Monday, January 5, 2015

New Approach of case taking

New Approach of case taking
New Approach of case taking - The Old Approach In "The System of
Homoeopathy" I explained that an ideal case had four steps, which
could be likened to four spheres each within the other and with a
common centre. Each successive sphere was therefore one step closer
towards the central state of the patient. With each step one obtained
finer and more specific data till one finally reached the central
point where the deepest mental and physical sensations, the miasm and
the kingdom all converge to a sharp focus. This is the patient's
delusion. With this approach, one lets the patient describe his
problem: physical or emotional, and while the patient was allowed to
speak the physician's focus would be on picking up peculiar symptoms
and on getting to the bottom of the Mental State. The emphasis
therefore was mainly on understanding emotional phenomena. Often this
proved a difficult and confusing task, especially when one got lost in
the story, rather than understanding the patient's feelings. The
concept of Vital Sensation As I made progress with my study of the
plant families I realized that the concept of the common sensation
(refer Introduction) was not just confined to the plant kingdom. In
the case of disease and remedy states from all kingdoms one can
perceive this common sensation both, as a physical sensation as well
as on the emotional sphere. With the old approach there had been a lot
of emphasis on the mind state and mental symptoms. Having discovered
the concept of the common sensation however I realized that the
central state was not merely an emotion or feeling, but was this
common sensation that connected the mind and the body. I call this
common sensation the Vital Sensation as it is something deeper to the
mind and body. What is the level is deeper to the mind and body? That
is what I call the Vital Level. I used to think that the centre of the
Mental State was the deepest point that we could reach, but I realized
that the Vital Level is a step deeper than the Mental State. As for
example when a person says that he feels jealous or suspicious or
expresses something mental and emotional then we might ask him for the
experience behind that. He may feel he is being attacked and is
frightened. In this way an emotional situation is perceived behind the
mental symptom, which is good enough, but if you want to take it one
step further you ask him how he experiences the attack. At this point
you come to the intersection or cross point where the mind and body
meet. Here they may have the feeling that something is breaking or
burning or twisting. This is the common point between body and mind
(The Vital Sensation) and here he will describe his emotional symptoms
and physical symptoms in the same terms. This is a very deep level and
if you reach this point there is a much better chance of success. With
this new understanding I saw the patient's delusion not only confined
to the mind but also expressed on the physical sphere. In fact I could
see that the Mental State is merely one expression of the Vital
Sensation. And when I started looking for this common sensation or
delusion or vital symptom in the physical sphere I realized that it
was apparent right at the outset, with the chief complaint itself.
Importance of the Chief Complaint I started concentrating on the
various details of the chief compliant and I realized that here one
always came across an element which had more than just a physical
connotation and spontaneously connected to the mind state. Thus one
could get directly into the center, to the Vital Sensation, from the
chief complaint itself. In many cases when the patient expressed a
physical sensation in relation to the chief complaint one could see
the same sensation emerge in the emotional sphere. In other cases the
effect of the chief complaint on the patient's life was an expression
of this Vital Sensation. In yet other cases it was the modality of the
chief complaint. With more cases it became definite that the chief
complaint itself gives direct access into the central state of the
patient. So now I was starting with the core of the case right from
the outset and then examining other, more superficial areas, which are
more like expressions of this core state. This was completely opposite
to the earlier approach where I would start with broad and seemingly
disconnected data and then go step by step into the center. With the
old approach if we did reach the connecting symptom it was at the end
of the case. The chief complaint itself was often neglected with the
belief that we are not treating the pathology but the person having
it. As a result one was impatient always to get over with the chief
complaint and get to the nature or the mind state of the person.
