We cannot solve problems with the same level of thinking that created them.—Albert Einstein
Problem-solving is an energy-intensive approach that focuses on deficiencies in the hope of identifying and removing them. Solution-orientation explores and develops options, choices, and possibilities with a view to re-orientating the individual or group towards flexibility and growth.
Problem-solving is reactive, remedial, and piecemeal. Solution-orientation is active, generative, and holistic.
Problem-solving looks at people as a collection of ‘parts’. Solution-orientation sees the person-as-whole.
Problem-solving is external to the patient’s experience (both ‘cause’ and symptom are regarded as alien invaders, disrupting the integrity of the patient’s body–mind system). Solution-orientation is internal to the patient (the person who exhibits the problem is unique, and is as important as the problem itself).
Many of the current problems in healthcare derive from a reductionist, mechanistic view of humans and human nature that is several centuries old. Still largely committed to both a reductionist cause-and-effect model and the enduring myth of Cartesian Dualism, the separation of humans into mutually exclusive domains of body and mind, mainstream medicine has little power over the rising tide of complex, chronic, and inexplicable dysfunctions that can result in lifetimes of debility and pain.
People are living longer, mainly because of science’s massive advances in the areas of infection and acute medicine, but they are not necessarily enjoying a consistently better quality of life. The nature of the problems we now face is changing. Disease itself is changing. But we—health providers and patients—are not.
Today, a doctor may go through his entire career without ever encountering a case of smallpox, diphtheria, or epiglottitis, but he will almost certainly feel overwhelmed by the sheer weight of the conditions that now characterize the majority of the problems patients present.
In Britain, the Royal Society of General Practitioners has been reported as estimating that around 50% of the problems seen by general practitioners are social, 25% psychological, and approximately half of the remaining 25% are psychosomatic.35 In practice, physicians report that most of the remaining 12.5% of ‘organic’ disorders seen involve at least some aspects of the psychosocial dysfunctions mentioned above.
The cause-and-effect model, when routinely applied to some complex, chronic conditions, is contributing to a massive epidemic of new problems. Over-dependence on the ‘magic bullet’ approach contributes to tunnel vision; iatrogenic illness; antibiotic-resistant organisms; and reduction in treatment options for the practitioner. The complex, multi-factorial nature of illness and the inherent biological diversity of human beings are in serious danger of being ignored in the pursuit of a ‘perfect’ science.36,37,38 Meanwhile, misdiagnosed and under-treated anxiety disorders alone cost the United States’ economy $54 billion a year, with much of the economic burden resulting from patients seeking—and receiving—treatment for the physical symptoms of the dysfunctions.39
In England, the total cost of mental health problems has been estimated by the Sainsbury Centre for Mental Health at £77.4 billion, including £12.5 billion in care, £23.1 billion in lost output, and £41.8 billion in ‘hidden’ costs.40 Despite the best intentions of its practitioners, medical practice is morphing from the provision of ‘healthcare’ into costly, and often inadequate, attempts to manage or contain ‘dis-ease’, including distressing and incapacitating, but not necessarily medical, conditions.
The rise of evidence-based medicine (EBM)—the standardization of treatments based on randomized controlled trials (RCTs)—as the only acceptable basis for healthcare is also giving rise to problems. Its application, to the exclusion of human qualities such as instinct, experience, and common sense, diminishes artistry and compassion, both qualities long accepted as significant adjuncts to the practitioner’s application of best available scientific knowledge.
Some researchers, including Professor John P.A. Ioannidis, of the Department of Hygiene and Epidemiology at Greece’s Ioannina School of Medicine, believe that most published research findings are false, for a variety of reasons, including the fact that the researchers may simply be measuring accurately the ‘prevailing bias’. This is another way of saying heuristical (rule of thumb) thinking predisposes people—even scientists—to verify what we already believe.41
Behavioral science has provided the basis for many drug-based treatments now accepted as gold-standard in Western medicine. The only problem is, when they are applied to an undifferentiated patient population, they often don’t work … perhaps because we’re all just too WEIRD.
