Complementary therapies in cancer care

This short overview is based on a talk I recently gave to the members of Sweet Louise, a New Zealand charity for the support of people with incurable breast cancer.

Complementary therapies can be loosely defined as those not included in orthodox medical training or practice, though this can change, for example acupuncture has been used in pain clinics for many years. Some therapies involve physically touching the body – examples include massage, reflexology, acupuncture. Others involve taking substances by mouth – herbal remedies, homeopathy, flower essences, special diets. Then the mind body therapies such as relaxation, meditation, yoga, visualisation and guided imagery, energy healing. And creative therapies with art, music, writing and dance. Several types can be combined.

They are often known as “natural” therapies, and the same ones may be called “complementary” when used alongside orthodox medical treatments, and “alternative” when used instead. The “integrative” approach combines them both but has been slow to get established, perhaps because of prejudice and misunderstanding on both sides. All these therapies are grounded in the “holistic” approach, which aims to balance the whole person in body, emotions, mind and spirit, and mobilise the potential for self-healing. This is in contrast to the approach of conventional medicine, which uses powerful drugs, surgery or radiation to suppress symptoms and destroy disease, and in which patients have a passive role. Both approaches have their place and can often be used alongside each other.

Surveys show that as many of two thirds of women with breast cancer are using one or more natural therapies, and there is good evidence that they can improve quality of life – helping to relieve physical symptoms such as pain and nausea, mental symptoms such as anxiety and depression, reducing the side-effects of radiotherapy and chemotherapy. They appeal because, in general, they are safe and natural and many of them are pleasant to receive. When I was practising with the Bach flower remedies, many of my clients told me they wanted a therapy that treated them as a unique person, rather than just one more case of a diseased body part.

While all the modalities have specific effects, their benefit is partly due to their positive influence on mind-body relationships. The self-help element, especially with therapies that require some active user participation, enhances a sense of choice and control. Spending time with an understanding therapist in a relaxed setting is comforting. Expectation of improvement can help to bring it about. Such general factors are important, and it is a mistake to devalue them as “just placebo”.

A key question is whether using these therapies can lead to a longer life expectancy or even to remission of the cancer. Many individual cases of remarkable recovery have been reported. But there are few formal research studies on this aspect, and it is a difficult thing to investigate for many reasons – for example treatments are used in individual combinations rather than standard protocols, and patients’ beliefs and motivation affect the outcome.

Some of the therapies carry risks, for example herbal remedies can have adverse interactions with prescribed drugs; massage and acupuncture occasionally cause physical injury. They can be expensive. The field is not tightly regulated and, while most therapists are skilled and honest, there are a few self-styled practitioners who cause more harm than good by making unrealistic promises of curing cancer while advising clients to refuse conventional treatment that would have been effective.

More detail about these topics, with case histories, can be found in some of my non-fiction books.

A writer’s purpose

My writing career has been at a standstill lately, perhaps due to being distracted by various health concerns and family events, and discouraged by a couple of negative reviews. Looking back at my own advice about dealing with writer’s block, taken from my short ebook Wellbeing for Writers:

“Inspiration tends to come in waves. There are times when writers are full of ideas. At other times they may have none, which is always frustrating, and presents a major problem for those who earn their living from writing or have publishing deadlines to meet.

There may be an obvious reason for feeling blocked. I always find myself unable to engage with a new book immediately after finishing the last one, even though I am only really satisfied and happy when I have a writing project underway. I make use of such fallow periods to organise and de-clutter the paperwork in my office and the files on my computer, and to market the book I have just completed.

Some of the other causes for writer’s block, for example striving too hard for perfection, feeling upset about rejection or criticism, adverse experiences in another sphere of life, having too many other things to do, or suffering from a depressive mood swing, are discussed in other chapters.

Besides dealing with any remediable underlying causes, there are various strategies for overcoming writer’s block. If circumstances permit it can be a good idea to take a complete break from writing, and do something else for a day or two or even much longer. Preferably this will involve activities, people and places completely different from those encountered in your usual routine, which may provide new ideas. Other forms of creativity, such as painting or dancing, can help.

