“The patient is not a problem to be solved, but a mystery to be met.” — Rachel Naomi Remen
M was a mother of two, in her mid-50s. She booked an appointment because profound exhaustion had descended on her like a fog. She ate intentionally: fibre, fruits, and vegetables. She usually slept well. Recently, she started experiencing abdominal distension and a feeling of fullness. She read about intermittent fasting and decided to try it: skipping breakfast.
Her family doctor had ordered blood tests and called to tell her everything looked fine. I requested a copy and found that she had high triglycerides and liver enzymes. She said her doctor had mentioned something like that, but said nothing could be done. They advised her to keep eating well and exercising, and to repeat the tests in three months.
Within three months, the liver enzymes returned to the normal range. Her doctor offered her a statin drug for her elevated “cholesterol.” M declined, still feeling tired and bloated, but preferring to focus on lifestyle factors before trying medication.
L was in her 30s. She lived alone and worked from home—a repetitive and unfulfilling admin job. As a teenager, she was diagnosed with major depressive disorder and prescribed medication to correct the “chemical imbalance” in her brain. The medication might have helped a little; she wasn’t sure. Her depressive episodes would often last for weeks, during which she was unable to get out of bed.
When she booked her first appointment, she had tried more medications than she could remember and was currently taking three, her psychiatrist trying to get the cocktail right. She was still experiencing a chronically low mood, cloudy thinking, and troubling memory loss. Her doctor had recommended electroconvulsive therapy for her “treatment-resistant depression,” and suggested that her symptoms were worsening because of peri-menopause.
She wished she could pursue a more meaningful career, but with her depression, she didn’t think she could handle something challenging. She also needed the job security and health benefits to cover the medications for her chronic autoimmune disorder.
H was in his 40s and suffered from gastrointestinal bloating and erratic bowel movements most of his life. As a child, he was diagnosed with ADHD and generalized anxiety disorder. He remembers horrible stomach pain that would keep him home from elementary school. In many ways, this was a saving grace because he remembers the chronic bullying and devastating boredom he dealt with there.
His doctor ordered colonoscopies and gastroenterologist referrals, but when nothing showed up on testing, he was diagnosed with Irritable Bowel Syndrome (IBS), linked to stress.
To find relief, H researched alternative therapies like meditation, red light therapy, cold plunges, and ketogenic diets. Could his mental health issues be connected to his gut health? His doctor said that diet was unlikely to shift his symptoms and that his anxiety, ADHD and IBS were separate and unrelated.
These examples are from various patients I’ve seen over the years—their names and identifying details have been changed and combined with other patients to represent overarching patterns in everyday healthcare experiences. There are differences in the details, but they, I, and hundreds of other patients, have all found ourselves in a similar space: leaving an unproductive and invalidating healthcare encounter in tears, feeling utterly alone, unseen and unheard.
M, L, and H all presented with a constellation of symptoms affecting various body systems, including their digestive organs, brain and nervous system, hormones, immune system, muscles, and metabolism. Their doctors were supportive and well-meaning, ordering blood tests and imaging, making referrals, and providing solutions within their scope of knowledge.
However, when their tests were normal, medications failed to provide relief, or symptoms escaped defined diagnostic categories, they and their practitioners hit a wall.
Like many others, these patients are victims of a medical model that overlooks the broader context in which people seeking healthcare solutions often find themselves. Symptoms may be dismissed, data is prioritized over experience, mental health is either minimized or overmedicalized, and care is separated into systems: brain, body, digestive system, hormones, or heart.
What was the significance of M’s elevated liver enzymes on her bloating and fatigue? Did her history of caloric restriction and people-pleasing predispose her to the burnout and exhaustion she was experiencing? How might intermittent fasting and overfunctioning have perpetuated her condition? How did the absence of a clear and defined disease negate her experience of being unwell and prevent her from finding the tools and strategies that might have helped?
What is the connection between L’s longstanding untreatable depression, autoimmune disease, and inflammation? How did carrying her diagnostic labels since adolescence impact her identity, hope for the future, and career aspirations?
Is it true that H’s anxiety, ADHD, and IBS were unrelated? How might bullying have impacted his physical and mental health? How might biohacking give him a sense of agency, or even creativity (May, 1983)? When does striving to understand slip too far into micromanagement, health anxiety, orthorexia, and self-punishment?
One of the reasons I became a naturopathic doctor is to work within the space and framework to ask these questions: Who is the person in front of me? What is their story? How can I serve?
For all three case examples, their family doctor’s office was the first place they sought help. Patients in the current healthcare system are fragmented into signs, symptoms, diagnoses, and labels. They are offered reductionistic linear solutions: one drug, test, or treatment per problem. When solutions are exhausted, practitioners throw up their arms: “It’s peri-menopause/aging/stress.” The system leaves little room for curiosity, meaning-making, transformation, growth, or uncertainty.
The result is a breakdown in the doctor-patient relationship and a lack of faith in the healthcare system. For patients, this can lead to a sense of powerlessness and mistrust of their bodies. Practitioners can feel frustrated, compassion-fatigued, and burned out.
In 1977, the journal Science published a seminal paper by George Engel entitled “The Need for a New Medical Model: A Challenge for Biomedicine.” In it, Engel outlines the limitations of the biomedical model and introduces a new approach to healing: the Biopsychosocial model, a holistic framework that acknowledges the interplay of biology, psychological, and social factors on health and illness.
Even nearly 50 years after Engel’s paper, modern medicine still largely adheres to the biomedical model. The model is based on the tenets of reductionism and dualism, which offer relative simplicity and a sense of certainty. These dogmas are difficult to release in favour of a more complex, flexible, multifaceted, and interconnected holistic framework.
Reductionism is a philosophical approach that seeks to understand the whole by breaking it down into its constituent parts. Health and illness can, therefore, be understood at the molecular and chemical levels: type I diabetes is a disease characterized by insulin deficiency, and coronary artery disease results from high cholesterol levels. However, a Lego sculpture cannot be recreated by turning over and examining the little coloured plastic pieces; the human organism is more than the sum of its parts. Our bodies are layered, interwoven, and interdependent dynamic systems that depend on and interact with the social world and environment.
We are wild, magical, and endlessly puzzling, with pieces and parts that weave, knot, and untangle in molecular dances that connect, disappear, and remanifest from the unseen depths of the mysterious beyond. The truth is as horrifying as it is accurate: despite the degrees, papers and expert-level bravado, we understand very little about ourselves.
Emerson M. Pugh puts it famously and beautifully: “If the human brain were so simple that we could understand it, we would be so simple that we couldn’t.”
The Human Genome Project is a prime example of the limitations of reductionism. Launched in the late 1990s and early 2000s, it aimed to decipher the body’s genetic code to understand the language of disease. While the project helped advance science in many ways, it failed to provide significant breakthroughs in disease research. It turns out that there is more to understanding Shakespeare’s works than reciting the alphabet.
Some diseases are caused by specific mutations in individual genes. Still, the reality is far more complex, with the relationship between genes and health involving combinations of mutations and epigenetics —interactions with the environment, life experiences, and behaviours that impact our DNA.
The second feature of the biomedical model is mind-body dualism, developed and promoted by Descartes in the 17th century. He postulated that the body is a material entity that could be dissected, examined, and altered without impacting the mind, which was considered ethereal and non-physical. The body might have been considered a temporary vessel for the mind, but the two were governed by different principles and troubles of the mind were not thought to impact the body, and vice versa.
The healthcare system still presumes mind-body dualism. We have psychiatrists for the mind and neurologists for the brain. Dead-end symptoms that evade disease categories are hand-waved as “stress” or “psychosomatic” (which paradoxically assumes a connection between mind and body).
Centuries of adopting this ill-fitting assumption have led to the obvious and pervasive mind-body problem: if the mind and body are distinct, then how can anxious thoughts quicken our heartbeat, trauma impact our immune system, stress lead to indigestion, and a placebo produce a healing effect?
The biomedical model views the body as a machine, with diseases representing deviations from normal functioning, and healing involving the restoration or replacement of broken parts. But, despite the comforts of certainty and control, biomedicine is no more scientific than leeches, bloodletting, and celery juice. It provides us with rituals in the form of tests, diagnoses, and prescriptions. The amulets we hold onto to ward off the demons of disease are chemical fixes for depression and ADHD, antibiotics for viral infections, and medications to lower lab values.
The biomedical model is the folk medicine of our time. It promises answers to the more complex questions of what is wrong and what can be done about it, while failing to address the why, how, what for, and, importantly, what this means (for me, my life, my family, my future).
On the other hand, the biopsychosocial model invites us to see the person as a constellation of living systems: interwoven body, mind, relationship, and spirit. It considers the rhythms of our biology, such as blood sugar, hormones, nerves, and neurotransmitters, inseparable from our inner world of thoughts, emotions, defences, and longings. It honours how we move through the world: in families, communities, and systems that shape our choices and burdens. It also asks how we make meaning through purpose, ancestry, connection, and the implicit possibility that links others to our suffering: we belong to something larger than ourselves.
The biopsychosocial model rests on a web of interconnected pillars, each supporting and shaping the others in a living system of feedback loops and resonance. No part can be isolated and touched without creating ripples that contact the whole.
Even a single intervention, such as a medication, sends ripples through the entire system because a pill, even a placebo, is not inert. It holds our beliefs about healing and medicine, our relationship with the prescriber, the meanings we attach to illness, and the social stories we carry about being unwell.
In “Why Make People Patients,” Marshall Marinker (1975) distinguishes between illness, sickness, and disease. The medical establishment diagnoses and treats diseases based on symptoms, signs, and lab tests that fit into neat categories, with defined biological treatments.
Illness is the experience of dysphoria and dysfunction that brings people to the doctor. It is the interpersonal and subjective experience of how unwellness is experienced or lived. Therefore, it is possible to feel ill (or unwell) without meeting the criteria for having a disease.
Sickness is a social role that an individual adopts when they are seen or see themselves as unwell. Those with chronic illness may experience being sick (and ill) without having a disease.
Within the biomedical model, disease receives the most attention. Its cause and course are known, and its treatments are rational and specific (Engel, 1977). Biomedicine can offer patients disease labels and treatments. The biological, psychological, and social dimensions of suffering are medicalized and collapsed into the narrow definition of disease. Care is often dehumanized, and people are treated as problems to be fixed (Marinker, 1975). People with chronic, invisible, or unexplainable symptoms or conditions that have yet to be classified and recognized as diseases are often dismissed, a phenomenon identified as “medical gaslighting.”
