Maladaptive Stress Response, Personality Patterns, and Fatigue with Alex Howard

Living in a pandemic era filled with political, environmental, and social turmoil is tiring – downright exhausting. So is it any wonder the number of chronic fatigue cases has crept up to 1.5 million people in the US? In this episode of New Frontiers, guest host Dr. Patrick Hanaway talks with Alex Howard, the creator of the Therapeutic Coaching methodology and Founder of The Optimum Health Clinic, one of the world’s leading integrative clinics specializing in chronic fatigue syndrome. Alex has published several research articles and books on the topic, with his latest book, Decode Your Fatigue: A Clinically Proven 12-Step Plan to Increase Your Energy, Heal Your Body and Transform Your Life – just published. In addition, he is currently working on a randomized control trial with the UK national health service, NHS, as a follow-up to a preliminary study on his integrative approach to chronic fatigue syndrome. Dr. Hanaway and Alex discuss the key factors contributing to fatigue, using personalized mapping to untangle the picture and the importance of intervention sequencing to create positive, long-term shifts in patients’ well-being. I’m so proud to have these two incredible humans sharing what they know with all of us on New Frontiers – it’s an amazing conversation and I could listen to them talk all day! Please leave a review, rating, and share this episode far and wide! ~DrKF

Maladaptive stress response, personality patterns, and fatigue with Alex Howard

with Special Guest Host Dr. Patrick Hanaway

How can we help patients struggling with fatigue and a multitude of related symptoms who are not improving with treatment? In this episode of New Frontiers, Dr. Hanaway interviews Alex Howard on the complexity of treating chronic fatigue and how creating personalized maps can help put the puzzle pieces together. Alex is a therapist, expert speak, author of several research articles and books, and the founder of a world-leading integrative medicine clinic specializing in chronic fatigue. Using his own 5-year healing journey and 18 years of clinical work, Alex shares with us the two primary maps to unrooting and recovering from chronic fatigue. He takes us through factors such as personality patterns and loads that can trigger fatigue and the states, stages, and interventions for effective recovery from chronic fatigue. Alex also highlights the importance of curiosity, compassion, and honesty for improving patient compliance and inspiring lasting change.

In this episode of New Frontiers, learn about:

Dr. Patrick Hanaway: And here we go: Welcome to New Frontiers in Functional Medicine where we interview the best minds in functional medicine. And today is no exception. I’m your guest host, Dr. Patrick Hanaway sitting in for Dr. Kara Fitzgerald. And I have the pleasure today to speak with Alex Howard. Alex is the founder and chairman of the Optimum Health Clinic, one of the world’s leading integrative medical clinics specializing in fatigue with a team of 25 full-time practitioners supporting thousands of patients in over 50 countries. The Optimum Health Clinic team has pioneered working with patients remotely since 2004. Alex has published academic research in publications such as the British Medical Journal Open and where I first heard about his work. As well as author of a book called Why Me? My Journey from M.E. to Health and Happiness. And a new book coming out in October called Decode Your Fatigue. We’ll hear more about that.

Alex is the creator of the Therapeutic Coaching Methodology. And since 2020, he’s been documenting his therapeutic work with real life patients in his In Therapy with Alex Howard YouTube Series. He’s put on a series of large online conferences, which have been attended by over 350,000 people. And so, Alex, you’re doing great work in the world and really appreciate you being with us here today.

Alex Howard: Thank you, Patrick. It’s a pleasure to be here. It’s a subject that’s perhaps a little closer to my heart (laughing) than I would like and I’m always really happy to have the chance to talk to people about it. So, thank you.

Dr. Patrick Hanaway: Great. Well, why don’t we get started there? It’s close to your heart. What got you started working with fatigue?

Alex Howard: Well, I think like a lot of people, working in these areas, I came in through my own personal experience. I was 15 years old and I don’t know what a normal childhood is, but I had three loves at the time. I loved music, I loved sport, and I loved my then girlfriend. And one morning I woke up and it was almost like there was an energy supply into my body. Somebody had pulled that out, and it really catalyzed the first two years of that journey. And I remember actually at that time the doctor saying to me, “It might be six months for you to get back to normal.” When you are 15, 16 years old, six months sounds like someone’s given you a life sentence. And then six months became a year, became two years, and symptoms from a severe fatigue, at times bed-bound, often house-bound, muscle aches, headaches, dizziness, and sleep problems. I think it often seems ironic that you’re tired all the time, but you can’t sleep.

And after two years of this, I reached the point that I wasn’t suicidal in as much as I wanted to end my life. The thought of continuing the path I was living just seemed so horrific. And I had a conversation with my uncle who was someone that was a bit of a hero to me at that time. He had an indie record label and I was in this quite, I thought great punk rock band. I listened to the recordings, now I’m like, it’s amazing how things can sound different with a little bit of time. But I had this conversation where he helped me realize that if I wanted the circumstances of my life to change, then I was going to have to be the one to change them. And this catalyzed a five-year healing journey. And in those five years, I read hundreds of books. I saw dozens of practitioners. I became very committed to meditation, yoga. Changed my diet numerous times. At one point… not something I recommend, but at one point I think I was taking 70 supplements a day. I think I had the most expensive thesis in South Wales perhaps, I was at university at the time. But I just did everything that I believed could help facilitate my recovery.

There was no one magic answer. And even these days, I’m a little intolerant to anyone that comes out and says, “This is the answer to fatigue,” because I think it’s a complex picture and different things help people in different ways at different stages of the recovery process. And I didn’t, obviously, have a map. It was a little bit like trying to navigate from where I am in London to where you are in the States without a map. And you sometimes find yourself walking days in completely the wrong direction. And it was enormously frustrating at times, but I ultimately was able to find the interventions and the approaches that facilitated my recovery. It was a five-year process from actively working on that healing journey.