The opposite approach is to discipline yourself to keep on writing for a set period each day, but again try doing it with a new approach. Clear the clutter from your desk to encourage a fresh start. Write a short and simple piece instead of attempting the major work on which you feel stuck. Some authorities suggest inducing a relaxed state with deep breathing or slow music and then using your non-dominant hand to write something – anything – which even if it turns out to be nonsense may still stimulate the creative flow. Or try writing late at night or early in the morning, when you are half-asleep and more able to access the reservoir of images and memories in the subconscious mind.

Getting started again often presents the biggest barrier, and if you can get past that it will usually be much easier to continue.”

Fair enough, but I also find myself asking what is the point of writing at all? This is what I said in Wellbeing for Writers:

“The most fundamental and compelling motive for writing is for the sheer love of it. Some people feel they were born to write, in the same way that others know from early childhood that they were born to climb mountains, to heal the sick, to do scientific research or to make music. Writing is their vocation, destiny or soul’s purpose; the one activity which brings them ‘into the flow’ and if they are prevented from doing it they will feel frustrated and unfulfilled.

Even if you do not feel quite such a passionate commitment, you may find that writing brings other personal benefits. These could include making sense of your life experiences and challenges, expressing emotion, exploring new subjects, exercising your intellect, or feeling that you are creating something original to form a lasting legacy of your time on Earth.

These inner rewards of writing can be seen as doubly important when you consider that it takes long hours of solitary work to complete a book, and that the fate of the eventual product is unpredictable. Finishing your book, getting it published, receiving positive responses from readers, and receiving royalty payments are all worthwhile outcomes and not to be devalued. But not all writers will achieve these goals. Some books are never finished; others do get finished but are never published; many of those that do get published are seldom read or reviewed; and few authors make a good living from their royalties. The market is currently supersaturated with self-published books many of which, however good they are, will be overlooked. So it is highly desirable for the actual process of writing to be perceived as satisfying and worthwhile. In other words it is just as important to enjoy the journey as to reach the destination.”

I hope my inspiration for writing will return again soon. Meanwhile, remembering what I put in the section on writers’ health, it is better to spend time walking outdoors in the bright sunshine of the New Zealand winter than sitting down at the computer.

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Fitbit and Zumba Gold

Having read a lot lately about the health benefits of exercise, and the health dangers of sitting down too long, I resolved to spend less time at my desk and more time on the move.

I replaced my wristwatch with a Fitbit Alta HR, in order to track my level of activity. I have always liked walking – though since getting a car I no longer do all the supermarket shopping on foot – so there has been no difficulty in meeting my goal of 12,000 steps per day. Sometimes I do more than that, and get a message on my iPhone about being an over-achiever. The Fitbit also provides heart rate data, and I was pleasantly surprised to be told that my cardiovascular fitness is “excellent”. Another pleasant surprise was that, assuming the reports are accurate, I sleep better than I thought I did and usually meet my target of seven hours per night. Fitbit also measures other physiological variables, and displays text messages, as well as telling the time. Whether wearing this sophisticated technological device does any harm to the body is not known.

So far well and good, but I know my physical coordination could be improved, so I have joined a Zumba Gold class. According to Wikipedia, Zumba draws on diverse traditions including cambia, salsa, merengue, mambo, flamenco, chachacha, reggaeton, soca, samba, hip hop, axe and tango. The “Gold” version is less strenuous than the others, being designed for older people and beginners. Along with about 15 other ladies of a certain age, and the occasional lone male, I spend an hour a week trying to follow the teacher as she dances along with the upbeat music. Hopefully, if I keep practising, the moves will become easier to follow and the class will be more fun.

I already quite enjoy Zumba, certainly much more than I ever enjoyed sports and gym at school. But, apart from walking and swimming in the summer, I have never been very keen on taking exercise for its own sake and am in no danger of getting obsessive about it. Besides, too much exercise can be bad for the joints and the heart. There are other ways to keep well, and a research finding that especially appeals to me is that proximity to a purring cat not only reduces stress, but can improve cardiovascular function and even help to prevent osteoporosis.

Homer: rest in peace

clare & homer

Sad news for the many friends of Homer the cat.  He had developed an untreatable abdominal lymphoma, and yesterday the heartbreaking decision to euthanise him was made.

