Potential Harm of Self-Help

The reason you want to be better is the reason you aren’t.
Do you still think you can be happy by trying to be happy?
Allan Watts

My father died while a participant in an experimental cancer study. His previous attempts at chemotherapy unsuccessfully curtailed the spread of cancer, and unbeknownst to my mother and other family members, including myself, he had metastases to other organs in his body. Before consenting to the study, he shared with me all the forms detailing the potential risks and benefits of this experimental protocol. Soon after initiating the treatment, he grew weaker and, on several occasions, collapsed, causing him to be rushed to the hospital. Both the consulting and the hospice oncologists recommended ending the drug trial, yet his own doctor swooped in and convinced him to continue. Reviewing the list of potential side effects of that drug, my father experienced about 90% of these, and to this day, I believe this experimental treatment hastened his death. While accompanying him to one of his regularly scheduled visits to the cancer center, I voiced my concerns about these mounting side effects to his oncologist, who was quick to reply, Well, we’ve got to give him something.

A month later, once all his providers agreed that continuing this course of treatment only created more harm, my father found himself in hospice. In fact, this was the topic of the very last conversation he and I had by phone before he slipped from consciousness. Are they giving up? he asked. No, I replied. They (and we) want to focus on your quality of life. And there, in those few words, lie the crux of our challenge in healthcare and in life. People hear those words and interpret them to mean giving up, which translates to inactivity and lack of engagement, doing nothing. The irony, however, is that addressing the quality of one’s life is the perhaps the most challenging undertaking of all. Focusing on the quality of life requires you to confront how you orient and engage with the world and whatever is arising in each moment, and when the world around us seems to prize and value quantity and the never-ending acquisition of more, quality seems difficult to come by.

I chose naturopathic medicine because I deeply believed that lifestyle factors and practices impact health. What adult doesn’t acknowledge, on some level, that whole food, fresh water, daily movement, restful sleep, close connections with loved ones and supportive friends, and meaningful work would go a long way to create balance, if not improved wellbeing, in their lives? Whenever people talk about how stressful their lives are - and they quickly add how said stress is “killing” them - what follows is a detailed explanation of how these factor (food, water, air, time with friends, positive work experiences, etc.) are lacking or at least neglected in their current pursuit of the health. I am convinced that many of us have been conditioned to automatically respond to the simple question of How are you doing? with some mention of busyness, and to be utterly honest, I include myself among the lot. It’s as if we are players in the Suffering Olympics - whoever is the busiest wins, whoever is doing the most succeeds. But what is the prize? Increased headaches, more intense ulcers, elevated blood pressure, longer stretches of insomnia and chronic pain?

My professional and academic career has centered around behavioral health, and yet I feel compelled to call forth a precarious downside and harm inherent, not in behavioral health itself, but, in how behavior and habits are presented, discussed and embraced. I have witnessed all too many times the disdain in healthcare providers when discussing a patient’s medical history:

If they would just stop smoking…
Would it kill them to eat a vegetable once and awhile?
Just drink 1 glass of water a day, just one (a behavior I found myself pleading with my mother to consider for decades).

With integrative physicians and holistic practitioners, such narratives change ever so slightly, yet the fundamental message remains consistent:

Well, did you give up gluten and dairy yet?
Have you gone keto (or paleo, or vegan, or…)?
Sitting is the new smoking; so you are getting up every 20 minutes or so, right?

For me, naturopathic medicine promised an individualized approach to healthcare. Before moving to Seattle to attend Bastyr University, a doctor I was dating at the time tried passionately to dissuade me from a career in medicine. You’ll just be spending most of your time trying to convince middle-aged women to exercise or eat better. And they won’t listen! With an unfounded pride based on absolutely nothing, I puffed out my chest and declared, But I am going to be a naturopathic physician! Looking back, I had no clue what was behind my zeal other than the mere justification and defensiveness about my upcoming career choice.