Further, many times we would simply get caught up in the mental
phenomena without actually touching the sensation. In contrast, with
the new approach one reached the common sensation by sticking to the
chief complaint itself. And having unearthed this common sensation at
the outset one could see that the whole case and expressions as
branching out from this common core sensation. As I used this approach
more and more I began to understand that the chief complaint
represents the crystallization of the Vital Sensation. Hence it is the
best place to locate the Vital Sensation. It is the fountainhead where
all the vital phenomena are expressed in their raw form. It certainly
cannot be neglected; rather it is the main support around which the
case revolves. It forms the foundation of the case. I learnt then to
stick to the chief complaint and examine it in its depth and this has
revolutionized my case taking and yielded far better results in my
practice. Sensation and reaction As I started looking for emotional
and physical expressions of the sensation in remedies and patients, I
could see sometimes that the sensation would be expressed directly. At
other times it was expressed as a reaction that was always equal and
opposite to the sensation (and this I made the first law that has been
explained above). In some other cases it could be seen as
compensation. I could also see that reactions were of two types,
active and passive and they were both equal and opposite to the
sensation (Refer Introduction). For example if the sensation is
'caught up' or 'stuck' the active reaction will be to want to move,
the passive reaction will be being immobile or unable to move, while
the compensation will be a person who is always on the move. The
modalities essentially speak the same language as the sensation. For
example, if the sensation is of being caught the modality is better
from movement. If the sensation is of being tightened the modality is
better by loosening. In this way the modalities will also confirm the
sensation. While taking a case I would pay attention to the sensation
expressed in the chief complaint and later in the dreams, interests
and hobbies, fears etc. The sensations were of various types. In some
cases throughout one sees nothing more than a particular sensation
(for example, tied up); this means that the key issue for this patient
is sensitivity (to being tied up) and such a person requires a plant
remedy. If this sensation has to do with survival then the remedy
required will be from the animal kingdom. If it is linked with
structure a mineral remedy will be required. In this way the type of
sensation gives an indication of the kingdom. The Miasm Often I am
asked the question: In a given case if there is a feeling of 'being
suffocated', is this the sensation described in the Rosaceae family or
is it the suffocation of the tubercular miasm; how would one
differentiate the two? Similarly the forced out sensation of the
Liliflorae could be confused with the cast out theme of the leprous
miasm; or the stuck feeling of Anacardiaceous with the similar theme
of the malarial miasm. To re-iterate what I have already said above
the vital sensation is what the patient feels. Take, for example, pain
which one can feel as cutting, stabbing, pinching etc. The intensity,
pace and depth of this sensation or how he copes with it indicate the
miasm. In practice, if the patient says he feels suffocated or
something suffocates him the physician must endeavor to understand
whether: 1. The patient feels things to such a depth that it is
suffocative. In this case the suffocation indicates the miasm and the
area or issue connected with this suffocative degree will reveal his
sensitivity. For example: If he is vexed and excited so easily and
frequently that he finds it oppressive, then his sensitivity is in the
area of easy vexation and excitement, (family Ranunculaceae) while the
oppressive degree is indicative of the tubercular miasm; the patient
probably needs the remedy Cimicifuga. 2. In every area of his life
there is a sensation of being suffocated or pressed down. In this case
he could perceive this sensation to any depth. He could feel acutely
and dangerously suffocated (acute miasm, Rosaceae family), or he could
feel suffocated to the point of being stuck (sycotic miasm, Rosaceae
family) or he could feel so hopelessly suffocated that there is no way
out (syphilitic miasm, Rosaceae family). In all these examples the
suffocation is surely where his sensitivity lies and so indicates the
family. The type of sensation is only one of the components of the
disease. For example if the main issue in a case is the sensation of
being injured we can say that the patient will require a plant remedy
from the Compositae family. But this is not enough to help us select
one remedy from amongst the many, many remedies of the Compositae
family. We know the type of sensation, viz. Injured sensation, but we
can also perceive in the case the depth and intensity of the sensation
and reaction as well as the manner in which the patient copes with
these. Sticking to the same example of injury there are different ways
in which the patient may perceive the injury. He may feel he will be
suddenly injured in which case he may panic. The suddenness and the
panic suggest an acute situation and response. Another patient may
perceive the injury as an acute crisis. He will respond by making a
concentrated effort to overcome the crisis. The intensity of the
injury (acute crisis) and the response suggest the typhoid miasm. Or
then he may feel that he is persecuted by injury from time to time
while being stuck in a situation. The feeling of injury suggests the
Compositae family while the depth is of the malarial miasm viz. stuck
and persecuted intermittently. So we can see from the above examples
that the depth to which he perceives the sensation as well as the
nature of his response determine the miasm. The miasm is the other
component in the disease. So the disease has two components, viz. the
type of the sensation and the depth of the sensation. The sensation
and miasm together give the remedy. (Refer Introduction) In the first
example given above where the sensation is injury and the miasm is
acute the remedy will be Arnica or Calendula, depending upon the
symptoms. The remedy from the Compositae family of the typhoid miasm
is Chamomilla, while Cina and Eupatorium perfoliatum are the remedies
from the malarial miasm in the same family. Although often one can
determine the depth to which the patient perceives the sensation,
usually the response to this is very clearly seen. For example one may
be able to understand that the patient perceives the injury as an
acute crisis, but this becomes clearer when we see the patient's
response, viz. a concentrated effort to overcome it. This response
therefore is the best indicator of the miasm. I also call this
response the 'coping mechanism ' and this is best seen in relation to
the chief complaint as the patient's attitude towards the illness. If
his attitude is one of panic, the miasm in the case is likely to be
acute. If it is hopeful, it is likely to be psora. If he adopts an
attitude of resigned acceptance, avoidance or cover up it may be
sycosis and if he feels hopeless and destructive it may be syphilis.
