Application of the Ayurvedic Model of Human Occupation – A case study.

1. Introduction: As a member of the British Association of Occupational Therapists I refer to the Code of Ethics and Professional Conduct [1] and Core Standards [2] specified by the College of Occupational Therapists. I also refer to National Service Frameworks[3] produced by the Department of Health and guidelines produced by the National Institute for Health and Clinical Excellence[4]. Working within the National Health Service I rarely feel empowered to follow these standards or guidelines. This mismatch between professional ideals and working reality seems to be a never-ending source of conflict and emotional turmoil. To manage this conflict I refer to Hindu/Buddhist scriptures on the practice of yoga. Some essence of these has been summarised in a journal article titled ‘The Ayurvedic Model of Human Occupation’[5] in the Asian Journal of Occupational Therapy. This blog entry describes how I apply these scriptures to my working life, to manage my own well-being (that is threatened five days a week). It may make little sense to anybody that does not practise yoga. I would therefore encourage anybody that is interested to refer to the journal article.

The National Health Service is a chronically diseased organisation characterised by employee dissatisfaction and apathy[6]. Standards of care are compromised because employees do not believe they are achievable and therefore make insignificant efforts to meet them. This defeatist culture permeates every stratum of the National Health Service from clinical to managerial levels. From previous experience of National Health Service management I know that (at least in some hospitals) managers expend more effort on keeping up (false) appearances than actual service improvement[7], because they do not believe government-set targets are actually achievable. The result of this failed management culture is that experienced clinical staff are jaded and do not believe things will ever change for the better[8, 9]. Examples of this I have recently encountered are client-centred practice (or lack thereof) and documentation standards. My experience of documentation standards is that nobody even tries to follow them. I was even told by a senior physiotherapist that these standards cannot realistically be achieved and are just something to aspire to (but not actually meet). A senior occupational therapist said to me “you have to realise this is an acute setting”.

How can a basic grade occupational therapist survive in this environment? Thinking purely in material terms it would be sensible to tow-the line to advance my own career. Compromising standards in health care is like using performance-enhancing drugs in athletics; because everybody else is doing it, you have to cheat just to stay in the game. If I do not compromise my standards I will put my career at risk because on paper (statistically) it will appear that I am not working as efficiently as everybody else, as quality is time-consuming. It can take 10 minutes for example, just to make head or tail of a messy set of medical notes, to enable me to number the pages I write on. If I do disregard professional standards I will be more likely to fit seamlessly into the teams I work with. As I further my career I might conveniently forget the standards altogether and become a yet another diseased cell of the health service. Should I do this?

2. Dharma: My actions are based upon what I feel (not think) to be the right and noble path for me as an individual. This is termed Dharma. Each person’s Dharma is dynamic and unique. At this particular moment in time it is my Dharma to write this blog. I know this, because as I type, I am in a state of flow. How does this apply to the paradox I face at work? Do I believe the professional standards are right, or the professionals that choose to disregard them as unrealistic? For me, this is a simple decision. The attitude of the professionals that surround me is responsible for the current state of the National Health Service; it is a vital component of the disease. Once on a ward for example, I saw the abbreviation ‘NSTEMI’ in a patient’s notes. It was not written in full anywhere in the notes. Nobody on the ward at the time (including the charge nurse) could tell me what it meant. Why had nobody questioned this before? I suspect it is because people have come to accept not being able to read doctors’ handwriting or understand medical notes as a norm. When I worked in a pseudo-rehabilitation hospital the notes we received from acute hospitals were never in chronological (if any) order. It would rarely take less than half an hour to forty minutes for a therapist sifting through the notes to be able to figure out exactly what had happened to a patient. Does this type of miscommunication increase clinical risk? Of course it does. What would happen if, at the same time, on the same day, everybody chose to stick to their professional standards and stuck fearlessly and relentlessly to their guns? I suspect through-put would slow down, but standards of care would remarkably improve, and as everybody would be singing off the same song sheet the government would have to put more money into the health service if it wanted more output (sacking everybody would not be a feasible option).

3. Threats: It is easy to find people moaning about the health service, but as a junior member of staff, if I choose to fight for quality will there be anybody on my flanks as I run onto the battlefield? Unlikely; it is far more likely the complainers will be digging holes to cower in and avoid the fall-out. There are sources of help, but I am largely on my own and it seems that no good outcome is possible. This bleak picture was metaphorically described in the Bhagavad-gita.