The Latin root of the word “patient” means “one who suffers” or “one who endures.” Life is suffering, and in this way, we are all patients. However, patient is a half-word, like confidant or lover (Marinker, 1975). A patient exists as one half of a dyadic whole, the doctor, physician, or healer forming the other half. This therapeutic relationship is the unit from which healing occurs.
The patient enters the therapeutic relationship because either they are unaware of what is wrong or, if they are, they don’t know how to help themselves (Engel, 1977). In this therapeutic dyad, the physician is not just a mechanic, identifying and fixing the broken parts, but also a teacher, mentor, and psychotherapist, requiring knowledge of body systems and medicine, as well as psychological and interpersonal skills. Their task is not only to diagnose, but to soothe uncertainty, offer meaning, and strengthen the patient’s trust in their body.
The physician is an agent of hope.
Research has shown that the biopsychosocial model can be used to treat pain and improve mood and life satisfaction in patients; it enhances clinician skills and improves disability outcomes ( Dossett et al., 2020; Fricchione, 2023; Kusnanto et al., 2018; Mankelow et al., 2022; Nakao et al., 2020).
Though decades of research and clinical evidence support the biopsychosocial model, conventional medicine, shaped by hierarchy and tradition, has been slow to integrate it, preferring power and old dominance structures over change.
Furthermore, the limitations of time and attention in holding space for the biopsychosocial model, the nuance of taking a thorough history, and systems thinking make it difficult to standardize into a rigid and overly complex system.
We need practice to bring the biopsychosocial model to healthcare. Below are real-world, grounded examples of how practitioners and patients can embody the model.
For practitioners:
Listen to Serve. Rachel Naomi Remen says that the doctor’s role should not be to fix or even help, but to serve.
She says, “If helping is an experience of strength, fixing is an experience of mastery and expertise. Service, on the other hand, is an experience of mystery, surrender and awe.”
In her book Narrative Medicine, Rita Charon (2006) recommends that doctors invite patients to speak without interrupting, asking them, “What do you think I should know about your case?” She listens for symptom onset, location, duration, and so on, but she also listens for nuance. How do the patients describe their symptoms? How are their lives impacted? What is important to them? Sometimes, she asks a patient, “Tell me about your scars.” Then, she listens.
In the biomedical model, where the doctor is on a hunt to uncover the broken or missing piece, patients are interrupted an average of 18 seconds after they begin speaking.
In many naturopathic consultations I’ve conducted, patients speak for thirty minutes or more, while I quietly listen, reflect nonverbally, and take notes before asking a single question.
In medical school, we were taught how to take a case, including mnemonics to help remember the key questions to ask. Now, 10 years in, I find that simply listening to patients provides me with the information I need to know, and more.
Perhaps this is why naturopathic doctors are often referred to as “Physicians Who Listen.”
According to Engel, doctors must learn to be high-level interviewers, versed in the cultural determinants of how patients communicate disease symptoms. How we talk about our bodies reveals our relationships with them, our experiences with symptoms, and the early life experiences that shape our bodies.
In the doctor-patient interview, the doctor must listen to understand and validate the unfolding story that led someone to feel unwell and seek help. This means identifying biological symptoms and holding space for the psychological and social elements shaping how the person suffers, and healing might begin.
Charon posits that a medical interview must allow for a layered, nonlinear, and metaphor-rich narrative. How does the patient tell their story, and what are their experiences with symptoms? What details do they choose to include? Or omit? Narrative thinkers like Rita Charon and Gabor Mate argue that our stories, or biography, shape our biology. They are just as important, if not more so, than the classic signs and symptoms that typically characterize a particular diagnostic category.
The doctor’s task is to help patients name their feelings and bear witness to the patient’s experience of dysphoria or dysfunction. They must listen for and begin to untangle the threads that shape the suffering and the individuals’ desire to wear the mantle of “patient” and entrust their body to care.
Begin with humility. The patient is the expert on their own body. While you may have spent hours studying this particular organ or condition, the patient has spent years, even a lifetime, living with it.
Science, while the best methodology we have for encountering the truth, is still just an approximation that we use until something better comes along. Knowledge is always incomplete. According to Babette Rothschild (2021), even the most evidence-based treatment for post-traumatic stress disorder will not help more than 50% of clients.
Even the most thoroughly researched cure will not benefit everyone. Nothing in medicine, psychology, or sociology is a hard fact. Science is a big, unanswered question.
In the words of Rachel Naomi Remen, “The patient is not a problem to be solved, but a mystery to be met.”
Remember why you wanted to be a doctor. If you’re like me, you were captivated by the awe and mystery of not knowing. You’ve studied and practiced medicine for years, and the not-knowing still hangs before you, lighting the way on.
My question to practitioners is this: Can you meet your patient, head down in reverence and awe, with curiosity and compassion, without the need to fix? Can you sit in the discomfort of uncertainty?
Practice systems thinking. From a systems perspective, rather than a reductionist one, each part is integrated and interacts with its layers and within the whole. What layer must be addressed first?
Consider how social forces like poverty, racism, and social categories may affect patients’ symptoms and their ability to heal. Ask how organs, cells, molecules, diagnoses, lab results, and the social and psychological interact. What threads are present, and how might they weave and knot together?
See the person, not the problem. Michael White (2016), the developer of Narrative Therapy, is famous for saying, “The person is not the problem, the problem is the problem.” When we separate people from their problems, we leave room for stories of suffering and strength. We can hold and better listen to their stories, while tackling the problem without erasing the person.
Centre patients as the experts on their own lives and their bodies. Flatten hierarchies and de-centre practitioner power. Educate with curiosity, not to fix or dictate. Leave room for questions and doubt. Learn to roll with resistance rather than fighting against it.
Instead, get curious. Why might these recommendations not be landing for the patient? Ask if the diagnoses and treatment plans make sense to them. And then ask: What matters most? What do you notice? What are you ready for?
Ask patients what threads they would like to tug first. Addressing patient issues and developing plans involves a patient-centred, collaborative approach in which courses of action are suggested, tried, and evaluated for feedback. This way, an intricate dance happens between the patient and the practitioner (Graham et al., 2023).
Self-care. Finally, practitioner burnout is real. Ensure you regulate your nervous system, make space for reflection, and seek support as needed.
For patients:
Trust yourself. Health is not just the absence of symptoms or the relief of pain; it is the sense of wholeness, coherence, and aliveness in your body and your being. Normal lab results don’t cancel out your suffering; a diagnosis cannot fully contain your story. Your instincts and insights are also essential data.
You are not a broken part needing repair, but a whole person, complex, relational, and worthy of care. If something feels wrong, trust that. If you feel unseen, trust it. Your frustration is valid. Your symptoms are messengers.
You deserve understanding, presence, comfort, care, and a path forward.
Empower yourself within the system. Our healthcare system is stretched thin, and sometimes, your suffering may be overlooked. This is not because you don’t matter; it isn’t always because your doctor doesn’t care. Sometimes, even the most well-meaning practitioners work within an overwhelmed structure.
Before your appointment, take a moment to ground yourself. Breathe into your belly. Feel your feet beneath you. Gather your thoughts and write them down. Bring someone who can hold space, ask thoughtful questions, and accurately remember what is said.
Write down your questions before you go. Appointments move quickly, and it’s easy to forget. Describe your top two or three concerns and how they shape your days, energy, and life. Be honest about what you’ve tried, what’s helped, and what hasn’t.
If something feels off, you can gently point it out. “Could we look at this another way?” “This doesn’t quite fit.” “Would you be open to checking this?” If it’s difficult to speak, consider having someone speak on your behalf. You deserve to be witnessed.
Afterward, write down what was said, how it landed, and what you wish you’d asked. Over time, this will build a personal health narrative you can revisit and share with future providers.
Participate in your healing. Responsibility is not about blame. You are not expected to carry everything alone, but you are invited to become a curious, compassionate student of your own body. We can reclaim our agency.
Start by paying attention. Track your symptoms, not obsessively, but as an act of self-witnessing. Look for patterns: what soothes, what aggravates, what precedes the flare or the crash. Learn the basics of your biology and mind: how stress ripples through your system, blood sugar, trauma, hormones, sleep, and your nervous system speak. What are their symptoms, signs, and sensations? You don’t need to diagnose yourself, but knowing your inner landscape helps you recognize when something feels true and when it doesn’t.
Your voice matters, too. Healing is a dialogue. Informed consent is about being an active participant in the conversation. This means learning to describe what you feel, notice, and need.
Pain, for instance, can be more than just “it hurts.” What kind of pain is it? Where does it live? Is it burning, tight, dull, or pulsing? Does it move or stay in place? Is it eased by warmth, made worse by movement, or does it come on with memories or moods? The more we can narrate what we carry, the more we can be seen.
When it comes to tools, focus on what’s within reach. You don’t need a life overhaul or expensive therapies. Sometimes, healing begins with the most minor shift: more rest, a nourishing meal, honouring a boundary, a walk in the sun, or a moment of joy.
The human body requires fresh air, water, sunlight, physical activity, restful sleep, nutritious food, and social connection. While finding a balance of these isn’t always easy, sometimes, the solutions are simpler than we think.
Build yourself a circle of care. No single practitioner can hold everything we carry. If it’s within reach, widen your support: consider consulting a naturopathic doctor to explore root causes, a therapist to help map your inner world, a nutritionist, an acupuncturist, or a massage therapist. Each practitioner can offer a different lens and a different kind of listening. Ask about referrals, covered services, sliding scales, or community programs.
You are allowed to ask for more, to want a second opinion, and to assemble a community of support that sees you more fully. If you have coverage, use it. If you need a referral, ask. If a door closes, it’s ok to knock on another.
Seek information from people you trust. Let wisdom be relational and guided intuitively. Be cautious of algorithms, especially those that induce fear or urgency.
Above all, refuse to give up on yourself. I always believe there is a path toward feeling better. Even when we can’t fully restore the body, healing can still occur through meaning, connection, presence, and peace. Your body is not betraying you. I believe symptoms are cries from the body that deserve to be heard.
Healing begins when we stop reducing people to their symptoms and begin seeing them as whole beings, complex, feeling, and worthy. You deserve care that honours not just your biology, but your personhood, spirit, and life.
You deserve to tell your story and have someone receive it with attention and care.
You deserve a physician who listens.
References:
Charon, R. (2006). Narrative medicine. Oxford University Press.
