Holistic Medicine – John Heron

John Heron

Published with the title Humanistic Medicine in February 1978 by the British Postgraduate Medical Federation, University of London, in association with the Human Potential Research Project, University of Surrey.

This paper develops ideas discussed at a workshop on holistic medicine which I led at the University of Surrey in October 1977. I wish to thank participants in the workshop for theircontributions to the discussion.

CONTENTS

Current Approaches

Comments on Above from Workshop Participants

Two Kinds of Choice

Cartesian Foundation of Modern Medicine

Non-Cartesian Approach to Medicine

Critical Incident Analysis: Negative Experience of Medical Attention

Rewarding Incident Analysis: Positive Experience of Medical Attention

Non-alienating Practice: Overcoming Eschatological Alienation

Non-alienating Practice: Overcoming Emotional Alienation

Non-alienating Practice: Overcoming Interpersonal Alienation

Deprofessionalisation

Action-planning

References

Current Approaches

The Institute for the Study of Humanistic Medicine, founded in 1972 in San Francisco, offers the following definition of ‘humanistic medicine’ (more recently referred to as ‘holistic medicine’). I have restated it in my own terms, retaining the meaning.

Optimal healing often requires a whole person to person relation between doctor and patient: the doctor is more than a technical expert, the patient more than a locus of disease.
Health involves a balanced interdependence of body, emotion, mind, spirit, within a social context. Illness can best be understood as a disturbance within this dynamic balance.
Doctor and patient are in a relationship of co-operative endeavour, one aim of which is to increase patient self-help in healing and self-determination in living.
Illness can provide the patient with an opportunity for personal growth. The doctor can facilitate the patient to use the experience of disease creatively to re-evaluate personal goals and values, to reshape a life-style. In this sense the patient can be invited to consider the “meaning” of his illness in relation to the immediate context of his life and to his total personal history.

Comments on above from Workshop Participants

The ISHM points omit social factors in disease, the effects of social and political oppression.
They also overlook an element of pure arbitrariness in disease processes.
Consumers collude with the prevailing mechanistic model. Society gets the medical system it deserves/wants/legitimates.
Our society applauds disease producing activities.
Some consumers complain, but leave the onus for change on the profession. Other consumers are active in promoting change.
The concept of self-induced illness is entering the medical journals.

Two Kinds of Choice

There is conscious rational choice, and a degenerate, blind quasi-automatic “choice”, for example the child’s “choice” of a defence mechanism as a form of emotional and social survival. One can choose in the rational sense to atop “choosing” in the blind, compulsive and degenerative sense. Thus a person can choose to dismantle and do without redundant defence mechanisms.
Quite apart from obvious cases of hysterical conversion (of mental distress into physical symptoms), is there some similar degenerative sense in which a person “chooses” a disease? And can thus learn to choose in the normal sense to abandon such a “choice”? Biofeedback research is relevant here (see below).

Cartesian Foundation of Modern Medicine

Descartes’ (1596 – 1650) philosophical dualism: the body as a self-contained mechanistic system extended in space, the mind as purely immaterial with no spatial properties, accessible by introspection. This very influential philosophy set the backdrop for the development of pathology, anatomy and clinical technology. Modern medicine is still primarily Cartesian: the body as a self-contained mechanistic system that is the locus of disease processes that have a physical aetiology and that are to be resolved by chemical and mechanical interventions. The patient’s Cartesian ego is pushed aside for the patient to get on with privately while the doctor gets on with the technology of treating disease.

The Cartesian disease model has led to the development of powerful and in some respects effective medical technology. But it clearly has its limitations.

It gives disease a purely physical meaning in terms of basic medical sciences and does nothing to help the patient give human meaning in terms of purposes and values to his illness (his experience of disease in the context of his life).
So it tends to alienate the patient from his disease and his body – he hands full responsibility for both of them over to the medical technologist, and ceases to regard himself as significantly self-determining in the healing process.
It leads to the inappropriate application of the mechanistic disease model – disease label, passive patient, expert-determined physical interventions in his body – in many cases in primary care where an educative psychosocial model would be more appropriate – co-operative insight into an underlying human problem, with patient self-help and self-determination.
Disregarding the Cartesian ego to get on with treating the Cartesian body can lead to interpersonal insensitivity and incompetence, with patients complaining of brusqueness, offensive autocracy, inadequate explanations.
Cartesian philosophy is out of date. Although it provided a powerful and historically relevant impetus for the development of modern science (over against the Aristotelian-mediaeval world-view), it never did work philosophically – how can a purely non-spatial immaterial mind have any locus of interaction with the spatially extended physical body?

