Positive Health Online

Striving

An old joke recounts a drunk searching within the light of a street lamp for his keys, more probably dropped some distance away in complete darkness. His effort mixes the plausible and the futile, not uncommon to the endeavours we make in life to evade harm and seek benefit. When distress drives action, the body is always an available target even if reason would indicate it is unlikely to be relevant to the problem.

A person who is hard up might be advised to search for a better job, acquire a new skill or revalue frugality, acting in relation to world, competence or perception respectively. These are justifiable suggestions but difficult to follow. More to hand are eating chocolate or pulling hair, which somehow seem to relieve distress temporarily and, who knows, something or someone may appear as rescue.

This is a systems issue, a matter of component inputs and outputs, channels, signals and noise, feedbacks positive and negative. The great physiological criterion of homeostasis, the maintaining of a steady internal state, depends on negative feedback curbing any factor that tends to excess. It is a deep puzzle that psychologically we, as individuals and societies, so often go awry into positive feedback. If we begin responding to a threat by prayer or hoarding, failure may well intensify our chosen response rather than lead us to doubt its efficacy and try something based on better evidence. Quickly arriving at explanations and assenting to action presumably have evolutionary advantages faced with sudden threats, but for enduring difficulties we seem not to have a sufficient liking for fact and reasoning.

Modern society has promoted the view that “You can!”. This encouragement has had many positive effects, but it is often over-stretched. It may enable those successful - “I did!” - to claim their full gains even if more likely due to initial advantage or mere chance; failure then implies personal defect and deserves no assistance. Therapy too has encouraged an internal locus of control, but again the realities of resources and opportunities need to be carefully assessed if effort is to be rightly applied.

Trying to find a way forward in life it is unsurprising that, especially when young, we experiment with our physical presence, for appearance and identity are immensely interactive (compare Kafka's profound dark Metamorphosis). The irony for self-conscious beings is that the concept of self does not age in parallel with the body. For many older people 'in here' can seem eternally young, still striving to find an acceptable mode of expression in the world. The worse our treatment of body, the sooner its ultimate extinction of the self is likely to begin.

Bodies

The one thing even the socially helpless and psychologically hopeless can act upon is their body. The most obvious epidemic current in our society is obesity, with anorexia and bulimia as related symptoms involving eating. Other consumptions, the legal or not drugs that are commonplace, vary widely in context and effect. Some cause little medical harm (it is their criminality that brings trouble to some and profit to others) and at one time smoking, its consequences unknown, was often a matter of style, whereas binge drinking and the drugs of 'leisure' may be simply a getting out of mind and reality.

The self-infliction of minor injuries is quite frequent, often as impulsive but habitual acts by young women, whose bodies are so routinely scrutinized by fashion. A rather different population, mostly of older, isolated men, plan suicide. Their problem is typically a lack of regard and affiliation, and the solution may be seen as rational (perhaps on doubtful evidence) or sometimes irrationally to the paradoxical escape “When I am dead then …”. This is akin to taking on a new image for the self, rebellion, in the way that tattooing and body building also offer escape by reconstruction. Plastic surgery runs the gamut from the judicious elimination of anomalies to fantasy substitutes.

For a central concept of body there are such alternatives as mean, median and mode, prototype and stereotype, natural and achieved, composite and optimal. Our own recent population is a fair guide (how bizarre that it is now the poor who are fat) with evidence from other cultures, science, portraiture, and the study of physical action. Idealization and condemnation, prudery and pornography, act in concert to undermine a simple acceptance of our physicality. There is a distinct streak of cruelty in modern art (compare medieval torments of didactic purpose, and the response of artists such as Goya to brutality and war). Are the deliquescent monsters of Bacon, the raw exposures of Freud and the technological violence of Hirst to be understood as symptoms, generators or just recyclers?

Our evolved bodies are certainly not perfect (that's the difference between the contrivances of natural selection and a design), but they are rather splendid. With modest inspiration, if we can accept the limits of biology and mortality, they give delight in movement and skilful performance. Above all, our sense of self cannot be disentangled from how others perceive and react to us.

Can the disparate clinical concerns be unified in some way that will help us with treatment? At present we are notoriously unsuccessful. The commonplace of people for whom a normal conformity would provide reasonably healthy, pleasant and functional bodies applying themselves to a protracted self-killing by food is surely appalling, and so too the collective descent of urban drunks. Conveying the dreadfulness of this (but protecting the self) might be a boldly imaginative treatment alternative to what follows.

Over-Eating

Fatness is a common physical symptom that many therapists will have attempted to remedy. Excess eating may be adopted initially as an attempt to cope with a huge variety of problems. There may well be an underlying biological disposition to eat for comfort whenever stressed because hunger is such a frequent threat in nature. Counsellors uncover many and varied possible motives: the security of being like the rest of the family, misinterpreted childhood injunctions, compliance with parental compensations, evasions of sexuality, mistaken images of jolliness or generosity, accidental links with praise or social opportunity.

