He is the author of The People’s Pharmacy, and the drugs editor of Medical Self-Care Magazine.

TF: You were saying that you first got interested in helping laypeople learn about drugs because your friends used to ask you questions.

JG: Yes. When people learned I was a pharmacologist, friends, neighbors, and complete strangers would have all these questions about the drugs they were taking: “the little blue pill I’m taking for my high blood pressure,” “the little white pill for depression,” and so on. And when I asked them the name of the drug, they practically never knew. I was struck by how commonly people take drugs—some of them very potent ones—completely on blind faith. They didn’t know the first thing about them. They didn’t know the side effects, they didn’t know the possible interactions with other drugs. In many cases they didn’t even know exactly what the drug was supposed to do.

They certainly wanted to know, but their doctors just weren’t making the information available. And I began to realize that there were a lot of people out there who wanted to know about drugs. who weren’t getting the information they needed from the people who should be supplying it. So I thought, who better than a pharmacologist with a special interest in communication to try to provide some of this information.

What are the most important things for people to know about drugs?

The first and foremost thing is not to focus exclusively on drugs. If you have an ailment, the most important thing is to understand what’s going on and how it relates to the rest of your life. First, try to understand the problem, its causes, its signs and symptoms. Then you can go on to possible ways of treatment, with drugs being just one possible kind of treatment.

What are the things a person should be sure to ask when his doctor wants to prescribe a drug?

You should ask whether the drug is intended to give purely symptomatic relief, or whether it will actually help the body cure the underlying ailment. People tend to focus exclusively on side effects, and while that’s vital, it’s also crucial to know what the anticipated benefits are. Any time you’re considering taking a drug, you’ve got to weigh potential benefits against potential drawbacks.

And that would be true for over-the-counter drugs as well.

Yes. Another thing you should always do when your doctor wants to prescribe a drug for you: Know the name of the drug. That should be an absolute rule. It sounds simplistic, but it’s frequently not provided to the consumer. Make sure that your doctor pronounces the name of the drug so that you can understand it, and pronounce it back. Many drugs have difficult names.

And have your doctor write the name of the drug down for you.

Yes. And not only write it down, but write it down legibly. It’s not going to help too much if it’s an unreadable scrawl. Any health worker who prescribes a drug should not let the client go out of the of office without having in his or her possession the name of the drug, typed or neatly printed. Ideally, they should also be provided with a sheet of written information about that drug.

If the drug is prescribed by brand name, your doctor should also write down the generic name of the drug. And if it’s a combination product, he or she should write down the name of each ingredient.

What else should people know besides the name of the drug?

Find out precisely how to take it. “Before meals.” is not specific enough. You need to know exactly how long before meals. Find out the reasons behind these instructions so that they make sense to you.

How about side effects?

That’s the next thing. Be sure to find out about all the common side effects, whether they’re serious or not. Also be sure to find out about any dangerous side effects—no matter how infrequent.

I’m not going to be worried about a very minor side effect which occurs in one out of two thousand people. But if 20 percent of the people taking the drug feel drowsy? I want to know.

I’m also going to want complete information on very rare side effects, if they’re serious ones, even if they only occur in one out of ten thousand people. I’d want to know what the early warning signs are for the serious side effects.

I guess the other thing would be possible drug interactions.

Yes, and this is more of a problem than ever because so many people are taking more than one drug— sometimes prescribed by different doctors. I’d want to receive a list of all the drugs and foods that might interact with the drug I was taking.

I think it’s vital for the prescriber to give not only verbal information but written material to take home. There’s a wonderful book available for exactly this purpose. It’s called Drug Information for Patients, by H. Winter Griffith. It’s published in a looseleaf binder with removable pages so that a health worker can remove the appropriate pages, copy them on the office copying machine, and give the client a copy. It gives information on taking the drug, possible side effects, how the drug may interact with your activities of daily living, how to store the drug, refills, and dealing with overdoses.

Are there any completely safe drugs?

No. There are potential problems with every drug. Both doctors and their clients are at risk of being lulled into a familiarity-breeds-contempt kind of attitude. If your doctor has prescribed a drug a number of times and no one has ever complained of any side effects, he may begin to assume it’s completely safe, and may no longer feel it necessary to warn people about side effects. But every person responds differently and you may have a side effect even though none of your doctor’s previous patients did.

Incidentally, this is an excellent reason for letting your doctor know about minor side effects of a drug you’re taking—if you don’t tell him, he might not think to warn the next person for whom he prescribes that drug.

What are the important differences between prescription and nonprescription drugs?

It’s a somewhat artificial distinction. There are a number of drugs, presently available only by prescription, that will soon be available over the counter, such as Benadryl (diphenhydramine hydrochloride), an antihistamine. The more potent or potentially dangerous the drug, the more likely it is to be available by prescription only.

I think that a number of drugs that now require a prescription could be made available over the counter—if the buyer was provided with good, clear information on how to use them.

I think the idea of increased access to a limited number of drugs is very exciting. The number of effective pharmaceuticals available is much smaller than most people think. We have thousands of drugs. But there are only about three or four dozen really widely used and effective therapeutic agents. The average physician prescribes only about two dozen on a regular basis.

I have no doubt that with an effective medical education program in our schools, we could have high school graduates with a level of drug expertise sufficient to safely use many, many drugs that are now available only by prescription.

You were saying that you felt we relied much too heavily on drugs. Why is that?

I think there are four main reasons. Number one is the huge amount of money spent on advertisements for over-the-counter drugs. Kids grow up thinking that pills and potions are the answer to health problems—a pill for your headache, a cream for your hemorrhoids. Just count the number of drug ads on television in one week. You’ll be astonished.

Number two is an even more intense effort by drug manufacturers to advertise their products to doctors. There are thousands and thousands of detail people who do nothing but go around to doctor’s offices pushing their companies’ drugs. Almost every major medical journal, including the most reputable ones, contains gobs and gobs of very impressive and expensively-done drug commercials. That can’t help but have a big impact on doctors’ prescribing habits.

Number three is the way health workers are educated. Prevention and nondrug treatment are either ignored or given lip service. The message we give health workers is that there’s a pill for every ill.

Number four is the pressure from the very nature of the clinical visit to give a prescription. The doctor has perhaps ten or fifteen minutes to see each patient. That’s not enough time to even begin to ask how the current problem relates to the rest of their lives. You can’t even begin to think about prevention. That’s barely time to take a brief history, check your blood pressure, and write a prescription.

And a lot of people will feel cheated if they get advice instead of a prescription.

Absolutely. A lot of the pressure comes from the client. We live in an “instant” society today—with instant hamburgers and instant checking. So when we’re ill, we expect instant relief.

There’s an economic pressure, too. The doctor who’s charging you fifty dollars for a fifteen-minute visit is going to have a lot of difficulty prescribing aspirin— even if that’s the best and safest remedy. The person could have done that much for himself.

How can we get away from these patterns?

I think that people have to learn some basic clinical medicine. 1 think that health workers need to help them do this—by stepping out of their authority roles and sharing their uncertainties and their doubts.

I think that medical education needs to stress nondrug treatments. If someone comes in with high blood pressure, most doctors’ first thought will be to prescribe a thiazide diuretic, but a much more appropriate first step might be to recommend that the person lose weight, begin exercising, quit smoking, cut down on salt intake, learn new ways of dealing with stress, or apply some combination of these self-care approaches. The drug should be used only as a last resort.

You were saying that our health workers are being trained in a professionally- and pathology-centered medicine rather than in a client-centered medicine. What would a client-centered medicine be like?

Some health workers are already practicing client centered medicine. For instance, someone seeing a person with an ailment might ask, ”What’s worked for you when you’ve had this problem before?” Maybe the person has used hot baths for menstrual cramps or an over-the-counter remedy for indigestion. If a person has strong feelings against pharmaceuticals, an herbal remedy or a homeopathic remedy may be more effective—for him.

I would think that one good local resource for information on drugs would be your local pharmacist. How can a person best use their pharmacist?

The pharmacist is probably the most overlooked and underused health professional. It’s a shame, because not too many years ago, the pharmacist was a respected and important source of drug information within the community.

One of the big problems is the way pharmacists are used in the big chain drugstores. The center of these stores is devoted to selling fishing tackle and cosmetics and motor oil, while the pharmacy is stuck in some little corner way in the back. The pharmacists are kept out of sight, filling ”scripts,” as prescriptions are called, as fast as their hands can move. They frequently receive incentive pay for the number of scripts filled in a day, and they’re not encouraged to spend any time giving people drug information.

This is a very sad misuse of talent, because the pharmacist is a well-trained pro who is perfectly capable of answering most questions on prescription and over-the-counter drugs.

This assembly-line approach allows the chain stores to charge less for prescriptions—which makes survival difficult for the old-fashioned pharmacist. With a small pharmacist who runs the store himself, you can develop a useful, personal relationship. Look for an individual who is good at communicating and is willing to take the time to deal with your concerns. Ask your friends about the pharmacists they use. And once you find a good one, let him know you appreciate his services.

So you’d advise trying to understand a particular symptom instead of just trying to get rid of it.

Sure. Symptoms are an early warning signal. Eliminating symptoms without paying attention to the underlying process that’s producing the symptom is like putting a penny in the fuse box when a fuse blows. The next warning is likely to be something a lot more heavy-duty.

That doesn’t mean I think we should all be masochists. If you’ve got a headache and you know it’s from stress and muscle tension, there’s nothing wrong with taking aspirin. If you have severe menstrual cramps, codeine may be very effective. If you have diarrhea, you may decide to take codeine or Lomotil even though you know that the diarrhea is helping to cure you of something else—because the inconvenience just isn’t worth it. And there are some cases in which a drug actually attacks the root of a problem instead of just removing a symptom. If I had a bad sore throat, I’d have it cultured. If the culture grew out strep, I’d be the first in line to get some penicillin.

It should always be a carefully weighed decision whether or not to use a given drug. And I think that it should be the informed consumer who ultimately makes those decisions.

What other kinds of products are available in drugstores that might be good self-care tools?

One very promising tool is the dipstick sets that allow you to test your own urine. They provide a number of easy, inexpensive, completely safe screening tests for excess sugar, blood, or protein in the urine.

Another device now being tested is a tampon which will allow women to collect menstrual blood and cell samples to be sent in to a laboratory and examined for evidence of cervical cancer. If the present testing goes well, it will be marketed under the trade name Ascend.

I highly recommend blood pressure cuffs for home use. Some of the new automated models make a stethoscope unnecessary. Having a cuff at home is particularly helpful if you have high blood pressure and are working on controlling it on a self-help basis— through such approaches as weight loss or exercise or stress reduction or quitting smoking or meditating, or a combination of these methods. The cuff provides a kind of biofeedback, rewarding you by letting you see the immediate results of your efforts. And people taking blood pressure medication can help adjust their own dosage of the drug if they can monitor their own blood pressure at home.

Another new kit allows you to test your own stool specimen for traces of blood. This test is highly recommended once a year for persons over forty. You just touch the fecal specimen to a piece of moistened test paper, and if blood is present, the paper changes color.

What drugs should be kept on hand at home?

If I could take only one drug with me to a desert island, I’d take codeine. It can be used to relieve quite a few common, distressing medical problems.

Codeine is good for pain—a toothache, a headache, or bad menstrual cramps that aspirin won’t handle. And codeine plus aspirin has an additive effect, so that both together are especially powerful. Codeine can also be used to control diarrhea.

Codeine is a prescription drug in most states, so you’ll have to get your doctor to prescribe it for you. You don’t need much, and if you ask for a whole lot, your doctor might start thinking you’re a drug addict. Ten 30-mg. tablets should be plenty. Take a whole tablet for serious pain, half a tablet (15 mg.) for a cough or diarrhea. At our house we go through maybe one or two tablets in a year.

While it is true that codeine can be abused, it is almost never habit-forming in the doses we’re talking about. Drug companies have made millions by playing on the fears of people and doctors by claiming that their expensive preparations are safer than the older and much cheaper codeine.

If your doctor resists prescribing this cheap and effective medicine, make sure that he does prescribe some Lomotil for potential traveler’s diarrhea and something like Capital with codeine or Tylenol with codeine for pain.

The one caution would be not to use codeine—or any other painkiller—for a pain of unknown origin. If you had an inflamed appendix, for example, a painkiller might make it hard to diagnose what was really going on.

What else belongs in a home medicine chest?

I always keep some Tinactin (tolnaftate) handy. It’s one of the best antifungal agents for athlete’s foot or jock itch and it’s available over the counter.

People troubled by motion sickness might want to include Dramamine (dimenhydrinate). It’s an antihistamine and may cause sleepiness. Another antihistamine, Phenergan (promethazine), available by prescription, is a stronger antidote for motion sickness, and has such a strong sedative effect that it can do double-duty as a sleeping pill. Don’t try to drive or operate machinery while taking this one.

For occasional indigestion, I use a little baking soda in half a glass of warm water, but that’s not for people with high blood pressure because of its high sodium content. For chronic indigestion I’d recommend any product with magnesium and aluminum hydroxide. Ask your druggist for the cheapest stuff that contains these two

Aspirin is a mainstay of any home medicine kit. I buy the cheapest aspirin I can find. You can also buy aspirin as a powder. Or you can crush regular tablets between two spoons. The crushed or powdered form may be a little less irritating to the stomach.

If anybody in your family has an acne problem, I’d recommend the cheapest product containing benzoyl peroxide.

If I had an allergy to bee stings, I’d definitely keep a couple of syringes with adrenaline around. You’ll need a prescription and your doctor will have to show you how to perform an injection. Some people don’t think they could ever do such a thing, but you’d be surprised how easy it comes when somebody’s life is at stake. More people die from allergic reactions to insect stings each year than do from snake bites.

There’s an excellent Emergency Insect Sting Treatment kit available from Hollister Stier Laboratories (P.O. Box 3145, Terminal Annex, Spokane, WA 99220). You’ll need a doctor’s prescription to purchase one. And if I lived in snake country, I’d have a snake bite kit around. These are also available by prescription from most drugstores.

If I had children in the house, I’d also have a poison antidote kit. The best one I’ve seen contains a syrup containing activated charcoal and syrup of ipecac. (But don’t use ipecac for all poisonings. It can be extremely dangerous in cases of corrosive or irritating chemicals or petroleum products.) The charcoal absorbs the poison, and the ipecac is an emetic—it makes the child throw up. The kit is available without prescription from Bowman Pharmaceuticals (Canton, Ohio 44702). I’d also want to have a poison antidote wheel. You dial in the poison that the person swallowed and it tells you what to do. There’s a good one available from SlideGuide (Box 241. Pacific Palisades, CA 90272).

For an occasional case of constipation, I’d have something containing either psyllium or methyl cellulose. Both of these work by increasing the bulk of your stool. They’re found in such products as Metamucil and Serutan.

For traveler’s diarrhea, I’d have some Pepto-Bismol. There’s good evidence that one of its ingredients, bismuth subsalicylate, really works for this annoying problem.

A lot of people report that thiamine, Vitamin B-1, taken orally, will keep away fleas and mosquitoes. There have been no controlled studies on this yet, but the existing evidence is impressive. If I had problems with these critters, I’d keep some thiamine around the house.

For preventing sunburn, anything containing para-amino benzoic acid is good. Pre-Sun is probably the best buy.

A paste made up of meat tenderizer and water is a good treatment for insect stings. And, of course, ice is the best emergency treatment for minor burns, bumps, sprains, and bruises.

To return to the doctor-patient relationship again . . . whose responsibility is it to make drug decisions?

I don’t mean that laypeople should never take drugs, but that the decision to take a drug should be their decision. Sometimes it may work the other way. Sometimes a doctor may not want to prescribe a drug that a person wants.

After writing a recent column in which I criticized the widespread use of estrogen for menopausal women, I received a letter from a woman who had been using estrogen.

“Mr. Graedon,” she wrote, “You have no idea what it’s like to have hot flashes. It gets so bad that sometimes I just can’t stand it. They’re so unpleasant and they upset my life so badly that I’m willing to take a risk and use estrogen for a limited period of time. And I don’t think you have any right to tell me not to.”

And she’s absolutely right. She’s looked into the available evidence about possible risks and weighed the risks against the benefits and has made the choice that’s right for her. She made the right choice because she went to the trouble of really informing herself.

