Hope and salutogensis


Four patients in my afternoon surgery were suffering from chronic pain and had spent years being treated by pain specialists, spinal surgeons, psychologists, physiotherapists and complementary therapists. None of this specialist attention had alleviated their pain to any significant degree or provided a satisfactory explanation for their suffering. I have long-since stopped trying to ‘explain pain’, but for people who want explanations there are excellent resources online like ‘Pain is Weird’ by Paul Ingraham on Painscience.com and Tame The Beast by Professor of pain science, Lorimer Moseley.

Two of these patients with chronic pain had suffered child sexual abuse and one had also been a child slave. One had been tortured by the police in his home country and one had been traumatised by having to kill people when he was an army conscript. One of the women who had been abused had been seeing me with her back pain for 13 years and yet I only learned a few weeks ago about how she was sold into child slavery and some of what happened after that.

In nearly 20 years of working as a GP, I have very rarely come across patients with chronic intractable pain, who do not have a history of trauma. It may not be necessary to talk about what has happened, but it is necessary to acknowledge that what has happened long ago can have lasting physical effects,

For patients who have suffered with chronic pain for years, discovering the links between past trauma and present suffering may very often be re-traumatising and bring on symptoms of PTSD, like nightmares and flashbacks, also worsening the pain and fatigue and other symptoms like IBS (irritable bowel syndrome). Even where we are aware of the links, there is a fear that confessing to a history of abuse will mean that fellow pain sufferers – who by this time may make up an important social/ supportive network, along with professionals who have been treating them – will reject them because their pain is somehow less ‘real’. The shame that is inherent with trauma, comes into sharp relief; shame goes with self-blame “I am to blame for the way I feel – emotionally and physically, it’s up to me to fix myself, no-one can help me now”.

Talking about the past may also be overwhelming for clinicians. Doctors exposed to stories of rape and incest, torture, domestic violence, neglect and loss, can suffer from secondary trauma. There are days when I am completely, emotionally overwhelmed. And like most GPs I don’t have a therapist of my own.

My patients and I need to be able to find hope amidst past trauma and present-day suffering, and we are discovering this together by changing our focus of attention away from ‘pathogenesis’ – the science of what makes us ill and the subject of medical education – to ‘salutogenesis’, the science of what makes us well.

At this point I would recommend you watch “What causes wellness?” an amazing talk by Harry Burns, recently chief medical officer for Scotland, in which he gives a brief history of salutogenesis grounded in the reality of trying to improve outcomes for Scotland’s most deprived citizens.

I wanted to be able to share these ideas with my patients, but 20 minutes was too long to spend watching Youtube during my consultations, so I had to find something that summed it up, that people could easily remember. The picture at the start of this piece is on the wall of my consulting room. If you hold out your left hand in front of you, fingers outstretched, looking at the palm and then look at the picture you’ll be able to imagine our conversations. Each area requires care and attention if we are to be well. Salutogenesis requires a balance; neglect one or two areas and you’ll need the others to be robust to compensate, but that’s not sustainable for long.

Beginning with the little finger, ‘Mind’ refers to feelings/ emotions/ memories, thoughts, and interpretations. Shame and anger, depression and fearfulness, heart-ache and grief, confusion, hope and despair. Taking care of your mind depends on how overwhelming (or numbed) your feelings are. For some people a good therapist is essential and the quality of the therapeutic relationship is more important than the type of therapy, but in general, the further back the problems go, the longer the therapy needs to be, and CBT probably won’t delve deep enough for long enough.

Taking care of your body definitely doesn’t require gym-membership or marathon running, many people who have experienced trauma or who suffer with pain, irritable bowels or other chronic physical symptoms have very difficult relationships with their bodies. Taking care of your body means changing those relationships, so that your body isn’t a cause of shame or dread, but something that belongs to you and does what you want it to. Yoga, dance, singing, painting, making music, arranging flowers, or baking bread can be as therapeutic as fell-running or mountain-biking. You and your body are working together, you’re enjoying what you are able to do. And you don’t need to go over painful memories.

Taking care of your biology refers to everything that you consume; food, drink, medication, supplements, alcohol and drugs, even the air that you breathe. I talk about this with patients to put medication into a holistic context – it’s one part of biology which is one finger on the hand of salutogenesis. It’s something, but it’s not, by a long way, the only thing. With a sceptical eye always open to the science of nutrition, I’m pretty confident that so far as diet is concerned, Michael Pollen is right: “Eat [real] food, not too much, mostly plants”. Most people who come to be discussing salutogenesis with me have really strained relationships with food – it’s either a punishment or a reward. Their appetite comes and goes, their weight goes up and down. They’ve been on and off diets and supplements half their lives. Helping vulnerable to stop smoking, cut down on alcohol and reduce their intake of drugs and prescribed medications can always do more to improve their wellbeing than anything new that I can prescribe.

