Thoughts on Visiting the Cardiologist

by Siegfried Othmer | May 24th, 2006

Even a regular visit to a cardiologist is an occasion for a sobering appraisal of one’s lifestyle. It is Judgment Day of a sort, as one’s cumulative neglect of dietary prescriptions, exercise mandates, and stress management regimens come to be exposed in the language of the heart waveform pouring out on the chart paper while one labors on the treadmill. My cardiologist seems to be a kind man. I judge this from his touch, as he does not make eye contact. In his past life, he must have been a mole. We’ve only just met, but already he is “my” cardiologist. Once you are talking openly about your heart, the wall to intimacy has already been breached.

When it comes to cardiology we are in the inner sanctum of our medical edifice. This is what medicine does exceedingly well. We have a whole raft of remedies for what ails the heart system, and the whole enterprise is greased to provide these services efficiently and promptly. Cardiologists themselves must incline toward philosophy, in that they have to sit so close to the edge of life with many of their patients. They are at the same time masters of their myriad skills and yet bystanders to much of what transpires with their patients. Their mastery is more apparent to the outside observer; their inner reality may be closer to a sense of helplessness. I can be impressed with what they can see in an ultra-sound; but that same skill only appears mundane to anyone who has been reading ultrasound scans for twenty years. We sense their power; they are aware of their own boundaries.

So I was struck by the degree to which the conversation turned on matters of lifestyle. Diet and exercise were discussed seriously and in detail. A partnership was being established in which much of the burden of my life expectancy was my own. The power in the hands of the cardiologist was the very limited power to influence behavior. There’s only so much the body shop can do when all else fails. Cardiology hasn’t been there long, but it has adopted this posture apparently with a vengeance.

And therein lies the model also for what we do. Those factors that we can readily influence in the direction of health lie largely in the realm of functional medicine and in lifestyle factors. Or, put differently, our health future lies largely in the realm of voluntary controls, whether with regard to our own physiology or with respect to lifestyle.

The pictures on the cardiologist’s desk speak volumes about the long-term relationships he had established with his patients. If longevity in such relationships has value, as it most surely does, then shouldn’t that be even more the case when mental health and optimum functioning are involved? We have to move toward a model where our relationship with clients isn’t merely epochal, or merely problem-focused, but is the beginning of a long-term partnership in healthful living.

It also occurred to me in watching my cardiologist how comfortable he is within his specialty. That should not be too surprising for someone near the top of the medical pecking order. His serotonin levels are undoubtedly fine. But this also follows from being embedded in a network of complementary competences. He does not need to cover all of the bases. By contrast, we who are still in search of recognition for our own competences may feel the need to acquire lots of complementary ones.

It is not enough to understand biofeedback and neurofeedback as a discipline. One must have some degree of mastery of all of the professional interfaces we are likely to encounter, from neurology to psychiatry to psychology to education to rehabilitation. We are nomads in the field of health care. To function well we must have some understanding of seizures and migraines and panic and traumatic brain injury as well as of addiction and trauma and disorders of attachment, of cognitive function, of sleep disorders, of chronic pain, etc. Can this be a realistic undertaking? I think not. Let’s call this the Zelig Syndrome.

To build the field, we have to settle on one narrative, one essential paradigm, one explanatory principle that becomes the talisman of our professed competence. Our turf is the operational integrity of the neuronal networks that mediate the relationship of our psychological and physiological selves. This will turn out to be the very heart of mind-body medicine. It is quite enough that this domain defines our expertise. Nothing in the realm of either psychological functioning or of neurophysiological regulation can remain untouched by what we do. We defer to the prevailing mind/body dichotomy only for the purpose of demolishing it.

The target of our intervention is not any particular condition. It is regulation itself, i.e. the quality of our CNS self-regulatory capacity. This quality of functioning can be independently observed (i.e., independent of any clinical syndrome), and addressed as a distinct and separable entity. Resolution of any clinical findings will be seen as the secondary outcome of improved self-regulatory status. And what may initially start out as a modest initiative to find a niche within the healthcare field may in time turn out to redefine it.

I just ran across a piece that Joel Lubar had written for the BFE some years ago. He reflected on the fact that the mainstream view of ADHD has radically changed over the last few years: “Some…have gone so far as to say that [ADHD] is an outright example of a damaged brain. They have actually come around 180 degrees from what they believed ten years ago, when they said it was a behavioral disorder and a motivational disorder, to say now that is a structural, neurological, and neurochemical disorder.”

The image that comes up for me is of a creaky old weathervane at the top of a medieval church steeple, gradually twisting in the prevailing wind. On one occasion, the weathervane points in the behavioral direction, and on another it points to neurological substrates of dysfunction. It can only point in one direction at any one time, and it cannot, of course, ever point to itself, i.e. to the axis that connects these disparate compass directions of our mental universe.

Joel goes on to say that “These findings make ADD eminently appropriate for neurofeedback interventions.” In fact, however, the reappraisal of the core issues in ADHD has not moved our critics one bit closer to accepting neurofeedback. And we shouldn’t be surprised. The leap from a neurochemical disorder to biofeedback as a remedy is not an obvious one at all. We cannot succeed by simply framing our message in terms of existing models, and that follows directly from the fact that the different models were each inspired by a therapeutic approach, behavioral on the one hand, and neurochemical on the other. The mind goes in lock-step with how one earns one’s living.

Our proposed remedy must go hand in hand with new understandings of what is really at issue in behavioral disorders. The very core of that understanding is still missing in the world at large, but we clearly have a good handle on it already. And once a beachhead is established for a functionally-based approach in application to the dysfunctions of cerebral regulatory networks (collectively referred to as “The Self-Regulation Remedy”), it will gradually be recognized that we should actually occupy nearly the whole beach.

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