University of British Columbia psychologists have coined the acronym to help explain why results from behavioral studies on people in Western nations don’t usually represent the rest of the world.
According to the study, research subjects are drawn entirely from Western, Educated, Industrialized, Rich, and Democratic (WEIRD) societies (probably around 12% or less of the world’s population). Researchers—often implicitly—assume that all human populations respond identically to these ‘standard subjects’, whereas the comparative behavioral sciences database suggests that not only is there considerable variability in experimental results across populations, but that WEIRD subjects are particularly unusual compared with the rest of the species—what the researchers call ‘frequent outliers’.42
Given that the volunteers used in these studies are often young male undergraduates in good health, the proportion of ‘representative’ subjects drops even more. However, the generalization from the few to the many—from a handful of WEIRD young men in good health to the human race as a whole—is a fundamental aspect of RC testing.
Treatments not easily validated by traditional research procedures are largely ignored—despite the fact that much of our historical success in defeating disease has arisen from trial and error, based on bold hypotheses, rather than from RCTs. Many treatments still in use, and unlikely soon to be abandoned, derive from ‘another kind’ of evidence. These include antibiotics, insulin, tracheostomy (to relieve tracheal obstructions), the draining of abscesses, vaccination, and even the use of aspirin.
Some scientists—even those from within the ranks of EBM—are beginning to suggest that certain classes of evidence, other than that provided by RCTs, warrant acceptance. Professor Paul Glasziou, Director of the Center for Evidence-Based Medicine at the University of Oxford, together with three colleagues, has developed a simple and elegant algebraic formula for measuring what they call the ‘signal (treatment effect) to noise (natural outcome) ratio’. A high signal-to-noise ratio, they say, reflects a strong treatment effect, even in the presence of confounding factors, such as the natural progression of a disease.43
We continue to argue that an outcome that satisfies an individual patient’s needs (and does no harm) should be the prime objective of every consultation. ‘Flow’ (a relatively unselfconscious day-to-day existence) and ‘functionality’ (the patient’s own measure of her ability to operate effectively in her own world) are key objectives Medical NLP espouses.
Many studies now emerging help give direction and substance to the Medical NLP proposition that whole-person health is both possible and applicable—with some adjustment to current opinion. Some of these suggest that:
Most practitioners may well feel overwhelmed in the face of the implications raised by all this and, quite understandably, revert to the first-line response of attempted symptom removal. However, a simple shift of perspective, from a purely problem-solving to a solution-oriented approach, helps us to make sense of it all.
More than 30 years ago, when Dr. Richard Bandler posed the paradigm-shifting question, If knowing how people get ill doesn’t always help them recover, how do people get better?, he opened the way for the development of the methodology now known as Neuro-Linguistic Programming (NLP). This also alerted some leaders in other fields—humanistic, systemic, and family psychology, sports, and business, in particular—to the possibility that energy previously spent trying to remedy apparently intractable problems could be more profitably directed at exploring outcomes and solutions.
Regrettably, the approach seems to be defaulting back to the molecular, cause-effect approach favored by Big Pharma and those of a surgical bent. However, the astute and patient researcher will find that a more generative (as opposed to remedial) approach has since been strongly supported by numerous studies. As an example, several research projects have confirmed that expectation alone—the anticipation, of both health professional and patient, that something good and positive will result from treatment—can have a powerful, positive effect on clinical outcomes.44,45,46
When medicine’s essentially problem-solving approach fails to remedy a complaint, or constellation of complaints, a subtle transfer of responsibility to the patient takes place. Labels, such as ‘functional’, ‘psychogenic’, ‘somatoform’, ‘psychosomatic’, and ‘medically unexplained’ may carry implications of some degree of mental or emotional imbalance. Now, the label (and the patient) becomes the problem.
