Creative consulting: germinating recovery. What is a healing response?

Continuing his series on improving your consulting skills, David Reilly explores "reverse engineering"

This series aims to enable your therapeutic effectiveness. Combine that with your technical training and you will be doubly effective in helping your patients. So far, we have considered some reasons for doing this,¹ and looked at creating the right conditions for the work to begin.² Now we will take a first look at what is possible. Here we explore how patients with severe neuropathic pain and chronic distress, which were unresponsive to technical treatments and drugs, go on to be triggered into a rapid resolution of their distress by effective caring. Such self healing responses, however triggered, show some common characteristics--they are a final common pathway in all successful care--and recognising this is an essential foundation for our inquiry.

So let us meet Graham and learn from his experience of recovery, trying to figure out what helped him and so what might help others. We will begin with his referral letter, then we will jump to the outcome of his care. Each has different things to teach. To get the most from this exercise you will need to take some notes.

Your professional analysis

Begin by applying your current ways of thinking to the referral letter in box 1. Please take some notes to refer back to later in the exercise. If you are advanced in your studies apply your usual approach--perhaps an expert eye, or a PBL (problem based learning) exercise. If you are near the beginning of your professional study do not feel that you have no skills here--remember that your natural human senses and life experience will be the foundation of your future work and just try to figure out and imagine what you can. The more you get wrong in the first analysis the more you will learn later in the exercise--so just plunge in. Your task at this stage is to ask if this patient can be helped and how. Make a formulation of the issues in the usual way and plan what you might do to help. Based on your current approach, ask if there are any treatments that you might recommend. Importantly, ask what is possible here.

Patient's analysis

When you have completed the professional analysis, add a part 2 to your notes and then reread the letter, but this time become the patient and see if that throws up any additional possible insights for you--asking yourself from his perspective questions like: "What am I feeling about it all, what am I thinking? What do I think is wrong? What do I think needs doing? What do I think is possible?" Here you might like to play with the difference between, "If I (as yourself) was in this person's position" versus the more challenging, but effective, imaginative exercise: "If I (as this person) was in this position." This difference is important for the development of empathy. If you have difficulty imagining this, just recognise that and then see what the patient teaches you in the next part of the exercise.

What is a healing reaction? What triggers it?

Now let's study the result of Graham's care. We will jump to six months later. He returns as an outpatient and describes a marked success (see box 3). Whatever triggered it, a healing reaction had been activated. We will do two things. Firstly, describe his healing response as a first study of healing reactions in general, and, secondly, figure out what helped it activate--by working backwards from the effects to the cause. If he says, "I feel more relaxed" (reaction) we figure out that effective care might therefore have to reduce tension and induce relaxation (action/trigger). This "reverse engineering" approach is designed deliberately to get you to try to figure things out with a fresh perspective. Imagine you know nothing about the ingredients of healing success (more easy for some than others this bit) and let the facts teach you. (The truth is, medicine has not greatly studied this. Have a look in the index of your medical texts for words such as "healing responses" or "recovery mechanisms"--you will not be overwhelmed by the volume of information.) Like Darwin on the Galapagos Islands, imagine that you are an observer from another planet here to study healing and recovery responses in the human species. What does it look like, what scope and limits does it have, how do you know it's happening, what speed does it develop at, what signs indicate its progress, what triggers it, and why, why did previous approaches fail? You get the idea--that without books or theory you can become an expert from being consciously thoughtful in your daily work--studying with fresh eyes what works and what does not. Good science is grounded in evidence and direct learning, and in medical science patient experience is the final arbiter of good treatment and care. As you develop, be on the look out for real success, then choose to model your approach on it.

Consider two big themes as you study the transcripts of the interview: the result--what can you learn about some of the characteristics of a "human healing reaction"? and the triggers-- what were the ingredients of successful care? (see box 2).

The patient as our teacher

Before you read on, carefully consider what Graham has been teaching you, assembling your list of ideas and thoughts on what a "healing response" is and, from Graham's experience, what might therefore be helpful as goals in consultations in general. Look back at your notes and compare your earlier ideas with the actual data. Note points of "discordance," and any lack of understanding or incorrect directions. Also notice, were there any areas of discordance between your two viewpoints in the professional and patient analysis? The carer and the client coming to a "shared story" or understanding can be an important therapeutic ingredient. Later in the series we will see (for example, from the placebo literature) just how much help or disruption can be determined by this.

