(Note: D: Doctor, P: Patient, Italics: Consultant’s commentary, Bold: Pertinent portions in the case, HG: Hand Gestures)
Case of a 30-year-old man suffering from asthma. He was on regular steroids and inhalers. The interview has been concise for the reader’s convenience.
First consultation dated 25.12.04:
D: Tell me what your problems are.
P: I have asthma and that is my major problem. Pollution, dust, paints – I am very allergic to all of them. I cannot stay there for a minute. Immediately I start wheezing. I do not get asthma by stress. And my job is stress free. I am also allergic to certain foods. I have done an allergy test, and I am allergic to eggs, though I have never developed asthma when I ate a boiled egg or omelet. I think I am allergic to some dals (pulses), though the reaction is subtle. But I am very allergic to dust. If I go into the attic, I immediately start feeling it. I have to go wash my hands and face so the smell goes out of the body. My wife puts an allergy cover on the bed, and keeps the house very clean, washes the clothes with cold water, just for my sake. I also have very high cholesterol.
In case-taking most of the time we start with the chief complaint, as that gives us a strong footing. While the patient is narrating his complaints, we need to identify at which level he is talking, what are the PQRS symptoms, which are the symptoms he expresses with highest energy, etc. The moment we identify these symptoms, we anchor on them and move ahead into unraveling his state – from the symptoms to system.
From this junction the patient spoke about a very serious attack he had suffered in the past.
Since the patient has himself jumped to this level, we should not back track him, but encourage him to describe the attack in as much detail as possible. This could reveal some peculiar symptoms of his case.
P: Three years ago, I borrowed my cousin’s car to go for a wedding with my wife. It was not clean and was very dirty from inside. I was anyways not feeling well that day. On the way there was a smell of burning plastic and rubber. Plus the dust smell in the car was there. By the time I reached the wedding, I was extremely bad. I could feel it. I could not even park the car. I felt a sense of constriction. Then I fainted and collapsed. I didn’t know what happened next. I went to the hospital and they started on oxygen. I was completely blank. I was lying in the bed, all of my relatives and friends were there. Everyone was concerned. I didn’t even know I was in hospital, I thought I was at home. That was the worst attack of my life. After that incident, I have been very, very careful. I know when the attack is going to come. I am very self aware in that sense. If I feel slightest uncomfortable, I get out of that environment as soon as I can; otherwise all of the things can lead to an attack. I take many inhalers or tablets. I am very aware when things are going to go wrong. That event completely shook me off and it was very bad. To recover from that, was long. I was in the hospital for 1 week.
If I am out with friends, and if there is too much smoke, I will make it a point to go out and tell them I cannot handle it. My physical condition is known to everyone around me.
As a child, I never used to admit I had asthma. I felt that other kids wouldn’t play with me, or call me. Maybe they will pity me or sympathize with me, or take me as weak.
But nowadays, I say I have asthma. I immediately tell people.
So far this is it what we have. We have to be very sharp in our perception of the patient and simply keep probing further until we reach to his core experience. For example, when the patient said, “It completely shook me off”. What does this mean? What it means for him, we don’t know! What about the aggravation from sympathy, or feeling of weakness? We have to understand why these are important for him and if it holds throughout the case-taking. We keep all of these observations in our mind, and just wait.
Never interpret anything. Do not put your words into the patient’s mouth.
We have to just ask the patient to describe more about it, what exactly they felt. We have to understand what is common to the disease and what is strange. For an asthmatic, being aggravated by odors or experiencing constriction is a little common. But, if the patient repeatedly tells you something, this is important and we must focus on it!
D: Tell me more about this, what exactly happens to you? Explain it to me.
P: That is it. There are no other complications except for these three.
In case taking, the prime quality is to have faith, faith in yourself and faith in the patient, that they always speak the right thing and they will repeat it ten times if it is important. And the second is persistence. So I ask him the same question again.
D: So tell me more about this, what exactly happens to you when you feel this?
P: First, I get a lot of wheezing. I clear my throat very often. In a mild case, with the inhaler, I feel better. In a worse case, I develop labored breathing, and then it becomes completely constricted in my chest. It feels as if someone is sitting on my chest, and someone has put a lot of weight on my chest.
The constriction starts from throat downwards. I try to sip hot water for relief, but that makes me even worse. Every breath I take is precious. In severe cases I faint. I can classify a mild, moderate and severe attack. I take many medicines to make this get better.
With the constriction I cannot breathe, it is very labored, slow and deep. There is pressure, and to relieve the pressure I have to bend forward.
This is a typical modality in asthma. Asthma, bending forward ameliorates. We need to mark it and keep it aside. We need to understand if it fits into the whole system now.
You have to ask him to describe more completely to understand. For us, in this case, constriction is an entry point.