A problem-oriented approach easily confuses the removal or suppression of the symptom with its cure—but, as anyone who has been treated with antidepressants will confirm, ‘not being depressed’ is seldom the same thing as ‘being happy’. According to the problem-oriented model, illness, in all its forms, is the result of some deficit or other, whether it is the failure of the individual to pursue sensible dietary advice, an immune system that ignores a cancer cell, or a brain that ceases to balance its uptake of serotonin. Problem-oriented medicine looks for ‘proximal’ causes and largely ignores factors such as the evolutionary or adaptive nature of the illness; the unconscious ‘meaning’ or value the dysfunction might have to that specific individual, and the entire psychological, social, and spiritual landscape within which the patient and his problem exist.
A solution-oriented approach recognizes the need for an expanded view of both illness and health. Although many organizations and individual practitioners recognize the need for a more ‘holistic’ approach, few suggest how this might be achieved.
Some attempt to accomplish this by randomly incorporating or recommending ‘complementary’ techniques, such as homeopathy, acupuncture, and aromatherapy. But although any of these may well add value for the patient, their piecemeal incorporation does not equate with a whole-person view of the patient.
In some countries, traditional medicine is gaining ground. In India, for example, leading ‘alternative’ approaches, lumped under the label AYUSH (standing for Ayurveda, Yoga, Unani, Siddha, Sowa Rigpa, and Homeopathy), are state-sanctioned and allopathic practitioners are encouraged to incorporate them into their equally popular Western-style treatments.
The Medical NLP approach presented in this book does not favor any particular ‘alternatives’ to Western medicine, but aims to help widen the practitioner’s perspective, to include, along with her biomedical profile, insight into:
With this in mind, the practitioner is better equipped to explore with the patient her needs, resources, and endogenous potential for change.
All patients seeking help from a health professional for any chronic problem are stuck and stressed. The problem has not yet resolved itself (if it is self-limiting), or all previous attempted actions and remedies have failed.
The inbuilt capacity for self-regulation (shared by all living systems) has been compromised. This either causes, or is a factor in, almost every major illness to which people fall prey.47,48 Flexibility, responsiveness, adaptability—these biological necessities must all be restored if health is to be improved and maintained.
Medical NLP regards the human being as a biological system embedded in a succession of larger systems (psychological, social, spiritual, and evolutionary). To help an individual create options at any of these levels is to increase the flexibility of her functioning as an integrated whole. Practitioners themselves also benefit from having more options—especially those which have the potential to help their patients in the moment, without unnecessary recourse to drugs or outsourcing the problem to costly, time-consuming ‘talking’ therapies.
The possibility of something positive emerging from the challenge of illness and dysfunction is surprisingly appealing to many patients. It is easy to understand how compelling (and sometimes how useful) such a belief might be when they are faced with the fear and chaos that can accompany chronic, inexplicable dysfunction, and dis-ease.
Some writers and psychologists, including Joseph Campbell and Carl Jung, have suggested that the metaphor of the individual’s journey through crisis, challenge, and renewal is embedded in our cultural DNA. Certainly, the structure known as ‘The Hero’s Journey’ is encountered throughout all story-telling societies, including in fairytales, movies, soap operas, and computer games.
The structure of The Hero’s Journey involves a call to action (the crisis) and the protagonist’s response to the call (seeking options, opportunities and guidance in an effort to resolve the crisis). A series of challenges and setbacks lead to a decisive—though often risky and frightening—final act, in a bid to gain healing, redemption, or reward. The hero then returns to her own world, renewed, healed or somehow transformed, with a message of deliverance to her people. (For a moving and inspiring contemporary non-fiction account that reflects this process in the context of healing and health, see Choosing to Heal: Surviving the Breast Cancer System, by musician and Medical NLP practitioner Janet Edwards. See also later chapters on the patient’s story.)
Whether you and your patients choose to regard the consultation process as part of a symbolic journey or a partnership based on developing more choices, it is an opportunity to bring order out of chaos. To accomplish this, both need to explore the possibilities (other than the moderation or removal of the symptom) that can emerge when a previously stable situation suddenly destabilizes, and we embark on the complex, intriguing, and challenging process of change.
Change can be easy, instantaneous, and lasting. Curiously, as family therapist Virginia Satir often observed, it is also something that many people fear more than anything else.
