It’s dissertation season again, and a student emails me:
Dear Practitioner, I am undertaking a research project into the transition from acute to chronic. The aim of the research is to understand how practitioners identify, manage and treat risk factors for chronic pain.
What an important issue, but one that is very badly understood. So I reply:
I tend not to answer these emails anymore, because undergraduate research places us in between two realities: the holistic healing reality of a living self-righting system always doing the best it can to survive under the circumstances; and the medico-research reality, where physiology is what just happens until pathology just happens at which stage the body’s natural compensatory mechanism is to get a prescription.
In other words, it becomes impossible to answer the questions truthfully and still convey the truth!
What may not help you now, but will save you many years of anguish later on, is if I tell you this:
Acute situations are the symptomatic expression of healing. Symptoms are the healing process, and in the patient experience they convey the information the patient needs. The pain/fatigue/nausea/whatever tells them what they need to do to have a chance to recover.
Chronicity is the result of suppression of the acute;
…or some other failure of the body to respond completely to an acute challenge. For instance, taking anti-inflammatories and going back to work, lowering of fever with drugs, and cracking of specific sore joints, all remove the natural healing or protective mechanism and allow the patient to keep going when nature is telling them to stop. They mask the problem and thus sabotage the natural responses as well as the actual healing process.
The other cause of chronicity is repeat or sustained stress, ie. maintaining factors. This becomes more possible if we palliate the patient, ie. treat the symptoms not the cause. They feel ok initially, so they have no reason to change their strategies in life. And so then they become dependent on therapy. Eventually the therapy stops working as the body adapts to cope with both the stress of life and the confusion of therapy. The cause of the problem hasn’t gone away, and so the body changes its structure and function around it instead, usually to create limitation. Chronicity is adaptation, and it comes with complete deniability for the practitioner (Just the ageing process mate! Go see a surgeon).
[Stress doesn’t always lead to disease. Some stresses do lead to strength, but they always depend on sufficient chance of recovery in order to do so. Athletes don’t get fitter while they are training, they get fitter while they are resting. If they hit the wall from overtraining they can be limited for a very long time afterwards.]
Chronicity resolves through acute episodes. For instance, a chronically inflamed wrist, knee, pancreas or whatever is continually attempting to repair itself – that is what inflammation is. But it is unable to finish the job for some reason or usually reasons. It is those reasons we must deal with. But the inflammation itself is the healing process, it has to happen or the patient will never get out of the mess. Do our job properly and it will be transient and not too unpleasant.
Likewise, fever, vomiting, diarrhoea, skin eruptions, fatigue etc. These are all ways for the body to sort out a problem. Nobody in their right mind would want to stop them if they need to happen. But they are all temporary, providing a) you don’t fight them and b) the body has its basic needs. The answer to fatigue is to sleep, with diarrhoea you sit on the toilet. You have to obey your symptoms, support the body, and then seek help for the underlying causes. Suppression achieves nothing. Making the patient comfortable without sowing the seeds of a worse problem later on means managing their symptoms not making them go away. We are not taught this in college. We certainly learn the role of these things, for instance everybody understands why drinking too much tequila leads to vomiting, and why the body needs to do that. And that the person who is so intoxicated they cannot vomit is actually in much worse trouble. But translating these broader principles of healing into practice in the teaching clinic simply does not happen anymore: it all boils down to ‘symptoms reduced, job done’.
Pain is not a malfunction
Pain is not an outdated response of lower life forms; some kind of primitive bodily function we no longer need. It is our oldest and therefore most highly evolved protective mechanism, and is right virtually 100% of the time. It is usually what our patients want us to make go away. Their experience of pain will diminish once the body no longer needs the signal. If, however, they have adapted to continued stress then the adaptations maintain their pain. But the patient is usually taught it is their weakness, their age; or of course, their ‘condition’, chronic pain. Nothing to do with their actions, habits or environment! So they never address those things, or else are give all the wrong advice: go jogging, make yourself eat something to keep your strength up, put ice on it, strengthen the muscles around that damaged knee, bring down that fever. These all make me cringe!
The worst is take painkillers and keep going, then you won’t establish a pathway. As if keeping going and ignoring what their body is telling them isn’t how they got into the mess in the first place.
And these strategies don’t work. So now they are told it is all in the brain, and sent off for thinking lessons. Perhaps every prescription for Cognitive Behavioural Therapy should include the words: ‘sorry we failed last time’.
If we start dismissing the body’s responses as irrelevant or unhelpful, then we are moving away from our claims to work with nature, with the body’s own healing mechanisms.
Yes, there may be times to palliate. For instance, if I had the chance to play a violin solo for the Queen, but I had a thumping headache, I might take nurofen, but always aware of the price of doing so. You can’t just magic a problem away: holistic healers live in a world of cause and effect. It isn’t logical to think you can make a problem go away without actually changing anything.
If the acute is the healing process, then it is a lie to try and treat it.
We are taught to treat acute and manage chronic, in fact what we should do is the opposite. The acute body is already dealing with the problem, the best we can offer is to provide the conditions where it can succeed. I would never go to a practitioner of any kind who claimed to be a specialist in acute problems. It proves to me straight away they don’t understand what they are doing.
We don’t heal anybody. Healing is what the person does, not us. They don’t leave our office healed, they go away and heal afterwards. The best results are the ones that creep up slowly, the patient often doesn’t notice, sometimes they need reminding that they ever had a problem. Or else they have an unpleasant acute episode that is well managed without drugs, and afterwards feel much better.
So, the real challenge is treating the chronic, which in turn means managing the acute symptoms of recovery. And of course, selling this to the patient isn’t easy either.
How to identify the patient who is chronic, or at risk of becoming chronic
You can often tell who is on the way to chronicity from various possible clues. There is no perfect formula, and remember, every case is unique. For instance one patient may push away good advice: but another may take all advice going, and the hard part is getting them to be selective.
- Increasing dependence on therapy
- Patient knows all the medical details of their problem
- They have been given all the wrong advice
- They have ‘tried everything’
- They blame somebody else for their problems (external locus of control)
- Their problem has a ‘name’ and they are stuck with it
- Their problem has been blamed on: genetics, virus, autoimmunity, their age, or the alignment of the planets, and they are happy with that, because it means they can ‘get on with their life’
- They believe it is incurable, rare, unknown, there is something special about it
- They are worried because tests have found nothing wrong (perhaps that should be taken as good news)
- Their life has become structured around their disease, ie they would lose something if they got better
- Multiple therapists on the case (too many cooks)
- Reliance on quick fixes
- Strong emotional reaction to help (often resistance)
- Absence of physical response to treatment
- There is some kind of glamour or uniqueness in their problem, it gives them something to talk about at dinner parties.
- Getting better would cause them a problem
- Insurance claim for injury or illness
- They are sick because they need a more expensive doctor
- Their diet/herbs/pilates etc works, which is why they keep doing it (except it hasn’t worked, or they wouldn’t still have a problem)
- They know more about health than anybody
- But for some reason the principles of health, which they understand completely, don’t apply to them: they are the exception
And of course:
- persistence of symptoms, but often with a confusing pattern, eg their headaches come on their days off, not when they are working
- Low vitality
- Unhealthy appearance
- Bad sleep, bowel movements etc
- Always getting minor ‘infections’
- Achey joints
- High medication load
- Problem slow to develop
- Habitual behaviour, unable to break
But there is no exact formula, every case is different. For instance people on autoimmune meds are often the picture of health externally, because their body doesn’t react, they internalise their issues. It is an overall picture that the patient has in some way come to terms with their problem that is the thing.
Ok, I hope that helps
[Disclaimer: the above is not medical advice]