Hero's Code

Why doesn’t Mrs Smith help herself?

Going into the amputee rehabilitation centre today I saw a number of people – minus various limbs - sitting around outside in wheelchairs smoking. 

This is not unusual I have to say.  I am not a fan of smoking but it always strikes me as sad that people who have lost limbs due to compromised blood circulation aren’t motivated enough to eliminate smoking from their diet.  But when you think about, I am passing judgement from my viewpoint and I don’t have a clue how these individuals see the world.

Now I don’t wish to debate the rights and wrongs of smoking here.  I wouldn’t like to think that we start passing judgement on others too quickly in order to control them.  There is a great tendency anyway for more and more control applied to each of us for the collective good.  I don’t really want to debate that here.  I am interested in the attitudes and beliefs of people that lead to behaviours and consequences.

One of the challenges we face in the UK at least is that medical science allows many more people today to survive the consequences of, for example, peripheral vascular disease for longer.  This is surely a good thing. 

Once upon a time a person may have had a leg amputation and even after rehabilitation with a prosthesis or a wheelchair we would realise that prospects of survival would be limited.  Today however, we have leg amputees who are surviving longer – going on to have other higher-level amputations of the leg as well as having increased likelihood of arm amputations.  When blood flow is compromised it sadly affects all of the circulatory system.  Whilst prostheses and rehabilitation are improving it is always going to be a case of “shutting the stable door after the horse has bolted.”  Prevention is what matters and one aspect of shaping that is to consider human behaviour and attitude.

What I did have the opportunity to do recently was discuss with a group of clinicians the motivation strategies that could be used with their patients.

Imagine you are a doctor - Did you ever have the feeling that you made strong recommendations to your patient, used your best possible words to “persuade” someone – and thought that he or she really got the point – only to find that your patient did not do what you recommended?  Probably a special strategy might help.

Sometimes it is very useful to find out how people are motivated.  Fundamentally, one way of thinking about this is that we all are moving towards pleasure or away from pain.  Put another way, we are

“Moving towards something“ kinds of people or “Moving away from something” kinds of people

My view – and just look around you to check what you think– is that there are many more moving away from pain kinds of people than moving towards people.   People mean to do things, say they will do things … and yet they wait and wait and wait.

There are those people who respond much more readily to running away from a threat than approaching an aim.  There are people that like to have a blank, clutter free, desk and others who simply don’t want to sink into total chaos as paper cascades from heaps piled all over the desk.

There are people who fill in their tax-forms to feel good that they have dealt with all of that in lots of time – and others who only respond at the very last moment when they realise that the pain felt by not dealing with this is now greater than the perceived pleasure that would come from doing something else.

There are people, who do sports to stay in good health – and others who do so because they would like to lose weight or have some other complaint go away.

And .. there are those who invest in pension plans to have a good time during retirement and others who are afraid of being poor and old.

So lets have a look at Mrs Smith. 

She is an “away from something” patient.  When you want to attract her with positive benefits such as “better mobility” or “improved cosmesis” it simply won’t work as well as if you came up with a different strategy that’s meaningful in her world.  For her, the new prosthesis will seem like gold if she knew that this prosthesis would help her avoid some dire consequence – like losing her other leg.  And remember that what would be a bad outcome for one person would be of no consequence to another.  It’s the individual’s perception that matters.  We have to be careful here about the ethics of scaring people I guess.

Mr Jones, who is by contrast a “towards something patient” would not be motivated by the same things as Mrs Smith.  He would be much more interested in the fact that if he had this prosthesis he would be able to join his daughter at her wedding next month or that this would keep him independent for so much longer.

For all clinicians, if you know how someone is motivated, life gets much easier.  You can avoid having to struggle with people to “get your own” way against the will of someone who simply does not and never will, see the world the way you do.  Compliance to treatment will grow once you meet the person in his or her own world rather than broadcast from the lofty position of your own.

