Saving a Failed Case

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Dr. Sayali Mehta Butala explains the case witnessing process and the retaking of a “failed” case.

“Our greatest glory is not in never failing, but in rising up every time we fail.” 
― Ralph Waldo Emerson

Everybody will share their successes, but it is through failures that we learn the most, because we suffer many a sleepless night with them, we ponder them, meditate over them and fight with ourselves. Failures are the true test of our whole understanding and if we come out of it successfully, then it is worth a lesson to share with all…!

When I delve deeper into a failure case, it induces me to unlearn and relearn and in the process opens up new vistas, furthering my journey both as a healer and as an individual.

So today when I have this platform of Hpathy, I thought it would be worthwhile to share a case which didn’t work out the first time I gave him a remedy. It was followed by detail follow ups but the remedy didn’t bring out significant changes in the patient as expected. This made me wonder what went wrong in the case, when I was sure of the remedy after the first interview, and what should I do now?

The question which obviously arises is, what do I deem as a failed case?

The following criteria are applied to understand that the case is not progressing and the patient needs a reassessment:

  • Patient is not improving at all – physically, mentally or holistically
  • Patient improves for some time but comes to a standstill, and inspite of frequent repetition doesn’t progress or he improves in one aspect – physically he might be doing well but mentally and emotionally there is no change at all or vice versa; in both cases the remedy we are giving appears to be a partial similimum.
  • In one-sided cases where during the first case there were only PQRS symptoms in one area, related to only physicals or one situation alone, and not holistic PQRS in different areas. In these cases, I know beforehand that the patient will undoubtedly need a retake/ reassessment a few months down the line.
  • When some new PQRS or out of place expressions are coming up in follow-ups which do not seem to be a part of the remedy we are giving the patient. This makes a bell ring in my mind that I have not understood this person completely and there is still something unexplored.

I follow the three steps of Case-Witnessing Process in my practice:

  1. Passive Case-Witnessing Process (PCWP) – is the first step of the case taking process. Here we give the patient time and space to speak whatever is coming up spontaneously, in the moment. We note all expressions which are not related or common to his situations.

Other points which we note during the PCWP are –

  • Whether the patient is in touch with himself?
  • Level of experience – On which level is the patient vibrating? Whether he is seeing everything at the name/fact/feeling/delusion/sensation/energy/ nothingness level. This will also determine the potency we need to give.
  • Area? Whether the patient is stuck in one local area or going to various general and vital areas.
  • Hand gestures/ eye movements – These are the non-verbal expressions of the patient which denote where the patient’s energy lies.

Once these points are clear, we start the Active Case-Witnessing Process.

  1. Active Case-Witnessing Process (ACWP) – We start asking about the focus and the patient qualifies it further with more characteristic expressions. The whole aim of ACWP is to confirm the focus.
  • Active- Active Case-Witnessing Process (A-ACWP) – Once the focus is confirmed, we keep the patient with it and cut all his conscious talk. The Kingdom, sub-kingdom and the source become clear at this stage.

These are the 3 basic steps of Case-Witnessing Process. However when we are re-assessing the patient, don’t you think these steps need some modifications? This time the patient is also aware of the entire process, hence we need to tread with caution and be absolutely sure of the focus and centre of the case.

  1. So the first step is to have a longer Passive and Active CWP without focus. The benefits of this technique are twofold – One, a longer Passive CWP gives the patient additional space and time to go in to many more areas which he may have previously hesitated to go, and many more qualified and peculiar expressions come up. For the physicians, it provides us with many more areas/ PQRS terms to explore during the Active CWP.
  1. The chief complaint area is one of the most important and credible ways to get the total picture. We explore the chief complaint area thoroughly and obtain the –
  2. Exact location, the side and the physical appearance of the affected area, the local sensation experienced, the modalities, other aggravating and ameliorating factors, any concomitant symptoms, also the ailments from and the origin, duration and progress of the complaint. This gives us an idea about his physical particular symptoms, i.e. physical symptoms pertaining to the chief complaint.
  1. Understanding his mental/ emotional and holistic state. I ask him questions such as –
  • What do you feel because of the disease?
  • What thoughts come to your mind because of the disease?
  • Deep within how does it feel to have all these complaints?

The advantages of exploring the chief complaint in detail are –

  1. It gives us the direct rubrics/ references towards the remedy and
  2. It also gives us the thematic understanding of the patient through his delusions and central state

And the confluence of both leads us towards the exact similimum. 

