The variability of people and the complexity of factors that cause a person to seek help with fatness means that there can be no standard set of rules. You have to make a fresh ethical decision with each new request for help, often even within the handling of one client. Frequently, these decisions need to be made on-the-spot, without the opportunity to seek advice.

It is important to have thought through a general framework for ethical decision-making in advance, that will assist with making on-the-spot judgements and decisions.

There are four domains which are important to consider:

• yourself

• the client

• the treatment resources available

• the social context.

You must also consider the interplay of these four domains.

Yourself. Our past experiences and what we have made of them affect our reactions to people and situations. We see each new thing we encounter through a ‘filter’ of beliefs and expectations that helps us make sense of them. This in turn influences how we respond.

You need to know yourself well, especially your motives, attitudes and feelings regarding obesity, overeating, exercise and health. Failure to understand these things increases the risk that you will act unethically by unintentionally imposing your personal values on your clients.

What do you think is the most important outcome goal for this person? Why? In your work, you are pursuing your own goals as well as your clients’. This means that they hold some power over your job satisfaction—you cannot succeed without their active cooperation. This motivates you to shape their goals in line with your own objectives rather than being there simply for your client. If you are clearly aware of your own choice of goals in a particular case, you can more easily see any conflict between your own goals and those of your client.

What do you believe has made this client obese? How do you feel about that? Your theory about why a particular client is obese will play a big part in the actions you take. In reality, different

people come to be obese along different paths, but the feelings that arise in you because of your theory are very important. For example, you might decide that a particular client is obese because during childhood she learned to select sweet and fatty foods in her diet, following her mother’s choices. This theory may give you reelings that the client is ‘not to blame’ and that her mother was at fault. Indeed, you may have strong feelings about poor childhood nutrition and regard the mother as having been a poor parent or even somewhat abusive of the child for making her obese. This might lead to you feeling sorry for the client and trying to be the ‘good parent’ that her mother was not.

On the other hand, you might think that another client who has had good nutritional advice for years has remained obese because he has not put the advice into practice. This could give you feelings of hopelessness about working with him or even anger that he has wasted other busy helpers’ time and is going to waste yours too.

Do you believe it would be possible to have the things that are important to you personally if you were as obese as this client? Usually, we think that the things that we personally value are desirable to others as well. If you believe that your client needs to lose fat in order to have a chance of getting something that you value in your life, you are less likely to consider or support alternative goals and means of achieving these. For example, the client might be concerned that she needs to lose fat in order to get a partner. If you believe that you would feel this way if you were equally obese, it may be difficult for you to work constructively with her feelings about personal attractiveness and relationships.

What skills do you have with which to respond to this client’s needs? It is generally regarded as unethical to promise what one does not have the ability to provide. It is also your ethical responsibility to respond appropriately to a particular client’s needs. It is possible, perhaps even quite common, for the client to have come to the wrong person for help—they are not always well-informed about their needs and the services that cater to these needs.

This question helps you to think about whether the client has realistic expectations of what you can do. The most ethical response to a particular client may be to decline her request for help and discuss more appropriate alternatives.

*230\186\4*

Typical big eaters are:

• teenagers and young adults,

• people working as labourers,

• people doing regular strenuous exercise.

Big eaters need to eat:

• at least 8 slices of bread or the equivalent (crackers, rolls, muffins)

PLUS

• 3 pieces of fruit or the equivalent (juice, dried fruit) PLUS

• at least 2 cups of high carbohydrate vegetables (corn, legumes, potato, sweet potato)

PLUS

• at least 2 cups of cereal or grain food (breakfast cereal or cooked rice, or pasta or other grain)

PLUS

• 2 cups of low-fat milk or the equivalent (yoghurt, ice cream)

This provides 375 grams of carbohydrate which is suitable for a 10 500 kilojoule (2500 Calorie) diet.

An athlete who is training hard would generally need to eat double this quantity of carbohydrate.

WHAT ABOUT THE DIFFERENT TYPES OF CARBOHYDRATE? Traditionally, carbohydrate has been classified in terms of its chemical structure. We now know from scientific research and clinical trials with real people that the whole concept of simple and complex carbohydrates does not tell us anything about how they will actually behave in the body. Until recently, it was widely believed that complex carbohydrates, or starches such as rice and potato, were slowly digested and absorbed and therefore caused only a small rise in blood sugar level. Simple sugars, on the other hand, were assumed to be digested and absorbed quickly, producing a large and rapid increase in blood sugar. These assumptions were wrong.

Forget about the words simple and complex carbohydrate. Think in terms of low G.I. and high G I. factor.

