Whole Person Medicine, Forgiveness and Reconciliation

Dr Mike Sheldon

Meeting the physical, psychological and spiritual needs of patients

1964 – Qualified and ran away to sea 2

Jenny, the most beautiful Middlesex Nurse in 1965 3

Our 4 children as teenagers 4

Some of our 9 grandchildren 5

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The Complete GP

• Country Practice• Academic –

teaching and research

• Third world primary care development

• Back to Academe• Finally inner city

London practice

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My third wife is the curate8

YWAM Kings Lodge

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“Call from God”

David Pawson

“Ask God for your inheritance”

So I did

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My Inheritance

Michael, I want you to change the way medicine is practiced

I want you to treat the whole person

Develop whole person approach to medicine

“Christian Hospital” ??11

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Does Medicine have a philosophy?

MEDICAL MODELS Scientific Humanism Psycho-somatic Psycho-social-somatic

Post-modernism Narrative medicine Person centred medicine

“Whole Person”?13

That’s great – but what is the art and science of medicine today? Evidence Based Medicine

Is half of the equation The individual patient is the other half

Who delivers this treatment and care? The doctor is less than half of the equation An integrated team of professionals Plus the patient and carers as part of the team

What is the desired outcome? What is good health?

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Assessment in whole-person careMental

SpiritualSpiritual

EmotionalEmotional Physical Physical

SocialSocial Environment

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Paul Tournier

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Definition of Health

A new definition of health is needed.

Health is a statement about the present moment which mainly indicates the functional ability of the person.

Health has as many multiple facets as the person does

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WHO definition of health

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

Officially adopted in1948

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NOT the definition of Health

NOT the absence of disease – we all have diseases

NOT the absence of symptoms – we all experience pain and suffering

NOT complete happiness and fulfilment

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WHO Ottawa Charter 1986

Health is –

"a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities."

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A “whole person” definition of Health

Strength to be human – to live and die Minimising morbidity and then - Adapting to residual pathology Coping with pain and suffering Growing through difficulties Learning compassion and kindness Coming closer to “inner peace” - Shalom

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The strength to be human

To be human – In relationship with self In relationship with others Free to mature and grow Fulfil the purpose of our life

Health is not a state but a journey Health is relative and not absolute We become the people we are through our

relationships with others22

What is a whole-person?

Physical being Physical body Physical needs, reflexes, basic desires Biological level of functioning

Rational being Thinking and reasoning Feeling - emotions

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What is a whole-person?

Social Being Made for relationship

Spiritual being Moral behaviour Purpose and meaning Belief system Fully human –

what does it mean to be human?24

What is the spirit?

Old model of body, soul and spirit not helpful as leads to dualism

New model based on “golf ball” picture Seamless functioning of the spirit in ALL

human activity Spirit connects us with God/Spirit World

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SPIRIT

BODY

SOUL

SensesPhysical bodySexuality

CommunionWorship

Mind, intellectEmotionsWill

Old “Western” dualistic picture

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body

mind

spirit

A “new” modelof man - A golf ball

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I am an indivisible whole person

WillEmotionsDesiresRelationships

WillEmotionsDesiresRelationships

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The Three Windows

Physical window Normal ‘medical model’ view of problems,

translated into a whole-person approach Psychological window

Normal psychological counselling viewpoint looking at mind, emotions and life events

Spiritual window Looking at the spiritual and religious aspects

of a person’s health problems

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An integrated assessment - physical

Physical window Listening in a relaxed manner to the patient’s

story Build up a trusting relationship Concentrate on the medical aspects Picking up on verbal and non-verbal clues to

explore further Exploring their health beliefs Appropriate examination and investigations

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Psycho/social assessmentPsycho/social assessment

Best done by a counsellor Patient gives permission to share findings

with other team members Report is integrated with the other physical

and spiritual findings. This assessment can be combined with the

spiritual one

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Spiritual Assessment

Best undertaken by a spiritual care advisor Based on the 7 stage model Exploring patient’s understandings, beliefs

and actions. Highlight problems in – self image,

relationships, world-view, ethical practice, hope, purpose, meaning, will and beliefs

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What do we mean by the spirit?