  • Another important step is to take the focus/previous PQRS expressions which we had understood in the earlier CWP and see whether it connects with the present focus also.
  1. Now that we have obtained the holistic focus we confirm it once again in ACWPlet us call it ‘Active with focus’. The most important point here is to persist with the focus, till the patient starts joining the out of place, out of order, PQRS expressions of PCWP and you are absolutely sure of the focus.
  1. The Active CWP is followed by the Active-Active Case Witnessing Process towards the patient’s source.
  1. At the end of the CWP – we confirm the remedy by asking about the PQRS expressions of PCWP which the patient has not yet connected spontaneously. We ask the patient about these and see where they lead us to.

We also confirm the remedy by considering the rubrics and also the thematic Materia Medica.

Let me illustrate this with the help of a case:

The patient is a 34 year old male, with complaints of hypertension, recurrent sinusitis and nose-block and hairfall. The treatment was started with Medorrhinum, followed by Amyl nitrosum after a detailed follow-up. The patient was not better and hence a reassessment was done to see what we were missing.

(NOTE: The case has been edited for brevity. Peculiar sentences are highlighted in italics. My explanations, observations and notes are in plain brackets ( ) or are mentioned in points.  D, P, stands for Doctor and Patient respectively. Follow ups have been summarized at the end of the case. Also the patient’s sentences are as he has expressed them – in his own language and flow)

PASSIVE CASE WITNESSING PROCESS

D: I want you to be in this moment as if you are meeting me for the first time, whatever spontaneously comes up keep talking, saying what you think will help me to understand your individuality.

P: Light headed and lethargic feeling with complaints of sneezing and nose block. Get too much anxiety, because of that feel too much acidity (HG claw closing). Any excitement catches me. It is like a wave.

(Note that even while describing his chief complaint, the patient is giving us qualified expressions. (Patient has connected his physical complaint with ‘anxiety’, and a hand gesture has also come up, so we know ‘anxiety’ is important in the case. Another peculiar expression has come up when describing ‘excitement’ – we make a note of it.)

D: What else about you, your stress?

P: Something wrong is there, negative things come first, work or health, thought process is not positive. I get hyper very fast, very irritated, within a second I get hyper, but cool down easily. I try to be calm, but on the smallest things I get hyper. Whole day I am just thinking too much. Brain goes (HG – finger rotating) too much thinking.

(Since the patient was not going further into different areas of his life I decided to explore the childhood area, to see what comes up. It is a sub-conscious area without any conscious cover-up and hence whatever comes up will be pure, undiluted language from the patient’s centre)

D: Tell more about your childhood nature, your childhood, whatever you remember.

P: Very sober, very shy, carefree. Not aggressive. Since last few years very aggressive and get hyper very soon… (Eyes upwards) In work and relationships I think too much. I get very hyper.

D: More about your childhood.

P: I have always been a very true partner or friend – one upon who you can rely on. If somebody is in pain, I think too much about it. Thinking too much is affecting my system; small things affect me since childhood. Since childhood, my stomach is very sensitive.

When I think too much, I sweat.

(A physical expression with ‘thinking too much’ has come up, so we know that this is important)

D: Go back and see what else is coming up.

P: Mind is working too much. I visualize a lot.

D: What childhood fears did you have?

P: Ghosts and horror movies; after watching horror movies I couldn’t sleep for 8-10 days, now also I can’t sleep. I can’t go to hospitals and see blood or surgeries – I get vertigo and sweating. If I hide anything from my parents that also used to give me fear.

Used to be very excited in childhood – when we used to go to cousin’s place, hill stations etc. Anxiety is also from my childhood, any excitement, anything which makes you happy, then anxiety comes.

(Narrates one incident) – I had to go and stay in a hostel – but I stayed for only 3 years – I was having constant thoughts about home. I am very attached to my mother.  Now also, whatever I am doing, whether my relations or my work I tell my mother.

During my final exams, my weight used to decrease because of too much thinking.

Maybe I am a thinking and cautious personality.

I am not open, I can’t express my feelings.

D: Tell about any abstract fears.

P: Exams, doing any wrong thing even if it’s a small thing. If there is a quarrel with anybody I go and become friendly with that person, I don’t hold grudges. I always think that I have to be disciplined, I am alone here, so I shouldn’t do weird stuff. If I scold someone, immediately I will try to make that person feel nice.