And you know what, when you really think about this, it works not just with patients.  It works with doctors, therapists, assistants - and in the world outside. This even works with your children.

How do you find out if they are away from or towards something people?  Well, I suggest you don’t interrogate but instead use metaphor (story telling) or just get to know them by asking innocently about situations and see how they respond.  By looking for contrast we can easily see what works.

Why not start with yourself. Go back to a time in your life when you were really strongly motivated to do something and you actually took action.  Remember what it felt like? What did you see, what did you hear, what did you feel? 

Now just for contrast think of another situation where you just knew that something needed to be done – but you just procrastinated – you waited and waited until the pain of further delay just overcame your resistance to react.  Note again what you saw, what you heard and what you felt.  Notice that how we represent these situations in our physiology is completely different.  For now, all I can tell you is that with patients it gets much much easier if you are working with representations that motivate them rather than ones that lead to procrastination.

The Placebo Effect - A matter of belief

You have certainly heard of the placebo effect and you may have thought that a placebo only works because the person receiving it (medicine, a lotion or potion) doesn’t know it’s a placebo.  It actually works because of belief.

As a person involved in the design and development of medical technology I now try to incorporate knowledge of belief and expectancy into many aspects of what we do.  The "look and feel" of products, the attitude and beliefs of the prescriber and many subtle influences need to stack up for the benefit of the patient.

Back in 1931 researchers had long recognised that the placebo effect was a useful conceptual model to better understand the safety and efficacy of medicines in development.  It had been known for decades that some patients would say that they felt better just with the suggestion that they were being given a remedy.  Back then, researchers interested in measuring the effects of a drug called sanocrysin on patients with tuberculosis, wanted to discount this observable placebo effect.  Their idea was to give some patients a glass of distilled water whilst telling them they were really receiving sanocrysin.  Ever since, placebo-controlled, double-blind studies have been deployed as a way of evaluating drugs in clinical trials.  Consequently science has an awful lot of information on placebos – probably more than we have on all drugs put together.

In his book “Time for a Change”, Richard Bandler describes (tongue in cheek) how he and a graduate student had planned to market placebo pills to the general public. They made plans to publish a leaflet with an index.  A person would look up “Headaches” for example and read,

“When tested against other drugs, placebos work five out of six times – and no side effects.”

Then it would say
”Take seven when you have a headache.”

Unfortunately, the FDA complained that the effects would wear off and that the placebo would lose its efficacy. Bandler says that he knew that this could happen because some people would not have strong enough beliefs first time around.  So they revealed their back-up plan.

“New! Placebo Plus! Twice the inert ingredients! Twice as powerful as before.”

Nevertheless, the FDA wouldn’t let them offer their capsules and told them it would be illegal and couldn’t work.  Bandler’s view was “We had proved it would work. After all, we had decades of their own experimental results directly from them.”

If the basis of placebo is belief, we can recognise that we must have learned or adopted beliefs in some way and therefore we can change them.  Belief’s are nothing to do with fact and are a construct of an individual or a group of individuals.  Bandler says,

“My clients often knew a placebo when they got one.  They still do. I actually give them the ability to believe that it works because it is a placebo.  I explain that because they already know it works for a placebo, it will work forever. It does.”

We can distinguish between placebo and placebo effect.  Basically, any sort of treatment can act as a placebo but what determines if there is a placebo effect is the actual response of the patient to the intervention.

Based on the Latin for “I shall please,” placebo takes many forms but has been offered as a sugar pill, a saline injection and distilled water.  We have also seen placebo surgeries where patients are anesthetised, cut open and stitched up again to appear as if they have had surgical interventions even when they haven’t. We have often heard sceptics dismiss responses to complementary and alternative therapies as “merely” placebo effects. However, whether in the past you have considered the effect a scientific annoyance or a miracle, its power is becoming much harder to deny as we shall see.

One of the most enduring questions about the placebo effect is whether this is an effect of human physiology or of psychology; is it of the mind or of the body?  To me even if it “is in the mind” that was pretty impressive.  Research is now demonstrating that it is both.