And along the way, I think like a lot of people that go through very difficult life experiences, it changed me. And it changed the things that mattered to me in life. I still like sport and I still like loud punk rock music, but the thing that really became my life’s mission and my life’s purpose was to hopefully help other people in similar situations. And that was really the origin of, around 18 years ago now, founding the Optimum Health Clinic.

Dr. Patrick Hanaway: And so, with the Optimum Health Clinic, what you did was you brought this, what we might call, eclectic array of different kinds of therapeutic approaches, but you began to work with them in creating a map of really how to take those interventions and put them together. Maybe you could just talk about the interventions first, maybe categorize them. And then let’s talk about how we really focus on creating a map that is in bespoke, if you will, or personalized for each of the participants.

Alex Howard: Yeah. Part of it was I mentioned in my own healing journey, I didn’t have the map. Well, when we started the Optimum Health Clinic, we also didn’t have the map, but there were… of course, this was 2003 at the time. There were lots of people out there doing interesting things. The thing was, there weren’t many organizations or practitioners that were particularly bringing those different pieces together. And I think one of the talents that I and some of the early people involved in the Optimum Health Clinic had is we… Well, firstly, we had a passion and we loved reading and we loved studying different people’s work, but also the passion to try to pull these different pieces together and try to make sense of them. And quite quickly in that process, we realized that there are different subtypes of people in the fatigue population. There are different stages of the recovery process. Things like the state that our nervous system is in is really important.

And so, my background whilst I was at university… I studied psychology in university. And while I was at university, I did a lot of training in things like NLP, EFT, hypnotherapy, life coaching, psychotherapy. Particularly looking at brief therapeutic interventions. I was, particularly at that time in my late teens, early 20s, wasn’t particularly inspired by the idea of spending years in therapy to make sense of things, but I was interested in ways that you could create significant change in short periods of time. And so, with my backgrounds on the… Yeah, you have question, Patrick.

Dr. Patrick Hanaway: Just for the acronym challenge. The NLP, neuro-linguistic programming; EFT, emotional freedom technique, a couple of different tools that are available. Just want everyone to know what you’re referring to. Go ahead.

Alex Howard: Yes, thank you. It’s very easy to start using acronyms left, right, and center. Thank you for pulling me up on that. So, that was my background on the psychology side. And then I met a nutritional therapist who… Nutritional therapy had been an important part of my own healing journey. And I recognize that psychology alone was not going to be enough. And I didn’t want to fall down this trap that I had seen so many people doing of, they have their lens and their lens almost over time gets increasingly narrower because you see things the way you see them then you get the confirmation bias that you look for the things you look for. And it’s a little bit like the way Facebook tends to curate people’s Facebook feed. The stuff that you like and you engage with, you see more of, and you increasingly see less of the stuff that challenges your perspective.

Dr. Patrick Hanaway: Right. We call that an echo chamber. Yeah.

Alex Howard: Right. Exactly. Exactly. And so, because of my own experience of seeing dozens of practitioners and being on… People will often say that the fatigue population, “Oh, we know they’re not very motivated and they’re quite negative that things aren’t going to work.” And the thing I always say to people is well, “See what happens if you go to see multiple practitioners that all inspire you with the hope you’re going to recover and then months and years later, you’re worse off financially, worse off physically because you haven’t made the progress you hoped. You’re also worse off emotionally.” And I don’t think the fatigue population is inherently negative. I think they protect themselves from the disappointment of investing too much hope in things that then don’t deliver on the promises they’re expecting.

So, I was very cautious to not set up an organization which was recreating, quite honestly, some of the traumas that I’d experienced on my own healing journey. And so, having a framework and a methodology which was as broad ranging as possible. And I was very inspired, particularly, in those days and still these days by the work of Ken Wilber, who’s a very well-known American philosopher and his integral theory of pulling together different jigsaw pieces. And was really inspired to try and do the same thing for understanding fatigue.

And so, I was working on the psychology side. There was a nutritional therapist working on nutrition side, and we really grew the foundation from there. Very quickly, we became hugely in demand. I think partly because there was a real absence of people doing what we were doing and we got lots of things wrong. We made lots of mistakes. I was in my early 20s and suddenly running an organization that had lots of staff and lots of complexity that goes with that.

And we were enormous and still are enormously passionate about the work that we were doing. And just like we did as an organization, and just like I had done on my own healing journey with our patients, we learn from mistakes and we learn with them. And we were always as upfront as we could be and said, “Look, this is what we know. This is what we know that we don’t know. And there’s lots of things that we don’t know that we don’t know.” And we learned through the process of doing it.

And those maps really have grown out of lots and lots of trial and error. And one of the reasons why I waited as many years as I did to write my new book, Decode Your Fatigue, because many times over the years, I had reached out to publishers with other books I wanted to write, and they would say, “We want you to write this book.” And I’d say, “I don’t want to write that book.” And the reason why I didn’t want to write it was I just felt to pull together all of these different pieces in one book just felt too complicated. The process of doing it has been great, and I’m really proud of the book that’s come out of it, but these maps are constantly evolving and they’re constantly changing. And it’s one of my great loves, working as a practitioner, is the constant learning. As I know that you know, it’s challenging when you have patients in front of you where you’re doing your absolute best, they’re committed and it’s not coming together. They’re the ones we learn the most from, but it still leaves one with a heavy heart at the end of the day.