Many doctors act as if choosing a drug is always the doctor’s decision.

And they’re taught to think that way. It’s not easy for doctors, because to support their clients to be self reliant health consumers, they have to unlearn some really deep-seated elitist attitudes. But some doctors are really working at it, they’re really trying to share their knowledge and their uncertainties.

I got a call the other day from a man who was in great distress. He had a skin condition that had been bothering him for three years. “It’s unbearable,” he said. “it’s gotten to where it’s preventing me from working. It’s really painful. I’ve gone the whole route of symptomatic treatment, and now my doctor’s suggesting that I consider going on methotrexate.”

Well, my immediate reaction was, “My God, you’re kidding! Methotrexate? For a skin condition?” Because methotrexate is a very potent antimetabolite with massive side effects. It’s normally used only in cancer therapy.

And he said, ”Well, my doctor explained it in great detail, and I’ve been reading up on the side effects. I think I understand what the benefits are and what the risks are.

”My doctor told me to take ten days and talk to anybody I could find—other doctors, anybody—to try to get any other suggestions or any other advice. That’s why I’m calling you, to find out what you think about the use of methotrexate for my condition.”

I’ll tell you, I was impressed by the way that doctor was taking the necessary time and giving the necessary information and support to help that fellow make his own decision about using a drug. I really had a sense that they were working as partners. And the doctor made it very clear that if the caller decided not to try the drug, he would not be insulted, and he would continue helping him in the best way he could.

We need more doctors like that.

Yes. And it doesn’t matter whether the drug under consideration is a very potent one like methotrexate or a widely used and relatively safe one. The doctor should supply the information and describe the alternatives, and the layperson should make the final decision.

What people do is to begin looking into their own hearts and into the eyes of those with whom they share their lives. And all too often they find that these aren’t places they’ve looked very deeply before.

Fred

We just spend some time with Fred, a 54-year old bus driver for Greyhound. After Fred’s diagnosis of terminal cancer, he and his family decided that he would prefer to die at home.

Because of his work, Fred had spent most of his married life away from home. He’d never had a very close relationship with his children. He and his wife had dealt with most major family difficulties — including some severe sexual problems — by totally ignoring them. Fred had always felt he needed to keep up a macho image, and his wife felt trapped in her role as wife and mother. His children only used the house as a place to eat and sleep.

But as his disease progressed, Fred reached the point where he could no longer play his accustomed roles. He couldn’t be a tough guy any more. He had a lot of pain, and all the members of his family has to work like hell to take care of him. His teenage son — whom he formerly hardly spoke to — was now giving him baths and rubbing his back. His daughter would read to him when he had trouble sleeping.

As Fred’s cancer progressed, he and his family broke through one barrier after another. It wasn’t easy, but through it all the family members drew closer and closer. Everyone in the house learned to trust and confide in each other. Neighbors who came to visit would tell us, “I expected to find a house of death. Instead I find a house of life and love. This family has never been as close as they are now.”

In observing the changes in Fred’s family, we were reminded of the thousands of Brahma bulls that wander around India. They’re considered sacred. If two men are trying to kill each other with knives, and a Brahma bull walks between them, they’ll pull their knives away, because they mustn’t scratch the bull.

Dying people are like Brahma bulls. In their presence, so many of our petty hassles are simply forgotten. We realize what’s impermanent, and what’s of permanent value.

For most of the people we’ve worked with, the diagnosis of a fatal disease comes as a frightening experience. One of their most frequent comments is: “I feel like I’ve wasted my life.” So much of who they are has been held back. So much of their precious time was spent running away from their fears, waiting for the future, or remembering the past.

So little of their lives was spent actually living. Although they’ve been alive 40, 60 or 80 years, it suddenly feels to them as if they’ve hardly lived at all. They’ve been so buy striving for security and trying to live up to one ideal or another that they forgot to taste and savor the texture of their lives. They were so busy making a home, building their career, becoming solid citizens, that they forgot to live.

Daren

We shared some time recently with Daren, a 38-year-old Los Angeles man dying from a degenerative nerve disease. Two years ago Daren was handsome, successful, and vibrantly health. He had reached the pinnacle of professional success. he was a singer, dancer, and virtuoso guitarist, and was greatly sought after by many for the major Hollywood studios. He had a wife and two children, a lovely home, and ran five miles a day.

Today Daren is strapped to a wheelchair, unable to support his own body’s weight. His lungs are so weak that he must consciously draw in enough air to make his vocal cords work. He can no long move his arms, legs or body. He needs help to go to the bathroom. His flesh is slowly melting away from his bones.

At first Daren was in agony because he couldn’t play, couldn’t dance, couldn’t earn money, couldn’t drive his new Mercedes, couldn’t make love — in short, he could no longer live up to his models of who the thought he should be. But after a time, he began to see that it was not his illness that was the problem.

“It was those damn models,” he realized. “Those models were always a hassle for me. They’re like balloons with holes in them — I’ve had to keep puffing and puffing all the time to keep them from collapsing. They’re not really who I am.” And gradually he’s been able to let go of his identification with his models.

One day we were sitting and talking and he said to us, ‘You know, I’ve never felt so alive in my whole life. I can see now how all the things I used to do to ‘be somebody’ actually separated me from really being alive. For all my outward success, my life back then was just a sort of busy, numb dullness.”

He laughed and shook his head. “We’re such fools, aren’t we? We spend so much time polishing our personalities, strengthening our bodies, keeping up our social positions, trying to achieve this and that. We make such serious business of it all. But now that I can no longer do the things I thought were so important, I have so much love for so many things. I’m discovering a place inside I’d never looked at, never knew. None of the praise I received in the world brought me half the satisfaction I experience right now from just being.”

Few Well Prepared for Death

Very few of the people we see are well prepared for their deaths, and no wonder. We are taught to keep thoughts of death out of our consciousness, ignore illness, to do our best to disguise the natural changes of aging. We grow up believing — and teaching our children — that we are not supposed to suffer. We are not supposed to grow old. We are not supposed to experience loss or pain.

We end up carrying a heavy load — a great deal of fear of illness and death. When Ondrea had cancer, people were afraid to visit her. They were afraid to touch her. And if they did come, they were terrified.

The Pepsi Generation

One of the things we can learn from the dying is simply that it’s all right to die. It’s all right to be ill. It’s OK to be in pain. Sometimes we’ll be working with a group of cancer patients, we’ll say, “You know, it’s OK that you’re suffering. It’s OK to suffer.” And there’ll be a lot of shocked looks, like it has never occurred to them that it really could be OK.

It’s the American way to be hale and hearty, and it’s very difficult for us to accept the fact that illness and death are a normal part of life. Everyone in the Pepsi generation must grow old and suffer and die just like all previous generations. But our conditioning makes it very hard to accept that.

It’s hard for us to accept situations in which we are unable to live up to our models of what’s OK. Elizabeth Kubler-Ross used to say that someday she would like to write a book titled I’m Not OK and You’re Not OK and That’s OK.

We learn to work hard to be OK — whatever that means for us. The dying can teach us a great deal about the ways we learn to distort ourselves, to diminish ourselves, to reshape ourselves in order to conform to that OK model, how we are raised to be constantly posturing, constantly inventing an acceptable reality.

A Mosaic of Awareness

The ebb and flow of our awareness is like a complex mosaic made up of many tiles. But because we learn that some of those tiles — parts of ourselves — are considered unacceptable, we begin, at a very early age, to pick out — or cover up — the offending tiles: “Oh, no, I’m not supposed to be angry,” so we take that tile away. “That part of my mind is too crazy for anybody to see.” So we cover it up. “Oh, God, I don’t want anybody to see my hatred. Or my jealousy. Or my confusion. Or my greed. Or my envy. That self-hatred, that guilt — that can’t be who I really am. That’s bad. That’s unacceptable. That’s crazy. That’s neurotic.” So out they go, until what is left is a pale caricature of who we really are. But the dying tell us that is who we really are — that continually changing flow of thoughts, those conflicts in values, that continual confusion and not knowing. This is our life.

Accepting “Unacceptable” Feelings

The dying teach us that because of our efforts to drive those “unacceptable” feelings out of consciousness, we end up wondering if we have ever really lived. They teach that it is better to sit quietly with our unwanted states of mind, to accept the pain, accept the waves of unfashionable feelings, to accept our own confusion — rather than to let these painful events drive us out of awareness, into defenses that pull us away from life.

Perhaps the greatest gift the dying have to offer is the realization that we need not wait until we receive a terminal diagnosis to begin to relax our attachments to our images of who we think we should be. How much better, they tell us, to realize that we are not our fears, not our confusion, not our defenses. That it is possible to let those states of mind flow through us without identifying with them, without holding onto to them, simply doing our best to stay open to awareness.

They teach us that it is possible to let whatever needs to happen, happen — without being driven into the life-denying reactions our fears would lead us to. It is possible to experience it all, to be threatened by nothing, to withdraw from nothing, not even death.

Learning to be Substantial

We are taught to make ourselves substantial, to take on certain roles and play them with utmost seriousness, to be responsible members of society. The dying teach us that we must live more lightly, take ourselves less seriously, accept our own impermanence, our own no-knowing. Not to harden against life, but to soften into it. They teach us that real growth comes from coming to the edge of one’s model, then letting that model go, and seeing what comes next. The dying can teach us that it’s possible not to be “something” but just to be.

Thousands of years of meditation practice teach us that thinking in terms of “the mind” rather than “my mind” helps clarify what’s really happening. When you look at your flow of awareness as “my mind,” there’s confusion, because if it’s your mind, then you must be responsible for what’s in it. But when we look closely at our thought processes, we see that much of what arises in the mind is actually uninvited. We don’t invite guilt. We don’t invite anger. They come by themselves.

The Worst Possible Insult

Try this experiment: Think of the worst possible insult you can imagine, then suppose that you arrive home to find your living space broken into and that message scrawled across your wall. You would experience — involuntarily — a state of mind that you did not invite, expect, or want. Whose mind did that?

The mind is constantly rating us on our behavior, constantly comparing things as they are to imagined models of things “as they should be.” The mind finds everything wanting: us, others, and the world. It is never satisfied for long. Identification with the mind is the very definition of suffering.

To the extent that we identify with “my mind,” our lives will be in constant turmoil. We will be jerked up or down by any tray thought that drifts across our mind.

The dying teach us that to be able to accept ourselves in our true complexity, we must, without judgement, accept the craziness of the mind itself — accept it without mistaking it for who we really are.

Just Sleeping, Just Eating

For those of us who live in the mind, life is 99 percent an after-thought. It isn’t tasting, touching, smelling, loving, being alive; it’s mostly the mind thinking about what we are doing. An action occurs, and a moment later we think of ourselves as acting. We see a bird, and a moment later we are no longer seeing the bird, but thinking of ourselves looking at a bird.

At other times we live in fantasies of the future or the past. If we start to experience our flow of consciousness as just the mind “doing its thing,” we find ourselves relating more directly to the world. It’s as though the mind, the “I” disappears, and there is just smelling, just dancing, just seeing the sunset, just sleeping, just eating our food, just being with someone we love.

Letting Go

The dying teach us that happiness comes from learning to let go of the things that cause suffering. Though they’ve lost much that they desired, they’ve found much that is of even greater importance. Through their investigation of suffering, they have gotten in touch with something deeper.

The dying teach that it is possible to let go of wanting, that desire is only a cloud that obscures our real nature. We see that our true sources of satisfaction lie in what we already have, and have always had: simple awareness.

Before we began working with the dying, we used to think of those who had not suffered losses as the truly fortunate. No more. We feel sorry for them now.

These well-intentioned people who have, by luck or planning, isolated themselves so well from life may feel perfectly secure in their possessions and their loved ones. They may feel that the whole business of dying has nothing to do with them. They may feel that they have what they want in the world, that they are safe from the flow of change. But we can assure you that for them, the inevitable loss of possessions, the inevitable loss of loved ones, will be the most difficult.

The dying teach us that the real tragedy is not the loss of possessions, not even the loss of loved ones. The real tragedy is losing our connection with humanness, with compassion, with kindness, with forgiveness — for ourselves and those about us — closing off to life.

In their efforts to find a safe place, to avoid the inevitable suffering of life, these seemingly safe, secure people have merely saved up their suffering. They have put off their pain. They have carried it around without realizing it. And, in the meantime, they have piddled their lives away maintaining their defenses. We have come to feel deeply sorry for such people, because they will experience death with the greatest horror.

Dying at Home

In a recent survey, four out of five people said they would prefer to die at home, yet in practice, four out of five people die in institutions. To die at home is to die in the midst of life, in the midst of love. Many of the people we have taken home to die have found they needed less pain medication because of the support and relaxation available in the home environment.

Many have said in the last weeks of a loved one’s dying in a hospital: “I wish I could do more.” We always think to ourselves, “Take them home to die and don’t worry, you will!”

Giving a loved one round-the-clock support may draw on energy reserves long unexplored, while feeding some place deeper than bodily fatigue. To bring loved ones home to die is like accompanying them on their last pilgrimage. There is no experience more intimate. To share that time with another, to encourage a loved one to let go gently while we ourselves practice what we preach, can bring beings together as no other situation can.

Here are a few things that can make the experience easier:

• A cassette recorder so the person can listen to a variety of music and guided meditations.
• A bedside bell so the person can feel in contact and summon help.
• Plastic bedpans, which aren’t as cold as metal ones.
• Daily baths, for human contact and protection against bedsores.
• Massage for decreasing tension and anxiety while deepening contact.
• Don’t force someone to eat. You are sharing an openness and ease with what is.
  If the person wishes not to eat, so be it.
• A blender is useful when one does not wish to take in too much at a time.
• A hot plate or plug-in teapot in the person’s room lets you have a cup of tea or light snack without having to leave the room.
• Water and juice should always be available.
• A hospital bed with side rails is convenient and comfortable, but many prefer to die in their own beds, and would rather use a foam wedge and a few extra pillows.
• Pain medications should be given as the person wishes. Don’t push your own ideas of how they should work with pain.
• The best place for the bed may be in the living room, near the window. This lets the person maintain contact with the familiar.
• It is not uncommon for people who are dying to feel that their illness may be a punishment for past actions. Supportive measures that can help dissolve the guilt
  should be encouraged.
• You may wish to call the Visiting Nurses’ Association in your town for further information and support.

Experiences That Will Give You Great Insight into Aging, Illness and Dying

1. Volunteer at a Nursing Home.
2. Volunteer at a Hospice.

People who’ve done either of the above — even if it’s only for one week — invariably have a memorable experience. You’ll see how your body is going to grow old some day, and all that entails — how difficult it can be just to sit up, just to life your fork and eat, just to walk, just to sit in a chair. You’ll see how, for the elderly, the being inside has not changed a bit since they were 15. Highly recommended and unforgettable.

We encourage the people we work with to adopt some kind of practice, one that suits their own life and preferences, but ideally a daily practice, one they can stay with, something to which they give first priority, something they do at a regular time, and do even if they don’t feel like it on that particular day.

It might be meditation or yoga, tai chi, running, silent prayer, massage, playing an instrument, karate, judo, writing in a psychological diary, breathing exercises, or the practice of an art or craft —whatever is right for their temperament and their preferences. Something that will encourage them to pay attention. We find that this kind of a daily practice is perhaps the most powerful tool for building awareness.

Who Dies?

Imagine that the time has now come when the energy in your body is no longer sufficient to allow you to participate in the world. You can no longer continue your former work, or earn the money you used to earn. You are lying in bed wit you new car parked in the driveway outside your window. You realize that you will never drive that car again. You see your closet. You know that you will never wear your wardrobe again. your children play in the next room. You are too weak to get up and join them.

In the kitchen, your mate cooks supper; you will have to be spoon-fed because you are too weak to feed yourself. You want to get up to help, but it is no longer possible. You sense that in the not too distant future, your mate will be making love to someone else, that in a short time someone else will be raising your children.

You must let go of every model of yourself you have ever created — wife, husband, father, mother, lover, breadwinner, parent, teacher, doctor, nurse, businessperson. Those models are no longer available for you . Can you see how you might begin to wonder, “Who am I? Who is it lying here in this bed? Who is dying? Who is it that lived?”