Experience shows that this fear is almost always based on the belief that gain can only arise out of pain, and on not knowing how—or, even that—a specific change can take place.
The opposing belief, that change can be relatively effortless, runs counter to the received ‘wisdom’ that suggests it should be a slow and painful process—or, as the old joke has it:
Q: How many psychiatrists does it take to change a light bulb?
A: Only one—but, it’ll be a long, difficult, and expensive process—and the light bulb really has to want to change.
Certainly, change does not need to be hard work. As they were exploring the structure of the patterns they were observing, Richard Bandler and his colleagues began to question the belief that change is always incremental and takes place over an extended period of time. Dr. Bandler’s suspicion, derived from the speed with which people learned to fear the object of a phobia, was that the brain was capable of rapid, or even ‘one-pass’, learning. Success with the now famous NLP fast phobia cure (also known as visual-kinesthetic dissociation, see page 300) bore this out. Since then, hundreds of thousands of people have benefited from this insight alone, in its wide range of applications.
This contrasts with slower, not necessarily equally effective, processes, including systematic desensitization, which gradually exposes the subject to the source of the phobic response, and flooding, which seeks to overwhelm the sufferer in a bid to ‘blow out’ the neurological circuits holding the responses in place.
Critics of these approaches (including ourselves) believe the first is too slow and, at best, only partly successful. The second carries a high risk that the subject may be unable to process the flooding, and be retraumatized by the ‘cure’. Bandler’s approach by-passes both objections. ‘It’s easier to cure a phobia in 10 minutes than in five years,’ he says:
[At first] I didn’t realize that the speed with which you do things makes them last … I taught people the phobia cure. They’d do part of it one week, part of it the next, and part of it the week after. Then, they’d come to me and say, ‘It doesn’t work!’ If, however, you do it in five minutes, and repeat it until it happens very fast, the brain understands. That’s part of how the brain learns … I discovered that the human mind does not learn slowly.
Although, on the face of it, this might seem like a version of desensitization, the Phobia Cure differs in three other important respects. Its success depends on the effective dissociation of the subject from the experience; disruption of the process the sufferer has been unconsciously using in order to repeat the phobic response; and the creation of a solution frame into which the subject can associate. We will deal with the first two ‘differences that make a difference’ in later chapters. The third—developing outcome frames—is critical to the Medical NLP solution-oriented approach.
In order to make change possible, the subject needs to:
Medical NLP regards the ‘resistant’ patient as a mythological creature. Perceived resistance usually stems from either a failure of the practitioner to uncover as yet unmet needs, or too little time being spent on trying to effect the change. Sometimes, the fear of changing is overwhelming, and this in turn we believe is based on the patient not understanding that change is possible, and not perceiving that both he and the physician have resources that have yet to be tapped.
It is the practitioner’s responsibility to reduce the patient’s anxiety level, identify unmet needs, and orientate the patient towards accepting the possibility of change. These will be discussed in detail later, but it can often be as simple as a form of verbal martial art:
Patient: ‘I don’t feel any better, and I’ve tried everything…’
Practitioner: ‘Everything? So, when do you get time to sleep?’
Patient: ‘Well, I mean I’ve tried a lot of things, and nothing has worked.’
Practitioner: ‘…yet.’
Patient: ‘Well, I can’t see how this is going to help.’
Practitioner (smiling): ‘…yet.’
Patient (smiles): ‘Okay…yet.’
Strategies such as this require good engagement and rapport with the patient. As you progress through this book, you will encounter (and, we trust, test and incorporate into daily practice) a number of principles and techniques to help increase motivation, change unresourceful beliefs and behaviors, and act directly on a wide range of chronic and ‘functional’ disorders.
Meanwhile, an important theme of this book, and the basis of any truly solution-oriented approach to medicine, is this: the patient needs to know how to get (and remain) well. As Albert Einstein observed, people can’t solve their problems with the same level of thinking that created them.