Non-Cartesian Approach to Medicine

1. Non-Cartesian dualism offers a more fruitful philosophical backdrop to the practice of modern medicine: persons are not just bodies, but do have spatial presence.

The conscious person is not the same as his body – to assert a strict identity of person and body leads to all the difficulties of radical materialism. The main difficulty is that meaning -which is central to the experience of a person – can never be identified with a physical state.
But persons are what we meet in and through bodies. We don’t encounter a purely physical thing, the body, and then infer the presence of a person. We encounter a person directly in his touch and in his gaze, although not totally.
Thus persons, as conscious intentional beings, are in some important sense present in space, in and within their bodies. Witness also biofeedback research, which breaks down the distinction between voluntary and involuntary bodily processes; the potential for intended personal influence on the body is possibly very much greater than the traditional distinction has allowed. And the corollary is that unintended (unconscious) personal and social influence on the body is possibly very much greater than traditional Cartesian medicine has allowed.
Hence a generalized and revised multifactorial theory should be given more aetiological scope than hitherto. Probably multiple aetiology is relevant: seeing susceptibility to physical causes (such as a virus) in psychosocial terms. There is also of course sociosomatic theory: disease as the effect of social and political interference and oppression. The theoretical problem is to integrate mechanistic explanations of disease with psychosocial explanations – rather than ruling either out in favour of the other. See next section.
The actual relationship between the two embodied persons of doctor and patient has a healing potential as distinct from the technology that the doctor applies. Touch, gaze, tone of voice, relative position, the types of psychological intervention, the changing interpersonal processes -all these may: have a direct healing effect per se; help uncover relevant psychosocial factors; facilitate patient insight, discovery of meaning in illness, self-help, re-evaluation of life-style, self-determination, and so on. Hence the importance of a doctor’s interpersonal competence.
A non-Cartesian dualism of the kind here outlined would imply not only that the patient can give meaning to his illness and use it as an opportunity for personal growth – important though this is – but also that the patient can work directly on healing the disease by self-help: diet, fasting, exercise, breathing techniques, autogenic training and mental methods, biofeedback training, and so on.

2. There are at least four major categories of explanation of human behaviour and, I suggest, of its interruption and breakdown by disease processes. In any given case, the challenge is to know which category or categories to apply, and if more than one, what weighting to give to each category, and what account of their dynamic interaction. Furthermore, the application of the categories in diagnosis is not necessarily the same as their application in treatment and/or self-help: Something of primarily psychosocial origins may be resolved by primarily mechanistic treatment, or vice versa.

Mechanistic: explanation in terms of basic medical sciences, of purely physical processes; treatment in terms of drugs, surgery, physical equipment.
Energetic or vitalistic: explanation in terms of energy regulation (high energy, low energy, types of energy, balance or imbalance of polar energies, energy flow, and so on); treatment in terms of energy regulation, often involving training patient in self-regulation, as in biofeedback, relaxation, autogenic therapy, gymnastic exercises, and so on – with appropriate conceptual modification. For “energy” read other words such as “arousal”.
Psychosocial: explanation in terms of the patient’s psychological state and history together with his social, interpersonal situation, present and past; treatment in terms of facilitating patient self-insight, catharsis, restructuring of life-style and goal-setting, restructuring of social/occupational situation, retraining in interpersonal relations, and so on.
Transpersonal: explanation in terms of alienation from some extensive mode of being that encompasses but is more comprehensive than the personal (Cf. the Transcendent in Jaspers’ Existentialism, the Transpersonal Self in Assagioli’s Psychosynthesis, Jung’s archetype of the Self, etc.); treatment in terms of facilitating patient openness to the transpersonal dimension of being.

The challenge to a new theory of aetiology is that these sorts of explanations are not necessarily mutually exclusive, but may interact and combine. One model of such interaction is that of a part-whole hierarchy, in which the part is in some respects relatively autonomous, but in other respects is functionally dependent on the whole. Thus in some respects mechanistic explanations are self-sufficient, in other respects their rationale derives from their inclusion in energetic explanations, which in turn in some respects are self-sufficient, yet in other respects derive their rationale from psychosocial explanations and so on. What all this – or any other model of multiple aetiology – would mean in practice we are far from knowing. Well-balanced aetiologies, as also well-balanced treatments, represent a very sophisticated future achievement.

Critical Incident Analysis: Negative Experience of Medical Attention

Workshop participants, all practising health professionals, were asked to share with each other incidents from their personal experience as patients in which they were the recipients of anti-human medical attention. The incidents were analyzed to yield the following causes (which are not given in any special order).