*20\33\4*

THE SELF-MANAGEMENT OF CHRONIC PAIN

This involves the understanding and practice of the various ideas which we have discussed. Remember that this is not difficult, but it requires a little time and a little perseverance. Remember that many patients whom I have told these things verbally have succeeded. The only difference with you is that I am telling you by writing it down instead of saying it in words; and actually by writing it down I am able to explain it much more fully.

We have spoken of six general principles in the self-management of pain. If you were with me in my consulting room, I would repeat them to you in order to impress them on your mind. So I shall do the same now.

1. Reduce your general level of anxiety by understanding the nature of pain, by facing and resolving conflicts which cause anxiety, and by using the relaxing mental exercises to reduce anxiety.

2. Guard against the reactions that make pain worse. Do not allow distress, guilt, or fear to take over.

3. Use the reactions that reduce pain. Deny it and distract yourself from it when you can. Relax deeply and practice autosuggestion. When you can, use dissociation.

4. Practise the relaxing mental exercises.

5. Increase your pain threshold by conditioning yourself with the exercises in discomfort and pain.

6. Learn to experience and accept pain in pure form, which does not hurt.

We have discussed the means of fulfilling each of these principles, and we have seen that each step in itself is not difficult, as one follows the other in ordered gradation.

I always warn my patients of three things: Do not expect too much too quickly. Expect a few ups and downs, good days and bad days in the process of mastering the self-management. Do not get cross with yourself if at first you cannot do just what I ask.

I could relate many examples of patients I have had who have been successful in learning how to control their pain.

A man with cancer of the prostate suffered severe pain from secondary growths in the bones of his pelvis. He learned to relax and control the pain reasonably well, so that the last weeks of his life were actually spent in a clear mind and relative comfort.

A woman in her sixties complained of continuous severe pain in the legs, the vagina, and the area of the bladder. An operation on her back had shown a cystic degeneration of the nerve roots. So there was no doubt about the organic origin of her pain.

At first she found it hard to accept the idea that a psychological approach could help pain of this nature. She kept saying, “But the nerves have this degeneration.” I asked her to stick some pins into my forearm. She was reluctant, but she eventually did so, and was obviously surprised that it did not seem to hurt me. I then had her relax, and I did the same to her. When she opened her eyes she was astounded to find a couple of pins well embedded in her skin. From then on she was most enthusiastic about the exercises. She lost all the pain in her legs, and most of it, but not all, in her vagina and bladder. She later stated that she had developed a real peace of mind, and she volunteered that she was sleeping better than she had for eight or nine years.

I well remember one of my first experiments in helping people with organically determined pain. A woman in her sixties suffered chronic pain in her back from a degenerative condition of her backbone. She said that she had to fly from Melbourne to London and back, and she was terrified of the pain from having to remain in one position in her seat for so long. This was before the advent of the jets.

I taught her to relax and wished her luck. A few weeks later she came in to thank me, saying that she had made the trip without discomfort.

Just a year ago I saw a retired doctor, aged seventy-six years, who had had an extremely painful condition of his foot for nine years. He kept describing it as feeling as if someone were screwing up his foot in a vice. One surgeon had cut the main nerve, another surgeon had dissected the little nerves that lead to the toes, and later the artery had been freed of its nerves. But nothing had any effect on the pain. Another psychiatrist had tried hypnosis, but this was also unsuccessful.

In spite of his age he learned to do the relaxing mental exercises, and soon found he could control the pain.

A few days ago I received a note from his wife saying that he had died, and thanking me for the relief he had had in this last year of his life.

*146\57\2*

The colour-signs in the iris, showing the deposition of pigments, are divided according to shape and colour. With regard to these conspicuous signs, there are three groups of pigments to be considered:

The endogenous pigments are important for iridology. To these endogenous pigments belong those of the haemoglobin group with the end-product haemosiderin (colour: red to brown), the melanin group (colour: brown to black), and lipofuscin, also referred to as the ‘wear and tear’ pigment (colour: light yellow to dark brown).

The melanin group of pigments have their origin in special dendron cells, melanocytes (also described as melanodendrocytes). These cells derive from the embryonic neural crest. The melanin originates in the melanocytes by means of complicated enzymatic processes. A first stage of melanin is the colourless amino-acid Tyrosine. This compound is transformed by the action of Tyrosinase through dihydroxyphenylalanine (DOPA) into melanin.

Melanin formation is also subject to hormone control. The pituitary gland secretes a melanocytotrophic hormone (MTH, also called melanocyte-stimulating hormone: MSH), which has a stimulating effect, while the adrenal hormones from the cortex and medulla appear to check the pigmentation process. From these different influences affecting the formation of pigment, it can be accepted that disturbances may give rise to a wide variation of manifestations within the total organism.