Dossett, M. L., Fricchione, G. L., & Benson, H. (2020). A new era for mind–body medicine. New England Journal of Medicine, 382(15), 1390–1391. https://doi.org/10.1056/nejmp1917461
Fricchione, G. (2023). Mind body medicine: A modern bio-psycho-social model forty-five years after Engel. BioPsychoSocial Medicine, 17(1). https://doi.org/10.1186/s13030-023-00268-3
Graham, K. D., Steel, A., & Wardle, J. (2023). The converging paradigms of holism and complexity: An exploration of naturopathic clinical case management using complexity science principles. Journal of evaluation in clinical practice, 29(4), 662–681. https://doi.org/10.1111/jep.13721
Kusnanto, H., Agustian, D., & Hilmanto, D. (2018). Biopsychosocial model of illnesses in primary care: A hermeneutic literature review. Journal of Family Medicine and Primary Care, 7(3), 497. https://doi.org/10.4103/jfmpc.jfmpc_145_17
Mankelow, J., Ryan, C., Taylor, P. C., Atkinson, G., & Martin, D. (2022). A systematic review and meta-analysis of the effects of biopsychosocial pain education upon health care professional pain attitudes, knowledge, behavior and patient outcomes. Journal of Pain, 23(1). https://doi.org/10.1016/j.jpain.2021.06.010
Nakao, M., Komaki, G., Yoshiuchi, K., Deter, H.-C., & Fukudo, S. (2020). Biopsychosocial medicine research trends: Connecting clinical medicine, psychology, and public health. BioPsychoSocial Medicine, 14(1). https://doi.org/10.1186/s13030-020-00204-9
On Pet Loss, Crossing the Rainbow Bridge, and The Places Grief Lives
My grief is tremendous, but my love is bigger.
– Cheryl Strayed
For my entire childhood, I wanted a dog. I didn’t care what kind of dog it was; I just wanted one. A sensitive child entering the world of broken promises and ruptured friendships, I craved the unconditional love of an animal. I would read to him and tell her about school: my dissociated teachers, the kids who had hurt my feelings, and my dreams and aspirations. I imagined he would sit there, forever interested, lovingly listening.
My parents promised my brother and me a puppy when I was nine and he was six. Instead, we got hamsters, gerbils, fish, and turtles.
After spending Christmas with my family in Canada, I returned to Bogota, Colombia, with my ex-boyfriend, Joe. I was 24 years old and taught English for two years out of university. I walked into our shared apartment, set down my things, looked up, and there he was! A tiny, black and tan Yorkshire terrier—Coco Loco.
I sat with him across my lap. He tucked his little head inside the crook of my elbow—lights out. His soft head and cold, wet nose tickled the inside of my arm. He and I would sit this way, my arms around his curled-up body, his head tucked—yoked together in warmth and comfort until his last day.
Small, rambunctious and mischievous, Coco was a ferocious ball of unbridled puppy joy. He chewed everything, peed everywhere, and once unravelled an entire roll of toilet paper while waiting for me to get out of the shower.
We walked everywhere in Bogota. He travelled on buses and accompanied Joe and me on long hikes through the Colombian jungles and countryside, harassing chickens and balancing on logs stretched over deep, rushing streams. He was curious and intelligent, head cocked, ears alert, always with some agenda.
When it was time for me to leave Bogota and return to Toronto to start naturopathic college, Coco flew with me. Emerging from the confines of his travels, he was soon bounding around my parents’ yard, paws touching new soil. He loved Canada: the snow, the squirrels, his family. He grew to be 16 pounds, giant for a Yorkie.
For the next 15 years, Coco was my faithful shadow. He was there throughout my four years at the Canadian College of Naturopathic Medicine, witnessing me studying for and passing my board exams. Coco joined me on the ride to the centre for the first round of board exams, perched on my knees. As we pulled into the parking lot, he sensed my anxiety and started shaking. He was my emotional mirror, our bodies empathically in tune.
He watched me graduate and start my clinical practice. He saw me fall in and out of love, move, try and fail, and try again, his nose nudging my tears after every heartbreak and disappointment.
My naturopathic medicine practice moved online in 2020, and I became a psychotherapist in 2024. Coco was at my feet during every patient encounter, absorbing all your stories and witnessing your humanity.
For 11 years, Coco volunteered as a St. John’s Ambulance Therapy Dog. Once a week, he would proudly wait for my dad by the door in his uniform—a bandana that read, “Please Pet Me.” They’d roam the hospital halls, bringing cheer to patients and burnt-out staff.
In a blog I kept while at the Canadian College of Naturopathic Medicine, I wrote many posts about how Coco taught me to live. He brought me fully into my kinship with nature. We hiked through parks in Toronto and logged hundreds of kilometres on the Bruce Trail. I remember him gliding ahead along the narrow path, light streaming through the trees, an orchestra of birds punctuating the quiet rhythm of our footsteps and breath, hearts held by the magnanimous life that was all around.
Dogs offer us a pure form of love and connection. Their unconditional love can soothe the wounds accumulated from our imperfect human attachments.
They are grounded, noses connected to the Earth. And this grounding keeps their lives in the moment, up for adventure, and free from the overthinking and neurosis that block our trust and joy.
Dogs remind us of our ancient history, when we lived in tune with nature’s frequencies, a time long forgotten but deeply missed. Dogs’ presence tells us the truth: the doors on our cages and cubicles are unlocked. We are still wild. And the earth patiently awaits our return.
Nature has guided me through pain and heartache. When I lose touch with myself, I return to the beach and the forest to find it. Coco taught me this.
He brought me to the forest, set me free, and left me there. He died on April 22, 2025. And I’ve returned many times to find him among the roots, the leaves, and the joy of other dogs living fully, who love their lives enough to lose them.
Over a year ago, Coco stopped eating. As the vet was running tests, my stomach turned over with anguish. He was diagnosed with an inflammatory bowel disease, and his prognosis was poor. But, despite their size and teddy bear appearance, terriers are persistent, tenacious fighters. After a few days of steroids, antibiotics, and a special diet, Coco miraculously bounced back. Still, the vet cautioned that he would likely need to be on prednisone and his condition closely monitored for the rest of his life.
Over the next year, Coco stoically trudged on. He kept up his fighting spirit until his last day—terriers never give up. Although duller and more easily fatigued, he motored along Great Lakes beaches and hiked in Nova Scotia. When he could no longer walk much, he rolled around in his dog stroller or rode on my back. When he was too tired to lift his head, I sometimes walked alone.
The prednisone thinned his fur, whithered his muscles, and messed with his sleep. I had to carry him up and downstairs, help him stand, and carry him outside. Each night, at two, three, four in the morning, sometimes several times a night, I would haul myself out of bed, nauseous with exhaustion, to take him out. I would fumble for my keys and coat in the darkness, and we would stand outside, wordlessly shivering with cold. I would wait for him, watching the snow blow in the glow of the street lamps, my body begging to return to the warmth of my bed.
Other nights, I was too late and calmly cleaned his mess while he watched me, confused and ashamed.
Eventually, the vet confirmed his kidneys were failing. He stopped keeping his food down. He began coughing and struggling to breathe. His heart was failing.
When referring to putting down a pet, people will tell you you’ll know the right time. They will tell you a dog won’t get up, or they’ll stop eating. Or, the vet will confirm it, waking you from your indecision and denial. Sometimes old dogs will pass peacefully in their sleep. Most likely, however, you will have to decide when, where, and how to end your best friend’s life.
Euthanasia is an impossible choice, like cutting off a part of yourself to spare the whole. Coco couldn’t tell me in words what he wanted, but if he could, how could one choose a road unseen, with the destination unknown? When pets die, the poem goes, they cross the Rainbow Bridge. Beyond the bridge lies a lush, sunlit meadow, where animals run free with old friends, and rest in warmth and comfort, nourished and unhurt. It’s an image that’s brought comfort to many pet owners. I don’t know if the Rainbow Bridge exists, but I knew he was suffering here.
My heart cracked under the weight of it all, and I made the call: I would lovingly release him from this life and guide him to the bridge. It was time.
There is a saying in veterinary medicine, “Better a month too early than a day too late,” and I let that steady my hand as I made the arrangement for a hospice vet to come to our house on April 22nd at 4:00 p.m.
When the vet came and eventually took Coco away, she left a pamphlet that contained this poem, called The Last Battle, author unknown, that reads,
If it should be that I grow frail and weak
And pain should keep me from my sleep,
Then will you do what must be done,
For this — the last battle — can’t be won.
You will be sad I understand,
But don’t let grief then stay your hand,
For on this day, more than the rest,
Your love and friendship must stand the test.
We have had so many happy years,
You wouldn’t want me to suffer so.
When the time comes, please let me go.
Many pet owners wrestle with the idea that we shouldn’t have the power to end our companions’ lives. Yet we’ve made every other choice for them: what they eat, where they sleep, when they go out. “Euthanasia” means “good death.” Offering this to Coco felt like a final act of stewardship: a responsibility to our bond and a firm expression of my love. When the time comes, please let me go.
It is hard to describe those final days, as we both hung between worlds, at the threshold of the Rainbow Bridge. Time slowed down. Every breath and moment hung heavy before evaporating into the ethers of the past. Soon, the past was all we’d have.
Anxiety, fear, and doubt swirling around, I found the eye of the hurricane on those last days. We walked to the lake on our final night together to watch the sunset. A thick mist fell, and we settled on Muskoka chairs, Coco’s head tucked, our breathing in sync. I could feel his last few heartbeats against my thigh.
On April 22nd, I gave him a Perfect Last Day. We went to the Pet Store, ate cheeseburgers, wheeled through High Park, and took our last hike together, the sun warming our faces. Something in the air must have revealed the gravity of the moment, the brevity of our time and the impending goodbye, because people lingered around us.
Two older women walking in the park smiled as they passed, “He looks so comfortable in his stroller,” one said. When I told them it was his last day, they both embraced me as I sobbed. One of them took a picture of us together.
After saying goodbye to her beloved 19-year-old dog, my friend and her husband went to the lake. A lady snapped a photo of them, saying they looked beautiful watching the sunrise together. “Sometimes people can sense when a stranger needs a beautiful moment to hold on to,” she said. Grief can soften our walls and invite others in.
We went home and sat together that last hour, waiting for the vet. He lay on my chest. The sun was beautiful. I saw the shape of Yorkies in the clouds.
His last moments were peaceful; he never left my arms. “He’s gone,” said the hospice vet, gently. She gathered her things as I sat with him. Then she wrapped him up, and they were gone.
The mantle of loneliness wrapped me tightly. Now it was just my grief and I.
The word “grief” comes from the Latin “gravis,” which means “heavy” or “serious.” Related words are “grave,” “gravity,” and even “gravitas.”
As a society, we squirm away from grief. We fumble with the words to comfort and wrestle away from the stronghold of sorrow. We numb, distract, try to move on, and forget. But life’s truth is harsh: we will lose everything we love. Grief comes for us all; it is the work of the living to hold and process it.