Quality of care interrupted by (i) pressure of work (ii) expediency (iii) inappropriate bureaucracy.
Clinical incompetence.
Autocratic, non-consultative therapy; inadequate communication from professional.
Mechanistic insensitivity: inappropriate, anti-human, unnecessary use of medical technology.
Lack of empathy, care, concern.
Obsequiousness from practitioner when patient is a fellow professional.

Rewarding Incident Analysis: Positive Experience of Medical Attention

Participants were asked to share with each other their personal experience as patients of satisfying medical attention.

Expression of human support through the professional’s use of touch, physical contact.
Warm personal approach; warmth, personal courtesy.
Supportive communication of medical information; intelligent, adult communication.
Clinical competence.

Non-alienating Practice: Overcoming Eschatological Alienation

(eschatology: that part of theology which deals with first and last things)

An historical and cultural phenomenon: society legitimates the modern doctor to manage birth and death, but because of his Cartesian approach, he does so in mechanistic terms. That is, he is legitimated to manage these great human events purely as technical, physical phenomena. The clinical management of birth and death tends to exclude these events being conducted, at the same time, within a ritual of human meaning, in which the emergence-of a person (birth) and the departure of a person (death) is duly acknowledged. Clinical management is alienated from human meaning.

For birth the ritual of meaning is conducted in the phase immediately after birth – the reception of a highly sensitive, vulnerable person into a new environment. For one method see the work of Leboyer (1975), for one rationale see the work of Grof (1976) on LSD therapy and perinatal matrices.

For death the ritual of meaning is conducted in the longer period leading up to death, except of course in sudden and unexpected death: orientation in feeling and thought to death, giving retrospective meaning to one’s life as a whole, putting one’s legal, financial and other affairs in order, dealing with unfinished emotional business with friends and relatives, accepting and dealing with separation anxiety. This can all be done outside the doctrinal auspices of any particular creed. Thus the work of Grof (1972) with terminal patients.

Future medical and para-medical education and training can include the multi-disciplinary, teamwork approach to combining clinical management with ritual of human meaning.

Non-alienating Practice: Overcoming Emotional Alienation

As well as the Cartesian tradition in medicine as such, we also have to take into account the Aristotelian tradition in our educational system as a whole, which applies the Aristotelian doctrine of function: the prime differentium of the human being is intellect, and the goal of education is the cultivation of intellectual excellence both theoretical and applied. An ancillary use of intellect is to control and regulate emotion. But there is no affective education as such, no education of the emotions – higher education is exclusively concerned with the cognitive, the theoretical and where relevant its technological application.

With this exclusive educational focus on intellect and the assumption that its incidental use is to control feeling, we get an emotionally repressive society, with redundant and inappropriate control of feeling – the repression of human distress feelings, the inability to work with such feeling cathartically, and the inability to identify how such denied feelings are acted out in all kinds of distorted behaviours – many of which are codified as social and institutional norms.

Our educational system, especially higher education, is crude and unsophisticated, underdeveloped, so far as working with feelings is concerned. But a person well-educated in human feelings would be able: (i) to control all kinds of feeling as and when appropriate; (ii) to express authentic human feelings of affection, love, delight, joy, valid anger, as and when appropriate, and without disabling self-consciousness and embarrassment; (iii) to release cathartically human distress feelings such as fear, grief, rage, in appropriate times and places, in ways that are harmless and undisruptive to self and others; (iv) to transmute tense emotion through art, ritual, symbolic imagination, transpersonal work.

Trauma, disease, death stir up valid human distress feelings of fear, grief and anger. Enlightened medical practice needs to be able to acknowledge these other than by disregarding them, or requiring the patient or relative to exercise repression and control. There seem to be at least two sorts of acknowledgment required: (i) the ability to see how denied and occluded distress from earlier years as well as distress from current troubles, distorts behaviour – in patient, in relative, and, of course, in the health professional; (ii) the ability to be able to facilitate cathartic release, and consequent self-insight, where appropriate, in patient and/or relative, and to honour it when it occurs spontaneously.

An extension of 4 (i) is the willingness to be open to the connection between denied and occluded distress feelings in the patient and disease processes that may have a relatively self-sufficient explanation at the mechanistic level. Psychodynamic processes here may provide a higher-order rationale for the mechanistic.

An extension of 4 (ii) is the ability of the professional to facilitate cathartic release in himself, to deal with his own distress feelings, whether these feelings are generated by professional exigencies or personal situations past or present. Otherwise the professional can act out his own denied distress in professional behaviour. Unfortunately at present in our Aristotelian educational system, the health professional during undergraduate training and subsequently, gets no assistance as part of the training in dealing with the distress feelings generated by early encounter with human disasters. To counteract this, co-counselling (a method that combines self-direction and peer support) could usefully be included in professional training, and thereafter become a regular adjunct to professional and personal life. Thus personal development, consciously taken in hand, becomes a correlate of professional development.