Throughout my education we were told to look at the individual in their entirety and customize our treatments on their specific psychophysiological make up, ensuring to get a comprehensive and detailed history and workup which often included appropriate lab testing. That was party line, anyway. I still remember that in the 90s small frequent meals to regulate blood sugar was all the rage. While reminded to adjust accordingly for the individual, general recommendations seemed standard across the board. Other colleagues dove more deeply into lab work and genetic markers to dictate lifestyle choices such as nutritional supplementation, dietary guidelines, exercises practices, and the like. This was considered to be more individualized. As I have already said, what person wouldn’t benefit from the broad strokes of fresh and clean food, water and air, accompanied by daily movement, deep meaningful connections and inspired work? These are foundational. However, I question whether advocating small frequent meals fits within the parameters of those broad strokes for all people. I raise this example since fast forward 30 years and now almost all my patients speak to me about intermittent fasting. To be clear, I am not saying that this is without merit. Furthermore, I have heard some supporters of this eating schedule discuss individual variations and for whom this might be beneficial practice. Overall, I cannot help to see this trend as another new fad in medicine. Does this mean that all the studies that we used as evidence to support small frequent meals were invalid and should be thrown out? That the research now is far superior and without fault to the data collected then? As I mentioned, my issue is truly not with these recommendations specifically, but rather the ways in which information is delivered and how we orient to our overall health and wellness in general. The art of creating an individualized plan lies in treating the person, not the symptom or disease.

A huge shift in my perspective in healthcare emerged from learning Motivational Interviewing (MI) through the public health department. Even with my background and education in humanistic psychology, cognitive behavioral therapy and Buddhism and contemplative practices, what enticed me about MI was the de-emphasis on the actual behavior and a greater focus on the core motivation for change. As a physician whose primary treatments consisted of lifestyle practices, this was a powerful jolt to my thinking. Until then, I assumed that patients came to the office to listen to the provider’s words of wisdom (advice) and comply. Give them enough encouragement, support and evidence about the reason to adopt the new behavior, whether diet, supplementation, exercise, meditation, etc., and they would fall into line. Obviously, I failed to recognize how such thinking even failed to apply to myself. How often did I know, I mean truly know and have the direct experience, that a particular behavior impacted my physical well-being. Spare you the specific details, I knew that when I ate dairy in any form, I would experience severe gastrointestinal distress. Yet it took me over 6 months to fully eliminate it from my diet. I knew that if I do not go to bed before 11 PM at the latest, I would likely remain awake until about 2 AM, and regardless my internal alarm invariably wakes me by 6 AM at the latest. This knowledge and first-hand experience did little during college to deter me from staying up for fear of missing out.

I am reminded of a woman with whom I consulted who suffered from debilitating inflammation and arthritis aggravated by food. While other factors compounded her health, consuming milk products in any form resulted in the need to use a cane or a walker just to get around her apartment. Opening the door to my office to meet her in the waiting room, my eyes fell on that gray aluminum device perched before her. Slowly maneuvering her way into my office, she fell into the chair and with an expression and tone of a child telling her father she broke the cookie jar, she said, Last night I ate a quart of ice cream.

If you have read this far, I admit my words are priming you. Yet if you can stop for a moment and reflect, What is going through your mind right now? What thoughts immediately pop up? If you were her physician, how would you respond?

Later that week, I shared this exchange with my medical students, providing them her back story, medical history and the exact words she said to me. I then asked, What would you say next? Comments flew at me like a deluge, all sharing a fairly consistent theme:

Did you talk to her about soy (or coconut, or rice, or cashew, etc.) ice cream?
Did you talk to her about moderation? She can eat maybe a few spoonfuls, but a quart (yes, she did say quart)?
What digestive enzymes is she taking?
Does she know about turmeric or curcumin?
Somebody must have talked to her about fish oil?

If intermittent fasting were in vogue at the time, I am certain someone would have mentioned that, too.