(Since there was nothing new coming up, I decided to explore his dreams – a subconscious area, to see what comes up)

D: Tell me your dreams, since childhood, whatever dreams you remember.

drownP: Once I saw that water has reached even the top of my building and the whole world is getting drowned. Sometimes ghosts, sometimes dreams about childhood and going out with parents, not reaching exams on time, and too many planes flying in the sky. This dream I have got many times. Sometimes I see that a helicopter has crashed.

There is an island and I am there with my relatives and they are leaving and I am not able to reach a boat. And I also get dreams of falling from a building.

D:  Was there any incident which had a deep impact on you?

P: (Narrates incident about keys left in the car and the car crashed) I was very afraid that father will scold me. Operations, accidents and blood if I see I get vertigo and sweating. When I was in the hostel I used to write to mother daily that I don’t like it here. Superstitious about some things… my mind becomes hyper and I keep thinking about it.

(Till here I had explored various areas, specially his subconscious areas. I have got the focus, but since it is a retake, I will still re-confirm it in ACWP.)

Focus – ‘small things affect me and I think a lot’

Comments

Whether patient is in touch with himself? Yes, since he is speaking about his situations, feelings, and perceptions spontaneously. There is no recurrent defense coming up.

Level of experience? Higher, as patient is describing qualified emotions and perceptions. Also, his constant eye movements upwards denote a higher level of experience. Hence, higher potency i.e. 1 M.

Area? Patient was speaking on a general level and was neither stuck in the local nor going through vital areas, hence general area.

Hand Gestures/ Eye movements? Few Hand gestures have come up at the start of the case, we note if they get connected further.

Eye movements were upwards which hint towards an imaginative/ visualizing personality. This knowledge tells me to use imaginary questions and visualization techniques during ACWP and A-ACWP.

Apart from the focus, I noted that I also need to explore –

  • Excitement, catches me and causes anxiety
  • Dreams
  • Fears

ACTIVE CASE WITNESSING PROCESS –

D: So, talk about this – ‘Small things affect me and I start thinking a lot’.

P: Suppose if I break something, then I hide it. If I don’t get good marks, then I used to hide it. If I have a fight, I hide it. They shouldn’t know any wrong thing I have done. They will scold you if you have hurt them. Now also I hide from friends and family things which will hurt them. I don’t want to hurt them.

If it is a personal thing, still I don’t tell them. Don’t open up easily, from childhood it is my nature. All these small things affect me and I start thinking a lot about it.

(The focus is confirmed since he has generalized it. He has connected many areas and described the same reaction of hiding things, so as not to hurt his friends and family. Here, I asked him to describe the fear behind this reaction of his, to understand his depth.  Also, now we know why he was given Medorrhinum earlier – the whole feeling of ‘hiding whatever I have done wrong’.)

D: Why, what is the fear?

P: I try to mould myself, listen to everybody. I can’t say ‘no’ to anybody – try to make the other person happy. I try to avoid it but do it. I don’t want to hurt.

(I noted that the patient is qualifying it further with new expressions, so I kept him on the fear to understand it in its entirety. Also, since the patient is an imaginative person, I ask him to imagine the fear.)

D: Imagine the worst that can happen, imagine the worst fear?

P: They might not talk with me…

D: Imagine the worst that can happen?

P: They shouldn’t think wrong about me… I don’t want to lose that person… that will be the worst.

D: So what can happen?

P: I will be left alone….

(Here, I kept the patient on – ‘fear of losing the person and left alone’ however he didn’t go any further; so I started exploring the other PQRS from PCWP to see what else is coming.)

D: You said – ‘Excitement comes like a wave’. What does that mean?

P: Too much excitement even going for a movie, even small things cause excitement, anxiety comes, blood circulation becomes fast.

D: What happens in that excitement and anxiety?

P: Hyper, wave comes for few seconds, but once I start doing that thing then I feel better. Suppose suddenly some plan gets fixed, suddenly suppose if I have to meet someone then anxiety comes.

D: What thoughts come? What do you feel?

P: Nothing… when I meet someone for the first time, I shield myself, don’t open up. That person has to make me comfortable, to open up more. (The patient has joined other PQRS from PCWP – ‘not opening up’ with ‘anxiety and excitement’, so we know that this important and part of his centre.)

