How to avoid PCSD (Post consultation Stress Disorder)

You know what it’s like—you’ve just spent most (or all) of your precious consultation time with a worried parent and a healthy child. Being a good clinician, you have performed a thorough examination, you have carefully excluded any signs of meningitis, septicaemia or other severe disease, and the child, who may have vomited or perhaps has /had a fever overnight, is alert, active and happily running around your consulting room.

Everything is clear.  Maybe a few sniffles. It’s of course possible the temperature will return when the Calpol wears off. You can happily reassure the patient and the parent.

However, nowdayswe need to document that we have given ‘Worsening Instructions’.These are designed to empower the patient to give him or her the knowledge to assess when to appropriately seek further medical advice.

So you tell the now reassured parents everything that might get worse in the imminent future. They might have to bring the child back. They may need to call the Out-of-Hours service.

You mention that if the child gets fever again or headache or dislike of bright lights or that rash spreads that they may have meningitis. Or septicaemia. Or if they get vomiting they may need to be seen again—urgently. You may well suddenly be involved in a detailed discussion of exactly how much vomiting constitutes an emergency…

That look of reassurance is now gone. Back comes that worried frown—only this time it’s worse.

Parent or carer leaves with a plethora of doubts running in his or her mind, along with graphic images of what their child might look like with a life threatening disease.

Sure enough they call the Out-of-Hours service that night. The fever came back after the Calpol wore off. He vomited once more after supper. So the child gets seen again at midnight in the Out-of-Hours service (or maybe the Accident and Emergency department). The child, getting better again as the next dose of paracetamol starts to work, is seen by the stressed duty clinician who tells to the parent that the child is fine now—BUT …

Sure enough you see them again the next day. Parents, who have had a sleepless night waiting for the septicaemia to appear, are feeling the worse for wear and fatigued after waiting in A&E last night.

The child however continues to play happily in the waiting room, although there is a bit of a sniffle … and is that ear looking a bit red? You see the child again, happy to do so. You tell parents there is nothing SERIOUSLY WRONG and they leave reassured a tiny bit reassured, but still looking anxious.

…and so it continues…

The everyday example above is replete with examples of the power of suggestion and the use of language in the consultation.

Of course have a duty to empower patients and give them quality worsening instructions. And, assuming we have ruled out anything sinister, we need to know how to do this so they don’t suffer with Post-Consultation Stress Disorder. And all this without spending an extra half an hour trying to be reassuring.

Considerthis example:

“…it appears to be a viral gastroenteritis. It’s always going round… usually it settles within a few days, But if he develops a rash, or if the vomiting or diarrhoea or the pain gets worse, then it might be appendicitis or an obstruction, so make sure to bring him back so we can make sure it is not serious “

The significant elements here are: 

  1. the law of Primacy and Immediacy – i.epatients will tend to remember the first and last bits of information told them
  2. the use of the word “but”. In Medical NLPTM the word “but” is a ‘turning word’, one of a group of words thatdiminishes (but does not delete) what was said before. It enhances and highlights what is said next
  • the use of negation (words like not, no, never, don’t)

Let’s apply these principles:

Law of Immediacy – the last thing you tell them is what they will remember best and think about most. You can either say :“…make an urgent appointment or take them to A&E If he develops a fever or a rash or you think he’s getting worse, or you are worried about him”
or, the revised version:
“make an urgent appointment or take them to A&E If he develops a fever or a rash or you think they are not getting any better or you’re not happy about how well they are progressing…”

Using “but” to focus attention—Contrary to what some NLP Practitioners believe, “but” is not  a “mental eraser”. However,is used to focus attention on the part of the sentence that is most useful.

You want to avoid saying something like this:“It’s probably just a common virus and he seems fine to me.But, if he develops a rash, headache, vomiting, dislike of bright lights or becomes drowsy or floppy then it could be something nasty like meneingitis so make sure you take him to A&E” 

This will almost guarantee high levels of anxiety amongst many (if not all) patients,

Alternatively, you could still give accurate empowering advice if you choose to say:“It’s probably just a virus. If he develops a rash, headache, vomiting, dislike of bright lights or becomes drowsy or floppy then it could be something nasty like meningitis so make sure you take him to A&E. But he seems fine to me—I am sure that over the next few days he will get better with just the paracetamol.”

Avoid using negatives which the listener has difficulty in processing. So, rather than saying, “There is nothing serious”(the patienthears and processes the word “serious”), say something like, “The findings are normal” (the patient hears and processes the word “normal”. Note how this also utilisesthe use of the law of Immediacy).

Used together, this is a powerful tool in reducing unnecessary fear and anxiety. And also helps lighten the load of the busy physician.

– Dr Khalid Khan


Increasing Functionality by Integrating CAM into Medical NLP

For decades, orthodox health care and ‘complementary’ medicine have largely treated each other with suspicion and disdain. And yet, hundreds of thousands, if not millions, of people worldwide can attest to the success of each approach.

Many critics of CAM claim it puts patients at risk if they don’t seek ‘proper’ treatment. However, many patients report turning to alternative methods as a last, not a first, resort when they have failed to receive relief from more orthodox approaches.

Personalised care, concerned practitioners, a greater emphasis on health and wellbeing rather than deficit and disease, are among the many reasons given for the shift. Furthermore, allopathic medicine’s growing reliance on surgery and drugs whose ethics and efficacy are under growing scrutiny increases many patients’ disquiet.