Finally, I shared how on that particular day, without skipping a beat, my response to the human being sitting in front of me was, What flavor? Her tone instantly brightened as she looked up, smiling and making eye contact for the first time since she dragged herself into my office, and said
Rocky road!
Well, I hope you enjoyed it!
It was good, her smile fading a bit.
I waited a bit before adding, So how did that help you? What was the overall benefit?
Swiftly, with a jaw tightened and she managed to squeak out, It is the only time I feel joy and love in my life.
Then no argument here, I replied softly. Why and how would I, or anyone, for that matter, tell you to not eat it?

In MI we call this impulse, this drive to fix the problem and fix the patient, the Righting Reflex. However, decades before Motivational Interviewing was formalized, Freud wrote about this same concept in 1914 in the Technique of Psychoanalysis:

“One of the most serious resistances to psychoanalysis arises from what might be called the ‘furor sanandi’ of the physician, his passion for healing, which is apt to make him forget all the difficulties of the task and all the limitations of his powers.”

He went to add…

“Human society has no more need of the furor sanandi than of any other fantasy.”

Just like the righting reflex, furor sanandi is a rage to cure, a passion or frenzy to heal. According to Freud, this passion to heal and fix is an essential ingredient and overall universal problem in the motivation for everyone in the helping professions. Yet make no mistake, healthcare provider or not, this drives rages within us all, frequently directed towards ourselves.

My students, in their compassionate passion (or rage) to eliminate the patient’s suffering, were driven to offer suggestions about alternative forms of frozen desserts available. Yet such suggestions and advice may be received as perpetuating her already present guilt and shame, reinforcing the notion that consuming a quart of ice cream was wrong. She walked into my office already judging herself, repeating the narrative about how she failed (her internal furor sanadi writ large). But who did she fail? In her attempt to experience some modicum of joy in her life, she was taking steps to take care of herself. Even if these attempts resulted in inflammation and limited mobility, she experienced some positive feelings, albeit for a brief time. Who reading this can’t relate? Don’t we all do the exact same thing on varying levels? We engage in some behaviors simply for the immediate payoff, as it either leads to momentary pleasure or maneuvers us away from pain. How much of our life is built on such motivations?

This passion to find the right formula is so strong and enticing we continually admonish ourselves (and others).

How hard can it be to turn off your cellphone an hour before bed? Blue lights prevent you from sleep and will kill you.
Do your breathing 20 minutes twice a day, period. Don’t you want to get better?
Cold showers - everyone should be doing cold showers… but first use the infrared sauna.
You MUST meditate. The more you meditate the better, faster, stronger, clearer you will be.

And for consistency, let’s add…

Intermittent fasting is the key to weight loss and a happy and more vital life!

What I hear in these words is the underlying belief in and prioritization of some idealized state. If you just push harder, try more, do more than you will reach nirvana. Of course that begs the question, whose nirvana? Who’s ideal are we trying to attain? At the beginning of the HIV epidemic, several groups denounced the conventional retroviral cause of the infection. Alongside those loud critics were individuals preaching that if you truly loved yourself then you not only would stay healthy and symptom free, but if symptoms ensued, you could heal yourself of HIV, which meant rid it from your body. In the mid-1990s, one such man who was in a discordant couple (his partner was HIV positive, while he was HIV negative) told me in no uncertain terms that if he was spiritually sound and emotionally balanced, then he would not seroconvert. My refrain was, “And you can use a condom.” To which he would counter, “But I won’t need one if I am spiritually sound.” “And spiritually sound people can still use a condom,” I would reply. Our back-and-forth call and response got us nowhere. In part because I stopped listening and failed to engage with the person before me. I did not seek to explore his beliefs in more detail as I was thoroughly ensconced in my own righting reflex, my furor sanandi blazing bright. As I later learned, arguing and trying to convince someone of your viewpoint prevents us from being present or listening, and rarely works. Needless to say, 6 months later, he seroconverted. His beliefs around the infectious nature of the virus have since changed, but at the time his initial reactions of self-loathing and self-judgment did not concern his HIV status, but rather his failing to be spiritually and emotionally pure. Heart wrenchingly, to this day I hear numerous men and women speak about their failings at self-compassion, self-love, and self-acceptance when whatever disease they are living with continues to progress. Witnessing people denigrate and judge themselves for lacking the skills to do the very thing that was supposed to heal them is confounding and is seemingly downright abusive. Any such therapy, theory or practitioner that perpetuated such a mindset to me seems damaging and harmful rather than helpful. Compounded by curated social media, many mentally rehearse the narrative that if they just loved themselves more, then they, too, would have that desirable life seen splashed across the feeds of the young, beautiful, healthy and rich. Do it right and everything will miraculously get better, that all dis-ease can be cured. I kindly remind people that The Buddha, or so I have read (the veracity of which I am unsure), reportedly died of food poisoning. How could he not have prevented it or cured himself? To this, my Buddhist friends reply, he was unattached to the outcome - he was unattached to this life. That might be the case, and I should note, my Buddhist friends are rarely the ones claiming that self-love, positive affirmations or visualizations would cure HIV, COVID or any other disease.