(Now, I explored the dreams further) –

D: Which are your scariest dreams?

P: Water is reaching the top of the building. And the island dream – water is advancing and I am stuck there and everyone is going and I don’t have a boat.

D: Tell more about the ‘Water’ dream? What happens and what do you see exactly?

P: Water is rising and we all will get drowned and die. Other people are getting drowned. I might also die. Island – island with bungalow and we all are enjoying – everyone is running, and I am just left alone.

D: Worst fear?

P: I am alone, I die and drown. (Again the patient has spoken of ‘being alone’, which earlier he had said in relation to ‘small things affect a lot, thinking too much and hiding his mistakes’)

D: And the ‘Helicopters’ dream, what do you see and what do you feel?

P: They crashed just near me, and I see thousands of planes flying, and I wonder what’s wrong, why there are so many planes? (Again I used a visualization question to understand the depth behind his dream)

D: Just to complete the dream… imagine?

P: They shouldn’t throw bombs, they could be war planes

D: What is the worst you can imagine?

P: You can die, war kind of thing, throw bombs and everyone dies.

(I explore his fears now.)

D: What was the exam fear?

P: Will I pass or not? Will I write the right answers? Not able to sleep for 2-3 months, what questions will come? What will parents and cousins say?

D: If you fail, what’s the worst that could have happened?

P: I will feel ashamed, they will laugh at me, parents will scold me, during family get together, what will they say or think about me? They will taunt me. Even now, when I am shooting, I am very, very afraid, although I have learned my dialogues.

(Connected his present work situation with his past fear of ‘exams’ – so we know that this fear is holistic and part of his centre. Also, we know that fear and anxiety is coming up in each and every area of his life and across time-zones, so I asked him about the worst fear, to see where his centre lies exactly.)

ACTIVE – ACTIVE CASE WITNESSING PROCESS –

D: So what is the worst fear and anxiety that bothers you?

P: What will the other actors, director say? They will say, “He doesn’t know…”But once I start shooting then feel better. After the first exam I feel better. It is only the first, the first exam, the first shoot, the first meeting – that is where I am afraid, that causes anxieties and butterflies.

(The patient has generalized the feeling and told us where he is exactly. Also, since the patient’s centre was clear, I now asked about his Physical Generals and ended the case.)

Physical Generals –

Cravings – chicken and paneer           Aversion – spicy       Perspiration – scanty                                                   Thirst – less                                                          Thermals – Hot

Now, let us reach the remedy step by step –

We all agree, that the patient’s centre is –

  • Fear of being left alone, fear of losing close people
  • Anxiety about smallest things
  • Fear of being scolded, injections, blood, surgeries, ghosts
  • Sensitive to being laughed at
  • Unable to express, can’t open up
  • The first – exam, meeting, shot – causes anxiety
  • Cautious personality
  • I am a person, on whom you can rely on
  • Very attached to mother, dislike for staying away from home
  • Get hyper and excited very fast
  • Dreams of bombings and wars and helicopters crashing
  • Fear of being stuck
  • Suddenness causes anxiety

Kingdom – The theme is of Mineral kingdom – as the patient’s issues are all related to ‘I’ and ‘myself’, there are no pure sensitivity (Plant Kingdom) or one vs. other (Animal Kingdom) issues. ‘Dependency’ comes up strongly in the case, where the patient himself is ‘dependent’ on someone or he is a person on whom others can ‘depend/rely’ on.

Here the fear and anxiety is of being alone and of taking the first step. During the A-ACWP – there is no opposite sensation with this fear or a reaction to this fear; which would indicate the Plant kingdom. Neither is the fear associated with any survival or attack issue which is the theme of the Animal Kingdom.

Sub- kingdomThe patient needs a remedy from the 4th row of the periodic table – since the issues of family and task predominate.

However, he is right at the beginning of the row, that is, 1st column, where there is complete dependency and panic even at the thought of losing the person he is dependent on. The dependency is for completing the task or for security. This was reflected in what the patient spoke, in his behaviour and also in his dreams.

Also, for him, taking the first step is the problem – whether it was the first exam, and now the first meeting or the first shoot, which again indicates the Kali component.

The second part was about ‘getting hyper, angry fast, excitement causing anxiety’ along with dreams of wars, bombings and crashing pointing towards Nitricum. Nitricum also has fear and delusion of ‘being stuck’. Nitrogen is placed in the 2nd row of the periodic table, where the theme is of the birth process. In Nitrogen the birth process has started and is undergoing labour. Hence we see lot of suffocation and air hunger.