Melanin tends to migrate within the body. Because of its poor solubility as such, melanin is taken up by the cells of the reticuloendothelial system, the melanophores, by a process of phagocytosis, and conveyed to wherever it supposedly serves some purpose. Melanin is found in the vicinity of inflammatory processes, and also with skin conditions accompanied by inflammation. Pigment migration also arises in the vicinity of tumors and within many tumorous conditions, e.g., melanosarcoma. One is also reminded of ulcerations of the lower leg, where melanin deposits occur over large areas.

It should also be mentioned here that melanin is found within the body as a normal constituent of the hair, skin and the posterior surface of the iris. It accumulates in the skin as a protection from the ultraviolet rays of the sun, where the melanin protects the skin from the carcinogenic effects of these rays.

If melanin deposits are found on the anterior surface of the iris, then there is a positive indication of the existence of serious metabolic disturbances. Indeed, according to the accompanying signs in the iris, one may speak of a pre-cancerous condition of the corresponding organs or systems which can ultimately lead to a cancerous state.

The iron-containing pigment: haemosiderin (haemofuscin) is a reddish colour to begin with, and may then change towards dark brown (the colour change of a piece of rusting iron!). On the destruction of large quantities of red blood corpuscles, this pigment becomes deposited within the tissues of the body. It can also appear in the iris following internal or concealed haemorrhage. In my opinion it is not a sign for haemorrhagic tendencies, but only the sign of a large destruction of red blood corpuscles in which the iron is deposited in the tissues.

*37\78\2*

Both Dr Dalton’s researches, which have been going on since 1953, and the more recent studies carried out at St Thomas’ Hospital, London, show that some women who suffer from premenstrual tension have low levels of progesterone in their bodies during the last half of their menstrual cycles. In other words, at the very time of the month when you would expect the level to be high. Dr Dalton treats her patients by giving them extra progesterone during the last half of the month. This treatment often has a marked effect on the whole range of symptoms. It may reduce the bloat, lift depression, remove those alarming mood swings and also have an effect on the sort of epilepsy, hay fever, cystitis, asthma and migraines that are linked to an approaching period. If you want to know more about this treatment, I suggest you read Dr Dalton’s book, Once a Month, and you’ll see if it could be for you.

Unfortunately there are only two established clinics that have followed Dr Dalton’s lead and will prescribe pure progesterone. So if you want treatment at either of them, you will have to go on a waiting list, I’m afraid. One is at University College Hospital, London, and the other is in the Hallamshire Hospital, Sheffield. It will not be easy to find a GP who is willing and able to prescribe progesterone suppositories (trade name ‘Cyclogest’) either. There are some, but at the moment they are rather rare. The trouble is that unlike the contraceptive pills, which have been on the market for over twenty-five years, progesterone treatment is relatively new. An added difficulty is that pure progesterone can only be given as an injection or in the form of suppositories. Some women are so glad to receive some treatment that will stop their symptoms they don’t mind where the treatment has to be put. But others are put off by the idea of suppositories, and would much prefer a pill. Unfortunately there’s no way, at the moment, that progesterone can be made effective in pill form.

*82\177\2*

Some women lose all their energy before their periods are due. They wake up tired and have to get behind themselves and push if they are to start the day at all. Little jobs like making beds, wheeling the pram down the road or vacuuming a room leave them so exhausted that they have to sit down to recover. A shopping expedition in the lunch hour is a chore to be dreaded and often results in the most disastrous purchases—food that isn’t wanted or needed, clothes that don’t suit or fit. As one woman put it, ‘I feel as if I’ve lost my judgement.’

Obviously all the things I have said about avoiding difficulties apply here too. Don’t go shopping if you can help it. Wait until you’re in a better frame of mind. Let your husband or your colleagues do chores for you. At home, see how many jobs can be done sitting down—like washing up or preparing vegetables or ironing. And don’t iron anything that doesn’t really need it — shirts and blouses only need ironing where they show. It’s hard to lower your standards, especially if you’re houseproud, but try. You need the rest more than that immaculate shirt.

Take a rest whenever you can. Allow yourself to potter and don’t feel ashamed of it. Plenty of middle and upper class Victorian ladies lay around on their chaises longues during off days, and nobody thought any the worse of them. They called it ‘having the vapours’. This applied only to well-off women. The poor and the servants didn’t get the same sort of consideration at all. They just had to get on with it, as most of us do today.

*40\177\2*

Symptoms: Tilting or cocking head; looking out of corner of eye; squinting; crossed eyes; sensitivity to light; headaches; dislike of reading; school problems.

Home care: Have your child’s eyes examined regularly, and be aware of the signs that might suggest the child has a vision problem.

Precautions

-    A child s vision should be checked annually from the age of four or younger.

-     If your child holds books very close to his or her eyes when reading or cannot see the television screen from a distance, have the child’s eyes checked.

By age four or five, 5 to 10 percent of all children have a problem with vision. By the end of adolescence, the percentage has climbed to 30.