Arjuna said: "I feel the limbs of my body quivering and my mouth drying up. My whole body is trembling, my hair is standing on end, my bow Gandiva is slipping from my hand, and my skin is burning. I am now unable to stand here any longer. I am forgetting myself, and my mind is reeling. I see only causes of misfortune.....Now I am confused about my duty and have lost all composure because of miserly weakness. In this condition I am asking you to tell me for certain what is best for me. Now I am your disciple, and a soul surrendered unto you. Please instruct me. I can find no means to drive away this grief which is drying up my senses. I will not be able to dispel it even if I win a prosperous, unrivaled kingdom on earth with sovereignty like the demigods in heaven." Bhagavad Gita (1:29-2:8)

3.1. Sources of fear: There are many reasons to cower and tow the line. One may feel unable to speak ones mind for fear of alienating himself or herself from his or her team, or due to a low position of power in the management hierarchy. One may fear for ones job security and as a result fear ones survivability in the material world. Applying the Tantric frame of reference[10] we can see that such fears can cause imbalances of bodily, egotistical and compassionate consciousness and discourage one from acting altruistically out of universal consciousness, or authentically by following intuition. These fears can metaphorically be termed demons.

4. Repercussions of deviating from Dharma: Superficially avoiding ones demons and towing the line may seem like a good idea. The problem with this is that while hidden from the conscious mind, demons do not go away; they become internalised. During a lifetime motivated by fear one is likely to internalise masses of demons. Hidden inside, they reap havoc with ones health on a cellular level. As well has causing deep-seated psychological problems, there is ample evidence that suppressed intra-personal conflicts predispose humans to a plethora of diseases from gum disease[11] and other inflammatory conditions[12], to cancer[13]. The deterioration in health for most people is so gradual, that it is attributed to the aging process. Have you ever wondered why some people age so much better than others[14]? There is a huge occupational influence on the aging process. Stress for example, is known to impair the DNA repair[13]. Towing the line against ones better judgement is therefore spiritual suicide!

5. Coping methods: Having ruled out humouring my demons, only one choice remains; Dharma. My intuition is telling me to struggle for what I believe is right. As I am facing what seem to be impossible odds I am at serious risk of burn out. How can I manage this?

5.1. Balancing the three humours (vata, pitta, kapha): The three humours are subtle energies that permeate my body[15]. I must keep them in balance to maintain good mental and physical health. I can estimate their level of balance from observing my moods, taking my pulse and paying attention to some of my other physical characteristics[16]. My occupational balance, environment and the flavours of the food I eat influence the three humours. At the moment I know I need more rest and would benefit from working part-time instead of full-time. As a rotational basic grade this is impractical, so I am compensating for my lack of rest with meditation and breathing exercises. I am also choosing very carefully which battles I fight, as if I tried to fight them all I would be overwhelmed in a matter of days (if not hours).

5.2. Balancing the three natures (gunas): "All men are forced to act helplessly according to the impulses born of the modes of material nature; therefore no one can refrain from doing something, not even for a moment" (Bhagavad Gita 3:5). I am a very passionate person. This trait has driven improbable success in my past, but poses a serious risk to my health. My excessive passion previously drove my career, but now motivates me to take on excessive altruistic work. The traditional term for this type of work is karma yoga. Too much of it is a sure path to burn out. To survive I need to balance my passion with wisdom (essence) and inertia. Management of these three natures depends on occupational balance and diet. To reduce my passion I need to avoid excessive emotive stimulation. In health care environments this factor is probably beyond my control. I can also influence this balance with the flavours of the foods I eat. To reduce my passion I need to avoid stimulant foods such as meat, garlic and spices.

5.3. Detachment: "Never consider yourself the cause of the result of your actions, and never be attached to not doing your duty" (Bhagavad Gita 2:47). When fighting improbable odds it is important to not care about the results of my actions. This does not translate into not caring about my work. To maintain my own well-being according to the Tantric frame of reference[10] I must develop compassion for all beings and therefore be passionate about following Dharma. This basically means I believe in following professional standards and acting in my patients’ best interests with no regard for my career or job security. I can do this because I am not attached to my career or wealth. I am not particularly bothered about whether the National Health Service improves or not either, as long as I am doing my bit to the best of my ability. If I did care about whether my actions would causally lead to service improvements, it is likely I would rapidly become de-motivated and give up, as to be honest, my actions seem mostly fruitless. My well-being depends on good actions, but not on their results.

6. Coping resources: Detachment is fine in theory but can be extremely difficult to practise. Dharma can be very difficult to see in times of trouble, or when intuition is weak. Yoga provides the coping resources to deal with these problems.

6.1. Raja yoga: Raja yoga is a system of practices to increase intuition. Components of Raja yoga I use include postures, breathing exercises[17] and meditation. All three of these are good for exorcising past demons. The intuition they afford me helps me to feel what my Dharma is at any time. During a four-week intensive yoga teachers’ training course I attended in Canada problems I had buried deep in my subconscious mind emerged to haunt me during the second and third weeks. I was forced to deal with them, and this was the basis of a psychological detoxification that enabled me to detach from my material ambitions and career. I was previously as physiotherapist with a successful military career. Attachment to these things would have prevented me from becoming an occupational therapist (my Dharma) and may have compelled me to act in unethical ways. I currently practice breathing exercises and meditation every day, and postures once or twice a week. It is Raja yoga that empowers me to be fearless about ethical issues at work.