Dr. Patrick Hanaway: Yeah. So, in that kind of theme and variation, as you’re working with individuals, you’ve talked about how you really are interested in sequencing the interventions to be able to see how the pieces fit together. And within that, you’ve talked about… There’s a number of subtypes of fatigue. There’s number of stages of fatigue. There’s a number of nervous system states that are going on, but in your book you’ve kind of honed that down, at least, on the theme, they say theme and variation, on the theme of two primary maps of fatigue. What are they?

Alex Howard: So, the first map is the map to decode someone’s fatigue. What are the ingredients that tend to come together to create the experience of fatigue? The second map is the map that we use towards the recovery process. So, just to kind of break it down a little bit. The map to decode fatigue is genetics plus personality patterns times by the loads on one’s system. And that is what equals the impact on one’s bodily system. So, to break that down a little bit more. The research is, and actually I quote some of Dr. Kara Fitzgerald’s research in this part of the book, that there is a modest amount of genetic impact when it comes to fatigue. Obviously with the emerging work on epigenetics, we recognize that that isn’t a guarantee or a life sentence. We can turn on and off, but there is certainly a genetic element.

And it’s certainly something anecdotally that we see in our patient community that I’m thinking of one particular family where mom and dad, and two out three children have experienced fatigue over the last five years, but there certainly is a genetic element that goes on. But then what we came to realize over time is there are certain personality patterns or types which are more likely to be prone towards fatigue, perhaps versus certain other conditions that one might experience.

And I’m mindful of talking primarily to practitioners here, but if there are those affected by fatigue that are listening, I recognize that this is a sensitive point because a lot of people have been told, “You have fatigue because you’re an anxious person,” or “it’s all in your mind.” And I want to be very clear that I’m not suggesting that fatigue is a psychological condition. It’s a very real physical experience. And there are certain energy-depleting psychologies, certain ways of relating to ourselves and the world, which become a drain on our system.

And so, just briefly, those personality patterns are: the helper pattern. This is where we make other people’s needs more important than our own. And an example might be, we get home from work. Our body’s telling us we’re tired and we need to rest. We get a message from a friend and they’re in need, and we prioritize their need as being more important than our own. And that’s a consistent pattern of how we relate to people in the world.

The second is the anxiety pattern. This is where we often try to think our way to a feeling of safety. We don’t feel safe in the world. Our mind and our nervous system speeds up to try and create that sense of safety. Third is the achiever pattern. This is where we define our self-worth by what we do and what we achieve in the world. We’re constantly pushing ourselves beyond our edges and our limits. We then have the controller. This is where we feel a sense of safety only when we have control of ourselves and the environment. And then we have the perfectionist where for us to feel safe, we need to do things perfectly or so often to feel loved, we need to do things perfectly.

So, these five personality patterns create a way of being in the world, which is inherently draining. We’re constantly putting more demand on our system than it necessarily has the capacity to meet. So, we’ve got the genetic element. We’ve got the personality patterns, these ways of relating to the world. We then have the loads. These are the different burdens and impacts that might happen to our system.

One of the analogies that I heard many years ago, in fact, during my own recovery process that really stuck with me is it’s like loads on a boat, and it’s no one load, which is too much for that boat, but the more loads that you get… Sometimes you can have a relatively small final load. And that’s the load that actually causes the boat to start to sink.

Dr. Patrick Hanaway: Right. Which we talk sometimes as a trigger within functional medicine, but it was just the last component. So, if you take care of the trigger, let’s say it’s some Lyme infection or some mold exposure, or some nutritional deficiency, it in and of itself is not sufficient to be able to take care of the problem because as soon as you have a little more load in some other domain, you’re going to have it. One of our mentors, Dr. Sid Baker, called it the tack rule. And he said if you sit on a tack and you remove it, you feel better, but if you sit on three tacks and you remove one, you don’t feel like one third better. You still have pain and suffering.

Alex Howard: Yeah. One of the things I say to practitioners is triggers can be red herrings. That you can think you’ve cracked it because you found the trigger, and actually you found that the final straw that broke the camel’s back, to mix metaphors slightly. Actually, what you need to do is find out all the other loads that have become too much for the body in the first place. And examples of loads, loads can be environmental loads. So, they could be toxins in the environment. They could be living in a home with mold. Loads can be physical loads. It can be your digestive system is not working in a way that needs to, and you’re not making energy and therefore there’s a load there. Can be psycho-emotional loads of these personality patterns which can mean that we’re less well equipped. But they could be ACEs, adverse childhood experiences, can be loads that we’re carrying in our system.

Figuring out these loads is important in as much as we want to understand the factors that have caused someone to get sick, but again, I think sometimes these loads, we can get over-fixated on the things that have happened in the history and not recognize that sometimes the loads have caused, for example, the nervous system to become overstimulated, become dysregulated. And we’ve got now this maladaptive stress response in the system and actually the loads have gone, but the system’s learned the response. And so, again, we can get… Sometimes, the value of maps is they simplify things. The danger of maps is they simplify things, but…

Dr. Patrick Hanaway: So, within that maladaptive stress response of working with individuals, how are you focused on working with them from the psycho-emotional state? Obviously, you’re going to be working on having a good diet that they can eat and working with them on their lifestyle factors of physical movement and sleep, but where else are you working to focus on the maladaptive stress response?

Alex Howard: Yeah. So, just to complete on the second map. I think it actually speaks really importantly to this. So, the map of recovery. We’re looking at states, which is the question you just asked, and I’ll come back to in a moment, that for the body to heal it has to be in a healing state. Then we’ve got the stage. We map three different stages to the recovery process. We then have the sequence of how we put together those interventions.