Being officially my cat, he has been buried in our back garden, though he never really regarded our property as his home.  After many wanderings he settled with my mother Clare (pictured) and they spent several happy years together until she died in 2015. After that he chose to live in turn with two younger couples, both of whom cared for him lovingly and are devastated by his loss.

To read more about Homer’s remarkable life, search for his name on this blog.

Wounded healers

During my medical career I met several doctors and nurses who had achieved excellence in their work despite – or maybe because of – health  difficulties of their own. I am sure I could not have coped so well as they did, but my recent experiences of the patient’s role have made me wonder what it would have been like if I was still in practice.

The term “wounded healer” is usually attributed to Carl Jung, who used it in a psychological context. Many of those who choose psychotherapy or counselling as a career are seeking, consciously or not, to cure problems of their own. If they have insight into these and have taken steps to resolve them, it may make their work more effective. If not, they risk causing further damage to their clients.

The term is also associated with Chiron, a figure from Greek mythology, who suffered from a chronic physical wound as the result of a poisoned arrow. He was able to heal other people but could never cure himself. I don’t know how Chiron felt about this, but many of today’s clinicians would be embarrassed by such a scenario – in line with the mantra “physician heal thyself”, there is a widespread assumption that healthcare professionals should not be ill themselves. Some patients do lack confidence in staff who have something evidently wrong with them. Others feel comforted to know that their attendants are vulnerable to the same ills as the rest of humanity, and encouraged to see them overcoming their limitations and carrying on their careers.

Compared to those in robust health, clinicians with personal experience of ill-health tend to be more sensitive and empathic, which within limits is a good thing but if taken too far can lead to over-involvement, excessive self-disclosure, loss of objectivity, and emotional exhaustion.

There is also the question of fitness to practise. There are both legal and ethical imperatives to give equal opportunities to those with illness or disability, and not discriminate against them. At the same time it must be acknowledged that they may be less capable of work than their healthy peers. Every case is different depending on the skills required in the specialty concerned, the nature of the physical and/or mental symptoms, and the time course of the condition – whether there is a chronic but stable handicap, or an episodic illness with recovery in between attacks. Whatever the diagnosis, it is likely that stamina will be impaired.

The main points that stand out from my own experience of the patient’s role relate to communication. I realised first-hand what a big impact the words of a healthcare professional can make; a casual or clumsily phrased statement regarding diagnosis or prognosis can stick in the patient’s mind, whether instilling fears that may prove unfounded, or providing reassurance that turns out to be false. Also, that the position of the patient’s relatives needs to be acknowledged, and considered in management of the case. Of course I knew about these things before, though I don’t recall being taught anything about them in my medical school days, and did not fully appreciate them till later in my career. Today’s students get more training in “soft” topics like communication skills, and hopefully do not need to wait till they or their loved ones are seriously ill to understand their importance.

Murder in the Library

Last night, along with two of the other authors entered for this year’s Ngaio Marsh Award, I had the pleasure of taking part in a “Murder in the Library” event in Takapuna. Besides describing our own books, we discussed some questions about crime fiction in general.

My husband came along for moral support but he is not a fan of this genre, and had asked me privately why on earth people enjoy reading novels about something so unpleasant as murder. I agree it is a challenge for writers to create entertainment out of such a serious subject. But crime novels are enduringly popular, and I think there are several reasons for this. They have a clear structure and focus, with a mystery to be solved and a solution at the end. They can provide insights into criminal psychology, and raise ethical and moral issues. The good ones have interesting characters and settings as well as convincing plots.

The crime genre as broadly defined covers novels of many different kinds. The traditional whodunnit, often featuring a private detective who is more competent than the police, begins with discovery of a body and ends with unmasking of the killer – usually the most unlikely of suspects from a circle of middle-class characters. This format may now seem old-fashioned but the books of “Golden Age” writers such as Agatha Christie are still very readable. Modern sub-genres of crime fiction are many: cosy, hard-boiled, police procedural, courtroom, spy, psychological thriller, and “noir” from diverse places including Scandinavia, Scotland and New Zealand.