Psychoanalyst Francis Weller says, “Grief is much more than an emotion. It is one of the central faculties of being human.
“Grief is a core capacity that allows us to digest the most bitter experiences into something meaningful, perhaps beautiful, something vital and alive.”
So often, depression is not depression at all, but oppression, unprocessed grief that accumulates around the heart like a sediment, blocking us from our vitality and the joy of our being (Weller, 2015). To chip away at this hardened sludge, we must learn to sit with grief, invite it in, name it, and give it space to release, thus becoming “skilled in the art of loss.” Grief work keeps the heart fluid and soft.
And so, I wade into the dark waters, welcomed by the other bereaved. When we dive into the blackness, we join the collective pool of human suffering. This community expands the heart’s container, deepening its wells of compassion. Grief work is soul work. It is necessary work.
Poet Rainer Maria Rilke says, “Yet, no matter how deeply I go down into myself, my God is dark, and like a webbing made of a hundred roots that drink in silence.”
We live in a culture of lightness, upward mobility, positivity, and optimism. We fear the descent into blackness.But my God is dark. We were gestated in the darkness of our mothers’ wombs. Our hearts beat in darkness. Seeds grow below the dark depths of the earth. Sometimes, we must enter the shadows, the depths of despair, to bring the riches back up to the light. Alchemical Psychology calls this descent “the nigredo.”
In the nigredo of grief, the ego softens. The rigid self we once hid behind begins to dissolve (Barn Life Recovery, 2020). We lose our usual sense of who we are, yet somehow become more fully ourselves. As we feel the pain of losing what we loved, we also feel love in its purest form. This is soul work because in the end, the soul remains.
Terry Tempest Williams says, “Grief dares us to love once more.”
What if we approach our grief experience not with resistance but hands together and head bowed in reverence?
According to Francis Weller, when we hold gratitude in one hand and grief in the other, and bring them together, we are now in the prayer of life. Oscar Wilde says, “Where there is sorrow, there is holy ground.”
In The Smell of Rain on Dust, Martín Prechtel writes that grief work is not only about expressing sorrow but transforming pain into beauty using the gifts given by the spirits. Grief requires a container and release. We must keep it warm through writing, poetry, meditation, contemplation, and art. Through creating, we weave the memories of those we’ve lost into the fabric of life and unravel the cycles of trauma born from unexpressed grief.
The morning after Coco died, I leapt out of the shower in a panic. I grabbed my phone and texted the hospice vet, asking them to change the urn I requested. I got back in the shower, calmer. Wait, was I crazy? I settled for a second, then threw open the shower curtain, suds flying, and texted back, “Sorry, no wait, the original decision stands, sorry, I changed my mind…again.” Was I insane?
Before Coco died, they had talked about the ashes. Did I want a private cremation? What did I wish for the ashes? The details had felt irrelevant, far away. I just wanted my dog. In Scandinavia, an individual would spend a sacred season in the ashes of their loss, occupying a parallel world of mourning, from which they would emerge changed (Weller, 2015). Ashes carry the gravity of what we’ve lost. My soul, too, knew it wanted to walk with the ashes. What would be reborn there?
In my closet now sits a memory box containing some of Coco’s things: his sweater, a collar, and a cherry twig, with buds, which I picked up the day of our last hike in a moment frozen in late April before the cherries blossomed. Martin Pretchel reminds us that grief is praise. It is a natural way to honour what one misses.
Many people offered comforting words, reminding me that Coco had a “Good Life.” In his book Going Home: Finding Peace When Pets Die, John Katz (2012) discusses the idea of the “Good Life.” He says, “When you clear away all of the emotional confusion, there is this: all we can give our pets is a Good Life. We can’t do more than that. We miss them because that life was good, loving, and joyful. Too often, this truth is lost in our grieving.”
Camus echoes the sentiment in saying, “The deeper the sorrow, the greater the joy.”
The box contains a framed picture of us at a lake in Quebec, watching the sunset—one beautiful moment among many of a life well-lived.
One thing people have said is that Coco will always be with me. I want to believe this, but as the distance from our last day grows, I feel him fading. I haven’t forgotten, but his presence feels quieter, harder to reach.
In his beautiful poem, For Grief, John O’Donahue writes,
Gradually, you will learn acquaintance
With the invisible form of your departed;
And, when the work of grief is done,
The wound of loss will heal
And you will have learned
To wean your eyes
From that gap in the air
And be able to enter the hearth
In your soul where your loved one
Has awaited your return
All the time.
Cheryl Strayed (2021) describes how her mother wanted her tombstone to say, I am always with you. “But I want you actually with me!” She protested. Coco and I will never make new memories again. He is another ghost gone into the gap in the air.
On the 30th anniversary of her mother’s death, Strayed writes, “Thirty years gone and my mother is always with me. Thirty years gone, and I still ache for her every day. Thirty years gone, and my sorrow has sweetened into gratitude.
“How lucky I am to have been her daughter. To still be. To feel her shimmering in my bones with every step.”
Sweet, little Coco, you will always be my dog.
Last week, I had my brother’s dog, Toby, with me. He is a 4-year-old mini golden doodle with nowhere to go while my brother and sister-in-law work, so I take him out sometimes. That day, he bounded around the beach, wild with joy, with a newfound freedom that must have felt like a dream.
I watched him with a heart that wanted to meet him in his happiness, but my heart still feels lost in the nigredo. When the work of grief is done, and the sediment is cleared, I’m not sure what I will find in my soul’s hearth, on the other side of sorrow’s edge. Maybe it will be Toby’s wild doggy grin, inviting me to play and dance among the dunes.
The poem I Walk With You (Author Unknown) goes,
I stood by your bed last night, I came to have a peep. I could see that you were crying, You found it hard to sleep.
I whined to you softly as you brushed away a tear, “It’s me, I haven’t left you, I’m well, I’m fine, I’m here.”
I was close to you at breakfast, I watched you pour the tea, You were thinking of the many times, your hands reached down to me.
I was with you at the shops today, Your arms were getting sore. I longed to take your parcels, I wish I could do more.
I was with you at my grave today, You tend it with such care. I want to reassure you, that I’m not lying there.
I walked with you towards the house, as you fumbled for your key. I gently put my paw on you, I smiled and said “it’s me.”
You looked so very tired, and sank into a chair. I tried so hard to let you know, that I was standing there.
It’s possible for me, to be so near you everyday. To say to you with certainty, “I never went away.”
You sat there very quietly, then smiled, I think you knew … In the stillness of that evening, I was very close to you.
The day is over and I smile and watch you yawning And say “goodnight, God bless, I’ll see you in the morning.”
And when the time is right for you to cross the brief divide, I’ll rush across to greet you and we’ll stand, side by side.
I have so many things to show you, there is so much for you to see. Be patient, live your journey out, then come home to be with me.
Last year, Nonna passed away, a few weeks before her 97th birthday. We must carry her with us, telling the “Nonna Stories” that capture her witty mind and fierce heart.
I took Toby to the woods where Coco and I used to walk. Young and free, he tore through the trees. “He doesn’t hike like Coco,” I told my mom. “He runs around in circles and doesn’t listen.”
“He’ll learn,” She said.
Last week, we found a quiet rhythm as we walked; Toby was a few paces ahead. He stopped, turned, and waited for me. Birdsong carried through the stillness. Something in the way he cocked his head reminded me of Coco. My heart still feels empty and full of missing him, but maybe, in the quiet hearth of my soul, head tilted, ears listening, he waits, too,
Someone, I think it was Eckhart Tolle, once said that when it comes to mental illness, anxiety is about worry for the future, while depression is concerned with regret for the past. While, I’m not entirely (or even nearly) convinced that this is true, there is little doubt that those with both depression and anxiety can get caught in the paralysis of going over past events and regrets in their minds. Therefore, healing regret becomes important for reframing our past experiences and present identity and improving mood and self-esteem.
Regret is a sticky emotion. It reminds us of who we once were. It’s the cold hand on the shoulder and the voice that whispers “remember…” in our ear when we’re getting a little too confident, when we’re actually feeling happy with who we are now.
My patients will often tell me that when they find themselves in a spiral of low mood, their minds are often playing and replaying past events over and over. They mull over painful memories until they are distorted, painting themselves as the villain the more they rewind and press play. Remembering in this way smears grey over their entire sense of self, and discolours the possibilities they see for themselves in the future and, worse, their abilities to take meaningful action in the present. It leads to deep feelings of self-hate and worthlessness. It causes feelings of hopelessness. And so I tell them this:
Regret, while painful, is not always bad. It is a reflection, a comparison between two people: the person you are now and the person you used to be. When this comparison is particularly vast, when the you you used to be is particularly painful to remember, then know this; you have changed. Regret comes with looking back with pain, wishing we’d taken a different course of action than the ones taken. However, when we flip this concept over and examine its shinier underbelly, we realize that in order to feel regretful about past events we are acknowledging that we (present we) would not have performed the same action or made the same choice now. The flip side is not that we’re bad, it’s a reflection of our goodness. We have learned and evolved. We’re different.
Looking back is different from looking forward. Our lessons are what shape us. The fact that we regret is proof that we learn, we grow and we change into better, preferred versions of ourselves. If we sit in the experience of regret, we can feel proud that, if faced with the same situation today, we’d be better. Regret doesn’t mean that we are bad people, it’s proof that we’re good people. In order to regret the past we’ve had to have changed.
To transform mulling over painful life choices and past actions, I recommend a writing exercise, inspired by Narrative Therapy. In every story of regret and “badness” there is also a story of values, skills, preferred identity and goodness. The next time you find yourself cycling through feelings of regret grab a pen and paper and answer the following questions:
1) What happened? What were the events that transpired? What did you do? What did other people in the story do? What were the events leading up to the action you and others took? What was the context surrounding you at the time? What influenced your decision to act as you did?
2) Looking back, what would you have done differently? What parts are particularly painful to remember? What actions or events do you regret?
3) What might these regrets say about you now? What might it say about you to know that you would have acted differently if you were faced with the same situation? What values do you embody that enable you to recognize that what you did in the past was regretful for you?
4) Looking at these values, how have you shown you have this value in the past in other situations? Do you have a particular story you remember?
5) How has that value or skill made an impact on the lives of others? In the story that you remembered, what might the actions you took in #4 have meant to the people around you?
6) How do you embody this value in the present? Where does it show up in the actions you take today? How might you embody this value in the future? What actions might you take while remembering this value? What does remembering this value and the story from #4 make possible for the future?