Another significant reason for seeking consultation with a complementary therapist is Western medicine’s comparatively poor record in treating the complex, chronic, multi-factorial problems now threatening to overwhelm physicians in both primary and secondary care. Between 25 and 50 percent of the problems for which patients now seek help have no evident pathological cause. [i]

On the other hand, despite the passion and commitment of its supporters, much CAM suffers greatly from a lack of acceptable evidence, a cohesive approach and the ability to demonstrate improved clinical outcomes. However, thousands of patients attest to the effectiveness of a number of its disparate approaches.

One of the missions of The Society of Medical NLPTM and its counterpart Strategic Health Coaching is to bridge the gap between the two approaches. The field was developed as a means of organising the many disparate approaches, to review and refine what worked and to provide a clinically proven format that could be introduced seamlessly into other healthcare systems, regardless of their disciplines and domains.

An initial informal audit of more than 600 particularly effective physicians and patients who showed unusual ability to recover from sometimes life-threatening conditions, revealed a single, surprising, underlying factor that positively influenced outcomes.

This, and numerous subsequent studies, as well as a growing body of clinical experience, showed clearly that communication reaches beyond simply transmitting information from one person to the next. How people communicate—verbally and nonverbally, consciously and unconsciously—can  impact the listener’s physical and psychological health and well-being, and directly affect the clinical outcome for better or worse.[ii], [iii], [iv]

So powerful is this effect that the systematic and experienced speaker may beresponsible for as much as 75% of a successful outcome …regardless of the treatment applied.[v], [vi], [vii]

If our goal is to restore functionality to as many patients and clients as possible, then we cannot ignore these facts. And both allopathic and alternative medical practitioners need to recognise that a truly integrated approach is not only possible, but absolutely necessary.

  • Garner Thomson

[i]Olde Hartman TC, Lucassen PL, van de Lisdonk EH et al (2004) Chronic functional somatic symptoms: a single syndrome? British Journal of General Practice 54:922-7

[ii]Thomas KB (1987) General practice consultations: is there any point in being positive? British Medical Journal 294: 1200–2.

[iii]Benedetti F, Amanzio M, Vighetti S, Asteggiano G (2006) The bio-chemical and neuroendocrine bases of the hyperalgesic nocebo effect. Journal of Neuroscience 26: 12014–22.

[iv]Krupnick JL et al (1996). The role of the therapeutic alliance in psychotherapy pharmacotherapy outcome: findings in the National Institute of Mental Health Treatment of Depression Col- laborative Research Project. Journal of Consulting and Clinical Psychology 64: 532–9.

[v]Kirsch I, Saperstein G (1998) Listening to Prozac but hearing placebo: a meta-analysis of antidepressant medication. Prevention and Treatment (online journal): htpp://content.apa. org/journals/pre/1/1/2

[vi]Dixon M, Sweeney K (2000) The Human Effect in Medicine .Oxfordshire: Radcliffe Medical Press; Horvath AO (1995) The therapeutic relationship. In Session 1, 7–17

[vii]Lambert, Michael J.; Barley, Dean E. The therapeutic relationship and psychotherapy outcome. Psychotherapy: Theory, Research, Practice, Training, Vol 38(4), Win 2001, 357-361


Why we need to be more aware of the Placebo’s ‘Dark Twin’

The placebo, and its impact on healing and health, has been known for thousands of years. But, only recently has the scientific community given its dark twin, the nocebo, any attention.

Even though the nocebo is more usually an inert substance that triggers adverse responses in the subject, communication at all levels, including the non-verbal, can negatively impact the listener. Even reading about diseases, or watching TV documentaries,can trigger adverse responses, new research has revealed. Doctors and pharmacists are well aware of the negative effect on patients of the list of possible side-effects usually included in the package of prescription drugs.

Dr Michael Witthöft of Johannes Gutenberg University Mainz (JGU), recently completed an important new study in what has been dubbed the “Wi-fi Syndrome” at London’s King’s College.

“The mere anticipation of possible injury may actually trigger pain or disorders. This is the opposite of the analgesic effects we know can be associated with exposure to placebos”, he says.

Curious about reports of an increase in “electromagnetic sensitivity”, Dr Witthöft and his colleagues showed news reports about the purported health risks of wi-fi signals to two groups of volunteers. A second, control group was shown a documentary on mobilephone security that included no reference to electromagnetic “pollution”. Then, each participant in turn was exposed to dummy “amplified wi-fi signals” and their responses were monitored.

Unlike the control group, more than half the participants who had viewed the report on the dangers of electromagnetic exposure reported experiencing characteristic symptoms, including agitation and anxiety, loss of concentration or tingling in their fingers, arms, legs, and feet.

Two participants quit the study because they were afraid to expose themselves to further “radiation”.

The impact of language has long been suspected by the more observant practitioners, though only recently better understood.Interestingly, most health professionals we meet regard themselves as “good communicators”. However, asked whether they see themselves as “effective communicators”, they are less sure.

The true this, if we leave communication to chance,we risk harming the patient or client as much as we want to help him or her.

Finnish linguist and communications expert Osmo Wiio has formulated several humorous, but nevertheless seriously intentioned, “laws of communication” to illustrate the pitfalls of careless talk.

For example:

  • Communication usually fails, except by accident 
  • The more important the situation is, the more probably you forget an essential thing that you remembered a moment ago, and 
  • If a message can be interpreted in several ways, it will be interpreted in a manner that maximises the damage.

More soberly, Sigmund Freud said, “Wordswere originally magic, and to this day words have retained much of their ancient magical power”.  He also commented, “By words one person can make another blissfully happy or drive him to despair”.

Two issues arise out of all this: the pressing need for more research into the effect of electromagnetic emissions on living beings, and the impact of communication—all forms of communication—on the health and well-being of both speaker and listener. The second necessity is at least as important as the first.

-© 2018 Garner Thomson