This miasm can then be confirmed throughout the rest of the case as an
action taken in response to the depth of the sensation perceived.
Sometimes some expressions of the patient with regards to other parts
of his case may point towards other miasms, but I usually only trust
what the chief complaint as well as the areas of most stress indicate.
The coping mechanism applies to the depth of the sensation as well as
the reaction. I have already explained that the reaction can be active
or passive or in the form of compensation. So if we take once again
the sensation of being injured as an example, if the depth of the
injury is to the point of destruction his reaction will also have the
same depth: he will want to injure to kill. But if he reacts passively
he may become numb and hopeless. If he is well compensated he can
respond by becoming the tough guy and facing the most severe and
destructive type of injury. If the sensation in the case is apparent
then one can understand the miasm by asking the question, what does he
do in response to the sensation? Or What is the action in response to
the sensation? Does he panic, does he make a desperate, last ditch
effort to overcome it, does he stretch himself far beyond his capacity
etc. This will give the miasm in the case. In some cases one can see
the action before one has actually understood the sensation. Here one
can ask Where is the area of the action? or What is the issue related
to the action? Is he panicking in response to sudden injury? In that
case the injury will be the sensation. Does he stretch himself beyond
his capacity to feel included? In this case the sensation will be that
he is not included or left out. In this way in any case from the
sensation we can find out the miasm and vice versa. Disease therefore
has two components: the sensation and the miasm. Also when we study
well proved remedies the most characteristic symptoms of the remedy
are a combination of the sensation as well as the miasm. The most
characteristic symptoms therefore point directly to the core of the
remedy. The New Approach Step one: Elicit the chief complaint exactly.
I have already emphasized the importance of the chief complaint. One
should stick to it and examine all components thoroughly for the
sensation and miasm. The sensation may be expressed directly, or one
can see it through the modalities or the effect that it has on the
patient's life. The chief complaint is the best place to look for the
sensation and the miasm. One begins the case by asking for a detailed
description of the main complaint and one keeps asking the patient to
describe it further and further till one comes to a sensation that
will have a greater connotation than just the presenting problem, or
something that will lead into the Sensation. I usually stick to very
simple questions at this stage, like "Tell me more about it." or
"Describe it further, I don't understand . . ." or "What do you mean
when you say . . . ?" or "What do you feel ?" If the patient gives a
sensation one can usually confirm it from the modalities. I also ask
the patient to describe the opposite of the sensation in detail as
sometimes the patient will spontaneously connect this with images,
situations, fears, or other aspects of his totality. As he is
describing the chief complaint one also makes note of the pace and
depth of the problem and the patient's response or attitude or coping
mechanism. These indicate the miasm in the case. The miasm becomes
apparent once the sensation is known and vice versa (Refer above).