Research at the Harvard Medical School and elsewhere is showing that a change in the mind-set or attitude of a patient alters their neuro-chemistry whether in controlled laboratory studies or in the clinic.  Patients affected by pain and debility, look to doctors and allied health professionals for the words, gestures and deeds that reinforce their belief in medicine’s power and reinforce our expectation that we will benefit from an intervention.  Research is showing that neuro-chemical changes are induced that have a catalytic effect on many body systems.

Belief, attitude and expectation – perhaps we could label these as “hope” – can be embedded and shaped by the encounter between patient and the universe of care they receive.  This hope produces an effect that can block pain by releasing endorphins and enkephalins that in turn influence fundamental processes such as respiration, circulation, elimination and motor function.  Hope is the leverage that can start a cascade of physical effects making improvement much more likely.

One of the reasonable questions we could pose is

“If we accept that placebo is real – how can we harness this power and really direct it in clinical situations to support our other strategies?”

As more people start to pose this question it becomes much more likely that research could be directed away from just demonstrating the effect exists, and more toward research and practice that can help us harnesses this power.

The placebo’s effect in treating depression was considered in a 1998 meta-analysis (bringing together related journal articles to provide a potentially stronger evidence base).  The authors suggested that the placebo effect might account for up to one third of the clinical benefit of modern antidepressants.  Some authors claim an even stronger improvement.  This level of benefit is highly significant and certainly worthy of attention.  It causes challenges for pharmaceutical companies who need to demonstrate that their formulations produce a measurable effect compared with placebo.

Pharmaceutical companies are interested in placebo because it complicates the clinical trial process.  The Wall St Journal in 2004 noted that clinical trials are finding that placebos are almost as effective as formulated antidepressants.  For example, Fluoxetine (Brand name Prozac) gave a response score of 8.30 compared with a response score of 7.34 for placebo.  The score was measured over five trials and noted the average improvement, measured in points on a standard, validated scale to assess the severity of depression.  Other formulations exhibit similar levels of performance relative to placebo.

Placebo response to antidepressants is particularly high in young people. A trial for Zoloft found improvements in 59% of children given a placebo compared with 69% who took an active medicine.

You see, clinical trials deal with statistics and typically require large numbers of participants to be of any value.  The smaller the effect that is to be detected the larger the trial needs to be.  What we do know is that some individuals respond very powerfully to placebo and others don’t – and we don’t yet know how to reliably spot who is who beforehand.  For example, to get permission to market a new drug, the manufacturer most convince a regulatory agency that its product performs better than placebo in at least two large, controlled trials.  If the makers could identify ahead of time the individuals that do well on placebo, then they could eliminate them from the trial, allowing trails to be smaller and conducted more quickly.  This is important because antidepressants represent perhaps $20 billion in world-wide sales.

Recent studies of patients with Parkinson’s disease, a condition in which one part of the brain (the striatum) stops producing enough dopamine to support normal movement and muscle control. Drugs called dopamine antagonists can provide some symptomatic relief by substituting for the missing dopamine. 

Funny thing is that placebo can bring relief too - and in ways that are more than just allowing people to ignore their symptoms.

Scientists at the University of British Columbia found that placebos improved the symptoms of Parkinson’s disease in some subjects and that in these individuals increased levels of dopamine were being generated in the striatum of their brains.

The majority of placebo-effect studies have focused on pain.  These days we have the technology to monitor brain chemistry and activity through the use of functional magnetic resonance imaging.

When we consider the placebo effect we are mapping some aspects of the mind-body connection and opening the lid on some of the pathways through which mental factors alter people’s symptoms, health, or even an underlying disease.

Some of the factors are coming to light:

The Person
Studies suggest that trial participants are more likely to experience a placebo response if they have strong belief in the treatment they are helping researchers evaluate.