Christian terms about the Holy Spirit, Man being made in God’s image and the Spirit of Christ within us.

Secular view of the human spirit as the highest levels of functioning within an ethical social situation.

In the NHS we need a broad understanding acceptable to all.

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7 stage model of the human spirit

1 Self-image 2 Relationships with others 3 Relating to the world 4 Moral and ethical practice 5 Purpose, Hope and meaning in life 6 Decisions, choices and Will 7 Belief and faith

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1 Self Image

Each person is a unique individual View of themselves and self-understanding

Realistic view of strengths and weaknesses Ability to “love” self and then others Ability to grow and mature and acquire

wisdom

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2 Relationships with others

Family Friends Strangers

Quality of ability to relate, to give and receive love, to mend broken relationships and relate appropriately in different situations

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3 Relating to the “world around”

Locus of control – themselves or others? Attitudes to work Social responsibilities Cultural influences Creativity

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4 Morality and ethical practice

Basis of their personal ethics Are they based on external standards Attitude to religious standards of morality How aware are they of their conscience? Attempts to act morally and consequences

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5 Purpose and meaning

What hope do they have for the future? Priorities in life What fulfilments and disappointments have

there been? What are the desires of their heart? What do they see as the purpose of life?

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6 Decisions, choices and will

Making good decisions This means understanding and making good

choices Will Power to follow good path Perseverance Facing challenges

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7 Belief and Faith (Values)

What do they put their faith in (faith is belief in action)

Concentrate of health and healing rather than everything in life

Beliefs which were handed down to them What do they actually believe in ? How do they put their faith into practice?

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Is spirituality part of a medical model?

Three responses –

1 Not at all, it may be important, but like the need for sewers and clean water, not part of a medical model. (Dualism)

2 Yes it is an important part of the delivery of health care, involving equality, respect of patient’s beliefs, compassion etc.

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The third option

The spirit plays an important part in both becoming ill and then in overcoming sickness, so it is an integral part of any successful model of care.

BUT this presents the big challenge How do we integrate spiritual diagnosis,

treatment and care into a whole person model which is practical and achievable?

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Main spiritual problems

Broken relationships Anxiety, fears and melancholy Shame Anger Guilt Wounds of abuse Loss, bereavement and loneliness

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Guilt

Guilt due to sin (transgression guilt)

Guilt due to internal high standards (perfection guilt)

Guilt due to abuse and wounds (rejection guilt)

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Perhaps it all boils down to

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Outward guilt

Inward guilt

Treatment of Guilt

1 Empathy in relationship

Personal empathy and understanding within a trusting relationship

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What is the value of empathy?

• Of 800 parents, 26 % said that they had not mentioned their greatest concern to the physician because they did not have an opportunity or were not encouraged to do so.

• Patients collaborated with the doctor best when they felt he/she was genuinely concerned.

• Most of the doctors felt they had been friendly. More than half of the patients disagreed

Korsch, B.M., and Negrete, V.F. "Doctor–Patient Communication." Scientific American. 1972. 227: 66-74

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Non-verbal communication

• Patient satisfaction is strongly related to non-verbal communication

– Facial expressivity

– Eye contact

– Smiling

– Nodding

– Body lean

– Body posture

– Tone of voice

Griffith CH Journal of general internal medicine 2003;18:170

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Finding common ground and mutually defining the problem is the most important factor in predicting:

Recovery from discomfort and worry

Better emotional health

Fewer diagnostic tests

Fewer referrals

Stewart M et al

J Fam Pract 49 796-804, 200050

Treatment of Guilt 2

Affirmation and acceptance

We are all guilty

“Moving from the guilt of doing to the guilt of being”

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Treatment of Guilt 3

Education to develop insight

My sins

Others sins against me

So to distinguish between repentance and forgiveness

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Treatment of Guilt 4

Build up Hope

Judgement but with mercy – this is Grace

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Hopelessness and the relative risks of death from myocardial infarction and cancer

a prospective 6 year study of middle-aged Finnish men matched for blood pressure, cholesterol, smoking, drinking, social class, education and prior depression and social isolation.