So what are you chasing? What is your attitude and orientation to this exact moment? In what ways might you be consciously or unconsciously reinforcing the perspective that you are still somehow deficient, less than, or lacking? Are you whispering or screaming to yourself about the need to follow some prescribed simple steps to cure all that ails you? What if instead of fighting the reality of this moment you were able to pause and breathe? And not breathe to lessen your stress, be more relaxed, or to increase your HRV (heart rate variability), but breathe as an intentional act of self-discovery and presence? Please don’t misconstrue my point. I am not advocating for inactivity. After all, breathing into this moment is an action, acceptance is a behavior. Rather than trying to fix anything my motivation is that we learn how to breathe fully into our lives, create more awareness of how we are orienting to this moment, and then armed with that insight, engaging more aligned with our values. This requires dedicated practice. As Aristotle wrote, We are what we repeatedly do. Excellence, then, is not an act, but a habit.

In no way am I denouncing the desire for growth and personal development. For I believe that suffering, not pain, but suffering, arises in a large part from our automatic conditioned responses, and that through the dedicated practice of inquiry and insight we can take steps to lessening suffering. My contention here is that much of the personal growth and self-help movement, and this includes functional medicine, holistic health care, biohacking and the like, tend to promote self-judgment and shame through their battle cries of You are not enough, you need to do more, you need to be more (and its variation - Be all you can be)! By continually dangling the promise of transformation, beauty, health and harmony, you can have the life you most desire. The Garden of Eden awaits you, just follow these easy steps. All the while we are constantly assessing and ruminating about the next step in the process. Should our cancer progress, our pain persists, our blood pressure remains elevated, then we just didn’t do it long enough, intense enough, or perfectly enough. Again, quantity.

As always, I am advocating a pivot, a perspective shift. The intent has more to do with the how than the what. Coming back again to my dad, his final round of chemotherapy was followed by another PET scan to determine the status of his cancer, after which he was sent home and instructed to relax, take it easy and wait for the doctor to call with the results within a week. Over the years I have sat with hundreds of people as they awaited such lab results. You might argue, Well of course I would be anxious, a mess, a wreck. I am waiting to see if the chemo worked, my status has changed, my blood markers have dropped? The fact of the matter is how you orient and breathe into this experience differs dramatically from person to person.

I was with my father when he died. All our conversations over the course of my lifetime, as well as the more pressing ones during his last 9 months, color my experience of his death, and in my mind, he died suffering. Nine months earlier, when he was diagnosed with stage 4 small cell carcinoma, the first things he said to me was, I just need 9 months. Nine months to get things in order. He wanted to get all his affairs in place for my mother. Sadly, this did not happen, and I believe this weighed on him so heavily, that he never told his children of some vital realities with which we, namely my sister who was the executor of his estate, would spend years navigating. I believe that my dad died with the belief he somehow failed - failed as a husband, a father, a businessman, an adult. Desperate for a different outcome, he continued working right up to the end. Quantity, not quality.

How do you wish to breathe into your life?