P: I sit forward and it gives me relief. If I sit on the floor and bend forward, hugging a pillow it gets better.
D: How do you feel in this constriction?
P: The constriction is a weight. It is as if there is a ton load of weight sitting on my chest.
As of a ton of weight. This is a very intense delusion. So much weight is sitting on his chest. We have two delusions, pressure and weight. They both reflect the same quality of constriction.
P: It is a huge weight, I cannot breathe anymore. Even a small thing like walking across the room is a strain. I try to read, relax, sit down and take my mind off of it. My children have not seen such a case like this, so it is good. I am happy because of the precautions I have taken.
D: So talk about this, ton load of weight, labored breathing?
P: It feels as if I should be in a position to shake it off. It feels like someone has applied pressure from the side, it is a four way pressure. It feels as if my chest is caught in an iron grasp. (HG – Patient uses both arms and pushes inwards from the sides of his body, with hands and fingers spread wide.)
This is sensation level, with a gesture. This is the beginning. Is the word pressure important? No. Is the word constriction important? No. The words constriction and pressure are helpful to us – but they convey the experience of pressure from the sides.
There are sensation words with gestures. This is the point where the words are not important. I have to look for this experience. We now, need to understand this gesture and the experience.
P: It is coming from all four directions. The pressure is intense. There is no let up of pressure. It is like this all the time.
Look at the flavor of this – there is very intense pressure, constriction. It has to be a very strong intensity in the remedy we choose.
P: I want to dissociate my chest from my body. It is like a foreign element sitting on me and pressuring me from all four sides.
He will give us delusions after delusions, but now we have to concentrate our efforts to the same direction.
P: It is very strong, it is very painful. My mind is constantly on it. It is seeing how I can remove it. The strain is so much that I get a headache. I need a dramatic change. I cannot live the life the way I have been leading. I have responsibilities to my parents, wife and children.
D: Talk about what you were showing with your hands? (HG – Patient uses both arms and pushes inwards from the sides of his body, with hands and fingers spread wide.)
P: It is like an iron clasp. My chest is being put into a cage. The pressure is mounting. It is not exactly a cage. It is like one block of metal or lead. It is being pushed from all four sides. The pressure is coming in from the sides. It is intense. The pressure is too much, and I feel like my effort is so much, even to do the smallest of things. (HG – Patient uses both arms and pushes inwards from the sides of his body, with hands and fingers spread wide.)
P: I had another attack that was so bad.
He gave us another different delusion, but it is pointing towards the same thing. How do I go ahead now? Just hold onto it, and ask him again and again the same questions.
D: Talk more about what you are doing with your hands. Just describe this.
P: like I said it is pressure coming from all 4 sides. I feel as if it is coming in further. The chest is compressing. It is coming inside, coming inside, and becoming narrower.
One more word, compressing. These are words which indicate sensation or experience.
P: So much of a constraint and strain on me. At the end of it I have a headache. It is like the iron clasp, the pressure is mounting, I cannot break free.
This is the first time he spontaneously talked about an opposite polarity. Most of the time, the patient will speak about the opposite. We can ask about the opposite when we have completely extracted the juice out of the first polarity.
We never ask the question, what is the opposite of it, unless we are at the sensation level. There is a right time to ask about this polarity – most of the time, patients will do this spontaneously themselves. This helps us to differentiate.
P: I try to push my chest back, but the stress is just mounting. It is a vicious grip. The more I try to resist, the more the pressure mounts. I sit kneeling forward. And the strain comes so much that I cannot get breathing. So much effort is there. It is not painful, like when you get hit.
Any spontaneous denials are very important. We have to ask questions about this. We have to ask, what do you mean not getting hit. You have to see where the energy is and how spontaneously it is denied. It has energy in this case. But I let the patient continue with his flow.
P: It is just pressure and that is painful.
D: Just talk more about this pressure and what you are describing with your hands.
P: My mind is thinking at that point, how do I get out of it. How can this pressure be relieved in one instant? This never happens; the pressure relief is very gradual. It is there, I slowly and steadily get my breathing back, and then the pressure goes off. The constriction is still there. Then I concentrate on my in and out breaths and then the constriction goes slowly. When it is gone, I feel as light as a bird.
“I feel as light as a bird.” So we are looking for a bird remedy? No! This is the commonest metaphor we use when describing free and light. If the bird remedy is right, it has to hold, and come with even more intensity. We have to see if it is holding throughout the case.
P: That is what I feel. I suddenly feel wow. I feel as if my chest is not there. My mind is focusing so much on my chest, now I feel my chest is full of air, it is free now, the strain is off.
You see that the energy of free and light he is describing has emphasis.
P: I feel I can breathe now very easily. I usually end up reading a book to take the strain off my head. The strain on my head is as much as my body.