Endlessly, commerce offers processed food of doubtful nutrition skilfully devised to entice (and physiological adaptation produces a kind of capture that makes giving up difficult), linked to misleading social constructs and obviating all requirements for practical effort and skill: to choose the invitation is enough. Simple rules that would enable people to systematically reduce dietary harm are undermined by deliberate evasion, emotional appeal and cognitive complexity. For example 'Eat less sugar' is obfuscated by the confusions of sweeteners (including 'no artificial'), fructose in many guises, the commendation 'low fat', the image of being a glamorous and successful high energy person whose activity needs must be quickly met, and so on.

If there is an independent cause for obesity then therapy should of course directly address it. Many overweight people present with a long history and the original distress may be remote, both irrelevant and inaccessible. But there may be a present cause, perhaps unconsciously receiving the same response that 'succeeded' before (very likely that problem just ceased for quite other reasons).

Continued over-eating brings its own self-sustaining systems that may account for many cases. Shopping and meal times, favourite treats, social networks and support groups, conversational topics, and much else gather around. The business of dieting and failing brings a focus on the self, effectively a career as a patient. These rewards provide positive feedback. Often, people acquire considerable (and immunizing) expertise about such ploys as smaller plates and substitute activities for fingers and mouth, are familiar with a variety of failed treatments, and will talk with confidence about nutrition, genetics and physiology, mixing truth and nonsense inseparably. Arriving at obesity can easily prompt a feedback of hopelessness due to the onset of social isolation, mounting discomfort and the doubtfulness of full recovery (organ damage, all that skin), even if weight is lost.

In therapy, the willingness to change (in any way) has to be tested initially. Gradually, as other rewards are put in place, an honest picture can be established and, piece by piece, the harmful system demolished. There is a need for specificity, progress by clear steps initially small, that will measurably accumulate to rebalance eating and activity so they merge into the biological and social rhythms of the days and a changed general lifestyle. But much of the work can lie, unemphasized but person-centred, in the good relationship and positive tone that the sessions establish.

Control Systems

It is a useful exercise to try a cybernetic approach and diagram the system elements regulating a case. Any graphic device - a formal systems analysis, a kind of flow chart or simply a loose spider diagram - can help. An input causes distress to self and a response is applied to another component. But if the proper target is not obvious or is difficult to access, things can go wrong. As problems develop, positive feedbacks can become vicious - social success by exaggeration leads to folly, a simple coincidence becomes an insistent habit: extreme states are increasingly irreversible.

Diagramming these elements helps to indicate at what point therapy may best intervene and hope to make progress. The role that the practitioner takes and the techniques to be used follow from this; often an orderly multi-aspect approach is required. For the patient the systems approach can add a novel impetus, and shared planning (perhaps using a whiteboard as a visual aid) promotes a rational level of control.

The incorrect perception of the physical self, the body image, can provide exacerbating feedback, but retraining towards reality (silhouettes can aid objectivity) is possible. Where a strong association exists - see friends so have cigarette, feel bad so inflict pain - the straightforward extinction of behaviour (exposure to stimulus with the usual response action restrained) can interrupt the linkage.

The concepts of control and deviance can provide a useful linking together of presenting problems. The transdiagnostic spectrum from obesity to anorexia is divided medically by little more than a convention about normal weight (by BMI). Intuition seems to indicate that obesity is a kind of giving up of control, whereas anorexia is a most determined attempt to impose it, with bulimia as illustrating an oscillating intermediary system state. For the morbidly obese there is an ultimate, but dubious, escape route by bariatric surgery that solves the symptom of body mass by a means magically external to the system. The sense of control gained by the anorexic pursuit of an ideal comes with a fatal price if it cannot be diverted.

Cutting-up and other injuries conventionally labelled self-harm seem on this basis also as attempts at control, simultaneously distractors and signals. Mind numbing by excess of alcohol or other drug seems more like abandoning control. Might extreme sports be a kind of oscillating tease? Other conducts that target the body, such as piercings, unusual garments and cosmetics, perhaps fit in as escapes, rebellions towards a substitute self.

In short, it seems interesting to consider this group of cases, for which the body is made the symptom bearer, in terms of systems theory and the character of the control process. The generating problem may be personal, within the family or more broadly social. With these concepts in mind the therapist may discover why, for example, control is abandoned helplessly or is desperately sought.

Debates

People watch screens that are carefully designed to maintain their attention indefinitely even though the content may be entirely worthless. Their bodies, along with most mental and social skills, have no use and deteriorate: infants, deprived of human interactions, and the disadvantaged are particularly affected. An ageing woman sits in front of the mirror, ritually painting her face, though any similitude of youth is refuted at her first step: a young man wears his trousers almost falling down because it was thought fashionable, but the rear view is fatuous. There is an excess of sexualization, even small children may be tarted up. People walk about with t-shirts displaying mottoes that would provoke if not camouflaged by meaningless surroundings. Some, with expense and bother, engage in intensive and bizarre gym work-outs in pursuit of an illusory, irrelevant self-image. It is as if ordinary bodies and pleasant movement, maintained with simple care, are no longer enough.