See also my Catharsis in Human Development, Human Potential Research Project, University of Surrey, 1977. Reciprocal Counselling, HPRP, University of Surrey, 1974.

Non-alienating Practice: Overcoming Interpersonal Alienation

Undergraduate and postgraduate medical education includes very little training in communicating skills, interpersonal skills. Industry and commerce are well ahead in this field, using sophisticated research and training methods (Rackham and Morgan, 1977). “In our contemporary sick society, the psycho-social factors of our patients’ illnesses are becoming more frequently observed and demand the use of skills which we have never been formally assisted to acquire” (Byrne and Long, 1976). Studies show an average 35% of patients are dissatisfied with doctor/patient communication, and some 44% fail to follow medical advice given to them (Ley, 1976). Patients’ associations correspondence files are full of complaints about the quality of doctor-patient relations.

The problem for doctors, as for any other professional group untrained in interpersonal skills, is that they tend to use a restricted repertoire of behaviours. The flexible use of a wide repertoire of interpersonal behaviours requires the ability to discriminate the repertoire; requires the opportunity to practise; and above all requires feedback from observers, aided by video or audio tapes of performance, for the individual to become aware of the strengths and weaknesses of his untrained repertoire, and to become aware of how effectively he is extending that repertoire by training. All this involves quite sophisticated training methods.

The wider problem stems from the education doctors have received: no training in how to work effectively with feelings in self and others; the Cartesian bias toward focussing on organic disease and physical treatments; lack of concern with how the patient gives human meaning to his illness; a defensive and sceptical attitude to psychosocial explanations and psychosocial treatments – which may involve facilitative counselling skills; and as already mentioned, the absence of any interpersonal skills training.

There are various approaches to such training. One is that of descriptive behaviour analysis. A comprehensive range of categories of specific verbal behaviour is derived from observing doctors at work (e.g. by means of audio tapes of actual consultations), and then used as a basis for training. The trainee brings to the course tapes of his own consultations, these are analyzed in the light of the previously derived categories of verbal behaviour; his behavioural strengths and weaknesses are fed back to him; he chooses which new behaviours he wishes to acquire; then uses training role-plays to build up skills in these new behaviours (Byrne and Long, 1976).

Another related approach is that of prescriptive behaviour analysis, which recommends categories of behaviour as a basis for training. Thus my Six Category Intervention Analysis method recommends that the doctor be able to move flexibly among the following six fold repertoire of behaviours: prescriptive, informative, confronting, cathartic (releasing abreaction), catalytic (eliciting/drawing out patient feeling/information/insight/problem solving), supportive. Each of these six categories subsumes a range of more specific verbal and nonverbal behaviours.

The training sessions involve: (i) a series of discrimination exercises to enable the trainee to identify the six categories and their subspecies of behaviour; (ii) assessment of individual behavioural strengths and weaknesses with respect to the six categories, based on transcripts of actual professional behaviour, on recollection, on role-plays within the course using video tapes; (iii) practice by means of a variety of specially structured exercises to build up trainee skills in his identified areas of weakness; (iv) modeling for trainee practice, and feedback on trainee practice, are important elements in the training. For details of this approach see Heron, 1974, 1975, 1977.

For a discussion of the differences, and the implications of these differences, between descriptive and prescriptive behaviour analysis see the Introduction to my Behaviour Analysis in Education and Training (Heron, 1977).

Other approaches to training have included the Baling type of seminar (Balint and Norell, 1973); role-plays based on Transactional Analysis from the work of Eric Berne (Berne, 1966) (for application of TA concepts to the doctor/patient relationship see Browne and Feeling (1976)); interview training on taking a history, using video replay with feedback and discussion (Maguire and Rutter, 1976); the well-researched method of Carkhuff (1969); and so on.

Carkhuff (1969) following the work of Rogers (1961), picks out through his training and research studies the following qualities of the effective person-to-person helper: empathy, respect and warmth, genuineness, self-disclosure, ability to confront, immediacy (ability and readiness to see what is going on in the helper/helpee relationship), concreteness (the ability to get down to the helpee’s real issues and concerns). He maintains that skills in expressing and using these qualities in a helping relationship can be acquired by structured training programmes.

Deprofessionalisation

Professionalisation is the process whereby a minority group in a society, through training, accreditation and often statutory registration, acquire special skills and expertise, which, in the extreme form, they are exclusively legitimated to practise on behalf of the rest of society.