The Materia Medica of Nitricum is closely linked to its chemical properties. It is a known combustible substance and the themes of ‘destruction on mass level’ have come up in the provings too. Nitrogen causes vasodilation resulting in congestion, burning sensation and redness of parts, which was also observed during the provings. Nitrous oxide (laughing gas) is known to cause excitement and light-headedness in subjects who inhale it.

From Prisma –

Kali nitricum –

Region – Vasomotor system, cavities (blood vessels, heart, kidneys).  Respiratory organs. Right sided

Leading symptoms

Mind – Conservative, regular, down to earth and combined with the Nitricum element – resentment, anxiety about health. Desire to enjoy himself. Anger and paranoia – thick wall of anger around them, anger combined with paranoia, fear of police coming to get them, devious, mistrustful and rigid individuals

Work – mental aversion to work, but once they begin they work very hard to complete it themselves

Generals – < cold, wet weather – hydrogenoid constitution, marked susceptibility to coldness and to cold damp weather. External sensitiveness – of scalp, abdomen, testes

Particulars – Chronic rhinitis and obstruction of nose

Rubrics

Mind

  • Anxiety and congestion to chest
  • Cautious
  • Dreams of danger, of falling from high places
  • Fear of death

Remedy differentiation – (From Prisma) –

Amyl nitrosum –

Region – Vasomotor nerves, respiration, left side

Action corresponds to physical effects of mental emotions; fright causes throbbing, anxiety about health, as if something might happen; anxiety during menopause

Flushing, congestion, sudden redness of face and abnormal sweats

Sunstroke; symptoms > open air, > cold air

Fainting and dizziness

Amyl nitrosum comes very close to Kali nitricum in physical symptoms, however the Kali part of – dependency for security and task, attachment to family, the first step of any task causing anxiety and panic, fear of losing close people, lack of confidence – is missing.

Hence it proved to be a partial similimum.

Medorrhinum –

Region – Mind, nerves, mucous membranes, cellular tissue, lymphatics, spine, kidneys

Anxiety about health, money, family

Shuns responsibilities; Confusion

Puts up a bold, egoistic, rude and aggressive front to cover his inner feeling of powerlessness and inner weakness

Sensation of unbearable inner emptiness, sensation of being rejected, doomed, weird thoughts resulting in efforts to escape.

Contrasting extremes in one person

Medorrhinum is similar to Kali nitricum with respect to the anxieties in multiple areas however the ‘feeling of inner weakness/ emptiness and need to completely cover up/ hide and put up the opposite front’ is missing in the case. Hence Medorrhinum didn’t help the patient much.

Remedy given – Kali nitricum, 1M, one dose, to start with.

Follow-ups –

Doses were repeated when either the physical or the mental or the emotional symptoms would flare up. Kali nitricum also helped the patient during his acute illnesses.

First 2 months – Nose block and sinusitis improved by 70% and he reduced the antacids from 1-2 tablets per day to 2 tablets per week. Lethargic feeling reduced, energy levels improved. However the anxiety before meetings was still there.

After 4 months – patient overall doing much better – physically, mentally and emotionally. Acidity is better, colds and sinusitis much better, now he is not affected by cold weather. Anxiety and getting hyper has reduced. Dreams, no longer destructive or of being alone. He had a dream that he is going in a spaceship with family and laughing and enjoying. Anti-hypertensive reduced from one daily to one in two days.

After 6 months – no physical complaints, mild acidity occasionally. Mentally and emotionally able to cope up well and relaxed. Anti- hypertensive stopped since blood pressure consistently normal. The whole state of ‘dependence and anxiety at first step’ reduced considerably.

About the author

Sayali Mehta Butala

Dr. Sayali Mehta Butala completed her BHMS in 2008 and MD (Materia Medica) in 2012. She has been working with and training under Dr. Dinesh Chauhan for the last three years. Under his guidance she is also writing a book with Dr. Chauhan on advanced case taking in complicated cases, like pathological cases, geriatric patients, retakes, psychiatric patients, patients who have faced abuse, autistic children etc. Dr. Sayali Mehta Butala is one of the senior doctors at Swasthya Homeopathic Healing where she looks after these difficult cases along with Dr. Dinesh Chauhan.

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