An example might be that you’ve got a heavy viral load, so you think that the place you go to start is antiviral. That’s the logical starting point. But actually it might be, in fact, to bring the state piece in, if your body’s in a maladaptive stress response, you take the antivirals and actually your system reacts to everything you try to use to treat the body because it thinks everything is dangerous. So, one of our key learnings over the years, and I think we were fortunate to have a head start in this because we already had a psychology department right at the beginning whereas I think a lot of functional medicine practitioners start in the more physical terrain. And then in time, they increasingly realize the importance of addressing some of these other areas.

But our realization was that when you suffer from what could be classified as a medically unexplained illness. Now, obviously, you and I, Patrick, it’s not a medically unexplained illness. There’s a great deal of explanation, but certainly to the patient and to the traditional medical world, sometimes you’re told there’s nothing wrong with you, even though you have all these very debilitating severe symptoms, or you’re told there’s something wrong with you, but there’s nothing to be done about it.

And if I can just be forgiven a slight soapbox rant for a moment, and I was told to tone it down a little bit in the book by the publishers like, “Oh, it’s a bit carried away,” but it is the highest level of arrogance to say, “We can’t find anything wrong with you, therefore, there’s nothing wrong with you,” or “We recognize there’s something wrong with you, but we don’t know what it is, therefore, no one knows what it is.” I mean, if you just pause for a minute and think about those statements, it’s an unbelievable level of arrogance because the assumption is that that medical professional knows everything there is to know out there when it comes to a fatigue related condition. But when you…

Dr. Patrick Hanaway: Let me just interject for a moment because I think it’s a critically important point. Even when I’m talking with patients about neuroplasticity and retraining the brain and work of Joe Dispenza or Annie Hopper, I see them balking as like, “You’re telling me this is all in my mind? It’s not real?” And I’m like, “No, no, no, not at all.” And I’ll relate it to the microbiome and the gut made brain microbiome axis. And there’s a lot of stuff going on, and you can change it. That’s the beauty of neuroplasticity, which is, what it sounds like you’re driving towards in that maladaptive stress response. And until you have dealt with that, you can’t actually deal with some of those other physical aspects on the nutritional therapy side of things.

Alex Howard: That’s right. And the way to think about it is when you go and see a medical professional, and you’re so unwell, you can’t function in your life, and you’re told, “Either there’s nothing wrong with you or we don’t know what’s wrong with you.” You’re left with this incredibly actually traumatic experience because your mind and your nervous system’s going into, “What’s wrong with me? Why is it wrong with me? What do I do about it? Will I recover?” Just down to very simple things like, “Can I go to the shops this afternoon and buy food or will it make me worse and should I stay home and rest?”

So, what happens is fatigue patients, particularly, when they don’t have clarity of what’s happening, find themselves in a perpetual state of stress and anxiety. A healthy, appropriate, nervous system response to not knowing what’s wrong and to go into, “I need to figure this out,” becomes maladaptive. And what we find is patients often end up in their nervous system in exactly the opposite state to what they need to be in to heal.

I notice, Patrick, you did an interview recently on this podcast looking at cell danger response. And I think that’s a really helpful framework within which to understand this. My very simple way of explaining it is that our mitochondria, which are the kind of powerhouse of our energy, they have two fundamental functions within our body. The first is energy production, and that’s what everyone’s familiar with and what people talk about, but they have a second function that often people don’t realize, which is danger signaling. When there is threat in the environment, the job of our mitochondria is to spread the warning of that threat around our system.

But when our mitochondria go into danger signaling mode, they are de-prioritizing energy production. So, when we’re in a maladaptive stress response, apart from the impacts that many practitioners already may be aware of, there’s enormous amounts of research around the impact of stress on immune function, normally around students at exam time. But there’s also enormous research on the impact of stress on things like wound healing. That if we have a physical wound and we’re in a stress state, it takes longer to heal.

There’s a very direct relationship, which I think Dr. Robert Naviaux work speaks very, very beautifully to, sometimes in ways that are far too complex for my simple mind, but my simple way of explaining it is, when the body goes into a maladaptive stress response, it directly impacts upon physical energy production. And so, to turn off that nervous system response is often critical, not just to energy production and one’s day-to-day energy, but also…

I remember pre the London bombings back in the early 2000s. Regularly, people would leave bags on the underground. Like someone would leave, I don’t know, their tennis clothes in a bag and we used to get these announcements on the underground in London saying, “Please do not leave bags unannounced,” because the worry was it might be a bomb, but no one really paid that much attention. And it was just sort of a thing.

And then the London bombings happened and suddenly anyone saw… A bag left on the underground, the whole network shut down. Everyone freaked out because our level of threat was massively increased. So, suddenly we’re… in a sense, overreacting to a bag of tennis clothes left on the underground of the whole of London shutting down because the threat level is raised. The same thing happens in our bodies. When we go into this maladaptive stress response, not only do we start reacting to foods and to chemicals and things that are not actually dangerous to us, we can start reacting to the very treatments that are actually necessary to support healing.

So, we found over the years that… Not true for every patient, but for a lot of the patients that we work with. Starting with calming their nervous system, sometimes alongside working on the nutritional therapy side, and sometimes before, is critical to get the body into a healing state.

Dr. Patrick Hanaway: So, I want to… A couple of things. One is talking about Robert Naviaux’s work on cell danger response. We’re going to put that in the show notes and we’ll have a highlight of his work and the importance of that great note there. I love how you talk about the differential of the cell danger response versus energy production and the tube metaphor. Actually on a very personal level in 2009, we were on the tube and we got caught in one of those, and it separated my wife and I from our two teenage sons.

Alex Howard: Oh, wow.