Going through this writing exercise can help us look back with more compassion for the person we were, who was growing into the person we are now. It might make possible ways that we can rectify anyone or anything was impacted in the past, if it means an apology, paying forward a good act, taking different steps in a similar present situation or even moving on and letting go of our tendency to hold onto the memory.
We all have a critic inside of our heads. Through talking to people, I’ve been able to form more complete pictures of what these critics look like. I’ve found them to be as varied as the heads they inhabit, with personalities and characteristics of their own.
Some critics speak in fragments, muttering key words in people’s ears: fat… failure… loser… always…be… alone. Some are quite articulate, forming complex arguments. All inner critics, however, are sharp in their cruelty and ingenious in the way they intrude into our thoughts and convince us of our lack of worth.
Our inner critics were born out of a need for protection. The inner critic’s job is to spare us shame and pain. If it criticizes us before we have the chance to say or do the “wrong” thing, it can help us avoid social humiliation, rejection and isolation. However, the disparaging, constant stream of criticism often leads to depression, low self-esteem and negative identity conclusions in many people–a strong critical voice has the power to convince the person it talks to that he or she is wrong. The critical voice in our heads has the power to poke holes in the social armour of our self-esteem, diminishing the good feelings we have about ourselves and destroying our sense of personal value, self-worth and resilience.
There are many ways to develop a healthy relationship with the critical inner voice and address issues of low self-worth and low self-esteem. One of these ways is to strengthen other, more positive voices, that serve to give us a balanced view of ourselves. Self-help books and feel-good memes emphasize the importance of positive affirmations.
“Write down ten things you love about yourself before you go to bed every night!”
“Recite ‘I am beautiful, healthy and happy’ five times each day!”
“Write ‘I love you!’ and ‘You’re awesome!’ in lipstick in the bathroom mirror and look at it every morning before you to go to work!”
“Paper your workspace with feel-good Post-it notes!”
The suggested ways of talking to ourselves are endless. A sample:
According to Guy Winch, PhD and author of Emotional First Aid, research shows that positive affirmations can be very effective at raising self-esteem. However, their efficacy only applies to a certain group of people (like Jessica here). Affirmations can boost the morale of those who already have high self-esteem and a high sense of self-worth. In people who struggle with strong critical voices, depression and feelings of self-loathing, positive affirmations only result in making them feel worse.
Science tells us that we accept statements and ideas when they fall into our current belief system. Therefore, people with healthy levels of self-worth, who already believe that they are loved, good at their jobs and successful, will reinforce those feelings through reciting positive affirmations about themselves. However, my patients struggling with issues of self-esteem will comment that when they feel unattractive, unloved or unworthy, reciting the opposite sentiments as affirmations (“I am beautiful, loved, worthy!”) only reinforces their current feelings of unworthiness and unattractiveness. When a positive affirmation doesn’t overlap with the beliefs we hold about ourselves, we will reject it, thereby failing to convince or persuade ourselves to feel otherwise. Trying to force oneself into feeling a positive emotion can often only serve to remind us of how unhappy we are actually feeling.
Dr. Winch offers an alternate 3-step exercise, which reminds me in many ways of Narrative Therapy as it aims to build on one’s preferred identity. The exercise is based on increasing the aspects of our identity we already believe of ourselves. It takes about 20 minutes and requires writing. Writing helps us process the information on both sides of the brain, properly integrating and enforcing these more balanced thoughts about ourselves. The exercise only works when you write your thoughts down.
Step 1: Choose a specific situation in which you feel bad or unworthy. Perhaps you have a test coming up and feel unprepared or convinced that you’ll fail. Perhaps there is a date you’re going to go on but you feel ugly and unworthy of someone’s time or attention. Maybe you feel unpopular and have come to the conclusion that you are a bad friend. Using context is important for creating an alternate voice to that our the critic.
Step 2: Once the context has been selected, write down a list of things—traits or behaviours you exhibit—that you have to offer that you believe are valuable to the situation. This list should be exhaustive. Perhaps you would make a good date because you are generous, always offering to pay. Perhaps you’re loyal or you care about others. Perhaps you remember important dates and make your partner feel special on his or her birthday. Perhaps you’re a good student because you get to class on time or study for an hour after class instead of watching movies. Perhaps you always take notes in class and often share them with others. Focussing on even the tiniest detail of what you have to offer the situation will help you in the creation of your list. If you can’t think of anything positive about yourself, pretend that you are writing it for a friend. What would your friend have to offer if he or she were faced with the same context and self-defeating thoughts as you?
Step 3: Choose one of the items on your list and write a short essay on why these traits or qualities are important to the context you are in. Why is being thoughtful (remembering birthdays, for instance) important for dating? How have you managed to manifest this trait in the past? How will you manifest this trait or behaviour in the future? Write about how this trait has been valued by others or might be of value to others in the context that you’re in. Focusing on specific details helps to flush out the narrative of how this trait has helped shaped your identity. Again, if you are unable to write about yourself, continue to write as if it were about a friend, sticking to more general ideas. Then put the paper aside, pick it up 24 hours later, and read it as if it were about you.
Writing a short, detailed essay about what we know we have to offer and why these offerings are worthwhile can help to build a more balanced view of ourselves and the qualities we bring to the world. Narrative exercises serve to strengthen what we already know about ourselves, thickening the preferred identity stories that either fail to get told or get drowned out by the dominant stories of negative labels and personal failings. The aim is not to shut up the inner critic, but to strengthen the voices that oppose it, balancing and creating a dynamic sense of self.
People seek out naturopathic doctors for expert advice. This immediately positions us as experts in the context of the therapeutic relationship, establishing a power imbalance right from the first encounter. If left unchecked, this power imbalance will result in the knowledge and experience of the practitioner being preferred to the knowledge, experience, skills and values of the people who seek naturopathic care.
The implicit expectation of the therapeutic relationship is that it’s up to the doctor to figure out what is “wrong” with the body patients inhabit and make expert recommendations to correct this wrong-ness. After that, it’s up to the patients to follow the recommendations in order to heal. If there is a failure to follow recommendations, it is the patient who has failed to “comply” with treatment. This “failure” results in breakdown of communication, loss of personal agency on the part of the patient, and frustration for both parties.
When speaking of previous experience with naturopathic medicine, patients often express frustration at unrealistic, expensive and time-consuming treatment plans that don’t honour their values and lifestyles. Oftentimes patients express fear at prescriptions that they had no part in creating, blaming them for adverse reactions, or negative turns in health outcomes. It’s common that, rather than address these issues with the practitioner, patients take for granted that the treatment plan offered is the only one available and, for a variety of reasons, choose to discontinue care.
One of the elements of Narrative Therapy—a style of psychotherapy founded by Australian Michael White—I most resonate with is the idea of the “therapeutic posture”. In narrative therapy, the therapist or practitioner assumes a de-centred, but influential posture in the visit. This can be roughly translated as reducing practitioner expertise to that of a guide or facilitator, while keeping the agency, decision-making, expertise and wisdom of the patient as the dominant source for informing clinical decisions. The de-centred clinician guides the patient through questioning, helping to reframe his or her identity by flushing out his or her ideas and values through open-ended questions. However, the interests of the doctor are set aside in the visit.
From the place of de-centred facilitation, no part of the history is assumed without first asking questions, and outcomes are not pursued without requesting patient input. De-centring eschews advice-giving, praise, judgement and applying a normalizing or pathologizing gaze to the patient’s concerns. De-centring the naturopathic practitioner puts the patient’s experiences above professional training, knowledge or expertise. We are often told in naturopathic medical school that patients are the experts on their own bodies. A de-centred therapeutic gaze acknowledges this and uses it to optimize the clinical encounter.
I personally find that in psychotherapy, the applicability of de-centring posture seems feasible—patients expect that the therapist will simply act as a mirror rather than doling out advice. However, in clinical practice, privileging the skills, knowledge and expertise of the patient over those of the doctor seems trickier—after all, people come for answers. At the end of naturopathic clinical encounters, I always find myself reaching for a prescription pad and quickly laying out out my recommendations.
There is an expected power imbalance in doctor-patient relationships that is taught and enforced by medical training. The physician or medical student, under the direction of his or her supervisor, asks questions and compiles a document of notes—the clinical chart. The patient often has little idea of what is being recorded, whether these notes are in their own words, or even if they are an accurate interpretation of what the patient has intended to convey—The Seinfeld episode where Elaine is deemed a “difficult patient” comes to mind when I think of the impact of medical records on people’s lives. After that we make an assessment and prescription by a process that, in many ways, remains invisible to the patient.
De-centred practice involves acknowledging the power differential between practitioner and patient and bringing it to the forefront of the therapeutic interaction.
The ways that this are done must be applied creatively and conscientiously, wherever a power imbalance can be detected. For me this starts with acknowledging payment—I really appreciate it when my patients openly tell me that they struggle to afford me. There may not be something I can do about this, but if I don’t know the reason for my patient falling off the radar or frequently cancelling when their appointment time draws near, there is certainly nothing I can do to address the issue of cost and finances. Rather than being a problem separate from our relationship, it becomes internal the the naturopathic consultation, which means that solutions can be reached by acts of collaboration, drawing on the strengths, knowledge and experience of both of us.
De-centred practice involves practicing non-judgement and removing assumptions about the impact of certain conditions. A patient may smoke, self-harm or engage in addictive behaviours that appear counterproductive to healing. It’s always useful to ask them how they feel about these practices—these behaviours may be hidden life-lines keeping patients afloat, or gateways to stories of very “healthy” behaviours. They may be clues to hidden strengths. By applying a judgemental, correctional gaze to behaviours, we can drive a wedge in the trust and rapport between doctor and patient, and the potential to uncover and draw on these strengths for healing will be lost.
De-centred practice involves avoiding labelling our patients. A patient may not present with “Generalized Anxiety Disorder”, but “nervousness” or “uneasiness”, “a pinball machine in my chest” or, one of my favourites, a “black smog feeling”. It’s important to be mindful about adding a new or different labels and the impact this can have on power and identity. We often describe physiological phenomena in ways that many people haven’t heard before: estrogen dominance, adrenal fatigue, leaky gut syndrome, chronic inflammation. In our professional experience, these labels can provide relief for people who have suffered for years without knowing what’s off. Learning that something pathological is indeed happening in the body, that this thing has a name, isn’t merely a figment of the imagination and, better still, has a treatment (by way of having a name), can provide immense relief. However, others may feel that they are being trapped in a diagnosis. We’re praised for landing a “correct” diagnosis in medical school, as if finding the right word to slap our patients with validates our professional aptitude. However, being aware of the extent to which labels help or hinder our patients capacities for healing is important for establishing trust.
