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Habits of Language Pt 2.

Humphrey James


Under The Skin: Health Beliefs


As a medical student I recall sitting through tutorials about 'health beliefs' and other topics with similarly bland titles like 'communication skills' and, along with my classmates, nodding politely while deep down wanting to get to the real medicine; the anatomy, the physiology, the pharmacology etc. Most of us wanted to be surgeons or some speciality in any case and not have to worry too much about why, for example, people smoked heavily and believed themselves to be invulnerable because they had an aunt who lived to a hundred even though she smoked like a chimney. I myself wanted to concentrate on the science because my background had been in the humanities and arts and I found the idea of hard facts very appealing, in contrast to the rather vague, ever shifting landscapes of human emotions and beliefs I had been immersed in. Yet when I became a doctor, eventually clocking up hundreds and then thousands of patient encounters I began to appreciate more the importance of 'soft medicine', on the human element; not least because those vague, unscientific beliefs would return time and time again to haunt me, mocking my hard-won scientific knowledge.


Health beliefs crop up time and again. Not just the obvious ones like the deluded smoker with the invulnerable aunt, but in the raft of problems that afflict almost all of us: the brain fogs, the bad backs, the aching joints, the rebellious guts, the gnawing fatigue, the ennui, the inability to focus, the anxiety, the low self esteem and so on. Regardless of whether these are physical or mental afflictions, we give them meaning and this meaning springs from our beliefs. These could be beliefs about what we're capable of, what we're afraid of, what we think might be happening, of who we are, and so forth. And so I might experience the sensation of pain, say in my back. If I have a robust self-belief and I go to the gym regularly I might shrug this off as muscle soreness, a good sign that shows I am working hard. In other circumstances I might attribute this pain to some sinister cause, evidence that I am getting old etc. My belief will affect my interpretation and response.


Why do we create these beliefs in the first place? It is likely that much of the time we fall back on belief as a kind of mental shortcut, a way of trying to make sense of complex and dynamic reality. Our bodies are the perfect example of such a 'complex and dynamic reality'. We cannot see what is going on inside our bodies or brains and, even if we could, we would struggle to understand it. The human organism is far too complicated to be understood in everyday language and the brain is, as far as we know, the most complex thing in the universe, so it is not surprising we generate a whole set of beliefs about it. However it is worth bearing in mind that these beliefs are always going to be gross simplifications.


Another question is what do we base our beliefs on? Are they the result of many years of study and experience, a synthesis of vast quantities of data leading to water-tight robust systems of thought? Or do we base them on what we were told by grown ups and our peers, or on particularly memorable or emotionally charged experiences we've had? Or do we believe something because it was stated to us in vivid or emotive language, or conjured up a striking image (like hell or paradise)? One of the problems with beliefs about health or the world in general is that they are often formed when we are young and impressionable, when we are the least equipped to process them in a useful way and measure them against experience, yet we still subconsciously consult these beliefs, like a defunct map.


A completely honest interrogation would probably reveal that a lot of my beliefs are not as grounded in evidence as I would like to think. But rarely if ever are we encouraged to question ourselves in this way - quite the opposite in fact, in our age of social and mainstream media echo-chambers. This is made all the more challenging by the fact that our beliefs remain 'hidden in plain sight': we are interpreting our experience via our belief systems all the time, yet are rarely aware that we are doing so; in much the same way that we are rarely aware we are 'using' language to string our thoughts together. However one way in which our beliefs do reveal themselves is through the language we use, and this gives us the opportunity to hold them up to the light.

For instance I am at the age now where me and my friends often talk about 'growing old'. Any ache pain or life problem is contextualised by this baleful phrase. But in what sense am I actually growing or getting old? In a strictly physical sense, of course I'm growing old. Everything is, even a newborn baby. But we could challenge this belief by saying that 'growing old' is a bit of a non-sequitur. Growing things are by definition not really 'ageing'. No matter how decrepit one may feel, the cells are still regenerating, the tissues still healing and so on. It is just that, gradually the recovery and regeneration phase takes a little longer. Most of what we call ageing - the loss of muscle mass for instance - is really de-conditioning. 'Too old for this' is a great excuse, and one I have employed on many occasions, but it really is just a statement about my state of mind, not about my body.


This may sound like word play, but actually these beliefs, and the language we use to encode them, can have a significant impact on our well-being. Take the example of 'wear and tear' often used to describe the condition of osteoarthritis. It's a breezy phrase, but conjures an inaccurate image of bones eroding over time, somewhat like rusting supports on a seaside pier. But this isn't how bones work. They are continually being remodelled, in a process involving not only the skeleton but the muscles, kidneys, skin, gut and brain. Happily this phrase is falling out of practice and doctors are now encouraged to use the phrase 'flare and repair' which is not only a far more accurate description of the physiological processes involved, namely inflammation and re-modelling of the bone, but is also more 'optimistic'. Then there is the phrase 'crumbling spine' used to describe a thinning of the density of the vertebral bones. True, this can make the risk of compression fractures more likely, but to describe them as crumbling is an unhelpfully dramatic flourish. Spines do not crumble like old buildings or rotten logs. Even thin bones are surprisingly strong. But the word-image 'crumbling' promotes fear of this happening, affecting posture, making one afraid of lifting or activity, etc. which is unfortunate as increasing stress on the bones is the best way of strengthening them. 'Slipped disc' is no better; The discs between the vertebral bones do not 'slip out' like a wet bar of soap (leading to instant paralysis, as is often feared). Yes, they can 'herniate' out and irritate the nerves, but do eventually reabsorb, though it is often a long recovery. Moreover, studies have found that evidence of herniated discs do not necessarily correspond to symptoms. In other words you can have back pain with or without herniated discs, and herniated discs with or without back pain. Back pain has many causes, but unfortunately once that 'slipped disc' is uncovered, say by an MRI scan, the genie is out of the bottle.


