary of an expert group concerned with reducing cardiovascular disease. This committee has devised strategies and procedures which will be enacted by all relevant health practitioners. Stella’s job is to brief and instruct the practitioners: to assure professional compliance for The Plan. Such compliance relieves practitioners of individual judgement and discrimination: The Plan prescribes and directs. Invisible experts decide. Dr Q is sitting amidst his peers, local GPs. Stella is explaining the latest addition to The Plan. A new computer programme is being introduced. The practitioners will feed in the relevant clinical data, and the computer will calculate the statistical chance of morbidity and mortality. This ‘scientific’ prediction is then shared with the patient for discussion and action. The GPs will receive an extra payment for compliance: Dr Q notices the galvanising ripple of interest and attention. Dr Q recently attended his own GP and received the kind of consultation that The Plan spawns. Dr Y was young, brisk, authoritative. Her attention was rapt to the computer screen, where she quickly garnered and collated

ON THE FRONTLINE 2 How to help Harry: Friend or foe? The scientific and the scientistic in the fog of the frontline

abstracted data. The computer prophesised favourably for Dr Q’s fate. Dr Y spoke for The Oracle, as she turned from the computer screen towards him: ‘That’s not too bad, not too bad at all…’. She illustrated her prognostic cheeriness with some itemised statistics. Her smile seemed winsome, but Dr Q wondered who the smile was for: he was doubtful how much she had really perceived him. There had been little real discussion. Beyond medical questions, she enquired little. Dr Q did not introduce himself as a fellow GP: his curiosity was then roused, to see what a ‘standard’ consultation was like. Was the smile another impersonal, though decorative, generic procedure? What is a smile to someone unseen? Dr Q is thinking about Stella’s financially-enhanced instructions, his own experience with Dr Y and how these would be templated with Harry. As he understands this, he is being paid to prime the computer, which then primes him to then say to Harry something like: ‘Harry, we have fed all your available personal and family health and lifestyle data into the computer programme. Your computed five-year risk for combined cardio/cerebrovascular events is 38.73%. This comprises a 14.71% mortality group, leaving another 24.02% with significant morbidity events. For your age group, this is very high risk … We can provide you with category subgroup differential analyses, if you wish …’ Dr Q is wondering how such formulaic and statisticised thinking or communication can possibly further help Harry, or many others that Dr Q sees. Dr Q’s monitoring and conversations, for many years, have approached the complex issues of self-protection and self-care, but in a form and language that are personal and vernacular – not those predicated by the technical: tethered to the computer, or decided by distant expert committees. Dr Q puts such notions to Stella. He adds that he has long-regarded what, when and how to share with each person, in each situation, as a delicate, complex but fundamental skill in medical practice. A good example of what anchors holistic medicine as an interpersonal art, a humanity. Stella listens politely, nodding periodically, looking tired. Dr Q imagines her nodding represents fatigued diplomacy, rather than engaged understanding. She reiterates how the computer programme has been designed by a team of experts, and it behoves us to follow their lead. In addition, conveying quantitative information to patients, in a way that can itself be quantified, confers

clear advantages to the management of practitioners, in their management of patients. ‘I think you’ll agree, doctor, it will make your treatment of these patients more scientific, and that has to be good for all of us…’ Dr Q thinks Stella is proposing this – especially her emphasised word ‘scientific’ – as an ineluctable summary. But Dr Q has many doubts and caveats. How to engage and interest another person in changing deeply established psychological patterns regarding their relationship to themselves, their body and their fate is often not a simple matter of data, formulation and instruction. Such complexity requires thoughtful investment in interpersonal interest, contact and understanding: activities far less accessible to quantification and science. Will not The Plan eclipse these subtle but important endeavours? Yet Stella’s declamation on the uncontentious blessings of anything that appears scientific represents a wider, currently thriving, kind of hypnotic rhetoric – a cultural ideology. The presentation of an apparent vocabulary and syntax of science becomes more important than its meaning for the participants. Appearing scientific becomes an end in itself, a new kind of Shibboleth. Science as a posture, a garment, a cultural or status commodity becomes scientism. Dr Q attempts to courteously and concisely condense this for Stella, but she is now more restive than receptive. ‘Look’, she says, ‘you don’t have to think about all that, because you’ll be paid for it’: a tired teacher attempting to control the end of a difficult class. Another doctor, Dr S, turns to Dr Q, looks at his watch impatiently and offers Stella tetchy support: ‘Yes, I can’t see what all this is about. What won’t you understand?! You’re getting paid for it!’ Dr Q thinks he does understand, very well. But he remembers different kinds of meetings, 20 years ago, where they had very different kinds of discourse. He found these much more valuable. He would like to talk with them now about how to help Harry. * Information is pretty thin stuff, unless mixed with experience. Clarence Day, The Crow’s Nest (1921)

Interested? Many articles exploring similar themes are available via http://davidzigmond.org.uk.