In working within the Medical NLP systemic model, the practitioner evaluates and may intervene at all levels of the patient’s experience: physical, mental, psychological, social, and spiritual. Since these operate as a Gestalt (an interactive system), and each Gestalt is unique to the individual, improvement or healing needs to be a bespoke process that the patient understands, and one which does not cause unnecessary concern or discomfort as it proceeds.
While a solution-oriented approach to consultation does not preclude the medico-legal requirements of due diligence, appropriate investigation, and best practice, undue focus on the problems has been shown sometimes to increase, rather than reduce, patients’ distress. Consider the following: when investigating pain, most physicians are taught to ask a series of direct clinical questions as part of the decision-tree process known as the differential diagnosis. Questions, where cardiac problems are suspected, may include:
Practitioners generally admit this is a problem-oriented approach, but consider it a necessary evil. At the same time, many suspect that even the mere suggestion of pain may in fact worsen patients’ reporting, or their subjective experience, of pain. This turns out to be true, in certain cases at least.50 Much more about this in later chapters.
In contrast, effective questioning can contribute substantially to the success of treatment. For example, the more general question, ‘What’s it like?’ may elicit specific details about the problem without exposing the patient to excessive and potentially harmful synonyms for suffering. In many cases, the patient will provide specific information about location, onset, severity, aggravating factors, etc—most, if not all, the information needed—without any prompting or further suggestion.
If necessary, further gentle probing can fill in the details necessary for a full and appropriate diagnosis. And, when the time comes to re-orientate the patient towards improvement, the question, ‘What will you be doing, and how will you feel, when this problem you’ve been having has been resolved?’ is just one of the tools of the solution-oriented practitioner. The way the human brain is wired requires the patient to direct his attention away from her present, problematic state, towards a future-oriented solution-state, in order for her to be able to provide an answer.
Quite literally, the practitioner has begun to alter the firing of the neurons in the patient’s brain. Purely conversationally, he is performing ‘microsurgery’, with language as his tools. (For more detailed suggestions for solution-oriented information-gathering, refer to the Medical NLP Clinical Questioning Matrix page 127.)
Solution-orientation is almost non-existent among existing consultation models. We have reviewed more than 15 frameworks, from the Calgary-Cambridge Comprehensive Clinical Method51 to Usherwood’s extensive model,52 and have found only two that suggest, in part, that the patient’s role may fruitfully extend beyond the end-point of merely understanding and following treatment advice.
The model advanced in this book supplements existing models with a number of elements, all of which have been demonstrated positively to influence the outcome of the healing relationship. These include: a proactive and equal partnership between doctor and patient;53,54 recognition of and matching to the patient’s unique world-view; the development of an increased sense of self-efficacy through manageable strategies;55 a clear blueprint for further action; a shared expectation that progress is to some degree or other possible; and an agreed system whereby progress can be measured.
Furthermore, focusing on solutions rather than problems (developing health and healthy behaviors in place of removing ‘sicknesses’) helps the patient (and, in many cases, the physician) ‘unstick’ from a stuck situation, and begin to reduce frustration and stress. This, in turn, opens up room for hope and belief to enter the arena—both of these are now known to influence positively a number of health-supporting processes, including the functioning of the immune system, cellular activity, and even the expression of DNA.56
Our proposition here is simply this: if, as Western health professionals believe, ‘psychosomatic illness’ is a reality, they should be obliged also to accept and commit themselves to pursuing ‘psychosomatic healing and health’.
Begin to reframe problems in terms of possible solutions. By asking the right questions, you can orientate yourself, your patients, family, and friends towards choices and options, as well as help to create a future beyond the problem-state. Some suggestions for solution-oriented questions include:
‘What will you be doing, [how will you be thinking, feeling, speaking, etc] when you have moved past this point?’;
‘What will be different or better when you are healthy again [have achieved your goal, etc]?’;
‘What have you not been able to do that you will really enjoy doing when this problem has been solved?’; and, ‘What will you have learned from this experience?’
Notice any differences in your own, or your subject’s, response.
Keep notes of any particularly effective patterns you create.
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