Rela

tive

haza

rds

Level of hopelessness

Low

Moderate

High

Myocardial infarction

Cancer

Everson SA et al Psychosomatic medicine

1996; 58:113-12154

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Treatment of Guilt 5

• Sorrow leads to repentance

• Stories from Annie Hughes (SCA in Birmingham)– Easter Saturday– Shit to manure

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Easter Saturday

• It seems to me that I often stand in “Easter Saturday”, a place that appears hopeless, without future, only blackness, fear and uncertainty. I believe in the resurrection and new life but it is important not to rush people before time into that place of acceptance and renewed hope. The stories of people that I hear are often of terror, abandonment and unutterable despair. A faith that cannot cry out to God in anger and confusion can only stifle growth and does not allow for healing.

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Making manure

• A nun I visit, once remarked to me that, “God can take the ‘shit’ of our lives and turn it into manure!” I quoted this to a lady I had seen on a number of occasions. She had suffered bitter betrayal and felt unable to move on. She thought for a moment and then said, “You mean the roses can grow again.” It became her experience that out of the dark soil of despair grew beautiful shoots of forgiveness, acceptance and joy.

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Treatment of Guilt 6

• Giving and receiving forgiveness

• The cycle of forgiveness

• “Naked” forgiveness

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Why should I forgive?

Forgiveness training reduced anger and improved myocardial perfusion in a small sample of men with coronary artery disease

Waltman, M. A. (2003). Dissertation Abstracts International: Section B: The Sciences & Engineering, 63(8-B), 3971.

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Treatment of Guilt 7

• Where possible lead into reconciliation

• “Two people can be pushed apart by injury. Reconciliation is to bring them together again”

• Two parts – forgiveness and penance61

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Reconciliation

Forgiveness Penance

Confession

Penalty

Repentance

Restoration

Reconciliation

• If not entered into can lead to –

• Separation

• Loneliness

• Anger

• Victim mentality

• Physical and mental health issues

• Broken social support systems63

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Reconciliation

Forgiveness Penance

Confession

Penalty

Repentance

Restoration

The 3 Golden Rules

• Speak in “I” messages

• Take the first step

• Enter into genuine dialogue with humility

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The cycle of forgiveness

• Understand

• Feel the pain

• Confess the sin

• Apologise

• Make penance

• Seek to reconcile

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The oil making it all happen

• God’s Grace• His Mercy• His forgiveness• His restoration

• Forgiveness is a two way street

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What would whole-person care look like?

What would whole-person care look like?

Major differences would be – 1: Integrated team includes patient 2: Full assessment of person through three

windows 3: Diagnosis made in whole person terms 4: Continuing assessment is dynamic 5: Therapy will be multi-disciplinary but

integrated

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Whole person diagnosis and treatment

1 Recognise the deeper problems 2 Conduct a whole person assessment 3 Make a whole person diagnosis 4 Make an agreement with the patient 5 Use an integrated team to treat 6 On-going dynamic assessment 7 Measure successful outcomes

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Spiritual Care Advisors (SCA)

To provide a core level of Spiritual Care provision, integrated with other health care professionals, and able to refer on to a wide variety of religious “chaplains” as required.

The job description states that the SCA is to provide “spiritual care for patients and staff”. Anyone may be referred, regardless of faith, by GPs, consultants, nurses, or by self-referral.

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Further information

www.wholecare.com

www.wphtrust.com

www.drmikesheldon.com This talk is on this web site, follow leads

through “Whole Person” and “Articles”

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Principles of whole-person health

1 Patient is central 2 Importance of narrative 3 The true story of the patient’s health 4 Man – whole greater than the sum of the parts 5 Making a diagnosis 6 Definition of health 7 An integrated health care team 8 Self-help by patient is encouraged 9 Outcomes to be achieved 10 Growth, development and maturity

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Guiding principles

Give love Provide hope Exercise faith

Within an integrated team Having a practical theology Practiced with humility Available to all

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Neuroimmunology of supportive relationships

A review of 81 studies monitoring the effect of social support showed improved immune functioning with higher levels of support.

Uchino B.N et al (1996) Psychol. Bull. 119 (3): 488-531

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