For those who remain attached to how it used to be, to how they thought it would always be, dying can be hell. But dying doesn’t have to be hell. It can be a remarkable opportunity for awakening.

Forgiveness Meditation

Bring into your heart the image of someone for whom you feel much resentment. Take a moment to feel that person right there in the center of your chest.

And in your heart, say to that person, “For anything you may have done that caused me pain, anything you did either intentionally or unintentionally, through your thoughts, words, or actions, I forgive you.”

Slowly allow that person to settle into your heart. No force, just opening to them at your own pace. Say to them, “I forgive you.” Gently, gently open to them. If it hurts, let it hurt. Begin to relax the iron grip of your resentment, to let go of that incredible anger. Say to them “I forgive you.” And allow them to be forgiven.

Now bring into your heart the image of someone you wish to ask for forgiveness. Say to them, “For anything I may have done that caused you pain, my thoughts, my actions, my words, I ask for your forgiveness. For all those words that were said out of forgetfulness or fear or confusion, I ask your forgiveness.”

Don’t allow any resentment you may hold for yourself to block your reception of that forgiveness. Let your heart soften to it. Allow yourself to be forgiven. Open to the possibility of forgiveness. Holding them in your heart, say to them, “For whatever I may have done that caused you pain, I ask your forgiveness.”

Now bring an image of yourself into your heart, floating at the center of your chest. Bring yourself into your heart, and using your own first name, say to yourself, “For all that you have done in forgetfulness and fear and confusion, for all the words and thoughts and actions that may have caused pain to anyone, I forgive you.”

Open to the possibility of self-forgiveness. Let go of all the bitterness, the hardness, the judgement of yourself.

Make room in your heart for yourself. Say “I forgive you” to you.

Like Worn-out Clothing

We have seen people experiencing the same falling away of the body, the same inability to be the individual they thought they were, who are able to leave their old roles and duties behind like so much worn-out clothing. As their bodies grow weaker, their spirits and their participation in the moment grow stronger and stronger, until their old roles and old masks are seen as the bars of a cage, and they experience a joyful release from the part of their life that was made up of models and ideals of how they were supposed to be.

We have seen these remarkable people flow wholeheartedly into the vastness of what is, no longer kept captive by their models of the world. They see everything as present in each moment. It seems that all blocks to their perceptions are gone. They see how identifying with fantasies of the future and dreams of the past has kept them in prison for their whole lives. As one spiritual teacher said shortly before his death, “Today I am released from jail.”

The Work of the Dying

It is from these remarkable people that we have learned that the work of the dying is to let go of self-protective control. To open, to live fully in the present moment, to accept the richness of each moment with an open heart, with a mind that does not cling to models.

These people are able to open up to an appreciation of all that is, beyond life, beyond death. They realize that they don’t have to do or be anything to be who they really are. They have escaped from the tyranny of the mind, the tyranny of models and shoulds and musts.

We see them touch the real. We see them become part of what is. We see them let go of wanting things to be any other way.

Those who are able to open into the experience of dying are the most open-hearted, clear-minded people we know. If we might share a composite of what we hear them say, it would go something like this: “It’s strange, but I’ve never been so happy in my life. I don’t really know who I am, but it doesn’t matter, because no matter who I think I am, I keep turning to to be something else.

“My knowing has always blocked my understanding, but now I am full of not-knowing, vulnerable, open. I had to lose it all to see how little of it was worth having. Somehow there is much more to me than I had ever imagined.”

These people die in wholeness, without struggle. They seem to simply evaporate out of their bodies. Their death is like the rain falling gently back into the ocean.

Our best wish and hope for ourselves, our friends and family, and for you, is that we might, each in our own way, follow their example.

Dr. Pelletier holds a Ph.D. in clinical psychology from the University of California at Berkeley. He is Assistant Clinical Professor, Department of Psychiatry, Langley Porter Neuropsychiatric Institute of the University of California School of Medicine, San Francisco, and Director of the Psychosomatic Medicine Clinic (2510 Webster Street, Berkeley, California 94705, 415-548-1115). He is co-author (with Charles Garfield) of Consciousness East and West (New York: Harper & Row, 1976) and the author of Mind as Healer, Mind as Slayer and Towards a Science of Consciousness (New York: Delta/Delacorte, 1975). He is an Advisory Editor of Medical Self-Care Magazine.

Ken has spent most of the past ten years teaching people to prevent stress disorders. As he answers the front door of his redwood shingled house in the Oakland Hills on a bright June morning, he looks as if he’s been following his own advice.

He waves aside my apologies for being late and leads me into a spacious, spotless office overlooking a lower level of the house. There is a wide, deep desk with an answering machine and a long bookcase full of perfectly straightened books arranged by subject. When I compliment him on his impeccable workspace, he smiles and leads me down a short hallway to his “working” office—a cramped, messy little room strewn with books and papers.

As we’re settling in, I notice a framed print of St. George killing a dragon, prominently displayed. Ken tells me that he has recently returned from a two month sailing trip to the Galapagos Islands off the coast of Ecuador, the home of the giant Galapagos tortoises. They are strikingly tame and curious, he says, and will come up and rub against you like a cat. They are totally silent except when making love (“imagine two boulders mating”). Then they let out a roar “like somebody starting a diesel engine.”

TF: How did you first get interested in the ways the mind and body interact?

KP: I guess it was when I took a meditation course on the Berkeley campus in 1967. We read the Bhagavad Gita and the Autobiography of a Yogi, and did a lot of meditation. It got me interested in what optimum health was and how it could be achieved.

Most of your writings since then have cantered around stress. How did you get from meditation to stress?

The meditation interest led me to some research at the University of California School of Medicine in San Francisco. This was back in the days when we weren’t sure if people really could regulate their autonomic nervous system.

We decided to look at people who seemed to have an unusual degree of control of autonomic functions— yoga adepts and experienced meditators. We hooked them up to our machines and found that they really could control their brain waves, their heart rate, their blood pressure. At that point, it struck me that many of the disorders I was seeing clinically might be problems in which a person’s autonomic nervous system is just completely out of control.

You thought the same kind of training might help your patients?

Yes. We asked the yogis and meditators how they’d learned to control their pulse and so on. They said it was just a matter of practice—like learning a new sport or a musical instrument.

What other things could they control?

Brain waves, blood pressure, heart rate, skin conductance, muscle tension, peripheral circulation, and respiration pattern and rate. Besides just looking at these individually, we fed all these simultaneous readings into a computer and looked at the relationships between them.

We were struck at the degree to which our subjects’ patterns were very coherent—when one went up, they all went up. When one went down, they all went down. The systems that controlled all these very different functions were very highly integrated.

How does that compare to a normal person’s response?

Non adept individuals were much more fragmented. Their heart rate would increase, yet their muscle tension would be very low; or their skin conductance would show a big change, but their brain waves would remain the same.

As though their different regulatory systems were out of touch with each other.

Exactly.

If the adepts were more coherent than normals, how did normals compare to people who already had illness problems?

I think it’s mostly just a matter of degree. People who’ve become ill have gotten even more disrupted in their level of functioning. In this context, the adepts could be seen as people who were physiologically superhealthy. So, recently I’ve gotten interested in how one can move from a state of average good health—and all that really means is that you’re going to get sick, grow old, and die along with everyone else of your age, sex, and weight—to a state of more than average health.

When you go through an annual physical and your doctor pronounces you healthy, that only means you’re average. The really exciting question, and one that a lot of people are beginning to ask, is how can you become more highly integrated than average, in the way that the adepts and meditators certainly were.

Can you give an example of how someone might develop an illness as a result of the kind of imbalance you’re talking about?

Whew! It took me a whole book to try to do that! What I tried to do in Mind as Healer, Mind as Slayer, was to show how we move from a state of relative health to a manifest disorder. That’s where stress comes in.

What we found in our research is that there are two kinds of stress, short-term and long-term. Short term we can take. That’s the kind we share with every other biological organism. We react in a certain way when we’re in a threatening situation.

Like when I came to the branch in the freeway on the way over here and didn’t know which war to go.

Exactly! So what was your experience at that point?

Well, I realised I didn’t know which turn to take, so I decided just to stay in the lane I was in. After I was past the junction, I let out a long breath.

You had a feeling of relief, of release?

Yes. The point was passed. Even though, as it turned out, I’d chosen the wrong turn.

That’s what happens with short-term stress. You encounter a stressor, you deal with it, and then there’s a period of relaxation.

Point 1 is your baseline level before the stress. Point 2 is the stress reaction that’s been so well described by Selye (The Stress of Life). It corresponds to the firing of the sympathetic nervous system. Point 3 is the period of compensatory relaxation after the stress has passed. This corresponds to the firing of the parasympathetic nervous system. Point 4 is the return to baseline.

So that’s the normal, healthy way of reacting to stress.
Yes. The long-term kind is what gives us trouble. This is a kind of stress that doesn’t go away as easily as a turn on the freeway: job stress; family stress; emotional conflicts; money difficulties. All the vague but ever present problems and worries. There’s no end point, no clear resolution to that kind of stress.

What happens physiologically is that all the bodily functions accelerate as though your life were in danger, and they stay elevated, without release. We experience it as anxiety, frustration, tension, and worry. If we were to hook someone in this kind of worry pattern up to a monitor, we’d see something like this:

They continue at a level of high excitation without the compensatory relaxation phase. This is the kind of biological stress pattern that leads to disease.

So what would the yogi or meditator do in the same situation?

What they’ve learned is to more clearly identify when the reaction is no longer necessary. They
would experience the same stimuli as a series of discrete short-term stresses:

The striking thing about this pattern is that it looks almost exactly like the EKG tracing of a series of heartbeats. What’s missing in the chronic worry pattern is the parasympathetic rebound, the relaxation phase. What the yogis have learned to do is to induce this phase. To let go of those excess levels of self-stressing neurophysiological activity and simply quiet themselves down.

They can intentionally produce the “Whew!” phase of the short-term stress reaction.

Yes. Then it is possible to come back to the baseline level and continue on. When we get into the chronic stress pattern it feels like there’s not going to be any end point.

You can think of your body as being naive. It can’t tell if your life is really in danger or if you’re just thinking as if your life were in danger. The fear of losing your job might feel just as threatening as if a speeding truck were coming at you. You might react this way to a nagging creditor or to your income tax coming due. Whatever the cause, you go up above the line, and before you can come back down, the next stressor hits—a job deadline, a family problem. And you go right back up again.

How long can that pattern go on?

A long time! In someone with a real chronic stress pattern, the only thing that’s going to break the cycle is some kind of illness experience. You then see a very sharp drop:

This represents a state of complete nervous exhaustion, a nervous breakdown, a heart attack, a debilitating headache, an alcoholic binge—it can be any number of things.

Everybody has his or her own favorite way to break the pattern.

Exactly—and it’s very often illness, because when you’re sick there is a very different set of demands placed upon you. It’s now okay to stay in bed and just take it easy.

How possible is it to predict who will get what diseases?

I think it’s possible to some degree. The Friedman and Rosenman book (Type A Behavior and Your Heart) looks at the relation between personality and heart disease and cancer, respectively. I’ve reviewed the relationships between these two diseases as well as migraine and arthritis in Mind as Healer.

So people do have their own favorite illnesses.

Oh, yes. The same stress level that might produce a headache in one person might produce a heart attack in another or gastrointestinal trouble in a third. Certain families, both genetically and behaviorally, will predispose to certain illnesses. Your environment will predispose you one way or another. So will your lifestyle.

One thing that’s struck me about your work, Ken, is that many people with similar interests have become interested in ways of working that have taken them a long way from the research lab or the traditional medical clinic. You’ve chosen to stay very close to the approaches and techniques of traditional research and clinical practice. Could you comment on that?

One of the things I’ve been trying to do, almost insidiously, is to stay very conservative in my approach. The data is there, in the psychological research literature. You don’t have to go look at far-out things. You don’t have to guess; you don’t have to speculate. You don’t need to have far-out theories. This area is easily approached with the traditional tools.

So I’ve limited myself to citing from the Journal of the American Medical Association, Annals of Internal Medicine, Archives of General Psychiatry, or Science—which, by the way, has devoted an entire issue (May 26, 1978) to health maintenance and contains some of the best articles and most radical statements you will ever see on the need for a new way of looking at medical care.

I’ve tried to stay within the scientific medical tradition to see whether medicine really is incapable of dealing with these kinds of issues or whether there’s simply a huge body of literature that has been ignored.

By and large, it comes down to the fact that the information is there in the journals, and it’s been largely ignored and overlooked. This stuff is as compatible with medical practice as anything you can imagine—that’s what makes me so optimistic that this is a valid direction for medicine. We’re not trying to set up some wild alternative. In fact, it’s probably more consistent with the roots of medicine than the biomedical fixation of the last thirty or forty years.

The most exciting thing about this work is that once you get people moving in the direction of health, they don’t want to stop at just being ‘`normal.” They keep going toward becoming much healthier than average.

What are some of the ways to break the chronic stress pattern?

I think the main ways are stress management, diet, and exercise. There seems to be a real synergistic effect among these three. If you start exercising, it breaks up both physical and mental tension. There’s a slide I use that shows all the supposed effects of drugs that lower blood pressure on one side and the effect of light exercise on the other. The physiological changes produced by exercise are comparable if not greater than those brought about by the drug.

As any runner could tell you.

Right! That’s the kind of thing that we, living in the Bay Area, have somehow picked up; but do you know that it’s never mentioned in the literature? It’s not taught in medical schools—and that’s really the status of most of this information. It’s there, but it’s not known. There are damn few doctors that will put a newly diagnosed hypertensive on a running program.

There’s a kind of conceptual shift that a person can undergo, so that afterward, things that were considered highly stressful are no longer perceived as so potentially perilous. Friedman mentions that a good proportion of post-heart-attack patients spontaneously go through such a shift after their heart attack. When he has asked them what kind of process it was, they say something like, “I just looked at all the things that used to bug me, and I said to hell with it.”

I hear that from patients all the time. That’s the kind of change we’re trying to learn to produce—how to help people learn to decide whether a given event is life-threatening or not. If it is a life-threatening event, you’d better be glad you’ve got all these psycho-biological mechanisms. If a car is coming at you, they give you the energy to jump out of the way.

It’s a mistake, then, to think that all stress is bad.

Right. The error comes in when you start interpreting relatively nonthreatening situations—like balancing your checkbook or dealing with a certain person—as though they were life-threatening. Then you are creating the crisis in that life-event. All the same responses take place as if a car were coming at you at eighty miles an hour.

I think you can achieve that conceptual shift in any number of ways, one of which is through the painful, involuntary way of a severe illness that forces you to look at your values. That’s why I think illness can be a very creative experience—a potential source of regeneration and renewal instead of just a breakdown.

Severe illness is one way to get that conceptual shift, or you can take a more preventive approach—become aware of the problem and make conscious changes.

How about paying attention to early symptoms, before an illness gets to a serious stage?

Definitely. There are usually many symptoms before the heart attack. The one thing you can count on is that if you ignore the symptoms, the body will up the ante. The next symptom will be more serious if the first is ignored, until finally, the body can do nothing but give out.

Most people think the symptom is the illness. It’s not. The symptom is often very useful, telling you that you’ve pushed yourself beyond a level of healthy functioning. Too many people miss the early signals and get the opportunity to examine their lives—perhaps for the first time—at the cost of a serious illness.

To get back to what people can do . . . what can people do?

Aha, the big question! What can you do other than becoming ill? Well, I guess some kind of centering or meditation—in a very wide meaning of the term.

Any activity that you have in your life can be used as a meditation. It can be looking at a mandala, doing a mantra, sex, prayer, walking, running—it can be anything.

Listening to Bach?

Exactly. Any activity that you can invest with prolonged and focused attention can be a form of meditation. Biofeedback is simply machine-assisted meditation.
Would you say that meditation is a way of intentionally inducing this post-stress period of relaxation that brings you hack to normal tension levels?