To be safe, it can help to simply ask, “So, you’ve been told you have ‘Social Anxiety’. What do you think of this label? Has it helped to add meaning to your experience? Is there anything else you’d like to call this thing that’s been going on with you?”
Avoiding labelling also includes holding back from using the other labels we may be tempted to apply such as “non-compliant”, “resistant”, “difficult”, or to group patients with the same condition into categories of behaviour and identity.
It is important to attempt to bring transparency to all parts of the therapeutic encounter, such as history-taking, physical exams, labs, charting, assessment and prescribing, whenever possible. I’ve heard of practitioners reading back to people what they have written in the chart, to make sure their recordings are accurate, and letting patients read their charts over to proofread them before they are signed. The significance of a file existing in the world about someone that they have never seen or had input into the creation of can be quite impactful, especially for those who have a rich medical history. One practitioner asks “What’s it like to carry this chart around all your life?” to new patients who present with phonebook-sized medical charts. She may also ask, “Of all the things written in here about you, what would you most like me to know?” This de-emphasizes the importance of expert communication and puts the patient’s history back under their own control.
Enrolling patients in their own treatment plan is essential for compliance and positive clinical outcomes. I believe that the extent to which a treatment plan can match a patient’s values, abilities, lifestyle and personal preferences dictates the success of that plan. Most people have some ideas about healthy living and natural health that they have acquired through self-study, consuming media, trial-and-error on their own bodies or consulting other healthcare professionals. Many people who seek a naturopathic doctor are not doing so for the first time and, in the majority of cases, the naturopathic doctor is not the first professional the patient may have consulted. This is also certainly not the first time that the person has taken steps toward healing—learning about those first few, or many, steps is a great way to begin an empowering and informed conversation about the patients’ healing journey before they met you. If visiting a naturopathic doctor is viewed as one more step of furthering self-care and self-healing, then the possibilities for collaboration become clearer. Many people who see me have been trying their own self-prescriptions for years and now finally “need some support” to help guide further action. Why not mobilize the patient’s past experiences, steps and actions that they’ve already taken to heal themselves? Patients are a wealth of skills, knowledge, values, experiences and beliefs that contribute to their ability to heal. The vast majority have had to call on these skills in the past and have rich histories of using these skills in self-healing that can be drawn upon for treatment success.
De-centring ourselves, at least by a few degrees, from the position of expertise, knowledge and power in the therapeutic relationship, if essential for allowing our patients to heal. A mentor once wrote to me, “Trust is everything. People trust you and then they use that trust to heal themselves.”
By lowering our status as experts, we increase the possibility to build this trust—not just our patients’ trust in our abilities as practitioners, but patients’ trust in their own skills, knowledge and abilities as self-healing entities. I believe that de-centring practitioner power can lead to increased “compliance”, more engagement in the therapeutic treatment, more opportunities for collaboration, communication and transparency. It can decrease the amount of people that discontinue care. I also believe that this takes off the burden of control and power off of ourselves—we aren’t solely responsible for having the answers—decreasing physician burnout. Through de-centring, patients and doctors work together to come up with a solution that suits both, becoming willing partners in creating treatment plans, engaging each other in healing and thereby increasing the trust patients have in their own bodies and those bodies’ abilities to heal.
According to Statistics Canada, 1 in 4 people suffer from a mental health condition in Canada. Most of these individuals will fall between the cracks of a medical system that is not equipped to deal with the rise of stress and mood disorders, such as depression.
Naturopathic doctors understand that the mind and body are connected. Science has long established the relationship between the digestive system and mood, often termed the “Gut-Brain Connection” and the connection between the mind, mental health and the immune system, even establishing an entire field termed “psychoneuroimmunology”, linking depression to inflammation in the brain and body. However when it comes to our conventional healthcare model, mental health conditions are treated as separate from the rest of the body. In mainstream medicine, depression is largely treated as a brain chemical imbalance. It is thought that deficiency in the “happy” chemicals in the brain, like serotonin and dopamine, influence mood and must be “corrected” with anti-depressants. Despite emerging science about the brain, emotions, and mood, mental health conditions are commonly viewed as something that has “gone wrong” in the brain.
This reductionist approach to mental health often overlooks the intricate interplay between various physiological systems and their collective impact on mental well-being. For instance, conditions like ADHD are frequently discussed in terms of specific symptoms and brain function, yet they also involve broader aspects of cognitive and emotional regulation. One notable challenge associated with ADHD is time blindness, where individuals struggle to perceive and manage time effectively. This symptom highlights the complexity of ADHD and underscores the need for a more holistic view of mental health, recognizing that these conditions cannot be fully understood by focusing solely on brain chemistry.
Most treatments for depression and anxiety are based on the low-serotonin theory of depression, which roughly states that depression is due to decreased production of certain neurotransmitters, such as serotonin, in the brain. Following this model, drugs are prescribed to artificially change neurotransmitter levels. While we understand that anti-depressant medications such as selective serotonin and selective serotonin and norepinephrine re-uptake inhibitors (SSRIs and SNRIs) work better than placebo (in about 40-60% of cases), scientists don’t know for certain why they have an affect. When starting SSRI and SNRI drugs, patients experience an immediate increase in neurotransmitter levels in the brain, however, it takes 2-4 weeks before there are noticeable changes to mood. This points to the fact that the proposed mechanism (increasing neurotransmitter levels) may not in fact be how these drugs work. However, it is in the interest of the pharmaceutical companies manufacturing such drugs to perpetuate the idea that anti-depressant medications are “restoring” the natural chemical balance in the brain, despite lack of evidence that this is the case.
This is furthered by a paper published by the Neuroscience and Behavioural Reviews last year that challenges the low-serotonin theory of depression, stating that improvement on SSRI medication might be the body overcoming the effects of the drug, rather than the drug assisting patients in feeling better (1). This may explain why patients feel worse in the first few weeks of starting anti-depressant medication. The authors venture to say that anti-depressant medication may in fact be creating an obstacle to cure in patients with depression, making it harder for patients to recover in the short-term. The authors of the study argue that most forms of depression provide an evolutionary advantage by providing the body with natural and beneficial adaptations to stress (1).
Since we understand that our digestive system and immune system are linked to our mood and overall functioning, it becomes imperative that we learn how to fuel our brains, improve digestion, balance inflammation and take proactive measures against our increasing levels of stress.
Getting help for a mental health disorder first involves removing the stigma and discrimination around mental health—depression, anxiety and other mood disorders are not signs of weakness, they are common conditions that a large portion of the population is dealing with daily. Next, it is important to seek help from a trusted practitioner who will take the time to listen to your case, treat your body as a whole entity, not just a collection of organs, and connect with you as a person, not just your symptoms or diagnosis. The following are some proposed and effective methods of working with depression and mental health conditions.
1. Healing the gut.
Science has largely started referring to the digestive system as the “second brain”, due to its possession of something called the Enteric Nervous System, a collection of millions of nerve cells that control digestive function and communicate directly with the brain. Because of this intricate connection, research has shown that irritation to the digestive system, through bacterial overgrowth, gut inflammation and a variety of other mechanisms, can trigger significant changes to mood (2,3). Since 30-40% of the population suffers from digestive symptoms such as bloating, flatulence, GERD, IBS, constipation, diarrhea and IBD, this connection is important. Additionally, emerging research is showing the link between beneficial gut bacteria and mood, establishing the fact that certain probiotics are capable of producing neurotransmitters and thereby contributing to mood and mental functioning (2,3).
Naturopathic medicine has long established a connection between the gut and brain when it comes to health, recognizing that conditions such as IBS are aggravated by stress, depression and anxiety and treating the digestive concerns with patients with depression by prescribing quality probiotics and identifying and removing food sensitivities among other things. In addition, not only is gut function important for regulation of the nervous system and, in turn mood, a healthy digestive system is required for proper absorption of the amino acids and micronutrients necessary for synthesizing neurotransmitters.
2. Essential nutrients and adequate nutrition.
If the body doesn’t possess the building blocks for building hormones and neurotransmitters, it won’t make them. While SSRI medication keeps brain serotonin levels elevated, it also depletes the vitamins and minerals responsible for producing serotonin. Supplementing with quality brands and correct doses of vitamins B6, folate and B12, as well as magnesium and zinc and ensuring adequate protein intake, is essential to treating mental health conditions and mood. Some sources state that 70-80% of the population is deficient in magnesium. Since magnesium is needed for production of a variety of hormones and neurotransmitters, a deficiency can cause an array of symptoms from low mood and muscle pain, to insomnia and fatigue. Getting put on high-quality, professional grade vitamins and minerals at therapeutic doses should be done under the care of a licensed professional, such as a naturopathic doctor.
3. Fish oil.
A meta-analysis in 2014 concluded that fish oils are effective at treating low mood and even patients diagnosed with major depressive disorder (4). Since the brain requires the fatty acids EPA and DHA found in fish to function, ensuring adequate intake of fatty fish or using a high-EPA supplement at an effective dose is a cornerstone of natural treatment for depression. The ratio of EPA:DHA is important, however, so ensure you’re receiving a prescription from a licensed naturopathic doctor (not all brands on the market are created equally and some products may even negatively impact mood). Another proposed mechanism of action for fish oil benefitting mood is in its anti-inflammatory properties. Emerging research has suggested that depression may be correlated with low-levels of brain inflammation.
4. Healing the adrenals.
According to evolutionary biology, depression may be a necessary adaptation to stress that promoted our survival and ability to pass on our genes. Since about 70% of the population identifies as being significantly stressed, it is no wonder that the number of mental health conditions is also rising. Naturopathic medicine and other alternative health fields recognize a collection of symptoms caused by prolonged, chronic stress that they term “adrenal fatigue”. Adrenal fatigue is characterized by high levels of prolonged mental, emotional and physical stress, low energy, insomnia, food cravings, and depressive symptoms such as low mood, apathy and lack of enjoyment in previously enjoyed activities, changes to sleep, weight, appetite and energy levels. Whether symptoms of chronic stress are misdiagnosed as mild to moderate depression in people, or whether lifestyle stress is the cause of physiological depression, there is often a significant stressor that complicates symptoms of low mood in most people. Using herbs, nutrition and stress-reduction techniques is important for improving resilience, as is taking steps to decrease the amount of stress present in one’s life. Researching and experimenting with various self-care practices is also important for managing low mood and promoting mental health.
5. Mind-body medicine.
Mind body medicine involves working with the body’s energetic healing forces to remove obstacles to cure and ensure the smooth flow of energy throughout the body. The main modalities that naturopathic medicine uses for these purposes are acupuncture, homeopathy and working with meditation and visualizations. While some reject these streams of healing as being pseudoscientific, there is a growing body of research to back them up. A study by the Journal of Alternative and Complementary medicine showed that acupuncture was as effective as medication at reducing depression after six weeks (5). Mind-body medicine works by integrating our thoughts, emotions and physical sensations to give us more awareness about the body as well as provides us with powerful tools for managing stress.