‘Human Relationships’ is usually the most painful area. “Do you have anyone in your life who knows you well, how you love and trust, who loves and trusts you back?” is usually how I phrase the question. Loneliness is one of the worst things that anyone can suffer from. It so frequently accompanies chronic pain and chronic mental illness. Sometimes the people I ask this question say, “Apart from you?” For too many people, the GP is the ‘only normal person they know’. Helping people connect compassionately with themselves and others is almost certainly the most important thing that can be done for salutogenesis according to the Harvard Cohort Study and other research.

Human connection also requires spaces for people to meet and connect with one another. In the next video, Eric Kleinberg explains how death rates in very similar neighbourhoods varied ten-fold during a drought because some places had a lot more places where people would gather, do things together, get to know one another, and in a time of crisis, look after each other.

People for whom the dark shadow of trauma lasts into adulthood were very frequently betrayed by an adult who they trusted, who they expected to care for them. The adult may have abandoned them or abused them, and they may find it very hard to trust other people from then on out of fear of being abandoned or abused. They may blame themselves for what was done to them leading to a sense of shame. To understand shame, a sense of being profoundly un-deserving of love, kindness and respect – I have written a series of blogs – beginning here.

I really like Dr Phil Hammond’s CLANGERS – the first, and most important point is ‘Connect’ – each day I will try to like myself and reach out to others.

The thumb refers to social security, by which I mean security of housing, finance, employment, and safety from violence, intimidation and all forms of abuse. The tip of the thumb touches every other finger, with adequate social security it is so much easier to access therapy, to join a gym or go to classes, to eat healthily and to socialise. Doctors have a duty to act as social advocates and help people access the benefits they are entitled to and draw attention to the health effects of poverty. A decade of austerity and failed welfare reform means that social security has hardly been worse in living memory.

Social prescribing, derided my some GPs but greatly appreciated by others like myself, helps people to connect with other people and to access social security. With awareness of salutogenesis Social Prescribing makes a lot of sense.

Crisis management is written across the wrist because that is where so often I seen cuts that have been inflicted in a time of crisis. When the pain gets too much, self-harm and suicide are ways to bring it to an end. A crisis plan should be written, shared with others, referred to in a crisis and reviewed afterwards. It should include warning signs that a crisis is coming, people to speak to, places to go, things to do. Even if self-harm is not part of what happens in a crisis, people with chronic pain will still have days when it’s too much, when the usual strategies are insufficient. They need a crisis plan or a ‘rescue pack’ for these days. https://stayingsafe.net/ can help.

A few months ago, I faced a woman whose daughter had recently died by suicide. The woman I faced, a patient I knew well, had suffered her own terrible traumatic past and suffered with chronic pain related to connective tissue disease, trauma and grief. She wanted me to prescribe more painkillers. “What kind of pain are we treating?” I asked her, “Is it physical, emotional or grief?” She stared back at me, confrontational, “What. Is. The. Difference?” She demanded. “How can you even tell?”

I can remember the confrontation vividly. She was right. All pain affects, and is affected by physical, biological, emotional, biographical and social systems. You cannot neglect any of these areas if you want to manage pain, but when pain is overwhelming, sometimes it is easier for patients and doctors to go for a prescription, and I gave her some more Oxycodone, “We know it works”, she said, “we both know, it numbs every kind of pain.” But we also know that it’s not enough, it’s not safe and it will soon stop working. Whenever we meet we check in on all the areas on the hand together, MInd, Body, Biology, Relationships, Social Security, crisis plan. In every aspect there is room for improvement, something to be done – and in there lies hope.

“How do you cope with seeing people like me every day?” asked another patient this week. He knows what I know, that the waiting room is full of people who are full of pain and trauma. He has lived around here for 30 years. I had to think before answering and I answered carefully. “It’s true, at the end of the day I am drained. But I’ve been here long enough to have seen people through the worst of times and out the other side. Sometimes that takes weeks and sometimes it takes months or years. So I share in the suffering, but I also get to see people go through the most appalling circumstances and then recover. And that’s priceless and that’s why I’m still here and why I’m going to stay here and stick with you for as long as it takes.”

Dr Austin O’Carroll, a GP who works with homeless patients in Dublin describes this commitment and continuity to patients as ‘high fidelity’.

And in a time of professional burnout, it is important for doctors and other health professionals to think about their own salutogenesis. We are prone to burying the bits of our past that we are ashamed of, we neglect our emotional health, eat badly (especially when on call), drink too much alcohol and lose touch with our non-medical friends and family, even though we are fortunate enough to be more socially secure than most people. We are prone to over-compensate when feeling stressed, by putting all our efforts into exercise, dieting or therapy, when what we need is a balance.