Yes. The upswing is the sympathetic component. The dip, which corresponds to the S component of an EKG recording of a heartbeat, is the parasympathetic rebound. It’s a compensatory period of relaxation or deactivation that’s characteristic of every single nerve cell, every single muscle cell in the body. That cycle of up, down, and return to baseline almost exactly describes the electrical activity of the heart during one heartbeat. To me, this pattern is a source of real wisdom, because it gives us, with every beat of the heart, with the firing of every nerve cell in the body, a demonstration of the optimum response to the environment.

It’s all very consistent with the Zen philosophy in which you perceive an event, react to it, and then let it go. The neurological pattern is a perfect correlate to this philosophical view, which I think is really fascinating.

It’s nice when so many things start coming together. Everything in this kind of work keeps coming back to some idea of individual . . . I don’t know quite what to call it responsibility is laden with so many unfortunate connotations.

Self-care.

Self-care! That’s it. It’s just paying attention to a beneficial way of living your life so that your exchanges and interactions with other people are loving and caring, and your attitudes to your self are that way, too. The kind of meditation we’ve been talking about is a fine way to come at it—although people come to it by very different roads. For some people, paying attention to nutrition leads to paying attention to other areas of their life. Others come at it through exercise. They realize that they can’t even run around the block if they’re feeling tense, and they get interested in meditation. Another person might start meditating and then realize, “Wow, I really don’t like that gut hanging over my belt.” Suddenly this person is into considerations of diet and weight. It’s really a very organic, unified process of discovery.

Paying attention.

Paying attention. Investing your life with attention. Was it Socrates who said, “The unexamined life is the unlived life,” or something like that?

That’s it. Meditation, biofeedback, relaxation methods, autogenic training—they all allow you to take a break from a cumulative, destructive cycle and to induce the parasympathetic rebound with all its attendant- slowing down and relaxing effects. On a psychological level, it’s taking that break, taking time to see why you’re involved in a particular phase of the rat race and whether you want to stay involved.

Another thing, too—all these things should be fun. Too many people are so dour. They’re going to be healthy if it kills them. The person who drives himself to jog and hates it. The person who eats so austerely and with such a restricted diet that it’s really masochistic. The person who insists on meditating half an hour twice a day whether it really fits into his life or not.

They’re equally not paying attention.

Yes, because when you’re doing it right, there’s a spark, an element of vitality, of discovery, that makes it really exciting. You’ve got to follow the little messages from inside that tell you what’s right for you, no matter what any expert says. If that spark’s not there, you’re sunk. no matter what you do.

Landing back in California, David joined the staff of Pacific High School in Palo Alto and soon began taking the students from this alternative school Infield trips to Mexico. In Mexico he found vet another vocation: medicine.

TF: How did you get involved in medical work?

DW: I took a walking trip by myself in the Sierra Madres one Christmas vacation. One evening I’d been delayed and was passing a little shack about dusk, and the family living there asked if I was hungry.

Well, I was hungry. So I stopped and they pulled a couple of eggs out from under the chicken and cooked them up for me—they were all eating beans—and asked me to stay the night.

It got very cold that night, and the family had only a couple of blankets for seven or eight people. Around two in the morning it got too cold to even try to sleep, so they got up and built a fire in the middle of the floor and sat around it, the older kids holding the younger ones, until dawn came.

When it got light, I noticed that one boy had a badly swollen foot. He’d stepped on a thorn three months before and by now the foot was seriously infected. I was struck by how unnecessary it was for him to have to suffer like that—all he needed was some antibiotics and some knowledge about hot soaks. Also, some of the kids were beginning to develop gaiters, and I knew that iodized salt could prevent that.

I went back to my students at Pacific High School and shared these experiences. We started talking about putting together some useful medical information and supplies and going back to the mountains to distribute medical kits and teach some basic medical skills.

So we made up some little kits in old coffee cans and went down to Mexico. We made about a hundred-mile loop through the mountains, passing out the kits and talking with people about health problems.

After we got back, I decided to go back down for a year to help the people there obtain the medical skills and supplies they needed.

And you ended up staying ever since.

Just about, though the program is now completely run by the community, and I’m just an advisor,

When was that first visit?

That was in 1964.

When you went down there to live, how did you get started ?

I started out making the mistake I think all experts tend to make, that is, trying to provide care instead of helping people care for themselves. Luckily, there was much more than I could do by myself, so I started recruiting the children who had begun to hang around out of curiosity, getting them to do things like washing wounds, suturing cuts, giving instructions. This group of kids, thirteen, fourteen, fifteen years old, became paramedical workers right from the beginning.

Then we went through a phase where we depended on young American students—many of them Stanford pre-meds—to come down and spend blocks of time helping out. We’d organized an unofficial course at Stanford to train these volunteers. The course was run by the young volunteers with local doctors as resource people.

It was very interesting to compare the graduates of this three-month, very practical course with some of the new medical school graduates who also came down to volunteer. The pre-med students were better in every respect, including the strictly clinical areas. They had learned to focus on the problems of greatest need, while the med school graduates would want to do an extensively detailed medical work-up with a complicated differential diagnosis. They’d feel frustrated because we didn’t have the technology to do all the lab tests and diagnostic procedures.

How did the villagers respond?

That was very interesting. We realized that the better our volunteers got—and by that time we were really getting the cream of the crop of Stanford students, really dedicated and committed people—the more they tended to undermine the capacity of the villagers to assume responsibility for their own care.

When the paramedical village workers, many of them teenagers, had to compete with the volunteers, we could see a real falling-off of interest.

So we went into another phase in which we decided that no outsider should provide any direct service at all. They should be there as educators. Their goal should be to leave behind their knowledge and skills with the villagers. This didn’t come until eight years after the program had begun. We learned pretty slowly.

So there have been several phases of the project….

Yes. The first was me working with the young people from the villages. I think that was a good start.

The second was using the American pre-meds, which I see now as an unfortunate back-sliding toward the kind of dependency that professionals always seem to produce.

The third phase was limiting the outside experts to teaching functions, so that the outsiders were really coming in on the villagers’ terms.

The fourth phase began about three years ago, when the village team in Ajoya decided they wanted to take the whole thing over themselves, including the supervision and training of the village health promoters. So it was decided that there would be no ongoing presence of outside providers.

Including you.

Including me. They did decide to invite outside professionals in as they needed them, but strictly to teach.

How has your role changed through those four stages?

I was originally a direct provider of services. In the middle stages, 1 was an active teacher. More recently, I’ve been more of a consultant and advisor. I’m moving in the direction of making myself completely dispensable. Because of my role in the past, it’s difficult for me to be there without being an authority figure. I’m now spending about a quarter of my time in the community there, and always at their invitation.

Are the village health workers practitioners or educators?

They’re both. Half their training is in communication and education. They don’t try to be some big expert. Even if they already know all about a problem a patient has, they’re encouraged to look it up in our handbook with the patient, so that a patient gets a sense of what he can do for himself. They try to transmit the idea that this isn’t some magical knowledge, and you don’t need some special ticket to have access to it. It’s something easily understandable; let’s find out about it together—that sort of approach.

Do they use medical supplies brought in from outside?

Yes, but less than they used to. Dehydration in children—secondary to diarrhea—is a major problem in rural Mexico. When we started out, we were infusing these kids with intravenous fluids, because that’s what they do in hospitals up here. But we realized that this was creating a dependency on skills and materials that required outsiders. Now we almost never use IV treatment, because the long-term survival of these children is ever so much better if the mothers themselves are involved in the rehydration process, using oral mixes they can make themselves from things they already have in their homes. Infant mortality has dropped from 34 percent to about 6 percent since we’ve been there. I think that’s due almost entirely to the fact that mothers now know how to rehydrate their own kids.

You were saying that some of the villagers had learned to do simple eye surgery.

Yes, they remove cataracts. You know, so many medical skills consist of some very simple knowledge combined with dexterity and a lot of practice. Somebody with a limited amount of education can learn a specific skill. Our chief laboratory technician has never been to school a day in her life, but she can do stool analyses, differential diagnoses of different parasites, blood workups, urine analyses, and so on, and report her findings accurately and intelligibly.

The dental workers there can run circles around recent dental school graduates from the States— because they’ve had more experience. Having a title or a diploma doesn’t necessarily make you any good. Some of our village kids have pulled ten thousand teeth, while a new dental school graduate might have had a chance to pull two or three in his four years of dental school.

As far as the skills of primary dentistry are concerned—drilling, filling, and cleaning—the village boy can be trained to a level of skill comparable to an American dentist in a matter of weeks and can provide those. services at about—oh, I’d say about one-fiftieth the cost.

So on the basis of that experience, how does the American system of health care look to you?

Disturbing. I think that a lot of our experience in Mexico could be valuable to people working in the States. Medicine here has become a priesthood complete with its whole hierarchy, with an ignorant populace down below on the receiving end. I think it’s a real tragedy that American kids go through as many years of schooling as they do and remain so shielded from an area which is of such importance to our own well-being.

Americans just don’t know that much about medicine.

No, and it’s a shame. So much medical knowledge is so simple to understand. If the things all our health workers in Mexico know were taught in the public schools here—all the stuff which has been the sacrosanct domain of the health professions—it would do an enormous amount to make people more aware of how to deal with their own health needs. It would be a tremendous boon to both prevention and treatment.

How might this come about?

It would take a big conceptual shift, a lot of consciousness-raising. The schools would have to place a lot more emphasis on the workings of the human body in health and disease—and that should include considerations of environment and social and political influences on health.

We need to set up situations in which people can share their experiences and come to recognize their mutual needs. Then they can focus on their power both as individuals and as a community to cope with some of those needs.

Health workers need to evolve in the direction of being better teachers, better communicators and sharers of knowledge and skills. I think a good many doctors go into medicine—or maybe they’re influenced in this direction by their training—because they want power and prestige. I think it’s going to take a major change in attitude for doctors to become more open about sharing their knowledge and skills.

I am impressed by your community-cantered approach in Mexico, having the communities who need a medical worker decide who’s going to get the advanced medical training.

That’s how they do it in China, too. Another thing they do there is graduate doctors up from the ranks, so that you start out as a barefoot doctor, then you can become a physician’s assistant, and finally a doctor, instead of going right to the top once you’ve received your M.D.

What’s been the effect on the young American premeds who worked in your program? Some of them must be doctors by now.

Yes. There are about twenty of them, most of them still in their training. They’re all committed to the kinds of changes we’ve been talking about. They’re all talking about trying to find a way to establish the same kind of special sharing-based relationship with a community that we’ve had in the Ajoya area.

You know, to me it’s a tragedy that people coming out of medical schools and the other healing professions are so often deprived of this real human closeness. It’s one thing to have a patient come into a hospital nice to him, and to have him be grateful, but it’s quite another to be a real member of the community where you live, to be involved with all the members of family from birth on up.

That doesn’t seem to happen with the way medicine is practiced here. The doctor relates to his colleagues, but in many cases there’s a great deal of social and psychological distance between doctors and their patients.

And that’s everybody’s loss.

Yes. The doctor’s as much as the patient’s. What I would encourage the young person interested in being a health worker to do is not to start medical school until he or she has lived in community with people, and established some sense of his or her ability to relate in human terms. It would be very good to have already developed a warmth and affection for a particular community before going to medical school, to have had a chance to engage in a wide range of community activities and involvements. Then if he or she does go on to medical school, to go through it with eyes open, critically, and with the plan of taking back to the community what will be of use to it.

You were saying that you thought a turn toward self-care in this country would have a beneficial effect on other countries, too.

Yes. As it is now, when students from undeveloped countries come here for medical training, we train them to depend on our highly technological way of medicine, and we socialize them to want to make a lot of money. As a result, they’re not trained to practice the kind of medicine their countries need, and they end up staying here or going to some other rich country.

When we support medical programs in these countries, we tend to build costly, elaborate hospitals in big cities, serving the elite, ignoring the majority of the people. We support programs to force birth control on the poor when they are so poor that they desperately need a big family to survive. What we should do is help them get a better standard of living, and they’ll regulate the size of their own families.

The health decisions we make in America will have a terrific impact on the health of people in the poorer countries. I don’t think we can afford to think of our health as something separate from the health of the rest.

Medical Self-Care Magazine’s women’s health editor Carol Berry listened to the tape, agreed that it would make a good article, and suggested that she conduct a follow-up interview with Dr. Witte and Heidi Bednar, a midwife who works with Michael. She did, and it broadened and deepened the original interview immensely.

Finally, I edited the two transcripts and dovetailed them together, so that somewhere in the middle Carol and Heidi appear and I disappear. I guess you could call it collaborative journalism.

TF: Michael, you were saying that many people are thinking and feeling differently about having their babies than they did five years ago?

MW: Yes. Many, many more people are actively looking for just the right person to attend their birth. People are much more concerned with the environment in which the birth will take place. The underlying concept seems to be that the mother, the pregnant woman, should command a lot of respect. Prospective parents are getting more assertive about wanting things done their way.

TF: Has that concern for people’s individual preferences been lacking?

MW: I think it has. Both I myself and the group I work with are constantly being approached by people who haven’t been able to find the kind of prenatal care and deliveries they wanted. They’re determined to create a way to have their own birth experience meet their needs.

People are becoming much more deeply involved with the birthing experience than they’ve ever been. They’re realizing that there’s an independent, benign force at work changing a pregnant woman’s life and her body in monumental ways, and there’s a widespread feeling that those changes need to be respected by health workers, by her man, by her friends, and by herself. She’s different than she was before she was pregnant, and she gets more different the more pregnant she gets.

TF: I certainly didn’t hear anything about any of that in medical school. We just learned about all the possible complications.

MW: Yes. The medical professions have focused almost exclusively on the technology. We’ve really approached childbirth as though it was a diseased state, full of potential complications. The technology of childbirth has been kept as secret and magical tools to be used only by physicians.
The technology has saved a lot of lives, but it’s been controlled by the obstetricians, nearly all of them men, which created a built-in insensitivity, and birthing got dragged into the hospitals. Human values were subjugated to the hospital routine, with delivery rooms modeled on operating rooms, even though birth is not really very much like surgery at all.

TF: All right, suppose you’re talking to a couple thinking about having a baby. What are the choices they should start taking into consideration? What are their alternatives? When should prospective parents start looking for someone to attend their birth

MW: When you’re planning a pregnancy is an excellent time. You have a lot more time to explore options. Certainly by the time you first find you are pregnant.

The first step is to find out what’s available locally. I would talk to your local doctor or a couple of local doctors. Another good resource can be the local public health nurse. Public health nurses are often pretty sensitive to people’s needs, and they should know what the local resources are.

TF: So you could just call the county health department and ask for the public health nurse?

MW: Right. Free clinics or women’s clinics are also good resources, if you’re lucky enough to have one in your community. If you don’t, you can get in touch with such clinics in the nearest big city. Two nationwide organizations can help refer you to a sympathetic doctor, too: the La Leche League and the International Childbirth Education Association You can write to both of these and they’ll send you the address of their nearest local chapter.

TF: Could you suggest some good books to be reading around this time?

MW: Yes. Commonsense Childbirth, by Lester Hazell and Birth by Catherine Milinaire are both good. The birth chapter in Our Bodies, Ourselves, also has a lot of good practical information.

Once you’ve really gotten along into pregnancy, some good books are Spiritual Midwifery and Immaculate Deception. Then there’s a super picture book, A Child Is Born, which has excellent color photographs of the fetus at the various stages of development. Pregnant women can spend hours with that one.

The midwives we work with have a library of books on these subjects which they loan out to prospective mothers. It’s a really nice service to be able to provide.

TF: What are the most important things to focus on in the prenatal period?

MW: The single most important thing is that the mother respect herself and take care of herself. Prenatal care is not something the doctor does. You can only do it for yourself. What we’re doing is monitoring the mother’s and baby’s well-being. It’s the mother who’s doing the real work.

TF: What can a couple do if they can’t find a local doctor that does things the way they’d like?

MW: I would hope that they would tell their doctor what they’d like. Impress on her or him that these requests are very important to them. Hang in there, and be prepared to negotiate.

If you’re assertive and persistent, you may find a great deal more flexibility than you expected. Ask the doctor what his reservations are about your requests. If the physician is worried about legal liability, you may be able to work out a legal waiver stating the things you want and the risks you’re willing to accept. For instance, you may want to try to deliver vaginally in the case of a breech presentation, instead of automatically going to a cesarean. It’s very important for you and your doctor to discuss these possibilities and choices in advance.