Deprofessionalisation is the process whereby this group itself takes active steps to delegate (a) to ancillary professions and (b) more basically, to the people themselves, some of its professional expertise.

Extreme professionalisation, where all the skills of a certain type can only by law be practised by the duly accredited professional, can be regarded as a form of political oppression – in the sense that a basic human right to self-determination is excessively restricted. Hence the political case for deprofessionalisation.

Deprofessionalisation does not, in my view, mean a profession totally dismantling itself. That would be absurd. It seems reasonable to suppose that distribution of function, of specialist skills, will always be part of a rational ordering of society. What it does mean is that a profession is willing and able to encourage and train people to be self-determining, to practise self-help in the more intellectually and technically accessible areas of professional practice. The profession, in other words, does not seek to create in the public redundant dependency. It seeks a healthy balance between I’ll do it for you and Do it yourself. Medical deprofessionalisation might involve the following:

The doctor de-mystifies his professional role; doesn’t use the role as a defence to mislead, manipulate, distance the patient; he closes the gap between the human person and the role, so that role behaviour expresses his humanity, doesn’t mask it.
He delegates therapeutic responsibility to ancillary professions where relevant (counsellor, gymnasts, relaxation therapist, social workers, and so on); especially where these professionals have special skills in training patients in self-help and self-management.
Where appropriate he encourages and facilitates patient co-operation in identifying the problem and in planning a solution – especially where psychosocial explanation of the problem is relevant.
He encourages and facilitates patient self-help and self-determination in managing health and healing.
He encourages and facilitates the formation of peer self-help (mutual aid) groups of patients with similar problems.
He encourages within the profession the development of self and peer assessment in training and thereafter as a form of medical audit, also self and peer accreditation; as distinct from forms of assessment and accreditation practised unilaterally on trainees by “authorities” within the profession.
He makes greater use of patient views and patient feed-back in managing his affairs both clinical and administrative. He may run a health centre such that some measure of accountability to patients is built into its organizational structure.

The complementary process of healthy professionalisation might involve the following:

Keeping up to date with latest advances within the profession.
Keeping abreast of educational methods especially those that enhance self-direction and peer group work in medical students; also those relevant to facilitate patient self-help and mutual support groups. This extends to include communication training, interactive skills training, education as personal development.
Improving grasp of management and organizational matters: team building, organizational decision-making, consultative and accountability structures, and so on.
Increasing awareness of the philosophical and ethical assumptions and implications of medical practice.

Action-planning

Each participant developed a personal action-plan for introducing change toward a more holistic approach in his/her professional work. Pairs fixed a date for telephone follow-up – an opportunity to be accountable to self for how the plan is going.

REFERENCES

Institute for the Study of Humanistic Medicine, 3847 Twenty-First Street, San Francisco, California 94114.

BALINT, E., NORELL, J.S., Six Minutes for the Patient, London, Tavistock, 1973.

BERNE, E., Games People Play, London, Andre Deutsch, 1966.

BROWNE, K., FREELING, P., The Doctor-Patient Relationship, London, Churchill Livingstone, 1976.

BYRNE, P.S., LONG, B.E.L., Doctors Talking to Patients, London HMSO, 1976.

CARKHUFF, R.R., Helping and Human Relations, New York, Holt Rinehart, Winston, 1969.

GROF, S., et al “LSD-Assisted Psychotherapy and the Human Encounter with Death”, Journal of Transpersonal Psychology, Vol. 4, No. 2, 1972.

GROF, S., Realms of the Human Unconscious, New York, Dutton, 1976.

HERON, J., Course for New Teachers in General Practice II, Human Potential Research Project, University of Surrey, 1974.

HERON, J., Reciprocal Counselling Manual, University of Surrey, 1974.

HERON, J., Six Category Intervention Analysis, Human Potential Research Project, University of Surrey, 1975.

HERON, J., Behaviour Analysis in Education and Training, British Postgraduate Medical Federation, University of London, 1977.

HERON, J., Catharsis in Human Development, University of Surrey, 1977.

LEBOYER, F., Birth Without Violence, London, Wildwood House, 1975.

LEY, P., “Towards Better Doctor-Patient Communication”, in A.E. BENNETT (ed), Communication Between Doctors and Patients, London, Oxford University Press, 1976.

MAGUIRE, P., RUTTER, D., “Training Medical Students to Communicate” in A.E. BENNETT (ed), Communication Between Doctors and Patients, London, Oxford University Press, 1976.

RACKHAM, R., MORGAN T., Behaviour Analysis in Training, London, McGraw-Hill, 1977.

ROGERS, C.R., On Becoming a Person, London, Constable, 1961.