Dr. Patrick Hanaway: And they didn’t have cell phones or know where we were staying in London. So, the trauma of that kind of event, it’s a great metaphor for me because that’s still felt 12 years later in terms of like, how could you leave us there? And I think that’s what happens in the system. That maladaptive stress response. So, therapeutically, where are you going to help with that maladaptive stress response?

Alex Howard: Yeah. It sounds like a simple question and it is, but there are so many answers. I have a program called the reset program, which is a 12 week in-depth online program that we do with people. We try to come at it from a few different perspectives because for some people, it’s as simple as learning a practice like meditation and just learning to be more present and more connected in the moment. And I’m a great advocate of meditation, and I think for a lot of people, it’s incredibly helpful, but what can happen is, firstly, there can be so much trauma in the body that as soon as one comes into the body, it actually causes a higher stress response. For other people what can happen is you calm the system down whilst they’re meditating. As soon as they stop, the body goes straight back in to the maladaptive stress response.

So, we’re really looking at what are the thought patterns that someone’s been conditioned to think, which are consistently sending those messages to the nervous system to activate it. Example might be that every time someone notices that they have a particular symptom, their brain goes into, why they got the symptom, what caused it, what do I do about it? Another example might be that every time someone gets invited to go and do something, they immediately start to think about what if they crash. So, there’s triggers and patterns that we’ve got. And often these are unconscious initially. When I say unconscious, what I really mean is things that are not currently in our conscious awareness. It’s not some deep, dark mystical thing that… We need to bring awareness to those thought patterns.

Dr. Patrick Hanaway: Blinders.

Alex Howard: Yeah. And again, for some people, that’s enough. We recognize those patterns. And I often say, if you can see it, you don’t have to be it. The more awareness we have of the pattern, the awareness alone, is sometimes enough to change the pattern. That said, often these patterns are very well entrenched. You mentioned neuro-plasticity earlier. We literally get our nervous system wired to have certain responses and awareness alone. People sometimes say to me, “Alex, I’m seeing it and I’m still being it.” So, it’s having the strategies and the techniques to rewire those patterns. And there’s different people’s work that have been developing over the years. You mentioned Annie Hopper, there’s Ashok Gupta. We’ve all being doing stuff, I guess, for nearly 20 years. And I think coming at the same piece from slightly different angles. And I think all using a version of a stop process, a way of recognizing patterns and often foundations in neuro-linguistic programming of being able to catch patterns and stop them, and then re-shift the state in the system.

The other piece, which I found to be particularly important. And it’s something that a number of people that have been through some other programs out there have said that’s been an important distinction for them in the way that we work with this in the reset program is if we just recognize the patterns and we stop them and we rewire the focus. It’s helpful to a point, but often the traumas we’ve experienced and the anxiety is in our body. And for our body to heal, we also have to be in our body. And so, I have a very strong emphasis towards an embodied focus of meditation around coming out of our mind. And as we come into the body, often then what we’re doing is we’re working with the underlying emotions. As we come into the body, we start to feel the unprocessed sadness or anger or grief.

And often the reason why people have got so far into their minds and into their nervous system has been to escape underlying issues that have not been dealt with and processed. I talk about a safety loop where we feel unsafe in our body. Our mind speeds up to try and protect us. We then feel even more unsafe, so it speeds up even further.

Dr. Patrick Hanaway: Right. The body keeps the score.

Alex Howard: Exactly, exactly. Bessel van der Kolk. Fantastic book on the subject. And ultimately we have to… Another way I phrase it, you can’t heal what you don’t feel. So, we have to feel and metabolize and process the underlying emotions, I find, to get a really lasting shift in the nervous system. Otherwise, what happens is that people are using these strategies and tools to reset their system for years. Whereas, actually, they should be used diligently for a period of time. And then there should be a stabilized reset of the system.

Dr. Patrick Hanaway: Which focuses on the emotional feeling process to occur, which really isn’t part of most healthcare interventions at all.

Alex Howard: Right. Exactly. And it’s often also not a part of a lot of the psychological interventions that are very focused on the cognitive level, which I think is very important, but that’s something that’s back to my point that you asked a simple question that I gave a quite in-depth answer to, but you need to work on calming the system with practices like meditation, breathing, whatever that may be. We have to work on a cognitive level with the patterns of thinking, but I find we also have to work on an emotional level and often it’s in that sequence. And again, sequencing can be important. If we try to work on the emotions without the cognitive strategies, people run so many patterns around the emotions that they feel overwhelmed in that process.

Dr. Patrick Hanaway: And then in that process, you talked about the embodied focus of being able to do that. Does that then lead to specific kinds of therapeutic approaches like somatic experiencing or you bring it into yoga and Tai Chi and Qi Gong as ways to be able to begin to feel and embody the movement of energy?

Alex Howard: Yeah. So, I really encourage people to have some kind of movement practice. I’m not overly prescriptive on that because I find that different things tend to resonate and work for different people. So, some people… I’m someone that’s really loved yoga over the years and other people that just doesn’t land for them. But if you ask them to take up swimming and they’ve got the physical energy to do so, that’s the thing that gets in their body, but some sort of movement is important. And to answer your question, yes. I don’t tend to use the phrase “somatic experiencing”, because I’m mindful of that very much Peter Levine’s work and I’m not trained as a somatic experiencing practitioner, but I have a very strong emphasis on the importance of coming into the body. And in a sense, I see emotional processing and metabolizing a lot like the digesting of food. The body has its own natural capacity towards it, but we have to get out of its way. If you’re having a healthy, working digestive system, the first thing you do is you chew on the food. And if you don’t chew on the food properly, you’re not releasing some of the enzymes that you need. You’re swallowing food that your stomach’s got to work much harder then to break down.

