Viewing the patient as a colleague and therapy as a collaboration would, I believe, greatly improve the quality of the patient-doctor relationship. Watch a spider weave her web. Wonder at the beauty of small things around you that aren't manmade. Sit quietly by a river, stream, waterfall, or the sea. Then, close your eyes, while listening to sounds around you and breathing in the scent of the environment. Pay attention to what you hear until sounds are loud in your mind and take over your thoughts entirely. Look closely at a crystal or smooth pebble. Run your vision and your fingertips over its shape, seeing and feeling every facet. Concentrate on looking so intently at your stone that you know it thoroughly from every angle. Select a peaceful color to concentrate on, using your inner or outer vision. Look deeply at the color as you breathe slowly. The Social Context of Chronicity The tenderness with which you have been pleased to treat me, through my long illness, neither health nor sickness can, I hope, make me forget; But what can a sick man say, but that he is sick? His thoughts are necessarily concentrated in himself; Though I am now in the neighborhood of the Peak, you must expect no account of its wonders, of its hills, the waters, its caverns, or its mines; The Double Bind In a series of insightful essays on her experience as an anthropologist working in a dialysis center for patients with chronic kidney disease, Linda Alexander (1981; Alexander shows through case descriptions how the double bind disorients patients and creates guilt feelings. Those responses interfere with effective care and over time can demoralize patients and their families, thereby contributing to chronicity.

Jeffrey Longhofer (1980) describes much the same phenomenon among patients and their families in a bone marrow transplantation unit. My impression is that we are slowly and haphazardly moving in the direction of this change. What is needed now is organized change of a more substantial kind. Though it sounds simple, this type of medical reform is hedged in with thorny questions. It would require coordinated political, legal, and medical change--thus, it can easily be dismissed as utopian. But I think that would be a sad error. We already have a large self-help movement in North American society, the popularity of which is in part a form of resistance to perceived professional dominance and in part a valid recognition of the limits of medicine. Techniques developed in training physician assistants and other paramedical staff can be redeployed in the family sector of care. Politicians might become interested in such change because of the possibility that it would reduce health care costs and alter the increasingly adversarial stance of patients toward the medical profession. Public health planners and experts in health education might be encouraged to figure out means to rationalize care given by patients and families. Social survey and ethnographic information that more precisely maps lay decision making and treatment actions will be necessary. Does the color have a sound? A temperature? Picture the color filling your lungs and flowing through your body as you inhale. Think of an animal or creature that you'd like to be. Sit comfortably and imagine how you would feel if you were that animal. Visualize how you would look and how it would feel to move around. See through the eyes of your chosen animal and experience being in its body. Listen to a simple, relaxing piece of music that you find uplifting. Choose music that is gentle and evokes a sense of calm.

Hear each note with clarity. Perhaps the problem is a structural component of high-technology, specialized treatment settings. Patients are expected to be active collaborators in their care in the outpatient phase; These aggressive/regressive phases of patients' behavior have their analogue in the general care of the chronically ill and in the relationship of patient to family and friends. Matthew Timmerley is a thirty-six-year-old black postman with chronic kidney disease caused by diabetes. Timmerley had this to say about his care in a dialysis unit: The signals are constantly switching. They tell you to run with the ball and help plan the plays, then when the situation changes they take the ball away from you and tell you to stay out of the decision making, leave it to the experts. It can be terribly frustrating. Do I leave it up to them, or do I take part? When I'm well, they're constantly pushing me to do more and be responsible for the care. And it will be essential to understand better the legal, legislative, and ethical aspects of such change. But, in one form or another, the chronically ill and their families will increasingly demand--and, I believe, ultimately succeed in winning--a greater degree of control over the resources required in their care. A step away from the family sector is the folk sector of care. Folk practitioners include a very wide variety of nonprofessionalized and usually noninstitutionalized specialists. Folk healers range from quasi-paramedical professionals to religious healers, from a huge assortment of lay psychotherapists to semilegal and even illegal peddlers of nostrums, from traditional healers in ethnic minorities to health food advisers, massage therapists, and television performers who reach out to members of the mainstream population. There is a long history of folk healing in North American society; McGuire (1983), for instance, described more than a hundred varieties of folk healing available in a middle-class suburb of New York City. These ranged from the traditional (for example, religious) to the latest (for example, polarity therapy, iridology, co-therapy, and so forth) forms of folk healing. Doctors of traditional Chinese medicine, yogis, various Christian and Jewish spiritual healers, herbalists, experts in martial arts and other forms of exercise, and characters who could only be described as unscrupulous charlatans were active in the treatment of some of the patients described in this article.