If you are negotiating with your doctor, it’s vital to get good counseling regarding risks and procedures. A good deal of this can be done by phone if necessary.

TF: What are the possibilities as to where the birth will take place and who will attend it?

MW: Well, the alternatives range all the way from having the baby at home and delivering it yourself, to home birth with a lay midwife, to home birth with a nurse-midwife, to home birth with a physician.

In the hospital, the alternatives might be an alternative birth-canter-type room, where you can have your friends and family in to witness the birth but have a doctor or midwife in attendance. Or you might choose to have your baby in a regular delivery room, again with a midwife or a physician in attendance.

TF: Could you say some more about alternative birth renters?

MW: Sure. They’re a good example of hospitals being responsive to people who want more control over their own birthing experience. The alternative birth centers are often scheduled months in advance.

The labor and birth usually take place in a room down the hall from the delivery room. The family has a good deal of control over this room—they can decorate it as they like, play their favorite music, and have their kids and friends and family members present. So on the one hand, there are many of the benefits of a home delivery.

On the other hand, if any complications develop—if the baby starts to come out feet first, or if the mother or the baby are having any difficulty at all—the parents and the doctor or midwife have the option of zipping down to the delivery room in a few seconds.

TF: An obstetrician friend said that he advises prospective mothers to pick the hospital first, then pick the doctor.

MW: If you’re planning a hospital birth, that’s not a bad idea. Most hospitals have regular tours of the labor and delivery facilities for prospective parents. If you pick a doctor first, you’re limited to the hospitals where he or she practices.

TF: You were saying that the changes in obstetrical practice here in Marin County over the last five years may foreshadow the kinds of changes we can expect in the country as a whole. How have things changed here?

MW: Five years ago the doctors here took a very interventionist, technical view of birthing. Deliveries were done in the hospital delivery room, period. Now we’ve become very family oriented. There’s much more concern for the quality of the birth experience. A significant percentage of babies born in Marin last year were born at home. This certainly reflects a change in consciousness among health workers and potential parents alike. It also indicates the power consumer demand can really have.

Probably the most important reason for this change is that the families have put on economic pressure. They’ve said, “If you don’t provide what we want, we’ll go elsewhere. We’ll do it at home, or in another hospital, or in another city.” We’ve had people from all over the state coming here to deliver because they couldn’t get what they wanted in their home town.

And what’s happened is that the health workers and the hospitals have responded to the economic pressure. Obstetrical units are usually real money-makers for a hospital, but not unless they’re active. When a few hospitals offered alternative birthing services, the staff at the ones that didn’t ended up sitting around twiddling their thumbs. They were forced to offer those services. Now you walk in the door of any obstetrical unit, and you’ll see this sign, “Family Birthing Experience.”

HB: Yes, they talk about it all the time, about losing patients to other hospitals.

CB: How should a family go about choosing between a home birth and a birth in an alternative birthing center in a hospital?

HB: It really depends on the family—especially the mother. Very few alternative birthing centers offer an atmosphere as supportive as being at home. If they went to the hospital, they might feel too out of their culture to really relax and have the quality of experience they want.

MW: Some women have a terrifying image of the hospital, or see it as a place very foreign and scary. Heidi and I have seen that lots of times—where a woman who’s in labor at the hospital has trouble because she can’t relax. On the other hand, there are plenty of women who wouldn’t be able to relax anywhere but in a hospital.

CB: How can women get in touch with their feelings about the hospital beforehand ?

HB: By all means, take a tour of the hospital. Talk with friends who’ve had babies there—and with friends who’ve had babies at home. I always encourage pregnant women to take the tour. The results are sometimes very striking—people who were definitely going to give birth at home may realize they’d rather have it at the hospital, or, just as commonly, the exact opposite will happen, and a couple who’s planned a hospital birth will decide to have it at home.

CB: What should a woman ask herself when she visits the hospital and takes the tour of the labor and delivery rooms?

HB: They should ask, “How do I feel about technology?” “How do I feel about being handled by competent strangers?” “How do I feel about mechanical things?” Sometimes the number of electric and electronic gadgets a woman has in her home will reflect her feelings about technology.

MW: Sometimes reading the right books helps people explore their feelings, too. It can make you aware that there are really more possibilities than you might have thought.

CB: Why do you think there’s been such heated controversy about home births in some places, while in other areas it’s just seemed to slowly evolve and be well accepted ?

HB: I think that some health workers are scared. They’re afraid that they’ll lose financially, or that obstetricians might be phased out completely. And some non-health workers have just turned their backs on health workers altogether and gone off to deliver their own babies at home.

My feeling is that both extremes are off the mark. A certain degree of technical training and experience is clearly helpful in figuring out the small percentage of women who are at higher than normal risk. At the same time, families need to be able to arrange a birthing experience that meets their needs, not the health workers’ needs. Birthing should be a collaborative effort, with input from both the family and the health workers involved. Neither party can manage as well without the other.

CB: What are the qualities to look for in the person you want to attend your birth?

HB: How you feel about a person is very important. When it came to choosing someone for my own birth, I passed up a number of doctors I knew and picked one I hardly knew at all because I had very good feelings about him.

MW: I would also want to check on their competence. Ask somebody they’ve helped to deliver, or ask other health workers who’ve worked with them. I’d ask a health worker friend whom he or she would go to. It’s also important to consider who has hospital privileges where.

HB: Another important thing is whether the person really listens to you. Birthing works best when both attendants and parents are really listening to each other and learning from each other.

Also, a doctor who delivers fifty or sixty times a month by himself is not going to have time to give you much personal attention. He’ll be forced to scoot you in and scoot you out. So be sure and ask how heavy a case load the person carries.

Finally, I’d choose a person who’s not locked into either a home birth or a hospital birth.

MW: Yes, the parents’ feelings may change at any point and they should be supported. The option to have a baby at home or to go to the hospital should be kept open as long as possible.

HB: To realize that you can change your mind, shift plans, and still have a positive birth experience is very important. Maybe you have been planning on a hospital birth, and once you get there, realize that it would have been better at home. Or maybe your game plan has been home birth and you feel yourself wishing you were in the hospital. It’s okay to say, ” Hey, wait a minute. This doesn’t feel right.” And change the game plan so that it does feel right.

CB: Heidi, you were saying that prospective parents should think in terms of having two birth attendants.

HB: Yes. There’ll be more than two at the hospital, and I personally don’t consider home birth safe unless there are at least two knowledgeable birth attendants there. It may be a nurse-midwife and a lay-midwife, it might be a midwife and a doctor. If all goes well, there’ll be one person to organize things and make phone calls, while the other stays by the bedside. If there are complications, it’s vital. After all, there can be two patients—the mother and the baby. The two health workers should not only be competent, they should work well together.

CB: What are the risks of home birth?

HB: Except for the mother who lives miles and miles from the hospital, I think they’re about the same as for being at the hospital. The important thing is who’s attending your birth. Are they monitoring the fetal heart tones? Do they have emergency equipment with them? If you have the right people, they can do nearly anything that could be done at the hospital—and in a less intrusive way. Competent attendants at home, with a good attitude, are much safer than less competent attendants in the hospital who are working at cross purposes. Technology is only a tool. It’s the people and the attitudes behind the tools that are even more important.

MW: I think that many obstetricians still believe that home births are less safe than hospital births. That may have been true at some time in the past, but with birth attendants who are well equipped and well trained, that’s simply not true any more.

CB: When people talk about the complications at home births, the most scary one is excessive bleeding. Can that be handled just as well at home as it can in a hospital ?

HB: Yes, it can. We have intravenous fluids and plasma expanders and oxygen and all the medications right there with us. We use the same technologies and techniques they would use at the hospital. The only woman I ever heard of who bled to death at childbirth did so in a hospital.

MW: The problem is more legal than technical, really. If a mother bled to death at home, the attendants might be charged with manslaughter.

HB: Yes. People assume that if a woman bleeds to death in the hospital, it’s justified because the assumption is that everything that could have been done was done. There’s a real double standard operating here. If a doctor delivered a woman in the hospital and she died, there would very likely be no recriminations. If a midwife delivered the same woman at home, provided exactly the same care, and the woman died, the midwife would undoubtedly be charged with murder.

CB: How about the risk of infection at home births?

MW: Well, generally speaking the baby comes out sterile and is immediately exposed to bacteria and viruses in the environment—he has to get used to them in order for his immunological system to develop. Babies born at home are exposed to the flora on the parents’ skin—and they have antibodies to these germs already. On the other hand, the germs in hospital nurseries are more likely to be the disease-causing kind, and therefore much more dangerous.

HB: In the hospital you’re at added risk of surgical intervention—episiotomies, invasive techniques— which increase the risk of infection. Hospital birth attendants are more likely to get tired of waiting and give a drug to induce labor. It may well be safer to wait—as we do when we deliver at home.

CB: How many home births have each of you done, would you estimate?

HB: Probably 150 over two years. And this doesn’t include the hundreds of births I’ve attended as a labor and delivery nurse in the hospital.

MW: I’ve been involved in about 350 births.

CB: Have you ever run into anything you felt you weren’t equipped to handle?

HB: No, not once. We can start emergency measures and get the woman to a hospital by ambulance in about the same amount of time it would take to set everything up in the hospital.

MW: And you have to remember that one reason for that is that we don’t try to deliver everybody at home. Any woman with a pre-existing illness or a disease of pregnancy is advised to plan for a hospital birth.

CB: What are the benefits of giving birth at home?

HB: I think that in many cases it’s safer. The home birth attendants I’ve worked with watch the patient more closely. I’ve seen complications arise in the hospital because there are six or seven women in labor at once, people are busy, and there’s a false sense of security because of all the technology. No machine can replace a birth attendant who’s totally there with you, so that if any little thing starts to happen, we can catch it right away.

MW: You can create your own routine at home— you’re not at the mercy of the hospital’s routine. This is your first chance to meet this new little creature, and it’s important not to have a lot of regulations getting in the way.

CB: It sounds as though a real polarity has developed between people doing home births and people doing hospital births.

HB: It has in some places, and it’s a real shame. My experience working both in the hospital and at home has been invaluable for me. In the places where things have gotten polarized, everybody loses. The hospital birth attendants have a great deal to learn from the people doing home births, and vice versa, and some of the home birth people could use more technical knowledge. In places like Marin, where there is a lot of communication between people attending home births and people delivering babies in the hospital, it’s been wonderful. Birthing doesn’t need to be divided into two warring camps. We need one whole flowing continuum with an emphasis on alternatives and individual choice.

After working in the Intensive Journal on my own for several months, I decided to attend a Progoff workshop at a Catholic retreat house in Menlo Park.

The most striking thing about an Intensive Journal workshop is that so many people come together to work alone. Each of the hundred participants sat, focused quietly inward, notebooks in laps, working with the materials of his or her own life; while Progoff, a kindly, soft-spoken man, short and rather shy, sat in a swivel chair on a raised platform and, sometimes, talked. His talking, he explained, was to be regarded as background music to the primary focus of the workshop, each-person’s self-directed writing.

He led first-time journal users through some introductory exercises, while those more experienced with the journal (many brought in binders bulging with pages, clearly the accumulation of years) worked away on their own, stopping to listen at times, going on when the spirit moved them.

The atmosphere was quiet, focused but relaxed. Participants were invited to make their own breaks, and from time to time someone would move silently in or out of the auditorium. Cocoa, tea, coffee, and several boxes of fresh apricots were available in a room next door. It all felt a little like being in church.

A number of the participants were, in fact, from religious vocations, but while the journal is open to religious use, participants must supply their own religion. After an exercise in which we were asked to have a dialogue with our own interior wisdom figure—a conversation with a person, real or imaginary, living or dead, whom we most admired and respected—there was mention made, in the coffee room, of Jesus, Moses, God, Picasso, Martin Luther King, St. Theresa, Lao-Tze, Malcolm X, Saul Minsky, William Blake, and Margaret Sanger.

The workshop ended on noon of the third day. Progoff had promised to meet me for an interview afterward, but first wanted to make himself available to participants who wanted to see him privately. He ended up meeting at some length with more than a dozen, exhibiting a remarkable patience considering that he had been working sixteen hours a day for nearly a week. It was late afternoon by the time we settled onto wooden deck chairs on the front porch of the retreat house and taped the following interview.

TF: One thing we’ve been trying to do in the magazine is to point out ways to move the focus of health responsibility from some kind of expert back to the individual himself. It seems as if you’re trying to do something very similar with the Intensive Journal

IP: Yes, I would certainly hope so. Emerson’s essay on self-reliance has always been one of my favorites. I see psychological self-reliance, or psychological selfcare, a way of being able to tap into resources and knowledge within oneself that can enable us to deal with our problems, our experiences, in new ways. That’s the principle I’ve tried to build into the Journa!.

You studied with Carl Jung for several years. Didn’t he have his patients keep a journal?

Jungians always keep a dream log and a kind of general inner diary. The problem with an unstructured journal, including many of the Jungian ones, is that they tend to go around in circles, and they only work in very limited ways. The Intensive Journal is set up to help you break out of that circular movement.

We were talking earlier about E.F. Schumacher and the appropriate technology movement. Do you think of the Journal as appropriate psychological technology?

It really sounds very similar, doesn’t it? I know I’ve felt for a long time that many psychologists and psychiatrists are trained to rely too much on what you might call inappropriate psychological technologies— ways of taking over diagnosing and controlling psychological problems with drugs or electroshock or whatever. I think good therapy is very often more a matter of helping someone who’s stuck get unstuck. I think people are much more capable of guiding their own efforts to get unstuck than we’ve given them credit for.

Has the Journal been used with people in mental hospitals?

I had never thought the Journal could be used by very disturbed people, but we’ve had a most interesting experience using it in this way at St. Luke’s Hospital in Phoenix. They had about thirty or thirty-five psychiatric patients on their acute crisis ward, and they invited me in to do three short workshops. The were open to everyone on the ward, no matter how disturbed. It was very interesting.

There were people there who hadn’t spoken in as long as they’d been there, they were diagnosed as catatonic. I gave them the stepping-stones to do and they did them and read them out loud. Two young guys were there as depressives. After the workshops I was walking through the ward with the head nurse. She said to them, “Hello, how are you?” And they said, “Fine,” and gave us a big smile. She turned to me and said, “Those two fellows haven’t smiled or done more than grunt in the two days they’ve been here.”

Word came back to me later that the senior psychiatrist, who specializes in electroshock, said he would not have believed it possible for so many seriously disturbed people, with no restrictions, to experience nothing negative and so much that was positive and integrating.

So we’ve been following that up by starting a program to train some of their people to teach the Journal on the ward, and then to have programs available in the community so people can continue after they’re re-leased.

What could you say about the Journal as a possible tool for our readers to use in their own lives? Who might find it useful? What would it be useful for? How could they go about giving it a try?

You can learn to use the Journal either from a workshop or from my book, At a Journal Workshop. The first exercise, the Period Log, is designed to give you a kind of overview of your life, with particular attention to the most recent period of your life. It might be a good introduction to do that exercise and see if it feels like a way of working that is right for you.

As to what the Journal is useful for, I like to describe it as an instrument—in two senses. First, it’s an instrument like a hammer or a scalpel—a tool to help you deal with difficult times in your life, times of change or decision or loss, or great success for that matter.

But it’s also an instrument in the way that a piano or violin is an instrument. Working in the Journal can be a fulfilling experience in its own right, an art form if you like. It’s something you can do just for the pure pleasure of it. You can play with it. Improvise.

Do you recommend that people write in their Journal every day?

It’s entirely up to the individual. A few people keep it every day. It’s not like keeping a diary. It’s something that’s there for you when you want it, when you need it. It’s more like “Gee I’ll think I’ll get my guitar out and play a little.” It’s definitely not supposed to be another responsibility to feel guilty about.

How would you compare learning the Journal from the book to learning it from a workshop?

It’s probably easier in a workshop, though of course coming to a workshop is not always convenient. If you can do it, though, a whole weekend away from home can be a real help in getting deeply into it in a short time. It gives you a chance to block off all outside pressures and just focus on the movement of your life.

Learning from the book is certainly more convenient. It probably works best if you can give yourself some big blocks of time, at least in the beginning.