So, we chew. And emotionally that means talking about things. That means journaling. That means reflecting on things. There’s an initial breaking down and metabolizing, but then at some point you have to swallow. You have to let go. You can’t just be in control of that. So, that means starting to come more into the body. The stomach’s job is to break down the food further and to release acids and digestive enzymes. That’s part of the process of, as you feel something, you start to break it down a bit more. And an experience of grief that feels, for example, totally overwhelming starts to feel a bit more like smaller pieces and they’re more manageable. Yeah.

Dr. Patrick Hanaway: You’re focusing kind of on the relationship between the metaphysical and the physical, and Gurdjieff talks about that in terms of where there are different symptoms that may emerge in digestion and how that may relate to the inability to actually be able to chew, to digest, to break down, to begin to absorb. Am I ready to receive what is being given to me? And seeing how that manifests in a huge array of gut dysfunction that then manifests itself as alterations in the microbiome that then has this feedback loop. So, I want to just talk for a little bit or hear a little bit about the food focus on the nutritional therapy, which I assume is sort of running in parallel with what you’re doing here. So, speak a little bit more… You’re not a nutritional therapist, you’re a psychologist, but speak a little bit more about the nutritional therapy side of things for our practitioners out there.

Alex Howard: Sure. So, having a team of 25 practitioners, I get the great pleasure of often thinking like the most stupid person in the room. We’re talking about a lot of this stuff, but I think some points that I think are worth making that I think will be valuable. Firstly, we have a very strong emphasis on a biochemical individuality. The recognition that the diet that works for one person definitively may be the worst possible diet for another person. And this was particularly challenging with the book actually because the publisher was like, “Well, what’s the diet for recovery from fatigue?” And I was like, “I can’t write that book. And no one should try and write that book because the truth is different things work for different people.” That said, we have a strong emphasis towards the obvious things that practitioners will be familiar with. Reducing things like sugar, complex carbohydrates, the usual toxins and-

Dr. Patrick Hanaway: Processed foods.

Alex Howard: So, the obvious stuff is a sort of obvious foundation. We also have, for the majority of people, a relatively strong emphasis towards a good amount of quality animal… obviously, organic where possible, protein. We find that a lot of people have issues with fermenting guts. And so, being sensitive to foods around that. We have a strong focus towards digestive function as a whole. I mean, it’s worth saying that we… Like a lot of practitioners, we have a systems approach. So, we look at the digestive system as a system and that for many people was an important piece. We also then look at the endocrine hormone system. And again, for a lot of people, that can be an important piece. Again, the immune side of it. And obviously, there’s been a growing interest in recent years around mold, lyme co-infections. And I think it’s great to see that evolving. I have a level of caution and concern around some of the level of invasiveness and intensity of some of those protocols and approaches. We seem to be…

One of the great benefits that we have. When you have a very large patient community. At any one time, we have well over 1,000 patients in active treatment with the practitioner team in the clinic. And so, you could be pretty stupid and still see patterns and still see the sort of themes in terms of what’s going on. And what I’ve noticed over the years is certain things come into fashion and people jump on bandwagons and often-

Dr. Patrick Hanaway: Yeah. SIBO. candida, EBV-

Alex Howard: Exactly. And I was a casualty of the raging candida focus in the ’90s. And still these days have gut issues related to some of the intensity or some of the protocols. We didn’t know what we were doing back in those days.

Dr. Patrick Hanaway: Which doesn’t mean that for some subset of people that becomes a critical factor to be able to do, but we’ve got to be aware and we can’t try to take a one size fits all approach when we see that. Even when someone has some indication of candida imbalance, we don’t necessarily want to hit them super hard right away because their system may not be ready to handle it. So, I think we’re…

Alex Howard: That’s right. I often get accused of being boring when it comes to things because I’m just so slow to get on the bandwagon. It’s not because I’m not watching everyone else, and not because I’m not super interested. As soon as someone goes… I said it earlier. As soon as someone goes down the path of everyone that has chronic fatigue has Lyme or everyone that has chronic fatigue has SIBO. Just seen too many people for too many years, but you’re absolutely right. When someone does have Lyme or someone does have SIBO or candida or whatever the focus is, until you deal with that specific piece, you are rearranging the deck chairs on the Titanic. And so, you need to have that clarity. And that’s, again, where the best practitioners are the ones that have that insane curiosity that they’re constantly learning and they’re constantly discovering more. And that’s where for one patient, they can go deep on a SIBO protocol. Not necessarily that’s going to be the only piece, but it’s going to be an important piece for another patient with the same set of presenting symptoms. They’re going to recognize actually as a completely different path they need to go down.

But I think it brings us back to an important point when I was talking about the second map of state plus stages time sequence. The sequencing of the intervention is so important. So, to take the SIBO example, you can have someone that’s got SIBO and you can jump straight in with rifaximin, neomycin. You can do a strong anti-

Dr. Patrick Hanaway: microbial.

Alex Howard: … antimicrobial or antibacterial protocol. And for some people that can work really well, but two, three months later, all the symptoms resurface. And you end up doing 10 rounds of antimicrobials or antifungals or whatever, and you’re still not actually dealing with the underlying issue that’s going on.

Dr. Patrick Hanaway: Right. One would hope that once you start that second round of treatment, you’re actually looking for curiously, “What am I missing here that’s underneath, that is a driver?” And before we got on, we talked briefly about different kinds of ways of assessing people. And you spoke eloquently about the importance of clinical experience. How it feels to be with someone. And I’d love for you to share a little bit more of that because I feel that… You have the map, but then there’s the individual therapeutic relationship that helps you to really understand how to apply the map. That’s where the personalization comes into place. And that’s what even your research said, “Hey, we’re not treating everyone exactly the same. Here’s the set of tools we’re using, but we’re sequencing it differently, and that all begins with the initial engagement in the therapeutic intervention.” So, can you speak a little bit more about that?