6. Counselling.
We know that counselling is a preferred first-line treatment for depression and other mood disorders and that counselling and medication in combination is far better than medication alone. While there are a variety of psychotherapeutic models and styles, research suggests that the therapeutic relationship is one of the most powerful determinants of positive health outcomes (6). Therefore working with a clinician that you trust, connect and resonate with is the first step to finding effective therapy. Cognitive Behavioural Therapy (CBT), a style of therapy based on changing ingrained and habitual thoughts, beliefs and behaviours that may be contributing to low mood, is one of the main therapeutic modalities for depression and is supported by a number of studies. Motivational Interviewing is another counselling model that helps patients work through and change addictive behaviours and has substantial evidence behind it.
7. Mindfulness.
More and more research is coming out about the Buddhist practice of mindfulness meditation for preventing depression, managing stress, working with mood disorders and preventing relapse in major depressive disorder. Recent evidence published in JAMA has shown that Mindfulness-Based Cognitive Therapy (MBCT), a form of secular mindfulness meditation was just as effective as medication for treating mild to moderate depression (7). Mindfulness involves looking inward, without judgment at the thoughts, feelings and physical sensations produced by the body. Practicing it cultivates the skills of awareness, attention and presence. According to Jon Kabat-Zinn, one of the founders of MBCT, “Mindfulness is awareness that arises through paying attention, on purpose, in the present moment, non-judgementally. It’s about knowing what is on your mind.” Mindfulness improves mood by allowing participants to better understand their own emotional states without getting caught up in identifying with negative emotions and belief systems.
If you or a friend or family member is suffering from a mental health condition, it is important to be educated about options. Naturopathic medicine is a great first-line option for those who have been newly diagnosed with a mood disorder, as well as a preventive measure for those simply dealing with stress, and a great complement to those who have been living with a mental health condition for some time and are already on medication. I work with children, adolescents, adults, pregnant patients, postpartum women and patients dealing with addictions. I have additional training in motivational interviewing, mindfulness-based stress reduction, narrative therapy and CBT and structure my visits to allow for more time for counselling. Contact me for more information on how to work with me.
References:
Andrews, PW, Bharwani, A, Lee, K.R., Fox, M, Thomsom, JA. Is serotonin an upper or a downer? The evolution of the serotonergic system and its role in depression and the antidepressant response. Neuroscience & Biobehavioral Reviews, 2015; 51: 164
Dinan, T, Cryan, J. Regulation of the stress response by the gut microbiota: Implications for psychoneuroimmunology. Psychoneuroimmunology (2012) 37, 1369-1378
Wang, Y. Kasper, LH. The role of micro biome in central nervous system disorders. Brain Behav. Immun. (2014).
Grosso G, Pajak A, Marventano S, et al. Role of Omega-3 Fatty Acids in the Treatment of Depressive Disorders: A Comprehensive Meta-Analysis of Randomized Clinical Trials. Malaga G, ed. PLoS ONE. 2014;9(5):e96905. doi:10.1371/journal.pone.0096905.
Sun, H, Zhao, H, Ma, C, Bao, F, Zhang, J, Wang, D, Zhang, Y. and He, W. Effects of Electroacupuncture on Depression and the Production of Glial Cell Line–Derived Neurotrophic Factor Compared with Fluoxetine: A Randomized Controlled Pilot Study. The Journal of Alternative and Complementary Medicine. September 2013, 19(9): 733-739.
Siegel, D. The Mindful Therapist. Mind You Brain, Inc. New York: 2010.
Goyal, M, Singh, S, Sibinga, ES, et al. Meditation Programs for Psychological Stress and Well-being: A Systematic Review and Meta-analysis. JAMA Intern Med.2014;174(3):357-368. doi:10.1001/jamainternmed.2013.13018.
A singular narrative is told and retold regarding medicine in the west. The story goes roughly like this: the brightest students are accepted into medical schools where they learn—mainly through memorization—anatomy, physiology, pathology, diagnostics, microbiology, and the other “ologies” to do with the human physique. They then become doctors. These doctors then choose a specialty, often associated with a specific organ system (dermatology) or group of people (pediatrics), who they will concentrate their knowledge on. The majority of the study that these doctors undergo concerns itself with establishing a diagnosis, i.e.: producing a label, for the patient’s condition. Once a diagnosis has been established, selecting a treatment becomes standardized, outlined often in a cookbook-like approach through guidelines that have been established by fellow doctors and pharmaceutical research.
The treatment that conventional doctors prescribe has its own single story line involving substances, “drugs”, that powerfully over-ride the natural physiology of the body. These substances alter the body’s processes to make them “behave” in acceptable ways: is the body sending pain signals? Shut them down. Acid from the stomach creeping into the esophagus? Turn off the acid. The effectiveness of such drugs are tested against identified variables, such as placebo, to establish a cause and effect relationship between the drug and the result it produces in people. Oftentimes the drug doesn’t work and then a new one must be tried. Sometimes several drugs are tried at once. Some people get better. Some do not. When the list is exhausted, or a diagnosis cannot be established, people are chucked from the system. This is often where the story ends. Oftentimes the ending is not a happy one.
On July 1st, naturopathic doctors moved under the Regulated Health Professionals Act in the province of Ontario. We received the right to put “doctor” on our websites and to order labs without a physician signing off on them. However, we lost the right to inject, prescribe vitamin D over 1000 IU and other mainstay therapies we’d been trained in and been practicing safely for years, without submitting to a prescribing exam by the Canadian Pharmacists Association. Naturopathic doctors could not sit at the table with the other regulated health professions in the province until we proved we could reproduce the dominant story of western medicine—this test would ensure we had.
Never mind that this dominant story wasn’t a story about our lives or the medicine we practice—nowhere in the pages of the texts we were to read was the word “heal” mentioned. Nowhere in those pages was there an acknowledgement about the philosophy of our own medicine, a respect towards the body’s own self-healing mechanisms and the role nature has to play in facilitating that healing process. It was irrelevant that the vast majority of this story left out our years of clinical experience. The fact that we already knew a large part of the dominant story, as do the majority of the public, was set aside as well. We were to take a prescribing course and learn how primary care doctors (general practitioners, family doctors and pediatricians), prescribe drugs. We were to read accounts of the “ineffectiveness” of our own therapies in the pages of this narrative. This would heavy-handedly dismiss the experience of the millions of people around the world who turn to alternative medicine every year and experience success.
We were assured that there were no direct biases or conflict of interests (no one was directly being paid by the companies who manufacture these drugs). However, we forget that to have one story is to be inherently and dangerously biased. Whatever the dominant story is, it strongly implies that there is one “truth” that it is known and that it is possessed by the people who tell and retell it. Other stories are silenced. (Author Chimamanda Ngozi Adichie describes this phenomenon in her compelling TED Talk, “The Danger of a Single Story”).
Despite the time and money it cost me, taking the prescribing course afforded me an opportunity to step outside of the discouraging, dominant story of the standard medical model and thicken the subordinate stories that permeate the natural and alternative healing modalities. These stories began thousands of years ago, in India and in China, at the very root of medicine itself. They have formed native ancestral traditions and kept entire populations and societies alive and thriving for millennia. Because our stories are not being told as often, or told in the context of “second options” or “last resorts”, when the dominant narratives seem to fail us, the people who tell them run the risk of being marginalized or labeled “pseudoscientific.” These dismissals, however, tell us less about The Truth and more about the rigid simplicity of the singular story of the medical model.
It is frightening to fathom that our body, a product of nature itself, encompasses mysteries that are possibly beyond the realm of our capacity for understanding. It’s horrifying to stand in a place of acknowledgement of our own lack of power against nature, at the inevitability of our own mortality. However, if we refuse to acknowledge these truths, we close ourselves off to entire systems that can teach us to truly heal ourselves, to work with the body’s wisdom and to embrace the forces of nature that surround us. The stories that follow are not capital T truths, however, they can enrich the singular story that we in the west have perpetuated for so long surrounding healing.
The body cannot be separated into systems. Rather than separating depression and diarrhea into psychiatry and gastroenterology, respectively, natural medicine acknowledges the interconnectivity between the body’s systems, none of which exist in a vacuum. When one system is artificially manipulated, others are affected. Likewise, an illness in one system may result in symptoms in another. There have been years of documentation about the gut-brain connection, which the medical model has largely ignored when it comes to treatment. The body’s processes are intricately woven together; tug on one loose thread and the rest either tightens or unravels.
We, as products of nature, may never achieve dominion over it. Pharmaceutical drugs powerfully alter the body’s natural physiology, often overriding it. Since these drugs are largely manmade, isolated from whole plants or synthesized in a lab, they are not compounds found naturally. Despite massive advances in science, there are oceans of what we don’t know. Many of these things fit into the realm of “we don’t know what we don’t know”—we lack the knowledge sufficient to even ask the right questions. Perhaps we are too complex to ever truly understand how we are made. Ian Stewart once wrote, “If our brains were simple enough for us to understand them, then we’d be so simple that we couldn’t.” And yet, accepting this fact, we synthesize chemicals that alter single neurotransmitters, disrupting our brain chemistry, based on our assumption that some people are born in need of “correcting” and we have knowledge of how to go about this corrective process. Such is the arrogance of the medical model.
There are always more than two variables in stories of disease and yet the best studies, the studies that dictate our knowledge, are done with two variables: the drug and its measured outcome. Does acetaminophen decrease pain in patients with arthritis when compared to placebo? A criticism of studies involving natural medicine is that there are too many variables—more than one substance is prescribed, the therapeutic relationship and lifestyle changes exert other effects, a population of patients who value their health are different than those who do not, the clinical experience is more attentive, and so on. With so many things going on, how can we ever know what is producing the effect? However, medicine is limited in effect if we restrict ourselves to the prescription of just one thing. This true in herbalism, where synergy in whole plants offers a greater effect than the sum of their isolated parts. By isolating a single compound from a plant, science shows us that we may miss out on powerful healing effects. Like us, plants have evolved to survive and thrive in nature; their DNA contains wisdom of its own. Stripping the plant down to one chemical is like diluting all of humanity down to a kidney. There is a complexity to nature that we may never understand with our single-minded blinders on.