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Suicide in the city

William House Retired GP; Chair of the BHMA

Suicide is a catastrophe. Perhaps this is even more so when it is totally unexpected and concerns a young person. Such is often the case in suicide among City financial institutions, especially investment banking. There tends to be public disbelief that an intelligent, well educated and ‘successful’, young man could take his own life. The method of suicide is often dramatic and City banking is currently a high profile occupation in the UK, so the pain of the bereaved is intensified by the wide publicity that usually attends the tragedy. Between 2007 and 2014 an average of 33 people working in the finance industry in England and Wales committed suicide each year.. Most (85%) were male, and most will have been working in the City of London. In a moving interview for the excellent website, Ecnmy, Jo Earle speaks with young City trader, Clark, about what his job is like. Being new to the industry he could cast the fresh eye of the novice on his experience of the culture. Banking is full of incredibly hungry and ambitious people who drive themselves to succeed… The culture is short term … and you can get fired very quickly. The Office for National Statistics (ONS) has analysed jobrelated features that carry a high risk of suicide in England and Wales. One of these is low pay and low job security. Low pay obviously does not generally apply to bankers. However, as the quotations above and below suggest, job insecurity is very much a feature of being a City trader. You’ll get supported as long as you are worth supporting … it’s a cutthroat environment. So the values of young traders are being tested in the high-pressure intensively competitive environment. They look around them to see what seems to be the norm, but this norm can shift almost imperceptibly. Several of the stories behind suicides involve a possible transgression and fear of being ‘hung out to dry’. Clark was able to compare this with his previous job.

Citi City by Poppy James

In my old job, I was getting finance for a wind turbine and other important, tangible projects. In trading, now my work is much more focused towards other banks and more abstract things…. Before I had to work longer for less money. Still, at least I’d be able to have something I could tell my kids about. The above is about values and this draws us all into the moral and existential dilemmas of this young City trader. During the interview he describes the overwhelmingly male dominance on trading floors and links this with the male competitive ethos. Men outnumber women throughout the financial services industry except perhaps in the lowest grades. Given that many more men than women in Britain take their own life (76% of suicides in Great Britain in 2016) a stressful industry that allows men to dominate to this extent is at best unwise. it seems likely that the pervasive male ethos is seriously unhealthy for those working within it. In Clark’s words again – said with regret: It’s not emotional; it’s a very rational culture… It seems to me that sectors of the financial services industry are a tragic caricature of our contemporary monetised society, where motivation comes not so much from intrinsic values but from the cut,throat competition described by Clark. Such extrinsic motivation becomes a recipe for mental and physical ill-health. Where is generosity of spirit and humility? What could matter more than these intrinsic values? The answer is in the phrase that characterised Bill Clinton’s successful election campaign in 1992: ‘It’s the economy, stupid!’ If you have been affected by this article these organisations are there to help: Samaritans: tel. 08457 90 90 90 or www.samaritans.org CALM: tel. 0800 585858 or www.thecalmzone.net U Can Cope www.connectingwithpeople.org/ucancope A video to give hope for those feeling low or suicidal Useful links for male suicide: Men’s Health Forum: www.menshealthforum.org.uk/suicide

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

Brain lymphatics discovered A recent piece of research from the USA’s National Cancer Institute has discovered lymphatic vessels in the dura, the tough outer covering of the brain. Before this we had no evidence of a lymphatic system in the brain. Although it has long been known how fluid enters the brain, it wasn't formerly known that brain fluid can drain out through the lymphatic system as it does from other organs in the body. If as seems likely, brain lymphatics are a pipeline between the brain and the immune system, we will need to rethink relations between the brain and immune system. Might further research even throw light on cranial osteopathy’s fundamental premise that rhythms in the brain’s fluid circulation are fundamental to health? Absinta M et al (2017). Human and non-human primate meninges harbor lymphatic vessels that can be visualized noninvasively by MRI. eLife, DOI: 10.7554/eLife.29738