Alex Howard: Yeah. It’s really a good point because this way of doing things is the only way that I know to do things that’s effective. And it’s been the bane of my life, particularly, the last five years because on the back of the BMJ Open study that you mentioned, Patrick, we decided, well, obviously the next step is to do a full randomized control trial with a national health service, NHS, patients in the UK. So, we started the process of getting ethics approval to work with NHS patients using our approach. The problem is our approach is not someone has this symptom, you give this supplement. Our approach is it’s much more nuanced and it’s much more clinically experience-based approach.

So, fast forward, five miserable years to get NHS ethics to do this research that we finally got granted last year. But ultimately, yes, the map is important, but the map is always evolving and changing. I find, and it’s incredibly hard to train and in more recent years we’ve got better at hiring practitioners that already have this instinct. It’s almost one of the most important things that we look for in hiring people is the ability to use your own curiosity, your own capacity to map, and to see patterns, and to pull things together. It’s also not just an intellectual capacity. Again, it’s sometimes hard to find the right words, but it’s an intuitive instinctive… when you’re with someone sometimes you just get an instinct that this feels like this other person that I sat with maybe five, 10 years ago, and I’m not quite sure why.

And then sometimes it’s that marriage of the intellectual prowess to make sense of the data and the research, and to be able to go deep on that with one’s own instinct, with also one’s own clinical capacity to build connection and rapport and trust with patients as well because you can be the best practitioner intellectually in the world, but if you can’t inspire patients and you can’t get the compliance that you need for people to sometimes make dramatic changes in their lives, you’re still not ultimately going to be effective.

And I think it’s very easy for practitioners to become often because they feel… It’s a way of covering up the feeling. I think a lot of practitioners feel in their early years. It’s kind of imposter syndrome that “I’m not a medical doctor and I’ve only got this nutritional therapy qualification.” So, they very closely follow protocols. And I think sometimes over-depend on lab results. And I think that’s okay. And that’s sometimes the developmental stage that I think people often have to go through. But ultimately the best work comes when we move beyond that stage and I think it’s really important to be open and honest with patients. We’re always incredibly transparent about… I think I was saying to you before we started recording of what we do know, what we know we don’t know, and there’s also a load of stuff that we don’t know that we don’t know, but when you’re working with people that have tried many things over many years that haven’t worked, they actually appreciate the honesty and you’re then learning from their feedback, but also their body’s feedback. And I think that becomes an incredibly important compass along the way.

Dr. Patrick Hanaway: Yeah, that’s beautifully said. I was writing down and I’ve talked with people about having curiosity and compassion, connection with the person, and then the courage to be vulnerable in the process. And that’s exactly what you’re speaking about there. To be able to move through and be able to listen to, what is the right answer for this individual? But you’ve done a wonderful job of creating these maps of ways to think about it and look at it so that it can ground the practitioners who are out there in the approach that you’re taking to be able to deal with fatigue. I really, really appreciate this conversation. So, some practical things that people can start with.

Alex Howard: Yeah. Look, I think for people that are listening to this who are on the healing journey, I think the first thing I would say is that if you feel alone, you feel misunderstood, you feel that no one has the answers, take solace in the fact you are not alone in feeling that way. You’re not alone in feeling alone on the healing path. And there are answers that are out there, and there’s a whole movement of people. And many of those people are listening to podcasts like this. People that have trained with people like yourself, Patrick. People that are deeply passionate about understanding these conditions and making the medically unexplained absolutely explained.

And so, really the first thing I would say is you need to find those people and you need to get clarity. The reason why I called the book, Decode Your Fatigue, and not fix your fatigue or whatever else is, I think you can’t fix the problem until you decode what’s wrong. And taking the time to figure that out, I think, is hugely important. So, you need the clarity. There’s a lot that people can do with themselves. And one of the things that I was really excited to do with the book that I mentioned earlier, the sort of place of overwhelm, “I can’t fit all in one book,” but I said to the publisher, “Okay, I’ll do the book, but I want to do a free companion course with the book where I can do a load of other stuff.” So, there’s a free companion course with the book that also has interviews with people whose case studies are in the book. So, you hear from it themselves. There’s recipes. There’s a downloadable meditation. for when I talk about meditation in the book.

So, it’s having the clarity and it’s having the resources. We can do a lot with ourselves and you often need to build your team like, who are the practitioners that understand these conditions and are working with them day in, day out? And often you need a specialist, not a generalist. You need someone that’s not seeing one or two fatigue patients a year, but someone that’s seeing them on a regular basis because that’s what brings the clarity to really be able to make sense of that. And obviously I’m evangelical about the team we have at the Optimum Health Clinic, but there are many great practitioners that are out there. And I was very careful in the books and not make it a sales pitch where everyone has to come to the Optimum Health Clinic. I feel deeply privileged to be part of such an incredible community of people doing fantastic work. And one of my great joys is on the conferences that every year I interview over 100 different people for the Fatigue Super Conference and the Trauma Super Conference, and I love learning from other people. Whoever the team is for you. And I do do a chapter in the book actually on how to find the right people and how to manage that process with them, but you need to build the team of people that are really going to be able to help you along the way.

And then I would say… We’ve spoken quite a lot in this interview around the importance of calming the nervous system. That’s a critical piece. Often meditation is a good start. It’s not the whole piece, but it’s a good start. We touched on digestion. Often that’s a really… As often, quick wins we find on the digestion side. Some of the more complicated areas like Lyme, mold co-infections can be… anyway you’re going to need to get the fundamentals in place. So, starting with the fundamentals is a good place to start.