I've listed some of the things which I think this case says about healing responses (see box 4).

Add your list and my list together as a start point for our study of what a healing response looks like. Please keep these notes to add to as the series develops. Now, let's work backwards from Graham's experience to consider what might be useful in our work to reduce harm and encourage positive change for our patient. Of course, you might be unclear about how to do this, but once you are on the look out you will start to learn. Remember the opportunity is there to ask people who have had such changes, "What helped this happen?"

When I asked Graham he said the consultation was the main thing, but everything helped. The persistence at six months without any other therapy in the interim strongly suggests a triggered process which then developed under its own strength.

Now put the two lists together: "Healing"-- "Triggers." Consider the two sides, and the join between them--the interface, the meeting. That's what I am coding the "consultation" or "encounter" in this series. The relationship between the patient and you (and the care system you are in). The more these factors "gel" the better. The consideration of this in medicine is scattered--under terms such as "concordance,"³ the "therapeutic alliance,"⁴ "empowerment," and "enablement,"⁵ which cover some but not all of the dimensions of Graham's change. Mostly you will have to assemble your own map of this journey.

There are two important final questions to consider:

Why was the healing response not enabled up to this point in Graham's care and what have we to learn from that? This is of central importance in considering healthcare education needs and system design. Failure at this level is a major force in driving dissatisfaction with health care, and the demand for complementary medicine.

Does such a healing reaction have any physiological impact and affect "organic" processes and diseases or both? We know Graham felt better and his symptoms and life improved, but does it stop there? Can any underlying diseases ever be affected by these general healing reactions? We will tackle this later in the series.

Integrative care

Graham's care perhaps illustrates what an "integrative" approach is and suggests why I have earlier defined it as "care which encourages more coherence in the patient and in their medical experience."⁶ There is much fragmentation in today's medicine. We need changes in medicine to address this problem.

Conclusion

We have studied a transformation that has affected the whole person and so their life. I have chosen to call this a "healing response" and have suggested that a direct study of such reactions could be a unifying focus in medicine.⁶

Thinking this way brings some important changes in perspective. The reaction is intrinsic to the person, a powerful self balancing, self healing capacity that was "triggered" or "catalysed" by the care. Because this was from within the person it is less dependent on continued external input--if the person has also been helped to care for themselves better. Seeing the potential in your patient, an untapped capacity, that perhaps they cannot see, is enormously helpful. Often we are frightened, down and out, in distress, broken spirited, or broken hearted; it feels like we will never get any better. Meeting a carer who respects us and holds some faith in our capacity can be the first step towards change. Of course, there is an enormous amount of skill and knowledge to gather, but realising that the patient, like all living organisms, has these built in self healing potentials means that if we just strive to do no fresh harm, and then bring a basic respectful presence to our meeting, that will often be a helpful start. This view also helps reduce burnout and arrogance, as we are less quick to ascribe the patient's healing reaction as due to us or our tools. Gardeners help produce the conditions, but the seed germinates itself. Even in the extremes of high tech medicine, we are still interdependent on the healing reactions in the patient--without them, no deal.

Next steps

So to your exploration of "making the room disappear" that we touched on in the previous article, you might now begin to study healing reactions more consciously. Some questions might kick start your study:

• Where is knowledge of these reactions to be found (hint: don't just think medically here)?
• What sort of research methods would be appropriate to study this? (Remember the two halves: what triggers it and what is it?)
• How might these self healing reactions interact with specific treatment effects?
• And as mentioned earlier: is there evidence that these general healing changes might affect organic disease processes?
• Most of all observe. Practise our theme of the patient as our teacher (there is a term "experience experts"--that is, a "cancer expert" is someone who has cancer). Ask your patients to teach you about what has helped, or hindered, them to feel better or get better or both. Then "reverse engineer" this new knowledge back into your own work. Watch out, the answers can seem so simple you might miss them, "well the nurse was so kind to me," and so complex you might accept them wrongly at face value, "those tablets were great."

David Reilly, consultant physician, Homeopathic Hospital, Glasgow, and senior lecturer in medicine, Glasgow University
Email: davidreilly1@compuserve.com

David Reilly welcomes correspondence or questions on this series.

studentBMJ 2001;09:443-486 December ISSN 0966-6494

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