You were saying you’re now working to make the Journal workshops more widely available.

Yes. We’re now working with a number of local groups across the country—churches, community mental health centers, adult schools, universities—to help them set up and run a program of local Journal workshops.

How might that work?

Well, suppose a minister or a therapist has someone in a crisis situation and both counselor and client have been trained in the Journal method. Perhaps the client has tried to work it out for himself in the Journal but hasn’t been able to.

The client could bring in his or her Journal, maybe read some of it if he chose, and the counselor, in addition to doing some individual therapy, could suggest some specific work in the Journal that might help. We’ve developed some specific exercises, a kind of crisis module, to be used at such times.

If some of our readers belong to organizations that might be interested in sponsoring a workshop, would you encourage them to contact you?

Oh, yes. Definitely.

How have other mental health professionals responded to the Journal method? I would think that some might find it a little threatening.

Well, of course, the ones we’ve been in touch with are the ones who like it and use it. A number of psychologists and psychiatrists are incorporating the Journal into their therapeutic work.

It turns out to be quite adaptable. One of the appealing things about this method is that it isn’t instead of anything else. It doesn’t promote or contradict any psychological or religious explanation of the nature of man. Freudians can use it. Gestaltists can use it. Behavior therapists can use it. Fundamentalist Baptists can use it. Suns can use it. We’ve had people from just about every possible religious or philosophical orientation use the Journal successfully. We have Catholic monks and Zen Buddhists sitting side by side in our workshops.

It sounds like you’re working toward a vision of a whole new way of approaching the area of mental health care.

Yes, and I’m very encouraged by what you’ve told me of the self-care movement in the area of physical health. I would hope that the Journal could be an important tool for a similar emphasis on psychological self-care.

The basic concept behind the Journal method is that when you’re having a hard time, when you’re troubled, it doesn’t mean you’re sick. It doesn’t mean you should immediately go out and put yourself under an expert’s care. It may mean that you’re in transition, that things are pretty confused for you right now, but that’s all right. That’s natural. It’s a part of the unfolding process of life, as it moves from cycle to cycle.

When you’re in a great darkness or feeling very depressed or a lot of anxiety, there are methods of working that will allow our life to tell us what it’s seeking to achieve beyond that blockage, beyond that stuck point.

When you use the Journal, you’re not saying, “I’m sick,” you’re saying, “I need a time of reflection, of quieting. I need a sabbath.”

I think the principle of the sabbath—the need for rest after activity—is still psychologically sound. It may be that the rhythm of six and one is not the only rhythm. The Journal is a way to follow one’s own rhythm, to create one’s own personal sabbath, whether you come to a workshop or just do it privately in your own life.

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Tom Ferguson, M.D. (1943-2006), was a pioneering physician, author, and researcher and one of the earliest proponents of self-care. Dr. Ferguson studied and wrote about the empowered medical consumer since 1975 and about online health resources for consumers since 1987. After attending Reed College, earning a Master’s Degree in creative writing from San Francisco State University, and a medical degree from Yale University School of Medicine, he launched a prolific career in consumer focused medical writing as founder of Medical Self Care magazine. Tom was in charge of “Self-Care Central” one of the 10 “buildings in Healthy’s original Health Village design on our original website launched in 1996. This interview was drawn from the archives of Tom’s Medical Self-Care magazine. It is as relevant today as it was 30 years ago. Tom passed away in 2006. He has so much more to offer the world.

I always find myself explaining Keith Sehnert as the George Washington of self-care. Keith graduated from Western Reserve School of Medicine in 1953. After working as a General Practitioner and later as Medical Director of Dorsey Laboratories in Lincoln, Nebraska, he joined the Reston-Herndon Medical Center in Herndon, Virginia. There, in 1970, he taught—and largely invented—the first of the modern breed of self-care classes, classes in which laypeople learned basic medical skills formerly reserved for doctors only.

The class drew wide media attention. In 1972, Keith became a visiting professor at Georgetown University and in 1974 founded the Center for Continuing Health Education at Georgetown.

The Center for Continuing Health Education did self-care research, taught health professionals from all parts of the country to conduct self-care classes, and prepared course materials for these classes. In 1977, Keith became Vice President and Director of the Health Promotion Group at InterStudy, a health-policy and health-futures think tank in the Minneapolis area, and joined the University of Minnesota School of Public Health as clinical professor.

It is in large part because of Keith’s efforts that there are now self-care classes in forty states. He is the author of How to Be Your Own Doctor (Sometimes).

TF: You were saying that you were a student of Ben Spock’s at Western Reserve.

KS: Yes, back in the early fifties. Spock was just starting out as a teacher there, and his book, Baby and Child Care (reviewed on page 207) was just out. Of course, no one had any idea then it was going to become so popular.

Did he have a big influence on you?

He did. He was very concerned that most patients were getting a great deal of treatment but very little teaching. He felt that was a mistake.

I don’t think there’s any doubt but that his book planted a seed for me. I’ve always thought of my book as a kind of Dr. Spock for adults.

Were there any other experiences at Reserve that nudged you in the direction” of self-care?

Yes, the influence of another very important teacher, T. Hale Ham. In those days the whole business of a doctor’s empathy for the patient and communication skills were spoken of as one’s bedside manner. We were all very concerned about our bedside manner. Dr. Ham used to say, “Keith, you just talk to your patients in whatever way is most comfortable to you—but keep in mind that if you’re a good teacher, your patients will think you’re a good doctor.”

How did you happen to end up teaching that first self-care class?

Well, you know, serendipity plays such a big part in these things. I’d just joined a family practice group in the Reston area of Virginia. The guy who’d actually planned the class was leaving to join the Family Practice Department at the University of Wisconsin. One day he just casually asked me, ” Look, as long as you’re going to be here, would you mind picking this thing up for me?” And of course I said yes.

How many students were there?

I think there were forty, maybe forty-two. About 80 percent women. Almost all of them were patients at the Medical Center.

What was the first class meeting like?

It was an interesting experience. Many of the people in the first class were women whose husbands had been recently laid off by a reduction in the Johnson administration space program. Some of them were living on unemployment insurance for the first time in their lives.

As we got to know each other better, a lot of anger toward the health-care system started to come up. Frustrating experiences. Times when they’d been treated insensitively.

The old authoritarian doctor image was hanging over our heads, even though I wasn’t the typical authoritarian doctor. There was a lot of asking, is this something that’s okay to talk about? Is it all right for me to ask this question? And when I made it very clear that it was, they really began to share their experiences and concerns. They began to express feelings they may never have expressed to anyone before—certainly never to a physician.

It soon became clear that they had a lot of health needs that weren’t being met by the health-care system. They’d been put down and ripped off. The women’s movement was beginning to be active around that time, and the women especially were beginning to look at their lives in some new ways.

Pretty soon people started saying, “Why can’t I take my father’s blood pressure?” “Why can’t I give my kids allergy shots?” “Why can’t I use an otoscope to look in my little boy’s ear when he has an earache?”

And I found myself saying, “I don’t know why not. Let’s do it.” So the whole course evolved out of the things people were asking.

Had there been any other similar classes up to that time?

No, to my knowledge, it was the first class of its kind. There had been orientation tours for new patients in certain clinics and patient education for some specific diseases like diabetes, but nobody had ever really gotten into this area before.

How would you define this new area?

1 think of it as directed toward a new kind of medical consumer, what I call the activated patient. In my Herndon class, their questions went well beyond the boundaries of what had been thought of as patient education at that time. They wanted to know why they couldn’t have their own black bags of medical tools at home. No one had ever thought of teaching laypeople to use such tools before. There weren’t any models for that. So we just had to go along and figure out how to do it as best we could.

What motivates a person to take a self-care class?

We’ve looked at that, and there seem to be seven basic reasons people give, over and over, for their interest in self-care:

1. wanting to save money on health expenses;


2. wanting to be able to take better care of their family’s health, to be able to make effective family-health decisions;


3. wanting to take more responsibility for their own illness care—like hypertensives who want to be able to keep track of their own blood pressure;


4. wanting to learn how to hook into the medical system like a number of older people who outlived their doctors and weren’t able to find a new one they were satisfied with;


5. wanting to learn more about their bodies and how they work;


6. people with illness in the family, wanting to feel more confident in dealing with it;


7. people who’ve gotten turned on to healthier life styles, wanting to hear more about jogging, nutrition, yoga, meditation, and whatever else there might be to this whole healthy lifestyle business.

So you include more than just traditional Western medicine in your classes?

Oh, yes. Of the really alternative approaches to health, yoga is the main one we’ve used—mainly because a neighbor of mine happened to be a fine yoga teacher. If I’d lived next door to a Thai chi teacher, we might have included that. The introduction to yoga has certainly been well-accepted by our students.

I think giving these kinds of alternatives is awfully important, particularly because through them people can learn to get the same kinds of things they might now be getting from alcohol and various other chemicals. And those are not ways I like to see people relieve their stress.

How long did the Course for Activated Patients go on?

We ran two classes a year for almost three years. Then, in February of 1973, Howard Eisenberg did a story on the class for Parade magazine, and I got over two thousand letters as a result. That made me realize that what we were up to might be something with a much wider appeal than I’d thought.

About that time I began getting inquiries from the federal Department of Health, Education and Welfare, from a number of foundations, and from several of the faculty and deans who were interested in doing something more in the way of self-care at Georgetown University.

Several publishers started wining and dining me and convinced me that there was a need for a book on what we were doing. So I took a six-month sabbatical and collaborated with Howard Eisenberg on How to Be Your Own Doctor (Sometimes). Shortly after that, the Center for Continuing Health Education was formed at Georgetown, and I became its director.

So you were there until 1977?

Yes. Then our grant ran out, and the functions of the Center were divided between the Health Activated Person Program at the Georgetown School of Nursing, where they’re continuing to give an ongoing self-care course for the Washington community, and the Health Activation Network (see page 268), who put out a newsletter, “The Health Activation News,” to train self-care teachers and help people establish new courses.

You know, Keith, I have a feeling that if it had been some other doctor teaching that class, it might have ended up as just a lot of boring lectures. Have you had special training in communication, or are you just good at it?

Well, as you know, one of my daughters, Cindy, is deaf, and that’s made me very aware of the importance of getting and giving feedback. It got me very interested in good communications, and when I was talking to a patient I would always give and ask for feedback to be sure we were understanding each other.

And then the other thing was how much I loved doing it. I discovered that I liked being a facilitator better than being an authority. There was a feeling of real partnership. It was wonderful to relax out of my professional role and, if somebody asked me a question, to say, “1 don’t know. How do you suppose we’d go about finding out?”

It was a very rare thing in my medical education to hear a doctor say, “I don’t know.”

Incredibly rare. We were taught we were supposed to know all the answers.

How have health professionals reacted to self-care classes?

I like to say, scratch a doctor and you’ll find a teacher underneath. Most doctors have been too busy with day-to-day practice to develop as teachers, but once they do it, they find that it’s fun.

I’ve brought a lot of health professionals into selfcare classes, and while at times I’ve had to more or less drag them kicking and screaming into the pit, once they take off the white coat, loosen the tie, and get their shoes off, they find they’re having a fine time. It’s a real relief to be able to show your human side, and the people in the classes are always so appreciative.

There’s a real sense of working together for a common goal. Most of us went into medicine for pretty altruistic reasons. We’re not all dollar-sign guys. And when you start relating to people as active partners instead of passive pawns, they really appreciate it, and they let the doctor know.

In my medical school training, except for a little bit in psychiatry, I didn’t receive any formal training in communicating with patients. Many people would say that medical education makes doctors less capable of communicating on a meaningful level. Are there any signs that this is changing?

Well, coincidentally, I just finished reading a report on self-care from the Association of American Medical Colleges. They’re getting together a major project in which they will begin teaching self-care communication skills in a number of medical schools. Dr. James Hudson is going to be the Project director.

The American Medical Students Association also has modest self-care programs going at a number of medical schools. And of course there are all kinds of new and fairly informal projects at individual schools—there’s something here at the University of Minnesota Medical School, the University of Arizona has one, as does Georgetown University. There’s a big interest at UC Berkeley, and you were just telling me about the self-care class you visited at Wright State School of Medicine in Dayton. There’s actually quite a lot going on in the medical schools already.

Any signs of health insurance companies being willing to reimburse policy holders for self-care education expenses?

Blue Cross of Montana has started doing this on a very small scale, and some of the other Blue Cross plans have been saying they’re going to get into this area— they’re putting on some prevention education programs now. Several other insurance companies are looking into self-care education. International Group Health in Washington has started several projects. IGP’s head guy, Jim Gibbons, is a real self-care advocate.

Could you comment on the kinds of people who are—and should be—teaching self-care classes?

I’ve always felt that the ideal teacher was the nurse. Certainly the greatest enthusiasm for self-care has come from nurses, nurse practitioners, and physicians’ assistants. Many of these allied health professionals feel much more strongly about prevention and self-care than about diagnosis and treatment—which continues to be the main concern of most physicians.

Do you think it’s important for the people teaching these classes to have clinical experience?

It certainly helps. One of the real dilemmas these days is that people hear this from Reader’s Digest, that from the National Inquirer, and something else from Prevention. They need to be able to ask someone who has done more than just read the books.

How about in the schools? Do you think it would be an advantage to include people with clinical experience as a part of health-education classes?

Yes. Not only are clinical workers more likely to have experience with these matters, but it’d be very valuable for kids to be able to talk to a health worker at some time other than when they’re sick or need shots.

Do you see a connection between the widespread popularity of running and the developing self-care movement?

Absolutely. Because as people start feeling better from jogging, and begin to sleep better and eat better, they’re going to discover they have more energy than they ever did before. Then they begin to realize that health is a resource to be conserved, not something you can waste and then discard like a cigarette butt or a wrecked car.

Yes. Your body is a temple. Why treat it like a motel?

Yes, that’s a good one. So when people increase their nutritional awareness, or start jogging, or get into stress reduction, they feel better. And taken they say, “Well, gee, maybe I can kick smoking and kick alcohol and practice a healthier lifestyle. And it’ll pay off.” And it does!

What other cultural changes are we likely to see?

One we’re already seeing is a change in men’s thinking and behavior. For so long we’ve had this macho male image about everything that’s harmful or illegal.

If I smoke and it’s bad for me, I must really enjoy it. It’s a sort of bad-boy mentality. To have fun, you’ve got to be destructive—driving too fast, abusing your body or those of people around you.

That tough-guy mentality is softening. As I go into groups of my peers—men in their late forties or early fifties—I find I seldom hear the sort of thing which was the rule not very many years ago. You know, ” Boy, did we have a good time last night. I bet old Fred and I drank a fifth of booze . . .” and so on. That kind of bragging.

Now I’ll more likely hear a guy say, “You know, I’m so proud of myself. I finally quit smoking after twenty-two years.” And everyone is very interested in how he did it. They’re talking about jogging and cutting down on their drinking.

I had some unpleasant experiences—before going to medical school—when I tried to find certain health information in a medical library. It would have been much easier to look for comparable information in just about any other field—engineering, physics, biology. But technical medical information—for someone who is not a medical professional—is almost impossible to come by.

I recently called the National Arthritis Foundation to ask how our readers could order copies of a book they put out. It covers arthritic diseases in depth, it’s comprehensive, and it’s cheap—one of the best available sources of information on arthritis. I was told that it wasn’t available to laypeople, ”because they might misunderstand it. ” A medical librarian at Yale told me that she had been taught to discourage laypeople who came into the medical library in search of information, “because it was probably somebody looking for evidence for a malpractice suit. ” Why is medical information kept so secret?

Until recently, the medical mystique was much like the religious mystique in the days of Martin Luther and the Protestant Reformation—the language of the laity was one world and the language of the clergy was another. They didn’t even say their prayers in the same language. It was a priesthood. There were things that the layperson wasn’t supposed to know about.

I think that what we’re seeing now, with the demystification of medical language, is comparable to the change Luther made in bringing Christianity into the language of the people.

That’s the most important thing that happens in these self-care classes. First, you let people know that it’s okay for them to step into this formerly forbidden area, and second, you guide them in their first steps. So the main thing is not the class itself, but the fact that it can get people started. It’s a perceptual door opener.