While folk healers often are helpful, they sometimes give advice and prescribe remedies that interfere with biomedical treatment and that are, in and of themselves, dangerous (Kleinman and Gale 1982). Focus deeply, and let the music drift over you like a comforting wave. Use one or more of these simple meditations and you're bound to feel calmer. In this relaxed state, your mind will gain clarity and focus, so you can more easily cope with your life's challenges. The affairs of the world will go on forever. Do not delay the practice of meditation. Stress doesn't stop at your front door. Work-related stress affects everyone at some point in their life, and the results can be nasty. Chronic stress can lead to a weakened immune system and lead to having to take time off work. Add to that a diminished enjoyment of your career, and you've got a lot of years of not much fun. Most people spend a good deal of their time at work, so it's worth your while learning how to be happy there. When I get sick, they tell me I brought it on myself by doing too much. You can't win. Phillip and Genia Wilson went to the genetic counseling clinic of their local teaching hospital after Genia delivered a baby with multiple birth defects who died soon after birth. Genia described their visits as follows: Frankly, it was very confusing and upsetting. They explain enough to you so that you are supposed to make decisions about future pregnancy. But there are so many improbables, so much based on probabilities and less than complete information, you feel very uncertain. How can we make the decisions? We're not doctors.

They either baby you when they explain things, as if you knew nothing, or they throw you into the pool and expect you to swim on your own, with not enough lessons and no practice. Physicians tend to be ill informed about their patients' utilization of folk healers, even where such knowledge is relevant to understand noncompliance and poor outcome. Patients hesitate to tell physicians about nonbiomedical healers whom they reckon their doctors disdain; The challenge to biomedicine is for physicians to recognize that folk healers are important not just in the Third World but in contemporary Western society, too. So ubiquitous are they and so anxious are the chronically ill to receive help of any kind that doctors should assume that in the course of chronic illness their patients are likely to receive folk treatments. Respect for the patient's viewpoint should include a willingness to learn about the use of so-called alternative practitioners. It should also mean that the physician tries to determine when resort to folk healers and their treatments is useful and when folk healing is potentially harmful. The physician's appraisals should be shared with patients as an integral part of the negotiation between professional and lay explanatory models. The professional sector of care in the North American health care system is also plural. There are alternative therapeutic professions--such as chiropractic, osteopathy, and naturopathy--with their own professional organizations, licensing statutes and exams, schools, texts, and research. Ophthamologists compete with optometrists for patients who require prescriptions for eyeglasses. Meditation at the office could be the answer to the problem. Taking five minutes out of work in order to meditate when you feel stress building up can prevent your anxiety from becoming overwhelming. The key to dealing with stress is to catch it as it happens (or even better, when you see it coming), rather than let it gather energy and grow. Find a quiet place, away from distraction, to sit and meditate on the sounds you can hear around you. If possible, lean against a tree or sit on a bench outside. But if this isn't possible, and you can't get away from other employees in the break room, try pretending to read a article or magazine. Close your eyes and focus entirely on the sounds around you. Let your thoughts completely disappear for five minutes and give your brain a break. Sometimes the most stressful times at the office sometimes occur when something has to be done RIGHT NOW.