Studies are conducted over the periods of weeks and, rarely, months, but very rarely are studies done over years or lifetimes. Therefore, we often look for fast results more than signs of healing. This is unfortunate because, just as it takes time to get sick, it takes time to heal. I repeat the previous sentence like a mantra so patients who have been indoctrinated into a medical system that produces rapid results can reset expectations about how soon they will see changes. Sometimes a Band-Aid is an acceptable therapy; few of us can take long, hard looks at our lives and begin an often painful journey in uncovering what hidden thought process or lifestyle choices may be contributing to the symptoms we’re experiencing. However, the option of real healing should be offered to those who are ready and willing.
When we study large masses of people, we forget about individuality. When we start at the grassroots level working with patients on the individual level, we familiarize ourselves with their stories, what healing means to them. In science, large studies are favoured over small ones. However, in studies of thousands of people, singular voices and experiences are drowned out. We lose the eccentric individualities of each person, their genetic variability, their personalities, their preferences and their past experiences. We realize that not everyone fits into a diagnostic category and yet still suffers. We realize that not everyone gets better with the standard treatments and the standard dosages. Starting at the level of the individual enables a clinician to search for methods and treatments and protocols that benefit each patient, rather than fitting individuals into a top-down approach that leaves many people left out of the system to suffer in silence.
It is important to ask the question, “why is this happening?” The root cause of disease, which naturopathic medicine claims to treat is not always evident and sometimes not always treatable. However, the willingness to ask the question and manipulate the circumstances that led to illness in the first place is the first step to true and lasting healing; everything else is merely a band-aid solution, potentially weakening the body’s vitality over time. No drug or medical intervention is a worthy substitute for clean air, fresh abundant water, nutritious food, fulfilling work and social relationships, a connection to a higher purpose, power or philosophy and, of course, good old regular movement. The framework for good health must be established before anything else can hope to have an effect.
The system of naturopathic medicine parallels in many ways the system of conventional pharmaceutical-based medicine. We both value science, we both strive to understand what we can about the body and we value knowledge unpolluted by confusing variables or half-truths. However, there are stark differences in the healing philosophies that can’t be compared. These differences strengthen us and provide patients with choice, rather than threatening the establishment. The time spent with patients, the principles of aiming for healing the root cause and working with individuals, rather than large groups, offer a complement to a system that often leaves people out.
There are as many stories of healing and medicine as there are patients. Anyone who has ever consulted a healthcare practitioner, taken a medicine or soothed a cold with lemon and honey, has experienced some kind of healing and has begun to form a narrative about their experience. Anyone with a body has an experience of illness, healing or having been healed. Those of us who practice medicine have our own experience about what works, what heals and what science and tradition can offer us in the practice of our work. Medicine contains in its vessel millions of stories: stories of doubt, hopelessness, healing, practitioner burnout, cruises paid for my pharmaceutical companies, scientific studies, bias, miracle cures, promise, hope and, most of all, a desire to enrich knowledge and uncover truth. Through collecting these stories and honouring each one of them as little truth droplets in the greater ocean of understanding, we will be able to deepen our appreciation for the mystery of the bodies we inhabit, learn how to thrive within them and understand how to help those who suffer inside of them, preferably not in silence.
As a child, I was obsessed with stories. I wrote and digested stories from various genres and mediums. I created characters, illustrating them, giving them clothes and names and friends and lives. I threw them into narratives: long stories, short stories, hypothetical stories that never got written. Stories are about selecting certain events and connecting them in time and sequence to create meaning. In naturopathic medicine I found a career in which I could bear witness to people’s stories. In narrative therapy I have found a way to heal people through helping them write their life stories.
We humans create stories by editing. We edit out events that seem insignificant to the formation of our identity. We emphasize certain events or thoughts that seem more meaningful. Sometimes our stories have happy endings. Sometimes our stories form tragedies. The stories we create shape how we see ourselves and what we imagine to be our possibilities for the future. They influence the decisions we make and the actions we take.
We use stories to understand other people, to feel empathy for ourselves and for others. Is there empathy outside of stories?
I was seeing R, a patient of mine at the Yonge Street Mission. Like my other patients at the mission health clinic, R was a young male who was street involved. He had come to see me for acupuncture, to help him relax. When I asked him what brought him in to see me on this particular day, his answer surprised me in its clarity and self-reflection. “I have a lot of anger,” He said, keeping his sunglasses on in the visit, something I didn’t bother to challenge.
R spoke of an unstoppable rage that would appear in his interactions with other people. Very often it would result in him taking violent action. A lot of the time that action was against others. This anger, according to him, got him in trouble with the law. He was scared by it—he didn’t really want to hurt others, but this anger felt like something that was escaping his control.
We chatted for a bit and I put in some acupuncture needles to “calm the mind” (because, by implication, his mind was not currently calm). After the treatment, R left a little lighter with a mind that was supposedly a little calmer. The treatment worked. I attributed this to the fact that he’d been able to get some things off his chest and relax in a safe space free of judgment. I congratulated myself while at the same time lamented the sad fact that R was leaving my safe space and re-entering the street, where he’d no doubt go back to floundering in a sea of crime, poverty and social injustice. I sighed and shrugged, feeling powerless—this was a fact beyond my control, there wasn’t anything I could do about it.
The clinic manager, a nurse practitioner, once told me, “Of course they’re angry. These kids have a lot to be angry at.” I understood theoretically that social context mattered, but only in the sense that it posed an obstacle to proper healing. It is hard to treat stress, diabetes, anxiety and depression when the root causes or complicating factors are joblessness, homelessness and various traumatic experiences. A lot of the time I feel like I’m bailing water with a teaspoon to save a sinking ship; my efforts to help are fruitless. This is unfortunate because I believe in empowering my patients. How can I empower others if I myself feel powerless?
I took a Narrative Therapy intensive workshop last week. In this workshop we learn many techniques for empowering people and healing them via the formation of new identities through storytelling. In order to do this, narrative therapy extricates the problem from the person: the person is not the problem, the problem is the problem. Through separating problems from people, we are giving our patients the freedom to respond to or resolve their problems in ways that are empowering.
Naturopathic doctors approach conditions like diabetes from a life-style perspective; change your lifestyle and you can change your health! However, when we fail to separate the patient from the diabetes, we fail to examine the greater societal context that diabetes exists in. For one thing, our culture emphasizes stress, overwork and inactivity. The majority of food options we are given don’t nourish our health. Healthy foods cost more; we need to work more and experience more stress in order to afford them. We are often lied to when it comes to what is healthy and what is not—food marketing “healthwashes” the food choices we make. We do have some agency over our health in preventing conditions like diabetes, it’s true, but our health problems are often created within the context in which we live. Once we externalize diabetes from the person who experiences it, we can begin to distance our identities from the problem and work on it in creative and self-affirming ways.
Michael White, one of the founders of Narrative Therapy says,
If the person is the problem there is very little that can be done outside of taking action that is self-destructive.
Many people who seek healthcare believe that their health problems are a failure of their bodies to be healthy—they are in fact the problem. Naturopathic medicine, which aims to empower people by pointing out they can take action over their health, can further disempower people when we emphasize action and solutions that aim at treating the problems within our patients—we unwittingly perpetuate the idea that our solutions are fixing a “broken” person and, even worse, that we hold the answer to that fix. If we fail to separate our patients from their health conditions, our patients come to believe that their problems are internal to the self—that they or others are in fact, the problem. Failure to follow their doctor’s advice and heal then becomes a failure of the self. This belief only further buries them in the problems they are attempting to resolve. However, when health conditions are externalized, the condition ceases to represent the truth about the patient’s identity and options for healing suddenly show themselves.
While R got benefit from our visit, the benefit was temporary—R was still his problem. He left the visit still feeling like an angry and violent person. If I had succeeded in temporarily relieving R of his problem, it was only because I had acted. At best, R was dependent on me. At worst, I’d done nothing, or, even worse, had perpetuated the idea that there was something wrong with him and that he needed fixing.
These kids have a lot to be angry at,
my supervisor had said.
R was angry. But what was he angry at? Since I hadn’t really asked him, at this time I can only guess. The possibilities for imagining answers, however, are plentiful. R and his family had recently immigrated from Palestine, a land ravaged by war, occupation and racial tension. R was street-involved, living in poverty in an otherwise affluent country like Canada. I wasn’t sure of his specific relationship to poverty, because I hadn’t inquired, but throughout my time at the mission I’d been exposed to other narratives that may have intertwined with R’s personal storyline. These narratives included themes of addiction, abortion, hunger, violence, trauma and abandonment, among other tragic experiences. If his story in any way resembled those of the other youth who I see at the mission, it is fair to say that R had probably experienced a fair amount of injustice in his young life—he certainly had things to be angry at. I wonder if R’s anger wasn’t simply anger, but an act of resistance against injustice against him and others in his life: an act of protest.
“Why are you angry?” I could have asked him. Or, even better, “What are you protesting?”
That simple question might have opened our conversation up to stories of empowerment, personal agency, skills and knowledge. I might have learned of the things he held precious. We might have discussed themes of family, community and cultural narratives that could have developed into beautiful story-lines that were otherwise existing unnoticed.
Because our lives consist of an infinite number of events happening moment to moment, the potential for story creation is endless. However, it is an unfortunate reality that many of us tell the same single story of our lives. Oftentimes the dominant stories we make of our lives represent a problem we have. In my practice I hear many problem stories: stories of anxiety, depression, infertility, diabetes, weight gain, fatigue and so on. However, within these stories there exist clues to undeveloped stories, or subordinate stories, that can alter the way we see ourselves. The subordinate stories of our lives consist of values, skills, knowledge, strength and the things that we hold dear. When we thicken these stories, we can change how we see ourselves and others. We can open ourselves up to greater possibilities, greater personal agency and a preferred future in which we embrace preferred ways of being in the world.
I never asked R why the anger scared him, but asking might have provided clues to subordinate stories about what he held precious. Why did he not want to hurt others? What was important about keeping others safe? What other things was he living for? What things did he hope for in his own life and the lives of others? Enriching those stories might have changed the way he was currently seeing himself—an angry, violent youth with a temper problem—to a loving, caring individual who was protesting societal injustice. We might have talked about the times he’d felt anger but not acted violently (he’d briefly mentioned turning to soccer instead) or what his dreams were for the future. We might have talked about the values he’d been taught—why did he think that violence was wrong? Who taught him that? What would that person say to him right now, or during the times when his anger was threatening to take hold?
Our visit might have been powerful. It might have opened R up to a future of behaving in the way he preferred. It might have been life-changing.
It definitely would have been life-affirming.
Very often in the work we do, we unintentionally affirm people’s problems, rather than their lives.
One of the course participants during my week-long workshop summed up the definition of narrative therapy in one sentence,
Narrative therapy is therapy that is life-affirming.
And there is something very healing in a life affirmed.