D: Keep the asthma aside and focus only on the gesture you are showing.
When you get a very intense sensation, you detach them from the situation. We dissociate them from their life, “Forget about you, forget about your asthma, I am not talking about your life or asthma. Just talk about this experience. Only talk about this experience (of the gesture)”. The patient may go back to the same thing, but you must take them back to the experience.
This is the level of nonsense, which can lead us towards the source. From there, the patient goes on further and you get a true experience when you ask them about their gestures.
P: The experience is extremely stressful, painful, mind numbing. I don’t feel any sensation but that. My mind is focused only on that. It really is intense. The pressure keeps mounting. My chest is becoming so compressed (Hand Gesture – Patient uses both arms and pushes inwards from the sides of his body, with hands and fingers spread wide, coming closer and closer together). It is mounting, it is severe. What can I do to expand it? it is in a clasp, being held very tightly, from all four sides, pressure is coming in and coming in. I want to break free. Even if I get one-minute relief is a big thing. I would take it but I don’t get it. This is constant and painful. I can only think, what can I do to relieve myself of the pain. I deviate my mind, watch TV or read a book, or take medicine.
D: talk about this, when you are in a clasp, it is mounting, constriction and you want to break free. Just the experience of this. Just describe to me the experience to be in this…
Even I had a problem asking these questions. The patient was not going beyond or ahead of this experience. What do we do when the patient is not going ahead? We have to have faith, be persistent, and wait calmly and coolly. The patient will speak.
P: If I have to describe the experience, it is just a stress, a pain. There is nothing in the world existing at that point, but my chest. I do not feel my hands, legs, eyes; I cannot think of anyone in the room, I don’t know who is around me. It is like a void, a vacuum, only one thing is in focus and highlighted, and that is my chest. It is only my chest in isolation. The pressure is mounting. I am being pushed by all four sides, it is coming very fast, it is coming inside and inside. (Hand Gesture – Patient uses both arms and pushes inwards from the sides of his body, with hands and fingers spread wide). The asthma takes over me, it controls me.
D: Forget about your asthma, only about this pressure mounting and what you were showing with your hands.
P: It is like a dark, dingy room, with no light. There is my chest in that. It is being held from all four sides. It is being put into a cage, and you have these huge blocks of lead, coming in from all four sides. It is not like it is coming in and going out, it is coming in and only coming in. (Hand Gesture – Patient uses both arms and pushes inwards from the sides of his body, with hands and fingers spread wide, going in and out repeatedly)
Here we can get distracted and the case sounds boring. But we need to maintain our vigilance and wait. Each time when he repeats, he gives a flavor to it. We have to perceive this flavor.
P: You have a claustrophobic chest. It is being constricted and wants relief but it cannot. The pain and stress is increasing. Nothing can be done at that moment. I need to help and give it relief.
D: describe the experience when the blocks are coming in and the claustrophobic chest. Just this, describe this.
P: The pain, the chest, the pain, the chest. There are two individual pieces to it. The pain is external. As if someone is pushing those blocks inside. No one is hitting and pushing me. The room is full of air and light, and my asthma is gone, my chest is open and big space. Only if the room is dark, dingy, and dusty, my chest is small with asthma. The chest feels as if it is trapped within something. It has no control. It is not in control of the external environment. It cannot push away, it cannot expand. It is a helpless thing. Only I have to help it.
D: Describe the experience of trapped, no control, cannot expand.
P: The strain and stress is tremendous. It is as if you are entering a narrow lane, someone has caught you and you are getting hit again and again, but there is no way out or exit. You have to pass through this stress and strain. The pressure is there, it is just sitting there. The pressure is constant. If I don’t take a medication and let that feeling happen to me, I feel I will collapse. Only after medications, the let up stage is there. The comfort comes gradually.
D: Describe this, someone has caught you.
P: It feels as if someone has caught you, and suppose he wants to hit you on the head 50 times. Whatever you do, he will not let you go.
D: Describe the opposite of this.
Now we know, since there is nothing new coming up, all of the juice is extracted. From here, we have to explore the opposite pole.
P: I can just think of a bird, who is flying over a grass meadow (HG – hand is in the air moving in a circular motion). It is just so free, blue skies, green grass, there is no sound, it is complete light and vast. You feel very light hearted and floating. You feel fantastic, after this dark dingy place, you come out to this large, open space. You look at things with wonder. You feel fantastic that you can smell what you are breathing, feel yourself moving, walking around, the let up of pressure is so enjoyable, so much at peace. You suddenly feel fantastic and back to normal. That lasts for 15 minutes after the attack.
We can perceive the intensity of what he is saying. The bird comes up again, the freedom comes up again. Earlier, we had a feeling that it could be just an analogy that was used. Even at this time, we saw the intensity and weight was strong. Here, we see the same words coming. Now we feel, it could be a bird remedy.