It should be the goal of every health professional to transfer useful and accurate tools, skills, and knowledge to his or her clients. To hide these “professional secrets” and keep them for one’s own aggrandizement is a malfunction of one’s professional role.

One last question, Keith. Would you look into your crystal ball and share your thoughts about the kinds of changes we’re going to see in the next ten years as a result of the growing enthusiasm for self-care?

When I first moved to Minnesota last year, I picked up a paper and saw that a man was considering running for governor on a health-promotion platform. I think we’re going to see mayors and governors and other political leaders picking this up—and probably in your state of California, too. I think self-care will be one of the big political issues of the next decade—in the way that education and agricultural reform and honesty in government have been hot political issues.

A second thing is that the business community is going to get increasingly involved in health promotion, self-care, and helping their employees become wiser buyers and wiser users of health-care services. The big corporations especially are feeling the pain of rising health-benefits costs. In fact, the guys bathe executive suites are hitting the ceiling. These decision-makers are suddenly realizing that health insurance premiums, disability insurance, early retirement, days lost from work due to illness, are all things they can do something about. Several companies last year paid more for health benefits than they did for any other product or service. So I think we’re going to see a lot of self-care promotion on the part of industry.

Third, I think a lot of leadership in this area is going to come from senior citizens. I think that women will continue to be especially active in self-care, and I think we’ll begin to see unions taking a major role.

Fourth, we’re going to see school systems putting in really high-quality self-care programs running all the way from kindergarten to high school. There are some exciting things happening along such lines in Maine, Montana, and Minnesota schools already.

And finally, I think we’re going to see a growing number of fitness/self-care/health-promotion groups, health-information centers, health clubs, self-care classes and study groups, alternative health centers, stop-smoking clinics, and exercise facilities, more widely available black-bag tools, and so on.

He is the author, with Alfred H. Katz and Erik Holst, of Self-Care: Lay Initiatives in Health, and is an Advisory Editor of Medical Self-Care Magazine.

TF: Lowell, you’ve probably school health education as extensively as anyone in the field. What do you think about the way health is taught in American schools?

LL: School health education is a real disaster area. Not only are we not teaching our kids much that is useful, we may be actively destroying their innate abilities to care for themselves.

Health is frequently taught by bored P.E. teachers who have little theoretical and no clinical training. It’s like studying auto mechanics with somebody who’s never picked up a wrench in his life. It’s a rainy-day activity. Few take it seriously.

We desperately need to transform our so-called health classes into experiences that genuinely promote increased self-care, self-discovery, and opportunities for increased control of one’s own life. In fact, that’s probably the single most important thing we could do to solve the so-called health crisis in this country. We need to give our kids a good solid education in clinical medicine, just like we do in reading and arithmetic.

How can a health class damage a child’s ability to care for himself?

By teaching children to conform to a very narrow, professionalized view of what health is all about. We’re teaching them that chiropractors and herbal remedies and homeopathy and other healing approaches are dangerous and harmful. In so doing, we’re prejudicing them against approaches that might be very useful tools.

We teach them that illness is a negative concept and not to be talked about. Health classes never talk about illness—though of course that’s exactly what children are most curious about. The message is that only health workers are capable of knowing about such things— which is absolute rot. These classes have been a real form of social control, and it’s no accident that organized medicine has had a very active role in determining the content of these classes

What do you think we should be teaching in the schools?

Some of the same things we teach in medical school basic human anatomy and physiology and the causes and treatment of disease. Use the school nurse or doctor as a teacher, and use the actual illness experiences of children and their families as opportunities to learn about illness.

We should teach them to diagnose and treat common minor health problems. We should also teach them which kinds of health problems really require professional help. We should teach them medical consumer skills, so that they’re not helpless pawns when they walk into a doctor’s office or go into the hospital. We should teach children to take a good medical history, and to understand the questions and what the answers mean.

Suppose you were a parent. How would you go about getting such a program started in your local school?

I’d start by talking with other parents, sharing my feelings and whatever information I had. I’d try to get parents and teachers together with people working in self-care, visiting some self-care projects. I’d try to give them an opportunity to experience some self-care education for themselves.

Then I’d put it on the agenda of the local PTA or welfare mother’s group or whatever kind of parents’ group existed—maybe invite someone working in selfcare to give a presentation. Then get the parents and teachers to come up with some specific proposals.

I don’t think you can have a good self-care program without the parents’ support, because what you have to do is really put the learners in charge. Give the students the initiative to invite people to come to class— physicians, dentists, alternative healers, runners, meditators, people from self-help groups. Give the kids a feeling that it really is up to them, that health is not just another thing they’re going to have rammed down their throats. You need parental support for that, because that’s a hard idea to sell to traditional educators.

There seems to be a real reluctance to discuss disease with children. A classmate of the children in a class I taught had a brain tumor. Our kids were very curious about what was going on with him. Why was he in hospital? Why was he being kept home? Why had he lost all his hair? What did it mean that he had cancer? Was he going to die? But they’d definitely gotten the message that it wasn’t okay to ask, that it was something so horrible you just didn’t talk about it.

I wanted to invite him and his parents and perhaps his doctor to come and talk to the class about what was happening. The other teachers were horrified. They felt that having him talk about his experience would be too scary for the children.

Yes, and it’s in large part this very pattern of treating such serious illnesses as if they were taboo—except for professional health workers—that makes being seriously ill such a frightening experience. Not only are you sick, but nobody will talk with you.

How did you first get interested in self-care?

It really grew out of my fascination with what was happening in the women’s movement in the early 1970’s Passing the speculum technology on to individual women seemed to point the way toward a much broader transfer of skills and responsibility in health. I got very interested in extending that kind of health empowerment to the population as a whole. Compared to what was happening in the new women’s clinics, most of what was being called health education was a pretty feeble effort.

The women’s clinics were teaching skills that really empowered the people who learned them. They were teaching laypeople to do things that had previously been done only by doctors. They were really transferring knowledge and power from the professional to the client.

Maybe you could describe the proposed adult selfcare project you’re working on in New Haven.

Our project is set up to allow four different communities to plan and carry out self-care programs that would meet their own needs. The four communities are very different in economic and ethnic composition. One is a blue-collar neighborhood with a good number of first- and second-generation southern European and Puerto Rican families. It’s served by a consumer governed free clinic. The second is a predominantly Black and Puerto Rican community with a strong community health center. The third is an economically depressed area which recently lost its textile industry. It’s a depressed working-class area, served by a community hospital and its clinics. The fourth is a university community—students, staff, and families—served by a prepaid medical plan on campus.

What’s the goal of your project?

We want to see what kind of self-care programs the four different communities will come up with. What kind of educational processes will they prefer? What content will they consider important? What outcomes will they want to use in measuring the success of the program?

The people in the communities will plan the program?

Right. We’ll let it be known, through the community, that there are resources available to set up some kind of a self-care or health-education program, but the organizing and planning will be done with the people in the community. They’ll decide how the program is structured, how long it will run, what will be included, and how it will be evaluated. I would anticipate that the four different communities will come up with four very different programs.

After the formal “program” is over, the people involved will continue to learn and to participate in meeting their own health needs. A good self-care program should include not only skill empowerment, but process empowerment. What’s going on in that community that affects people’s health? Maybe it’s environmental pollution. Maybe it’s lack of exercise. Maybe it’s on-the job stress. Whatever it is, it’s the people in the community who should be setting the goals.

Lowell, must lecture and speak about self-care as much as anybody. What kind of reception do you get when you go out to talk about self-care?

I guess the most difficult point to get across is that self-care is not just an extension of health education. We’re not just talking about creating some new, canned programs for professionals to run on the unsuspecting masses. We’re talking about big changes in professional roles, big changes in role for health consumers. We’re talking about shifting the initiative in health care from doctors and other health workers to the individual.

I am less interested in whether self-care will cut down on the use of services than I am in whether it will improve the quality of self-care practice, professional services, and the interaction between the two. Self-care may indeed save us money, but I don’t think that should be the main objective of these programs. For a self-care perspective, the enemy is not the disease, but ignorance and powerlessness.

So far, we’ve been looking at self-care from the point of view of the consumer. How are our doctors going to feel about it?

I think that physicians in primary care will be cautious. Once you empower people to make their own decisions, some people will make decisions other than the one the doctor would have preferred. An empowered consumer might also opt for some kind of care other than that offered by the traditional M.D.

Self-care-educated people will be much more assertive. Their questions will be sharper, they will demand more information, more education. They will ask health workers what they plan to do in much greater detail, and they will expect good answers. They will be more likely to seek different opinions or approaches.

Self-care offers additional degrees of freedom for both health workers and individuals, but it doesn’t mean that every individual will be on his or her own in health decision-making. The staunchest advocate of self-care, going in for major surgery, would want to be able to rest his or her trust in the surgeon doing the operation, to go to sleep trusting that everything would be all right. There are times when this parental, assuring role is very appropriate.

It’s less valuable, perhaps even harmful, when the parental attitude is used when somebody comes in with a stress-related illness. If the doctor just gives these people a Valium and a pat on the head, he or she may be doing them a disservice.

Doctors need to identify situations in which it is appropriate for them to say, “I can’t deal with this effectively,” and perhaps suggest that they make lifestyle changes or involve themselves with a self-help group.

You know, the basis of the whole problem of healthcare costs is that the provider almost always decides what the consumer needs. Health professionals make nearly all decisions about purchasing hospitalization, lab tests, drugs, physician’s services, and so forth. When these decisions are made solely by the provider, all economic controls go by the boards. It would be like going to the grocery store and having the checkout clerk tell you what groceries you had to buy.

A self-care-educated mother monitoring the health of her children can make very useful health judgments about her child—saving time and effort and minimizing the need for professional services. Family and friends can, in many cases, provide better health care than any hospital, because they share the client’s culture. So self-care offers some attributes far superior to what any professional could supply.

Some people in the alternative technology movement are calling self-care appropriate medical technology. Would you agree?

Very much so. Because we’re not talking about bringing in vast new programs, run from the top down. We’re talking about using resources we already have—and have been overlooking for years.

I wouldn’t want to overemphasize health workers’ resistance to self-care. A great many health workers are very excited about self-care, because it gives them an opportunity to get out of professional roles they find personally unsatisfying.

I couldn’t agree more. I’ve always felt that physicians who tend to be curt and abrupt with their patients—who show their stress in their patient relationships—do so because of the strain of having to deal with the patients who appear passive and helpless, who come in demanding that the doctor do things he couldn’t possibly do. If I were a physician, I’d much prefer working with assertive, educated clients who understand and believe they can and must participate in what’s going on.

I’ve been on the faculty of a number of workshops devoted to self-care for health professionals and I’ve been struck by the way that health workers, especially physicians, when they start to trust you and really start letting down their hair, will say that they feel at the mercy of their patients.

These doctors feel harassed by endless forms and paperwork, and on top of all that, now the public doesn’t love them any more. There’s a lot o f stress, a lot of anger. And there’s a wide-spread realization that they’ve gotten themselves into a role that’s not very satisfying.

That is very interesting. Those kinds of workshops are an extremely valuable resource, because we’re beginning to find more and more health professionals becoming—would you believe it—alienated.

Nurses have been feeling this way for a long time, and now alienation is creeping into other sectors of the health establishment. Medicine really is being demystified. The mystique is beginning to crumble—not only for consumers, but for the health workers themselves. They’re beginning to ask, Who am I? What am I doing here? Who needs us, anyway? Are there other ways of being a hearth worker that would be more useful to myself as well as my clients? And so on.

I would think that an important part of the workshops you’ve described would be an opportunity for health workers to meet in open dialogue with their clients.

One of the great gains of self-care is going to be to let us see our doctors as people. If you scrape the money away, you can see that doctors are insecure, beset by self-doubts, and under a lot of pressure—just like all the rest of us. But their training and society’s fantasies about their function have perpetuated a role in which they’re not able to admit their feelings, their fears, their uncertainties.

It’s encouraging to see that a great many medical students are excited about new career opportunities as educators.

Yes. I think that’s going to be the biggest future role for primary care physicians, nurse practitioners, and physicians’ associates. Health workers who are communicators and educators are going to be very much in demand. I think that the enthusiastic reception your magazine has received is a case in point.

I’ll have to admit, I’ve been stunned by the way Medical Self-Care Magazine has been accepted by health workers and health workers’ organizations. I got into this work very disillusioned with-conventional medicine, and I expected to be considered a real rebel, attacked by the AMA, the whole bit. It’s been absolutely the contrary. In fact, I’ve just been invited to speak to the AMA’s Annual Rural Health Conference.

It’s at these conferences, like the AMA Rural Health Conference you mentioned, that many health workers get introduced to these concepts—and so do other professionals- such as librarians, social workers, and agricultural extension workers.

In fact, that’s the stage self-care is in right now— networking. Getting the word around. Helping people connect with others with similar interests. Some of these networks are very informal communities with homey mimeographed newsletters. Some are more formal—some of the best national networking is being done by the National Self-Help Clearinghouse in New York.

What do you see ahead for self-care?

I would hope that we would see some changes on three levels: changes in our understanding of what self-care is, changes in government health programs as the result of an increasing awareness of self-care as a resource, and a gradual extension of the goals of the self-care movement.

Up to now, self-care has been thought of as an individual activity. I think we’re going to move toward a view that also takes into account the health-care-giving functions of nuclear and extended families, friendship networks, affinity groups, churches, mutual aid groups, libraries, groups of fellow-workers, and political groups. We’re going to broaden our notion of the nonprofessional health-care resource.

Second, I think that legislators considering new state and federal health legislation will have to be very sensitive to its effect on our lay health resources. We don’t want to professionalize these resources. We want to supplement and humanize professional health care by nurturing existing lay health-care strategies.

Finally, I think we’re going to see the self-care movement taking on some broader social and political goals—improving the environment, improving our communities. I would hope that self-care could build on its strong base of individual action and seek to improve our individual and community health by social action as well.

TF: Eight years ago you were one of the youngest vice-presidents of a major bank in the country and were considered a rising young star in the banking world. Why did you quit?

MP: Quitting the banking business was just the final step of a long process that began when one of my clients—who knew what I needed better than I did myself—sent me away on a cruise ship. I was thirty-one years old, and I’d never had a vacation in my life. I was nervous, tense, and stressed—a typical superachiever. I’d never in my life been able to just sit still and do nothing.

What happened on the ship?

Once I was on board and realized that there was literally nothing to do, I just about had a nervous breakdown. I even tried to get a helicopter to come pick me up. Finally, I was faced with the choice between going insane and just sitting in a deck chair and looking out at the ocean for several days straight.

It was the beginning of a big change for me—a big change in the way I thought about myself, about money, and about the world. In the banking world—and in the business world in general—making money is the name of the game. But once I thought through why I felt so driven to make money, I realized that my job was keeping me from getting what I really wanted.

What was that?

I spent a long time thinking about that. It came down to the things everybody wants—freedom, respect, health, security for my family, and security in my old age. I had been thinking that money would help me get these things, but in fact, it was keeping me from getting them.

What I was getting was hemorrhoids and stress ulcers. A psychiatrist I consulted helped me see that I was using stress to make me more effective in the business world—and that same stress was making me sick. And the more money I made, the more sick I was getting.

I realized that because l wanted freedom, and thought that money could get me freedom, I had ended up working in a job where I had very little freedom to do the things I really cared about. I thought that people with more money would be more loved and respected, but when I looked at the people l loved and respected—and looked at the qualities that made me care for them—money had absolutely nothing to do with it. I wanted security for my family and friends, yet I was hardly even able to see my family and friends because my life had become so excessively work centered.

In thinking about old age, I looked at my parents, and saw that their most important asset in dealing with being older was their ability to be competent, helpful, flexible, curious, generous, and involved with others. Money had very little to do with it.

So what did you decide to substitute for the goal of making a lot of money?

I decided the best thing I could do was to start right now to do the things I really loved, and to spend as much time as I could with the people I really cared about. Of course a person wouldn’t necessarily have to quit his job to do that—he or she could just begin to realize that they are not working primarily for money, and make their decisions accordingly.

Can you give us an example of that?