Even moderate alcohol consumption is bad for the brain A team of researchers at Oxford and UCL confirmed that even moderate drinking affects brain function long term. They used data on weekly alcohol intake and the accumulating data from 30 years of brain function testing on 550 healthy men and women in the Whitehall II study, which is evaluating the impact of social and economic influence on the long-term health of about 10,000 British adults. Participants average age was 43 at the start of the study and none were alcohol dependent. At the end of the study participants underwent an MRI brain scan. These results support the recent reduction in alcohol guidance in the UK. Topiwala A et al (2017) Moderate alcohol consumption as risk factor for adverse brain outcomes and cognitive decline: Longitudinal cohort study. BMJ 357

Zinc supplements for PMS 142 women (age 20 to 35 years) with PMS were allocated to receive either ZS 220mg capsules (containing 50 mg elemental zinc) or placebo. Data from the Premenstrual Symptoms Screening Tool (PSST) and 12-item Short-Form Health Survey Questionnaire was collected. The ZS group recorded significantly less PMS throughout the study period compared with the control group, but differences in quality of life scores were seen only three months after the intervention. Zinc sulfate, appears to be a simple and inexpensive treatment, associated with improvement of PMS symptoms and health-related QoL. Siahbazi S et al (2017) Effect of zinc sulfate supplementation on premenstrual syndrome and health-related quality of life: Clinical randomized controlled trial. J Obstet Gynaecol Res. 43(5. doi: 10.1111/jog.13299.

Why is lifelong mental health so rare? Why is it that some people manage to escape all psychiatric illness? It is often quoted that one in five people will experience

mental illness in any given year: most commonly anxiety, depression, and substance abuse. The latest lifetime figure is even more startling and suggests that mental illness may be the rule rather than the exception. Researchers examined data from the Dunedin cohort, which follows a representative sample of New Zealanders from birth to midlife. They compared people without a diagnosable mental disorder at any point in their life (N = 171; only 17% prevalence) with those who had been diagnosed (N = 409). Surprisingly, the people with enduring mental health were not born into unusually well-to-do families, nor did their mental health correlate with particularly sound physical health, or unusually high intelligence. However, they tended to have an ‘advantageous temperament/ personality style’, and very little family history of mental disorder. As adults, they reported high levels of educational achievement, occupational attainment and life satisfaction, as well as higherquality relationships. These findings suggest that as yet unknown temperamental factors support enduring mental health. Schaefer JD et al (2017) Enduring mental health: Prevalence and prediction. J Abnorm Psychol 126(2). doi: 10.1037/abn0000232.

Jury is still out on probiotics for mental health By 2020, the worldwide market for probiotics is projected to be almost $100 billion. Some studies have suggested that probiotics can help in obesity, functional gastrointestinal (GI) disorders, chronic fatigue syndrome and inflammatory illnesses. These disorders all have important central nervous system components, so the influence of dysbiosis. and the benefits of an optimised microbiome in depression, stress, anxiety and autism have all been proposed. We need a better understanding of the effects of the microbiome on the brain but actual research data are sparse. The authors of this review stress the need for comprehensive cross-disciplinary investigations to move ‘this exciting but challenging field forward in the next decade’. MacQueen G et al (2017). The gut microbiota and psychiatric illness. Journal of Psychiatry & Neuroscience 42(2). www.ncbi.nlm.nih.gov/pmc/articles/PMC5373703/

Chondroitin sulfate for knee osteoarthritis A rigorous three-arm randomised trial followed up 604 patients with knee osteoarthritis for six months. Both chondroitin sulfate and celecoxib showed a greater significant reduction in pain and stiffness than placebo. There was no difference observed between chondroitin sulfate and celecoxib. Both treatments demonstrated excellent safety profiles. The authors recommend that 800 mg/day pharmaceutical-grade chondroitin sulfate should be considered a first-line treatment in the medical management of knee OA. Reginster J-Y et al (2017) Pharmaceutical-grade chondroitin sulfate is as effective as celecoxib and superior to placebo in symptomatic knee osteoarthritis: The chondroitin versus celecoxib versus placebo trial (concept). Annals of the Rheumatic Diseases. http://ard.bmj.com/content/ early/2017/04/29/annrheumdis-2016-210860