Some rules I follow: 1. I will never use a word that the patient does
not use. I will always repeat the same word in exactly the same way
and only tell him to describe further or tell more about it or ask
about the sensation or feeling of it. 2. I will keep asking the same
question in various ways till the patient leads me to the next
question or step. This is reached when the patient gives another
sensation that is more precise or more descriptive or deeper than the
previous step. One needs a lot of patience and faith that the patient
will express something deeper. Sometimes the patient can get
frustrated from being asked the same thing repeatedly. One can
therefore ask him the same question in different ways Often patients
revert to the chief complaint and furnish you with more details about
when it happens etc rather than answer what you have asked. In such
cases I tell the patient that I understand when it happens, but what
is more important for me is what is happening rather than when and
why. With this sort of persistent and focused questioning there are
two or three things that can happen. 1. The patient can give you a
visual picture or an example. For example if he says he feels stuck to
one point and you persist with asking him to explain what he means he
can say that he is stuck to one point as if he is in the middle of a
street and there is a car coming at him at full speed. "How one feels
stuck in such a case", this is how he feels. 2. Or he can associate
this with something else in his life or in his story. For example he
can spontaneously describe an incident when was going in the street
and he felt stuck in the same way. In either case what one has to get
to is the sensation or what he experiences emotionally and physically
when he is in that situation. 3. Or he may describe the sensation as a
fear. Then the next question would be, "Where do you experience that
fear?" or "How do you experience that fear?" Where the patient can
express no more than an emotional feeling one can ask him how he
experiences the feeling in the body or what are the physical symptoms
he experiences at the time. This could lead to the sensation. In this
manner by chasing the chief complaint one can come to the main feeling
or sensation. Thus the presenting problem can be seen as an expression
of the Vital sensation. Observation of hand gestures: With the
emphasis on sensations I realized that in many cases these were best
expressed by hand gestures, even better than words sometimes. The
'forced out' feeling of Liliaceae, the 'obstructed feeling' of
Cruciferae or the 'pinched feeling' of Rosaceae can be well observed
even when the words may actually be saying something else. These hand
gestures are subconscious, involuntary and often not even noticed by
the patient. Sometimes I stop the patient while he is gesturing and
ask him what the gesture denotes. In one case the patient described
her asthmatic attacks to have a sensation of being tightly twisted in
her upper chest, like choked or strangled. She gave a picture of the
sensation like a python strangling its prey. Later on in the case she
spoke of being hurt when her husband admonished her. When I asked her
to describe the feeling of hurt, she used the word sad, while at the
same time her hands went towards her chest and were clenched, the same
gesture she had used while describing the strangled, twisted feeling
in the chest. What she could not express in words, her hands were
speaking to us, even without her being conscious of this. So when
thereís no hand gesture, no image, no connection then itís used
casually and need not be followed. Step Two: Go to the areas of least
compensation. Usually if we go in depth into the description of the
sensation and persist in this area, the patient himself will lead us
into all the significant areas of this life like vocation, relation
and recreation. If he does not do this despite our best efforts and
the case staking process is stuck at a point, then we may need to
inquire into some areas, especially those which are likely to show the
least amount of compensation. These include hobbies, interests,
dreams, fears and childhood. Here the delusion is best expressed. Once
one has derived the sensation and response or action in the chief
complaint the next step is to confirm these in the areas of least
compensation. The same sensation or its opposite will be found here,
as also the action and one will come back to the same core undisputed.
Step Three: Other areas Now one has the freedom to go into other
areas, especially those that are seemingly disconnected and see how
they connect to the common sensation. Step Four: Go back to the
sensation that the patient has repeatedly confirmed and take the
patient deeper till he gives a situation (actual or visual) where the
sensation, miasm and kingdom concur. Or Go back to the areas of most
stress and go deeper with the patient till a point is reached where
the sensation, miasm and kingdom concur. It is important to note at
which point in the case the local phenomenon becomes general or
emotional, or at which point emotional phenomena become physical. This
is the Vital Level, something that connects the mind and the body.
Illustrative Case: The method will be better understood if illustrated
with a summarized case. The method is explained in italics while the
case is in normal type. P: Cough four to six times in the day. Q:
Describe the cough some more. P: Blank out with the cough. Want of
breath. Pulling sensation in abdomen, throat. It is worse when going
out, from a draft of air. It comes on suddenly, especially when
talking suddenly. So one can see that he has a cough which gets severe
from time to time, and at such times he gets a black out. The cough
gets worse when he is outdoors and so he cannot go outside the house.
So there are two aspects to the cough: . blank out (sensation) . It
comes from time to time and he can't go out of the house anymore
(pace/miasm). Q: Tell me about 'blank out', describe it. P: It becomes
black before my eyes, as if I am stuck to one point. Q: Stuck to one
point meaning . . .? What is the feeling when stuck to one point? I
have used only the words of the patient and keep up this questioning
till he leads me to the next question. This could be a more precise
feeling or a visual picture or something that comes up by association.