The usual vision problems that occur among children and adolescents are nearsightedness (myopia), lazy eye (amblopia ex anopsia), farsightedness (hyperopia), and astigmatism. Nearsightedness or the inability to see distant objects clearly, is hereditary. It is rarely present at birth but develops as the child grows. Lazy eye develops during the first six or seven years of life. Farsightedness (inability to see nearby objects clearly) and astigmatism (blurred vision at all distances) occur at an early age and don’t usually grow worse with time.

*242/84/5*

The best hope for a cure for people with diabetes who depend on insulin treatment is the replacement of the non-functioning pancreas cells with healthy ones. This could be done by Pancreas cell transplants. Pancreas transplantation has been carried out in a number of centers for many years, but unfortunately they have not been as successful as it would be hoped.

Most have failed soon after transplant has occurred. Most pancreas transplants are carried out in adults who also need a kidney transplant, and in some centers over 40% are still functioning by producing insulin a year or more after transplantation. There are however many problems associated with pancreas transplants. This is partly due to the fact that the pancreas is also an organ of digestion, and the digestive juices have destroyed the capacity of the pancreas to produce insulin. It is a difficult surgical procedure to transplant the pancreas and all the problems of organ rejection have to be overcome. There is also the problem of adequate supplies of pancreases. The body has only one pancreas, so you can’t donate your pancreas to a member of your family. Some centers are working on the possibility of transplanting part of the pancreas, as the human body does not require all of the pancreas to produce insulin.

*76/54/5*

The key to our management of stress lies in those moments when our brain runs quietly in a way that restores harmony of function. This occurs naturally in our moments of repose and day-dreaming, in moments of stillness as we ponder some aspect of nature, and in the quiet that comes to our mind in the togetherness of man and woman. We can also discipline our mind to produce the same effect in meditation.

There are quite different forms of meditation in which the brain functions in quite different ways. I have abundant evidence to show that the form of meditation which I am about to describe is much more effective than other forms in restoring the harmonious brain function that relieves stress.

In classical meditation as in yoga, in Zen Buddhist meditation, and in the meditation as practiced by the early Christian mystics, the thought processes of the mind are helped by will power concentrating on some object or spiritual concept. The mind is active, striving to attain and maintain this ideal. In the meditation that I would advise you to practice there is no striving, no activity of brain function, just quietness, a stillness of effortless tranquility.

This is not the tranquility of drowsy somnolence. The mind is clear but still. At first, until the meditator has learned the art of letting his mind run in this way, there will be moments of stillness, but these are soon interrupted by the intrusion of thoughts. Do not try to dispel the thoughts by actively driving them from the mind. Just let them be, and they will fizzle out, cease, and stillness will come again. Then thoughts will recur. And again, if they are let alone, stillness will supervene. And gradually the space between the thoughts, the stillness that we want, will become longer and longer.

At the start this process will come and go, very much like the natural rhythms that are all about us, night and day, the tides, our very heartbeat. There may be a tendency for the beginner to get cross with himself with the recurring thoughts. This, of course, brings the meditative process to a halt.

Another error, which may befall the beginner, is a tendency to examine the situation. ‘How am I going? Am I doing it properly?’ Of course, any enquiry of this nature involves activity of the mind, which is exactly what we are trying to avoid. At the start it is best just to let ourselves experience a sense of being. Just being. Not even being in the room. Not even being alive. Just being. This state of mental activity, or rather inactivity, is a step towards the real stillness of mind experienced in full meditation.

*86/98/5*

In stress there is an over-alertness of brain cells. They fire off more easily than they should to minor stimuli which in normal circumstances would go unheeded. The result of this situation is that our aggression is aroused easily, and we tend to react with aggressive behaviour in a way that is less than appropriate.

This basic neurological state of affairs is aggravated by the sense of frustration that stress brings. We don’t like being under stress. It means we have failed somewhere. We feel hostile about it. Hostile to ourselves and this is easily transferred to others in the form of aggression.

If we let fly our aggression, it means that the over-alert brain cells discharge, and there comes to us a period of relative tranquility. This is a common experience. We get angry. Blow off our aggression, and then quieting down. Some people get into this inferior way of coping with stress. They do not do it consciously. It is just something that happens. They feel tensed up with stress. Then with some trivial irritation they blow up, and their tension from their stress is relieved. With some people this becomes a habitual reaction and, of course destroys, not only the quality of their own life, but also that of those around them, particularly husband or wife, whichever the case may be.

In this respect it is worthwhile noting that different fashions appear in clinical psychology and psychiatry. For the last ten years or so there has been a foolish vogue of encouraging patients to learn to blow off their aggression rather than bottle it up. What should be done, of course, is to show the patient how to let his mind run smoothly so that his aggression does not build up.

*79/98/5*