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Reviews The economics of therapy: caring for clients, colleagues, commissioners and cash-flow in the creative arts therapies Edited by Daniel Thomas and Vicky Abad Jessica Kingsley Publishers, 2017 ISBN 978 1 84905 628 1 This book answers a need within arts therapies literature by focusing on how it is possible to be both an arts therapist and business person at the same time. I found this book very interesting to read as there were striking similarities between my own experience of being a drama therapist and running my own business. The book has 11 chapters written by different arts therapists looking at different aspects of arts therapies in relation to business. There a few themes which run through many of the chapters. Perhaps the most glaring is the experience of arts therapists whatever their modality – art, dance, drama, music – wherever they are in the world, having to first fight for creative therapies to be understood and recognised. The fight of coming up against blank stares as they try to make their way in the medical model world. In this way there is a clear need for more research to be conducted on the value both economically and clinically of this work. Interestingly, it is argued in many chapters that there are characteristic links between arts therapists and business leaders. The book also touches on the ethics of being a therapist and asking for money – how do we do this and is it fair to do so? It gives practical advice on starting up a business, how to gain funding and at the end of most chapters there are useful practical exercises that can help to shift thinking around business ideas, thoughts and feelings. It touches on the fact that there is a lack of business education in arts therapists training and this is something that is very much needed. A sentiment I fully agree with. The chapters are heavily weighted toward the experience of music therapists. While it would have been interesting to gain a wider view of the experience of different disciplines of arts therapies, it is clear to see the issues faced are very much the same for most arts therapists and the skills and advice given are transferable across modalities. The work includes experiences of arts therapists around the world and it is interesting to see how issues faced are similar in different countries. I would recommend this book to training arts therapists and practising arts therapists. However, the book’s usefulness is not limited to arts therapists as it would be useful reading for other practitioners wishing to build a business. The stand out chapters for me were those in which I got a real sense of the passion of the work, businesses and the authors. There is a sense of honesty and openness running through the book which is comforting and what would be expected as it is written by arts therapists. I have enjoyed

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reading it and have found some useful advice and plenty of food for thought for my own business. Christine Northey

Being ManKind Being ManKind, 2017 This fine-looking large format book of portraits and biographical sketches is a treasure chest of stories from positive male role models. Being MankKnd is much more than a book though; a social entreprise aiming ‘to inspire young boys and men to grow into kind and confident humans, who break gender stereotypes and strive for equality’. As world heavyweight boxing champion Anthony Joshua says in his foreword, ‘It’s easy to follow the crowd rather than make your own decisions. Be open, be honest, and be an individual thinker. We have the blueprints of those before us to build our own futures.’ This is community-building, culture-changing talk, for the project is primed to start young people thinking about this early. The role models in this book will inspire boys but the conversation will be broader than that, because ‘being human is complex, diverse and should never be constrained by gender stereotypes. It’s the only way we can aim for an equal society’. Projects such as this are rays of hope; real evidence that as the world gets more troubled, sparks of goodwill spring up to push back the gathering darkness. So I’m writing this more as a fan letter than as a review because I’m convinced that young men need positive role models. To that end Being ManKind has set up a website using some of the book’s stories, collected under the headings identity, loss, mental health, body image, adversity and growing pains. I hope they will add video clips to the current texts and expand the library as this valuable initiative grows, as I’m sure it will. Meanwhile the site invites visitors to share their own thoughts and experiences and respond to themes raised. The idea is to connect with the Being ManKind writers so they hear how they have influenced readers, and to encourage others to join the conversation. For every book bought, another will be sent free to a school or youth organisation. The ultimate goal is for donated books to be read by young people throughout the UK and to spark conversations around the important themes raised. Being ManKind is a model for getting a social movement going, a movement men, not just young men, desperately need to take part in. www.beingmankind.org/stories

Transformational innovation in health: a gathering of change-makers A one day joint working conference organised by Westminster Centre for Resilience, the Scientific and Medical Network and the BHMA The neatness of medical science is unravelling. 20th century medicine focused on smaller and smaller parts with astonishing success: triumphant in infections, deficiency diseases, with surgical excisions and transplants, intensive care and anaesthetics. But 21st century medicine is confronting whole person (indeed whole society) problems: chronic degenerative and inflammatory diseases, stress-, environment- and lifestyle-mediated diseases, addictions and psychological disorders. Bio-technical single-solution approaches wonâ&#x20AC;&#x2122;t cure them. If, as has been said, the future is already with us but unevenly distributed, where might we find seeds of the new paradigm? This working conference, jointly hosted by Westminster Centre for Resilience, the Scientific and Medical Network and the BHMA, will bring change-makers together to celebrate the future. David Reilly and Bill Sharpe will give the keynote addresses. Topics will include transforming community health, making space for staff renewal, healing and therapeutic transformation, change and the three horizons model, transforming the healthcare system, reconnecting with the wild, and changing attitudes to birth, death and dying. Booking at https://explore.scimednet.org/index.php/events/

Saturday 18 November 2017, University of Westminster, London

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) 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

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