The relaxation facilitated by these techniques makes them great tools for occupational balance management. I occasionally practise advanced meditations that facilitate my awareness of bliss. Regular exposure to this bliss enables me to view the world as a beautiful (rather than hostile) place and alters my consciousness. In this altered state of consciousness, I find it difficult not to love people (even my most difficult patients and colleagues). The beauty of the world is a coping resource, whenever I take the time to look at it.

6.2. Karma yoga: "Perform your prescribed duty, for action is better than inaction. A man cannot even maintain his physical body without work"(Bhagavad Gita 3:8). My clinical work and the academic work I undertake to improve health service delivery are my karma yoga. These altruistic undertakings give my life meaning, and that meaning is a great coping resource in the face of adversity.

6.3. Bhakti yoga: I have a close personal relationship with God. One may argue that there is no scientific evidence for God, but the effects of faith are more relevant therapeutically than its actual validity[18]. My faith in God assures me that I will be looked after as long as I follow Dharma. This is a huge coping resource.

6.4. Jnana yoga: When all else fails it is worth remembering that nothing I perceive in the material world is permanent. If I am having a bad day, all I need do is weather the storm. Soon it will be over.

6.5. Balancing the humors: If a time ever arises when the yoga is not quite cutting it, I could always just visit the Bento Café. Yes, life is good :0)

7. Conclusion: This case study shows how I use yoga to regulate my own occupations for the maintenance of well-being. Pre-reading or previous experience of yoga is necessary for full understanding of this case-study, as terms have not been explained in detail. If you would like to try this model for yourself, please consider formal training in yoga. To network with other therapists interested in yoga you may like to visit this link: http://www.facebook.com/group.php?gid=2352527880

V

8. References:
1. College of Occupational Therapists (2005) College of Occupational Therapists Code of Ethics and Professional Conduct, London: College of Occupational Therapists
2. College of Occupational Therapists (2007) Professional Standards for Occupational Therapy Practice, London, College of Occupational Therapists
3. Department of Health (Various) http://www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/DH_4...
4. National Institute for Health and Clinical Excellence (various) http://www.nice.org.uk/
5. Mailoo V.J. (2007) The Ayurvedic Model of Human Occupation. Asian Journal of Occupational Therapy 6(1): 1-13 http://www.jstage.jst.go.jp/article/asiajot/6/1/1/_pdf
6. Canty M. (undated) The NHS Is Sucking My Soul Dry http://www.facebook.com/group.php?gid=2217865751
7. Revill J. (2003). Hospitals faking cuts in casualty wait times. The Observer Sunday 11th May 2003: Front page http://www.observer.co.uk/nhs/story/0,1480,953395,00.html
8. Thornbury Nursing Services.(2002) Public service workers feel stressed and under valued. Monday 14 October 16:36 Available from URL: http://www.thornbury-nursing-services.com/news.asp?page=4
9. Demetriou D. (2003) Professor claims St. Georges Tooting bent rules to hide op cancellations. Hospital accused of fiddling waiting lists. The Evening Standard Wednesday 30 April p 6
10. Mailoo V., Wickham J., Bannigan K. (2006) OT and the tantric frame of reference. Therapy Weekly 33(3):8-10
11. Lundy F.T., Linden G.J. (2004) Neuropeptides and neurogenic mechanisms in oral and periodontal inflammation Crit Rev Oral Biol Med 15(2):82-98
12. Mailoo V.J. (2006) Psychoneuroimmunology and occupational therapy for inflammatory disorders. International Journal of Therapy and Rehabilitation 13(11): 503-510
13. Mailoo V.J., Williams C.J. Psychoneuroimmunology: a theoretical basis for occupational therapy in oncology? International Journal of Therapy & Rehabilitation 2004 Jan; 11(1):7-12
14. Rowe J.W., Kahn R.L. (1987) Human aging: usual and successful, Science, 237(4811): 143-149
15. Mailoo V.J. (2005) Yoga: an ancient occupational therapy? British Journal of Occupational Therapy, 68(12): 574-577
16. Lad V. (1984). Ayurveda: The science of self-healing. A Practical Guide. Wilmot: Lotus Press
17. Mailoo V.J. (2006) Pranayama: potential tools to enhance occupational performance. Asian Journal of Occupational Therapy 5:1-10 http://www.jstage.jst.go.jp/article/asiajot/5/1/1/_pdf
18. Yates W.R. (2004) The Link Between Religion and Health: Psychoneuroimmunology and the Faith Factor (book review) Am J Psychiatry 161(3): 586