I hope that the image of the hand will help me, my patients and my colleagues to focus on what we need to be well, and will give us reasons for optimism, especially for those of us working in areas of deprivation. We can always find areas where positive changes, no matter how small, are possible.

15 responses to “Hope and salutogensis

  1. Thank you. This is ALL so so important. Thank you for what you do and the personal effort you put into it all

  2. I will share this with all of those I work with. thank you for taking the time, writing clearly and compassionately, it brings connection and real help. I like you said “hope” and salutogenesis, this seems a time when hope is much needed.

  3. Very well expressed. Thank you.
    Doctors need the sort of “supervision” that psychologists get.
    But then we’d need to recognise and describe our feelings!?

  4. Reblogged this on Musings of a Penpusher and commented:
    An innovative look at medical practice that opens up a whole new, yet realistic way of thinking about how doctors and patients can work together for the common good.

  5. An innovative look at medical practice that opens up a whole new, yet realistic way of thinking about how doctors and patients can work together for the common good.

  6. Reblogged this on My World, Your World, One World and commented:
    So much wisdom, with real hope for good practice

  7. Nicely put. I was a social worker in a Liaison Psychiatry team for several years and this summarises much of the approach I tried to take with a handful of people that I was able to work with over an extended period. Almost without exception the people who suffered intractable pain, or had diagnoses of somatoform disorder had histories of trauma, that were revealed little by little.
    In an age where we keep being told to “take responsibility” (for anything and everything apparently), compassion for ourselves and others is very much devalued and under-rated. I think it’s about time we re-asserted its importance. Thank you.

    • Thanks very much. It’s really heartening to know that it’s being increasingly recognised. The #metoo movement has been important for raising awareness of how much trauma there is, but in an age of medical speciaism, too often people lose sight of the bigger picture

  8. Extraordinary. I’ve yet to meet you but I’d hug you outright.
    Your whole unfiltered authentic view is rare indeed.
    I hope this blog gets to those that need to read it.

    • Thanks so much. You can have a virtual (or vicarious) hug. I do hug some of my patients with chronic pain – fully aware of what boundary issues there might be!

  9. What a blog. And for me such a timely blog. I have chronic pain which is easily put down to very severe joint disease for the past 30 yrs, almost my entire adult life. But I also have a significant trauma history – most of which I wouldn’t dream of mentioning to my GP. Or even the MH Trust I have been under for 15 years.

    Because culturally I was brought up that you didn’t talk about things to do with the mind. That was a ‘worried well’ concept. For the middle classes only. Plus, not of the generation that shares openly on social media. And if I at some level know how damaged by trauma as a child and adult I have been, why would I want to dump that on someone else so that they suffer. And of course God forbid I am then told I am resilient when no, I am not. I am simply just breathing. And some of me is broken.

    When an episode of pain has got to the unbearable and my autopilot has stopped functioning I always think first : What is stressing me out? Not, what have I physically done. Because my mind and body are integrated and a pained mind supressed this long has to present in some way. And for me, alongside psychosis, trauma presents as physical pain.

    You speak common sense with compassion. You obviously care on all levels. And get it. So thank you .

    • Thank you very much for generously sharing your thoughts and experiences. I’m stuck by the numbers of people who have shared their past trauma with me and have been thinking a lot about Judith Herman’s advice that trust and safety have to be established first and how patients need validation and vindication, and that they should be the ones to judge whether this has occurred. It’s not unusual to for patients who I’ve known for many years to bring up things they’re ashamed of. I think it’s because validation, vindication and trust with people who’ve been betrayed takes a lot of time and effort. I’m very afraid about the future of care in the NHS where the possibilities for continuity of care are being so rapidly and extensively undermined. I’ve twice meet with Simon Stevens (head of NHS England) to talk about this and will continue to raise awareness. Next year I’m part of a London ACEs conference – alongside survivors – I’ll make sure details are on the blog,
      Thanks again, Jonathon

      • Think we are all living in the the same fear. I worry about clinicians and professionals who take on so much. The load needs sharing. As for continuity of care, the old school GPs are desperately trying to instill in the next generation just how vital this is but I wonder if those coming through are political enough (with a small p) to fight the good fight. Will follow the blog closely. Always happy to speak up about the complexities and not of trauma focused care in case you need some more survivor voices. It’s a term that will become meaningless unless there is a sharp change of direction. Just want common sense and compassion to prevail. Less talking and more doing …..

  10. I’m reading some of Paul Dieppe’s stuff now. Interesting he said that dis-validation was much more powerful than validation, which I can believe. Also that validation was a judgement patients made rather than something doctors did. 

  11. For Trauma survivors in London Details here https://www.meetup.com/bpdcptsd/

    Trauma Matters [w London] a possible help point https://www.wecoproduce.com/consultancy-services

    Or Body & Soul [Angel, Islington] http://www.bodyandsoulcharity.org/about/our-whole-person-approach/

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