Dr. Patrick Hanaway: Right. And that’s where we see the best benefits of some of those specialized treatments is after the people have healed the gut and got on a good diet that they can actually work with. And as you said, work to reset the whole mental process that’s going on. The nervous system, dysfunction and dysautonomia. So, the book, Decode Your Fatigue: A Clinically Proven 12-Step Plan to Increase Your Energy, Heal Your Body and Transform Your Life. It’s going to be available in October. Is that right?

Alex Howard: It’s on pre-order now. It’s in bookshops certainly all over America, UK, Australia, and New Zealand. So, most places. It’s obviously in all the places like Amazon. People who want to find out more, actually, the best thing to do is to go to the book website, which is decodeyourfatigue.com. If you go there, you can download a free chapter, you can see there’s a whole bunch of information about the book. No book has all the answers. Again, I’m always nervous that people that come out there and go, “This is the only book that you need.” I think this book has a lot of answers and I’ve taken great care to make those answers accessible and easily actionable. So, yeah.

Dr. Patrick Hanaway: Wonderful.

Alex Howard: I really want to encourage people to explore.

Dr. Patrick Hanaway: Wonderful. Well, I’m certainly going to be picking up a copy and sharing it with some of my patients. In fact, I have one or two patients I’m thinking that I may need to refer over to your reset program right now because not any one individual is the right person for everybody. And being able to expand the network of other practitioners who can help to support us in the process, that is something that I look to and really appreciate your participation in the podcast and in the field of functional medicine and working with these patients.

Now, some of the books, the publications, the people we’ve talked about will be in the show notes. We encourage you to take a look afterwards to see the links that’ll be there to help connect you to some of these tools and perspectives that Alex Howard has brought to us today. I want to just give you a big shout out and thank you for the work that you’re doing in the world to help people with fatigue. And we both know and recognize that these kinds of things are applicable beyond fatigue as well, but your patients with fatigue is a beautiful place to start. Thank you so much. Anything you want to say in closing, Alex?

Alex Howard: No, thank you, Patrick. It’s a real pleasure to be here and I really appreciate the conversation and having the chance to speak to it. So, thank you.

Dr. Patrick Hanaway: Great. Have a great day.

Dr. Kara Fitzgerald:  And that wraps up another amazing conversation with a great mind in functional medicine. I am so glad that you could join me. None of this would be possible, through the years, without our generous, wonderful sponsors, including Integrative Therapeutics, Metagenics, and Biotics. These are companies that I trust, and I use with my patients, every single day. Visit them at IntegativePro.com, BioticsResearch.com, and Metagenics.com. Please tell them that I sent you and thank them for making New Frontiers in Functional Medicine possible.

And one more thing? Leave a review and a thumbs-up on iTunes or Soundcloud or wherever you’re hearing my voice. These kinds of comments will promote New Frontiers in Functional Medicine getting the word on functional medicine out there to greater community. And for that, I thank you.

Alex Howard is Founder & Chairman of The Optimum Health Clinic (OHC), one of the world’s leading integrative medicine clinics specializing in fatigue.  With a team of 25 full time practitioners supporting thousands of patients in 50+ countries, the OHC team have pioneered working with patients remotely since 2004.

Alex has published academic research in publications such as the British Medical Journal Open and Psychology and Health, and is the author of Why Me?: My Journey from ME to Health and Happiness and Decode Your Fatigue: A clinically proven 12-step plan to increase your energy, heal your body and transform your life (publication October 2021)

Alex is creator of the Therapeutic Coaching methodology, and since March 2020, has been documenting his therapeutic work with real life patients via his In Therapy with Alex Howard YouTube series.  In the last few years, Alex has created some of the largest online conferences in the health and mind–body markets; including the Fatigue Super Conference, and the Trauma & Mind Body Super Conference. Alex’s online conferences have been attended by over 350,000 people.

Contact info: www.alexhoward.com

Dr. Patrick Hanaway is a board certified family physician trained at Washington University and past president of the American Board of Integrative Holistic Medicine. He currently serves as the Senior Advisor to the CEO at the Institute for Functional Medicine. Dr. Hanaway previously served as the Chief Medical Officer at Genova Diagnostics and Chief Medical Education Officer at the IFM. He was the founding medical director of the Cleveland Clinic Center for Functional Medicine, where he also served as the research director and currently serves as a research collaborator. Dr. Hanaway’s focus is to leverage his skillset to transform medical practice through education.

Study in BMJ: https://bmjopen.bmj.com/content/2/6/e001079

Alex Howard Youtube: https://www.youtube.com/channel/UCZrNVG1fJIgqYjv2YwumzKA

Conference: https://traumasuperconference.com

Website: https://www.alexhoward.com

Website: https://www.theoptimumhealthclinic.com

Preorder book https://www.amazon.com/Decode-Your-Fatigue-Clinically-Transform/dp/140196110X

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Joe Dispenza https://drjoedispenza.com

Annie Hopper https://retrainingthebrain.com/team/annie-hopper/

Dr. Robert Naviaux https://naviauxlab.ucsd.edu

Peter Levine

Ashok Gupta https://www.guptaprogram.com

NFFM podcast with Ashok Gupta

Gurdjeff

ggurdjieff.com

The Body Keeps Score, by Bessel can Der Kolk

Dr. Kara Fitzgerald FxMed Resources

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Clinician Professional Development: DrKF FxMed Clinic Immersion

DrKF FxMed Nutritional Residency Program

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