Shifting the argument from lament to logic, consider (merely for convenience of illustration) an imaginary slogan 'Fat and Proud'. Setting aside the important and unobjectionable disconnected features case (a proud person who just happens to be fat), what might this celebrate? Fatness is odd (uncommon for humans) and handicapping (at least for most activities) and brings harms (hypertension, diabetes, joint damage). Is it coming to terms with these features that such a slogan might endorse, or is it fatness itself? It seems a plausible suggestion that the former meaning is neutrally okay (and if the fatness is involuntary, for example a medication side-effect, commendable), but the latter mistaken if asserted as an achievement that is justified by a false norm (“Four legs good, two legs better!” at Animal Farm).

Other possible examples of undue 'correctness' might be our reluctance to comment that running on metal springs rather than feet can be an unfair advantage in athletics, and the disapproval that met a suggestion that gay medics should not emphasize their orientation rather than highlight a particularity of gender that to patients is likely as irrelevant to good treatment as are most other coincidentally assorted personal characteristics except vital competence and care.  Counsellors usually adopt a prudent reticence about themselves, though disclosures are sometimes appropriate.

These are all contentious issues because very properly the emphasis, therapeutic and social, has to be on tolerance and acceptance: 'right answers' are uncertain, but plainly we have made immense progress since the days when impairments or minority characteristics resulted in automatic embarrassment, disapproval or concealment (nothing here endorses shame or shunning for difference).

We seem to find it hard to distinguish between diversity as a probable value (how impoverishing to be all alike) and oddity as merely indeterminate. Yet some norms are insisted upon (the mockery of Mowlem) and some groups can be insulted but others not (a U3A magazine names Cameron for insults about age that he would not dare to apply on grounds of gender or ethnicity). Research showing that races score slightly different means on IQ tests was pilloried, but it would be astonishing if amidst all the other differences this measure (of doubtful significance and not crucial to valuing persons) was constant. Our variety is a precious biological and cultural resource.

It seems easier to sustain a theory of equal rights if we can contrive to perceive and label people as more identical, but again the concepts involved are different (and how hideously easy it is to exclude a hated 'them' from those with human rights). Progress often warrants relabeling and the history of therapy is marked by such triumphs as the banishing of Bedlam and its lunatics. We may rightly treat Dr Jekyll as disordered, though it is prudent to notice that Mr Hyde is in the room.

A diagnostic label should aid treatment but often it seems to slide into the acceptance of a state as an inevitability that reduces responsibility (genes or metabolism may be blamed as incurable causes). The abandonment of the body by its proper caretaker can generate a great sense of hurt, a confirmation of loss of personal value. The least a therapist can try to do is to value the essential self and seek to restore it to fuller life, to interest and purpose in the world.

Even when the body deteriorates unavoidably, as through illness or age, we must continue to find what physical values remain while freeing the psychological self from negative implications. The religious seeing ourselves as divine creation (albeit condemned by sin) is abandoned by most in our own society; rather we may have a sense of inferiority to outstanding or admiringly publicised individuals, and even as falling far short of the capacities of made objects from tools to computers.

There is interesting philosophy to examine. Our intuition inclines to a dualism as though mind could exist independently of body, but poor physical quality of life is corrosive and body bling is signal with little value. There is also the sociology of customs and norms, the pluralism of subcultures claiming recognition, the clear stratification of body harms by class and wealth. But neither discipline can be decently accommodated in a provocative article that contains too many 'seems' because it is thrown out precisely to stimulate debate that may lead to better consideration. These speculations have focussed on the vulnerable body, experienced and signifying, but it is notable how, around the world, such irremovable givens as sex, race and faith at birth can be violently insisted upon as merits commanding respect, perhaps by people who have no basis through attainment and fulfilment for self-worth.

Immense, urgent problems need addressing and, for example, the careless attitude to our planet, climate and sustainability may be akin to our uncaring attitude to the body. But it is easier for leaders to fudge essential issues with words and dissemble with familiar trivialities, false but easy targets. Psychology deals with such errors and evasions in its everyday practice. Perhaps we should seek to apply the same insight for the good health of wider systems.

In our own present society we can see that the combination of unemployment, poverty, boredom and stress is particularly frightful in deforming behaviour and redirecting it into readily available but damaging alternatives.  It would also be wrong to end without acknowledging the most widespread of all body disadvantages.  To be a woman is, in many nations and faiths, to be subordinate.  Such denigration of human worth is the chief of follies, rejecting the most splendid and fundamental of physical diversities.

Related Articles Include

Life by Design - An Aesthetic Therapy. Positive Health Issue 165. 2009.

MultiAspect Therapy in General Practice. The Independent Practitioner. 2.2009.

Expressive Behaviour Therapy. JNCP 28. 2007.

The Body Ideological. Movement & Dance Qtly. 1. 2006.

Moving Well. Positive Health  Issue 107.2005.

A World in Trance. Hypnotherapy J. 2. 2002.

Fulfilment.  Lifelong Learning in Europe 3. 1997.

Letters in Positive Health include vol. 66 on BMI and vol. 194 on bariatric surgery.