Sure. Let’s compare two doctors. One is a doctor who loves his work and sees it as a way of fulfilling himself, and the second is a doctor who doesn’t really enjoy his work and just does it to make a lot of money. The first doctor will be able to make day-to-day and moment-to-moment decisions based on how he feels. The latter must suppress his feelings and pain to a far greater extent because his work and his sources of fulfillment—the things money can buy—are much less connected.

If the first doctor finds himself feeling sad and tense, he’ll be more likely to ask a friend to help. He may ask a colleague to cover his emergency calls and take off early and go for a walk in the woods. The other doctor, in the same situation, being more dependent on money for satisfaction, would probably push himself more, and make it up to himself with money. He might say to himself, “Boy, I’ve spent all day seeing these miserable patients, and now I have to go back to the hospital to take care of this stupid emergency case. I’m really going to charge this guy plenty. Then I’ll go out and treat myself to a steak dinner and a few drinks. And tomorrow I’ll go have a look at that new sports car I’ve been wanting.”
Three guesses as to which of these two will be happier and healthier.

So people who are more concerned with money tend to be less sensitive to their bodies’ messages?

That’s certainly been my experience. A person’s ability to listen to his or her body is influenced by the extent to which he or she is capable of being open and relaxed. That calmness lets you listen to the world, listen to your body, and listen to your friends.

You were saying that for some people, a useful health goal might be to reduce their incomes.

If you reduce the amount of money you have to earn, you’ll have a lot more freedom to do the things you love, and more freedom to spend time with the people you love. One of my friends recently left a very high-paying job. He’s now living on $450 a month and doing work he cares deeply about and working with people he loves. He’s better off in every meaningful way than he was before. His friends have come through for him again and again

So is money bad in itself?

It’s neither good nor bad in itself. Money is something society pays people for doing what the society—or certain members of the society—want to be done.

Say you’re a craftsperson and you knit little hats. And suppose that red hats sell like mad, but what you really love to do is to make blue hats. If you end up making whatever sells, you’ll end up doing what the society wants.

The same is true if you’re working for a company. You might start out saying, “I’m just going to work for this company for a year to earn enough money so that I can go out and save bighorn sheep.” But you’ll find that by the time that year is up, the values that went with the job have creeped into you. You get used to the big lunches, the big apartment, the big car. You get used to the ski trips to Aspen.

One of the things American culture does very well is to appeal to peoples wants and needs and to get them to trade whatever skills they have for money.

So it comes down to a basic choice—to do what you want or to do what pays.

Not necessarily—many people are lucky and get paid a lot for doing what they really want to do. But for many people, it’s a choice. You can do what’s safe and secure and pays well, even though you may not like it much….

Or you can do what you really want to do.

Yes, but that’s easier said than done, because to do that you really have to know who you are, and how you’re different from everybody else. And that raises some bigger questions than most people want to tackle.

Once you really start doing what you yourself want to do—start making blue hats when what people are buying are red hats—you’re going to become different from a lot of your friends and neighbors. You’ll almost certainly make a lot less money. Some people may think you’re irresponsible or weird. It means the beginning of a long quest to find out who you are and what kind of work you really want to be doing.

And the ironic thing is that once you really do find out what you want to do, really get your act together, the society will support you. If you really go into yourself, you will end up developing something that there’s a need for. No matter how weird it all sounded starting out.

Can you give an example of that?

My favorite is a man I heard give a concert at the YMCA in Chicago in 1954. This guy came out on stage, played a note on the piano, read some stuff out of a book, then he’d play another note. After half an hour of that the whole audience had walked out—and there were only six of us to begin with. At his next concert, he came out, put four radios on the piano, tuned them to different stations, and left. That was the concert.

Now I’ll tell you, this guy was as weird as anyone I’d ever known. It was very hard to believe that this madman would ever have a community to support his work, his maniacal ideas of what music was all about. But that man, John Cage, has since become one of the most respected composers and theorists of modern music theory. He’s had a profound influence on thousands of musicians and composers.

He let himself pursue his real interest, despite how far-out it seemed in the beginning. He kept working on it and developing it—and a community grew up around him. No matter what you do, if you get good enough at it, a community will find you.

Once you see that, it’s much easier not to be tempted by the kind of quick money the society may be tempting you with.

How can you find out what you really want to do?

The only place that answer exists is within yourself. There’s no external standard, no teacher who can teach you who you are. There’s no one way to get there.

One useful exercise is to write down the things you want to do with your life—the experiences you want to have, the skills and talents you’d like to develop, the kind of person you’d like to be. Then stop doing the things you dislike doing, and start doing the things you really want to do. If you want to be a world traveler, for goodness sake don’t take some horrible job to make a lot of money to travel with. Join the crew of a sailing ship. You’ll get to travel, you’ll learn about sailing, and you’ll have great stories to tell about hitting sharks on the nose in the Bahamas.

The effort of going out and earning the money to do what you really want to do is almost always less effective than just going out and doing it. By the time you do have the money, you may have lost all your vigor and joy.

Is there something about striving for money that makes people put less energy into their friends?

That is an absolutely great question. It takes us back one step to an even more basic choice people make, the choice of how much of themselves they’re going to be willing to share—”How open am I willing to be?” And as you make that decision, you’re also making the decision between friends and money.

Somebody once asked Einstein what was the most important question facing human beings. He said the question was this: “Is the universe friendly?”

Yes, and in making the decision to be open or not, a person decides whether his or her own universe will be, very literally, a “friendly” one. Because if you are open, friends will come to you, and help you meet your needs. If you are closed, you will need money to get the things you want.

I see a real connection between this kind of openness, and the kind of calmness, the ability to sit still and do nothing, that we were talking about earlier. If your life is chronically hectic, if you don’t have many friends, if you’re doing work you don’t really like, then the world will be a pretty hard, tight-fisted place for you. If you’re calm and relaxed and doing work you love, you can very easily be open and generous.

We seem to be getting into the realm of religious values.

Well, I think that our obsession with money verges on making it a religion. In the minds of many, money equals happiness, security, respect, and freedom, the very same things religion offers. I think that if people really believed you could take your money with you, the religion of money could compete successfully with Christianity.

The ideas you’ve been describing sound very much like the Buddhist idea of right livelihood.

I really don’t know enough about Buddhism to say, but I do know that these ideas can be found in the wisdom and teachings of every spiritual tradition.

The institution of the sabbath comes to mind. Isn’t the sabbath just institutionalized sitting still and doing nothing?

Yes. And the same idea is to be found in the practices of the Amerindians who lived here in the San Francisco Bay area. The teachers of all traditions have told us that the goal of amassing material wealth will not lead to good results. The wise people of every culture have advised us, for the longest, happiest lives, to love and care for one another and to do the work we love.

John Travis and his six co-workers at the Wellness Resource Center in
Mill Valley, California, do not practice medicine. They promote
wellness. Their model is educational, not pathological. They see no
patients, prescribe no drugs, perform no physical examinations. If a
client is ill, he or she is referred to another physician for
diagnosis and treatment.

It isn’t that Travis isn’t qualified to treat the sick. John graduated
from Tufts Medical School and the Johns Hopkins Medical Center
residency program in preventive medicine. But he found that even the
kind of “preventive medicine” taught there was too illness-oriented.
The Wellness Resource Center is the result of his personal quest to
shift medical orientation from sickness to health.

Tom Ferguson: John, maybe you would start by describing the
kind of relationship that exists between conventional health workers
and their clients – and why you have tried to change that model.

John Travis: I think that most health workers are trained to
want to rescue people – and most people go to health workers to be
rescued. Traditionally, Western medicine has viewed disease as
something out there, beyond the patient’s power or influence. When
disease strikes, you go to the doctor and he attacks the symptom with
the weapons of modern medicine. The doctor assumes total
responsibility, and the client becomes just a sort of unconcerned
bystander.

I call this the pill-fairy model of health care.

TF: What’s the alternative to the pill-fairy model?

JT: Taking a lot more self-responsibility. The pill-fairy model assumes that health is simply the absence of symptoms, that someone who doesn’t have any symptoms is healthy by definition. But that’s not true at all. There are as many degrees of wellness as there are of illness.

Medical education focuses on diagnosing and treating organic syndromes of disease. It’s frustrating to health workers when people come in who have no specific physical symptoms, but are bored, tense, depressed, anxious, or just generally dissatisfied with their lives.

TF: You’re saying that the treatment model doesn’t work with them.

JT: Right, though the treatment model is appropriate in some cases. Particularly in something like, say, bacterial pneumonia or acute appendicitis. If I had one of those illnesses, I’d want my doctor to use pills or surgery.

TF: What should a health worker do when somebody comes in who’s just bored and anxious?

JT: I think that once a specific organic illness is ruled out, they should turn them over to wellness educators.

TF: And what would a wellness educator do?

JT: The kind of thing we try to do here at the Wellness Resource Center – help people focus on the ways they are presently conducting their lives, suggest that other options are available, and support them in trying some of the options. The important difference from the pill-fairy model is that we make it very clear that we’re not providing diagnosis and treatment, we’re providing education.

We leave the responsibility for their own health squarely on their shoulders. It’s damn near impossible for a physician to do that. Existing doctor-patient relationships are set up in such a way that the doctor carries all the responsibility, makes all the decisions, calls all the shots.

When I work with a client, the first session is often spent with the client trying to hand the responsibility for his or her health back to me. And I have to keep saying no, no, no, you can do it yourself.

Your readers might assume that since I’m an M.D., I’m providing medical services. I’m not. I’m working as an educator. Having the M.D. experience is very helpful but not a prerequisite.

TF: How is it helpful?

JT: In having credibility. Mainly that. Also in knowing what the limitations of medicine are. In knowing if something might be organic or not. In understanding how bodies work, so there’s not an unknown between the psychological and the physiological. Some other practitioner might say. “Well maybe that’s something a doctor ought to look at.” I can often make that decision myself.

TF: Can a family practitioner use some of your techniques in
his or her practice? Or should it be a completely different person
doing it?

JT: It would depend on the circumstances. A family practitioner could certainly use biofeedback, but then it would become much more of a treatment. There’ s a real advantage to isolating the two. I think it would be ideal to have a family practitioner working closely with a wellness practitioner. Here’s what you can do and here’s what I can do.

TF: How do you define what you can do, when you’re making the initial contract with a client?

It’s essentially that we’re not diagnosing, treating, or taking care of the person. We’re serving as a consultant, to give them more information, teach them skills, to show them how to become more aware of their past, to see what’s going on inside their bodies, how to visualize, how to communicate better, how to love and accept themselves.

TF: What kind of success are you having in getting people that
come to your center to deal with those kinds of in-depth issues?

JT: I’ve been surprised that so few people are really willing to look at their lifestyles and consider changes. We see lots of people who have obvious, major stress related problems, but who aren’t willing to commit themselves to getting a full understanding of them and making changes.

What we’ve found is that there are quite a few people who’ll just come in for the initial evaluation÷but who aren’t willing to go any farther with it. Who essentially just want to come in and get themselves checked out, but aren’t interested in making any changes in their lives.

We’ve found that the people who are willing to commit themselves are people who are really hurting. It’s hard for people to feel comfortable about spending money on something they can’t see. They’ll spend ten thousand dollars on a car that can sit in their driveway, but they won’t spend two thousand dollars on themselves. Wellness is not a product, and we’re very product oriented.

TF: What are the kinds of hurting you see?

JT: Headaches, asthma, angina, high blood pressure, total body pain, insomnia, lack of concentration, sexual problems, chronic anxiety, fear, depression, the whole gamut.

TF: In terms of personal satisfaction. how would you compare
the kind of work you’re doing with the traditional medical role?

I think most helping professionals get positive feedback by helping other people, and in general have a hard time asking for and getting the same attention for just being themselves. I think that has to be debilitating in the long run. They don’t really take very good care of their health. They’ve externalized their attention to other people÷to their own detriment. They have high rates of suicide, they have heart attacks at an early age, they tend to be very uptight, in poor physical shape, they may be overweight. All because they’re so externalized to taking care of other people.

JT: So how does the model you’re creating offer an alternative to all that?

By making clear the limits of responsibility of the professional÷that he or she can only assist the other person in doing things for him or herself. Being a consultant, rather than taking on the main responsibility for the other person. Also, if you’re suggesting all this self-nurturing and self-care to others, it’s important to practice what you preach.

I see a lot of health workers who are feeling burned out. There’s a great deal of anger, a real feeling that the present system isn’t working. A lot of health workers come to the workshops we give here at the Center, looking for tricks and techniques they can add to their practice. They want the five easy steps to wellness.

TF: For themselves?

JT: No, for their patients. They figure that if they can just make their patients well, they’ll be okay.

TF: So do you give them the five easy steps?

JT: (Laughs.) No. We just share our own experiences and try to get them to go through a wellness evaluation themselves to think about starting their own wellness program.

You’d be amazed at how difficult it is for some health workers to start looking at themselves! They want techniques and tricks and handouts they can copy and give out to their patients. We have to say, “No. We can’t give you that.” And sometimes they get angry.

They expect some kind of magic formula. And what we tell them is that they’ve got to start by detaching themselves from the rescuer role. That seems to be the basic source of conflict for most health workers.

Health workers are trained to be rescuers, and then they burn out and come in trying to suck us into the rescuer role for them. Rescuers always end up becoming victims.

So we health workers need to start seeing clients as responsible people÷not victims÷who are making certain choices in their lives and that’s okay. You can’t take on the responsibility for them. It takes a very high degree of autonomy and self-confidence, and a very real sense of your own limits and the limits of medicine.

TF: The trick is to stay concerned, but not try to take on responsibility for the person’s problem.

JT: Yes. And that isn’t a cop-out. It’s just a matter of realizing your limits. Smokers used to drive me crazy. Now it’s okay with me if someone chooses to smoke÷ as long as they don’t do it when I’m around. I’ve managed to let that one go. But if they decide they want to quit, I’ll be there with suggestions, resources, a chapter in a book, or whatever.

It’s not that difficult to let people take responsibility for headaches or ulcers or high blood pressure. It’s much harder for, say, genetic diseases or accident victims. But you can do the same thing with them. I’ve been impressed by how many health workers rely on some kind of religious or spiritual belief system to support them in allowing the people they work with to be autonomous spiritual beings. We’ve ended up talking about religious belief and spiritual awareness at a number of the workshops. People seem to be hungry for this sort of thing. I think it’s particularly important for health workers÷who are going to be communicating about this change to others÷to keep growing spiritually.

The fact that you’re granting some kind of spiritual quality to people you’re interacting with can’t help but show. They can’t help but feel that respect. They pick that up, and they’ll probably respond in kind. They’re going to start taking more responsibility. If our attitude is that they’re helpless wretches, and if we don’t do something for them, they’re in bad trouble, they’re going to pick that up and live that out. And then they resent you and do everything they can to defeat you.

TF: It seems to me you’ve been getting more and more interested
in the changes that are taking place for the health professional. Is
that true?

JT: Yes. I’m interested in self-care from the point of view of the professionals who are groping, who see the problem, and in order to deal with the problem, have to grow themselves. If they grow, it’s going to rub off on their clients. Besides, once they open up real communications, they might find that some of their clients are a lot more grown up than they are.

I think the biggest lesson in this whole thing, personally, is an ego lesson. First of all, learning to handle power I never expected to have to deal with. I thought I was starting a nice, quiet two-person private practice in Mill Valley. I’d never heard of holistic health when I moved here. Then, suddenly, I got plunged right into the center of a movement. It’s done a lot for my own growth. It’s gotten me to look at my own feelings of competitiveness, of jealousy. Every time somebody else gets invited to a conference and I don’t, there’s that thought: Why wasn’t I invited?

I guess you need an ego to establish self-identity and purpose and determination. And then you have to learn to give it up. You outgrow it. At least sometimes you outgrow it.

One of my own focuses now is dealing with my own burnout, as a result of all this running around speaking and doing conferences. At a workshop recently, a friend took me aside and said “John, a little loving concern. People have been saying how tired you look!” I was a little defensive at the time, but I think he’s right. I spend most of my day with phone calls and meeting people. A lot of it’s gotten to be not really as satisfying as I could wish it to be. So I’m cutting back a little, learning to take my own time, to choose pleasure for myself.

It really does come back to taking care of yourself in the end.

© Tom Ferguson, M.D.