The Clinician
Doctors, clinicians and the individuals involved in the care of a person may also influence outcomes.  Research has shown that when physicians are hopeful and enthusiastic about the active treatment in a study, patients are more responsive to a placebo.  The effect of medical and nursing care (the “Hawthorne” and “halo” effects) and the nature of the patient-doctor relationship is definite although some people would dispute that this is part of the placebo effect.

The Particular Condition or Illness
It is suspected that placebo will work better for some conditions than others.  Studies suggest that problems with vague causes such as aches and pains or fatigue, are more responsive than conditions where the cause is obvious and structural.  For example, it’s hard to ignore the “reality” of a broken bone or an amputated limb.  By the same token, placebos have tended to work more consistently with acute pain than chronic pain.  Maybe the issue here is the ability of the person to secure strong enough emotional leverage or hope.

The Treatment
The usual placebos used in trials have been inert pills that have no direct physical effects.  In some studies though, patients have received an active placebo that cause symptoms that the patient will notice (raised heart rate for example) but has no therapeutic effect.  Not surprisingly the active placebo produces a stronger response perhaps because it is easier for the patients to believe they are receiving an active drug.

The Three Legged Trial
Some researchers have pointed out that trials would be better conducted with three legs. One group would receive the active treatment, one the placebo and a third would receive nothing. The idea being that many patients might have got better on their own.

The Privilege of Leadership

In today's world it is hard to be a leader yet it's a real privilege.

We are suffocated with data yet short of real information and no matter how hard we work it can be hard to sense achievement when so much remains to be done.

When you lead you ask your people for their commitment and loyalty and sometimes you will be disappointed.  I know people who let such disappointment lead them to a style of leadership based on orders and control.  From then on, communication and command become mixed and this will lead to problems.

Think and act like a General if you must - but understand that at its best, military leadership is not about rigid control.  It relies on trust and clarity of communication at all levels in your organisation.

It's not easy but it can be a lot of fun.  Calling the shots carries a great deal of responsibility, not only for yourself, but for your people.

Your employees’ lives, to a large extent, are dependent on you and your decisions.  Bad strategy can end up affecting a lot of people. This is where being a leader takes on a new dimension. 

Every decision you make is an important one, whether there are twenty thousand people working for you or only one.  Make a mistake with your first employee and you might never have a second one.

If you are extra careful when hiring employees, management becomes a lot easier.  I have in the past hired people because my head told me they should be good - even when my heart told me - careful this is a Bad Idea!!  Bottom Line: Find people who suit your business style and you’ll have fewer problems to deal with as time goes by.

Pace of Life

From time to time people will ask me about what matters most to me - the actual achievement of life goals or the journey toward them.  My snap answer is usually that the journey is what counts but there are limits to this  - when we really think about it.

I have sports car and a motorcycle and I like to drive quickly but safely and at my own pace.  It's not so much that I need to get to a destination quicker than anyone else - for me its all about the pleasure and experience of driving. 

Now I know that not everyone feels the same way.  I meet people on the road who want to race me because they feel they have something to prove.  I will get out their way.  Its nice to not play their game because ultimately I know that my car is fast enough to go faster than them if it really mattered.

I meet other people on the road.  They usually wear a cap.  They grip the steering wheel as if it would float away.  They travel at 25 in a 50 zone and won't move over.  They have all week to make this particular journey and yet they choose this busy time when the rest of us do have places to go and people to see.

Does anyone else think that older people should really be moving faster as they age rather than slower?  Surely if they have fewer years left to live they could feel a greater sense of urgency and really get on with making it to a few more destinations.

My martial arts sensei told me that when things are going great then just remember not to get too happy because things will change - and when things are bad don't get too upset because things will change.  Like so many things in life we need awareness of what matters and we need to find some personal balance. 

When we have a feeling that we have so many goals to achieve it is important to remember to notice the journeys we are on in this moment.  When we seem to need to rest from achievement its nice to remember that we can still assist many others on their journey - or at the very least get out of their way.