There may be an overlap with other fiction genres, as with my own entry Unfaithful unto Death which combines crime with black comedy, and touches on the themes of corruption in medicine and the pharmaceutical industry. It could almost qualify as a historical novel, because I wrote the first draft in the 1980s following a spell of working as a doctor in general practice in rural England. I had nearly forgotten about the manuscript until I found it among some old papers last year. Reading it through again, parts struck me as rather outrageous compared to my more recent work, and the practice of medicine has certainly changed a great deal since it was written. All the same I decided to publish it without changing the content too much.

The protagonist is Dr Cyril Peabody, who also made a brief appearance in my other two 1980s novels. He is a clever and hard-working doctor who means well but has developed a hefty dose of the arrogance and cynicism which besets his profession, and his bedside manner is appalling. Having failed to gain promotion as a hospital cardiologist because of his awkward personality, he takes what he considers to be an inferior position as a country GP. Predictably he soon clashes with his partners, his patients and his wife. He sets out to improve his status by mounting a trial of a new drug, but finds it has some unexpected side effects. One of the men who has been taking it dies, apparently from a heart attack. Cyril is called to his house in the middle of the night. Having examined the body and considered the history he decides that a post-mortem is indicated, but encounters vehement opposition from the dead man’s wife …

As discussed in a previous post the medical setting provides ample scope for murder both in fiction and in real life.

Medical murder in fact and fiction

Having one of my medically themed crime novels entered for this year’s Ngaio Marsh Award has led me to reflect on the topic of murder in healthcare settings.

Deliberate killings by doctors or nurses, though rare, are probably more common than can ever be known. Clinical staff are better placed than most people to get away with murder. They have ready access to drugs, anaesthetic gases and surgical instruments, and deaths due to these agents can easily be passed off as natural or accidental. They are privileged to know intimate details of their patients’ lives. And as members of trusted professions they are not readily suspected.

Among the most notorious murderers of modern times was Dr Harold Shipman, who incidentally trained in the class ahead of me at medical school in Leeds in the 1960s. He was found guilty in a court of law of murdering 15 patients in his single-handed general practice and it is likely that he killed many more over his long career, usually by injecting large doses of diamorphine. The estimated number of his victims was 250, most of them being elderly women who were in good health although he fabricated a diagnosis of serious illness on their records. The nature of the mental aberration that led him to commit all these crimes is unknown, because he continued to deny them up until the time he hanged himself in his prison cell. As a result of Shipman’s case, much stricter controls were imposed on medical practice in the UK.

Other convicted serial murderers from medical settings have been nurses, popularly dubbed “angels of death”, working in hospitals or care homes. Their crimes usually masqueraded as mercy killings, but rather than arising from any genuine sense of compassion for someone whose incurable illness was causing unbearable suffering, they were committed for the perpetrators’ own satisfaction and without the knowledge or consent of the victims or their relatives.

Psychiatric evaluation of medical murderers would usually lead to a label of psychopathy, or personality disorder: the lack of moral sense, the inability to feel empathy, the enjoyment of killing, the grandiose belief of having a right to decide that certain persons are not fit to live. These are the extremes of the arrogance, cynicism and wielding of power that are occupational risks in medicine and related professions. Hallucinations and delusions secondary to psychosis or drug abuse are sometimes implicated.

Most if not all murderers are found to have a psychiatric diagnosis of some kind, and this may be sufficient to explain their crimes. In the context of fiction, however, using mental disorder as the sole reason for killing would usually be seen as a cop-out. Readers of crime novels expect a murder mystery to have a more complex solution,  perhaps involving money, sex, revenge, or concealment of discreditable secrets. These motives may of course account for real-life cases too.

Some would say there is a fine line between deliberate criminal killings and the various other forms of unnatural death that can occur through the actions of medical personnel. Some result from malpractice, others are sanctioned by law in certain jurisdictions. They include euthanasia, abortion, execution, experiments such as those carried out in Nazi Germany, drugs or surgery used inappropriately for commercial gain, and simple carelessness or incompetence.

My novel Unfaithful unto Death is intended as a light read with elements of black comedy, but touches on some of these serious themes.