These examples demonstrate the importance of choosing our words carefully as they have a considerable impact on shaping belief. They also highlight a way in which beliefs are often at odds with the physiology of the body. This can lead to a 'guarding' response as we seek to reduce the threat of pain or injury by avoiding certain stresses. So with pain we might try to avoid putting stress on our backs or knees, and reduce movement or load bearing activity. If we are fatigued we might avoid activity in the belief that we need rest. If we believe our body is being filled with toxins we might seek out cleanses or detoxes in an attempt to keep ourselves 'pure'. These beliefs are based on understandable, even rational assumptions about cause and effect, yet are still simplifications and misinterpret how the body actually works. The body is a dynamic system and requires a degree of stress to stay healthy. The musculoskeletal system will respond to stresses placed on it, bones will become stronger with loads placed on them, not weaker; our internal energy 'thermostat' can be reset to a higher threshold with increased activity, rather than less activity; and the body's detoxification mechanisms require a certain influx of toxins to stay strong. It goes without saying that the stress has to be appropriate, the point is to be mindful that our 'body beliefs' could well be misleading us.


There are, of course, occasions when someone feels that 'something is wrong' and can't define what it is, but their intuition turns out to be nevertheless accurate and the subsequent tests uncover a rare but serious issue. The lesson here is that if a person has a belief it is the job of the health professionals to check that belief, to literally test the hypothesis with the relevant investigations. Problems arise when that belief has been tested and (fortunately) nothing dangerous or negative has been found, but the belief still persists. This holds true for any belief, not only about our bodies, but also about our minds, who we are, how the world is etc. We can be very attached to our beliefs, which is understandable as they are closely attached to our identity, but beliefs are essentially hypotheses, and what do we do with them once it has been found that they are not supported by reality. In other words, how do we deal with the issue of 'evidence-resistant beliefs'?


One way of testing our beliefs is to break them down into their component statements. These can be statements of fact, which can at least be verified and measured in some way, and statements of value which cannot, and are therefore liable to lead us down mental rabbit holes. 'I am overweight', 'I drink too much', 'I am addicted to this or that' are arguably statements of fact. We can measure our weight or alcohol intake for instance. However these are often accompanied by statements of value, like '...therefore I am ugly' or '...because I am weak'. Value statements like these are emotionally very persuasive, but they have no basis in fact, they are not true in any meaningful sense. Moral weakness or strength, ugliness, beauty etc. are all subjective, taking on different meanings at different times in different contexts. They can't be measured because they don't really exist in a material sense and as such nothing can really be 'done' with them. And yet it is often the 'value' component of the health belief which gives it power, even though it is the least useful.


These types of value statements can be cunningly well hidden. Another example of common but misleading 'health beliefs' are statements about willpower. Specifically we attribute poor, or less-than-ideal health, to a 'lack of willpower'. But here again we see that the belief is essentially a value statement, referring to some quality - 'willpower' - which has no measurable property and is little more than an evocative word. To say 'I am overweight / I can't stop doing x or y because I have no willpower' may seem, on the surface to be valid. The issue here is that willpower implies motivation because without motivation there is no willpower. You have to be motivated to lift up a weight at the gym (even if it's negative motivation like someone shouting at you), otherwise no amount of willpower will make you do it. So are we not really just talking about motivation? And to say 'I have no willpower' implies 'I have no motivation', yet experience tells us that in almost all cases there certainly is motivation...to lose weight for example. 'Willpower' is really only a superfluous concept, we might as well say 'I have no zap-zam!' It would be more useful to explore motivation, which is easier to assess, and which is something which can be developed with practice and positive feedback. (It is also worth noting that 'willpower' is a notoriously 'weak force' when attempts have been made to measure it. Research has shown that success in any given venture is down to other factors such as time, resources, support and luck rather than a mythical quality of 'will'. It is more realistic to think in terms of planning and support in any given project, be it health related or otherwise.)


I am aware that we have only really been exploring the negative side of health beliefs. Of course there are also positive health beliefs, like 'I am in great shape', 'I am strong', 'I can do this' and so on. Should we also deconstruct these to find their weaknesses? Well, we could, but I would say that the measure of any belief - no matter how valid - is how well it serves us. Positive health beliefs tend to serve us well and are worth holding on to, whereas there are other beliefs which limit and isolate us and erode our confidence, and it is these latter which are worth breaking down.


Reality - the reality of our bodies, our minds, the world - will always be far more complex than our beliefs. Our beliefs will always be wrong in some, often even fundamental, sense. The best we can say is that we don't know for sure about anything, and to keep what Zen masters would call 'Don't Know Mind'; a curiosity and mental flexibility about the world and our beliefs. But right now I need to get up and walk around a bit. My back is killing me.

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About The Writer

HC James is from London and worked as a teacher before switching careers to medicine. He currently works as a doctor in a south London Emergency Department and in his spare time visits family in California.   

 

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