P: It is as if I cannot move. Now this does not yield a finer
description of being stuck at one point, nor has he given a picture of
what it is like to be stuck at one point. You cannot go any further
with this. So I will again ask about his feeling when he is stuck to
one point. Q: What is the feeling when stuck to one point? He reverts
back to the chief complaint. Now it is our job to keep him to track so
repeat the same question till he goes one step deeper. P: It is like
you are in the middle of the street and car is coming at full speed.
That is how I feel. Now this is a visual picture. It could have been
an actual experience from his life. It is a window into the Mental
State , one level deeper than the physical. Question him further and
ask about his experience in this situation and one may be able to see
a connection with the cough. Q: How does one feel when one is in the
middle of the street and a car comes at you at full speed? P: It
happened to me as a child. I felt the same way. We have to get to the
sensation in that situation. Ask him now to describe the experience in
emotional and physical terms. We started with the cough and then came
to blank out and then to black before the eyes and then to stuck to
one point then to the childhood situation. All this by sticking to the
chief complaint and chasing it. P: The fear is I will be suddenly
killed and so I cannot move. So in this manner by chasing the chief
complaint one can come to the main feeling or fear which is that
suddenly he is going to be killed and he is stupefied from this
fright. Now you can see the connection with the cough. The cough comes
suddenly from time to time and he cannot go out of the house. It gets
black before the eyes and he is stuck to one point as if he is going
to be killed. He is frightened and stuck to one point. Fright
stupefies. The cough stupefies. He avoids going out of the house
because he will get a cough. He avoids the situation that stupefies
him but he still gets the cough from time to time. So this is the
malarial miasm, Solanaceae family and the remedy is Capsicum . So the
remedy became apparent from the chief complaint itself and could be
confirmed in other areas in the case. Once you get the sensation you
have to get the opposite. To get the opposite go to the area of least
compensation or no compensation: hobbies and interests, dreams,
childhood. For example in the case of a patient for whom I prescribed
Mangifera needed to be in company. When I asked about her feeling when
in company she replied that she feels things are moving and are not
static. What does that have to do with company?! So it is this that
she says which ties with the rest of the case. Mangifera is a sycotic
remedy from the Anacardiaceae family. The main sensation in this
family is of being caught or stiff or stuck. One can see the opposite
in her hobby, i.e. not static and always moving. The beauty of this
whole exercise is that you never know what comes up; as the case goes
on the sensations and feelings unravel as a surprise. So, nowadays I
concentrate on the chief complaint and in this way reach the center in
all my cases. The old way was from outside inwards whereas the new
approach is from within outwards starting with the chief complaint.
The concentration should be on the chief complaint, whether the
problem is emotional or physical. The chief complaint is the main
support around which the case revolves. And instead of letting
isolated emotional phenomena or physical symptoms mislead us the
emphasis should be on the vital symptoms, or the symptoms that connect
the mind and body. All this time instead of catching hold of the chief
complaint and not letting it go till we have understood it clearly, we
used to go all around to other areas in the patient's life. All that
is clothed in the expressions of the emotional state becomes naked in
the chief compliant. If we go to the other areas first we will only
feel the tremors; if we concentrate on the chief complaint right at
the outset we discover the volcano from where the tremors originate;
we discover the wound that is most tender. If we focus our complete
attention onto the chief complaint, its sensation and modalities, we
understand the very core of the case right away. The body and the mind
both express the same phenomena, same disturbance, and the same vital
problem. If we understand the physical aspect first it may be more
helpful and save us from getting ourselves lost in the mental
phenomena. This new approach to case-taking was the beginning of an
understanding of the various levels of perception and led to the
discovery of the seven levels viz. Name, Fact, Feeling, Delusion,
Sensation, Energy and The Seventh. In the medical terms, the first
level has to do with diagnosis , the second level with the complaints,
third with the feelings and emotions, fourth with the delusions and
dreams, fifth with the sensation, sixth with the energy pattern and
the seventh with what lies beyond. So far in Homoeopathy we could
treat the patient with symptoms, pathology etc. 'The Spirit of
Homoeopathy', introduced the level of delusion . This book introduces
the idea of sensation. The idea of levels has been a big step for me
and clarified not only case taking and analysis but also the vexed
problem of potency. An extensive understanding of the levels and its
practical utility will be dealt with in my forthcoming book entitled,
' The Sensation in Homoeopathy'

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