Before we go ahead with this thought, we have to learn the energy of the patient and if it matches the source. The intensity shouldn’t be flat and emotionless. There has to be a gesture and energy. For birds, we see wild, open, freedom, blue sky, and openness, flying, floating, soaring, and vast on one hand. On the other hand, shackled, oppressed, weight, pressure, constriction, caged, and trapped.
We never should take things for granted. Your experience shouldn’t become your obstacle. We have to see the intensity coming true. How can we go further from here? How can we know which bird? We have Sensation A (Kingdom) and B (Subkingdom – Bird), now we have to understand C.
You may ask, how is this animal kingdom? The animal kingdom will express a survival issue and victim/aggressor theme. Someone is pressing this patient from outside, someone is hitting this person. “Someone is doing something to me” is a theme of the animal kingdom.
Here, we should also differentiate between Hamamelidae, Cactaceae, and Nitrogen in the mineral kingdom because they can have similar sensations to Birds. You might ask how this is a flavor of the survival issue of the animal? There is immense constriction and pressure associated with the freedom, circulating, soaring, open sky theme of the bird remedy. He is not directly using the theme of victim-aggressor.
In a lot of cases, patients will give us the source directly. In others, the patient would not give us the source and we would be stuck.
Let us go further.
P: After the attack it is normal, there is no feeling.
D: Describe this blue sky, vastness, green grass, complete light hearted?
P: It is completely at peace. You feel you are suddenly at equilibrium with the world. It’s like you know you are in a hell and suddenly you are in heaven (G) and then you come back to earth. Suddenly you have come above; it is a feeling as if you are circulating in a meadow. (HG – hand is in the air moving in a circular motion slowly). I am soaring, circulating, feel light, air filled, happy and I am enjoying.
Now, you pick up the qualities of which bird. We are looking for a bird which is circulating. So many birds can do this action. We look at his hands (HG – hand is in the air moving in a circular motion).
P: You are moving around like a bird. You have suddenly gone above. You are much above the world, it feels very nice. Then you come back to earth. You are gone into a dark, dingy, horrible place, which is giving you a lot of stress and pain, suddenly you rise again; the kind of freedom you feel from pain, actually takes me straight above. It makes me feel as if I am bird who is looking at the ground from above. I feel I am flying in this meadow full of greenery, which has got lovely stream which is flowing and I am the bird who is just happy circulating around, (HG) taking in the entire colour, feeling very free. The word is free because the word for the other state is trapped. So you feel completely free, you feel at ease, mentally relaxed, the ordeal is over. I am happy.
D: Describe this.
P: Is it is from top down view. A bird can visualize the minutest thing. From a height it can see a worm and it catches the worm. So that is kind of vision which the bird has. Suddenly you minutely observe it. I can see a color; I can smell a rose, more minutely after the ordeal is over. I am more alive in the moment, minutely aware of things around you – my wife looking tense, the TV volume high, or a smell of cooking in the background.
D: Describe from the height from which you see.
P: Probably the biggest. It had come from my image of being free from childhood. Nothing is freer than a bird. Bird can fly to whichever place it chooses, can take in the sights, sounds and be completely disconnected. It is in its own observant state. You have seen that entire piece. You are not interacting with it. You are nowhere in the picture. You are looking at it from above. (G) So that is how whole feeling comes, the feeling of freedom, the feeling of doing whatever you want to do without anybody coming in your way or without you having to interact with anybody else.
D: We were talking about seeing the bird and feeling free something about disconnection you were talking.
P: In the stage of the attack there is complete disconnection from what is happening around me, there is nothing but me and my chest, therefore my pain and therefore my stress and pressure. So there is disconnection, there is dissociation from what is around me when I am in the middle of the attack. When I am relieved from the attack, when I come back to reality, I am so minutely aware of things. It is like looking at things from a greater height. The vision of the bird is so much minutest because from such a height it can see a worm. Standing on the ground you will never see a worm just standing next to you. I do not feel I am standing on ground, I feel I am floating in air. So free, freedom of a bird, I experience that at that time. I am free, feel light hearted, mind is at peace, the body is at peace. Nothing can touch me from down and I am not going to interfere with what is happening on the ground. It is not freedom from others but freedom from a bondage. There is gravity – you are actually flying against gravity, there is pressure, there is still the strain of gravity which is holding you but you are flying up, above. There is absolute peace.
Suppose you were to place a person in a dark dingy room. Suddenly you open the door and he is in this beautiful country side. You never realize that room was actually contained in a huge countryside which is full of green meadows. Suddenly when he goes outside, what will he feel, what a change? He was in a room where there was no light, no air and suddenly he is out in the open. That is the transition that happens from an intense attack.