A Fragile Essence: a Personal View
[How] can holistic healthcare survive in an industrialised and commodified world?
Dr David Zigmond © 2022
I was asked by Q, a freshly-hatched young GP, to summarise my experience and philosophy of attempting to provide holistic healthcare through my own five decades of NHS practice, and how I saw its future. Here is the condensed dialogue.
Q1: David, you have been an NHS doctor – a GP, psychiatrist and psychotherapist – for five decades. Were you always holistic?
DZ: Ha! That sounds like an anatomical or behavioural anomaly! Well first, what do you mean by ‘holistic’?
Oh dear! That’s difficult … I thought I’d be asking the questions…
Well, we’re already into something interesting: we’ll see how difficult it can be to define holism. It’s so much easier to insist on it, or campaign for it!
OK. But you’ve spent a working lifetime championing and espousing this elusive … word, so you must have some idea, at least for yourself!
OK, here goes. This is a personal view, not one propagated by the World Health Organisation. But be patient – as you’ll soon see, it’s not easy… It’s probably clearest if we start with what it’s not. It is not, for example, the knowledge or science of atomistic facts and defined mechanisms…
So what, in particular, does holism depart from when meshing with healthcare?
Well, it follows that holism is not anatomy, physiology, pathology, immunology and so forth per se. These are all analytically isolated parts, or layers of the whole.
But surely any whole is made of all those parts…
Yes, certainly/but: the whole is more than the sum of its parts. That subtle distinction – between what each of us just said – is crucial to holism.
I can see difficulties: if science – so our medical knowledge – breaks things down in order to define and know them, how can we then – at the same time – configure any larger ‘whole’ that is outside the frame of what we’re doing or looking at? And what is it that’s so valuable outside that frame anyway?
Well, outside the scientific definition of mechanisms lie the less directly observable and measurable dimensions of meaning: context, relationships and experience. Hard science can only operate around these, yet personally we all know how important, how central, these are to us…
This is getting a bit heady for me. Can you give me a concrete example?
Yes, OK. Here’s a real and recent one, necessarily abbreviated. A previously healthy young professional man, M, attends an A&E department with acute breathlessness and palpitations. All is there attributed to a Panic Attack. Nothing else is established. So M receives explanation, reassurance, palliating drugs and referral back to the GP largely by rote.
The GP, Dr G, manages to be less rote-bound. He deliberately clears headspace and heartspace to decipher this consternated constellation of events. M, at first tensely guarded, then senses in Dr G a safe and intelligent attunement. He tells the doctor of his imminent marriage: ‘Yes, I love her very much … I’m looking forward to it all…’ The doctor hears a strain in M’s voice; he wonders and waits.
The following week M is sitting with the doctor. His hands fidget, he gulps and then tells of an alien and alarming dream, clearly and strongly homoerotic. He is simultaneously shocked, dismayed, discombobulated … and yet, Dr G senses, curiously relieved – M’s sobs collapse into a spectral and fleeting smile.
M’s subsequent story of unravelling, then rethreading, constituted a hurtling drama, slowing to find his new and quelled stability – a conditionally happy ending. I won’t go into the human richness of this story now because we’re here using it to illustrate the difference between (increasingly specialised) biodeterministic medicine (BDM) and mindfully stretched holistic healthcare (HH).
At the hospital M was ‘diagnosed’ and ‘treated’ competently by conventional BDM parameters: the designations and interventions are protocoled and generic – there are no forays made into the vagaries of individual meaning, context or chimeric experiences. In philosopher’s language we can say that such biodeterministic practice is ‘phenomenological’: it confines its descriptions, understandings and actions solely to phenomena – what is actually happening and directly observable…
So are you going to say that, by contrast, Dr G was ‘holistic’ with M?
Oh, yes! In many important ways. And that rather abstract preamble is necessary to explain how and why.
Go on then!
OK, but I’ll have to administer some more abstraction, I’m afraid!
Well we can see how Dr G decided to invest his time and thoughts away from the mere biodeterministic, and make space for a speculative and imaginative realm of meaning – the world of relationships, unique experiences and contexts. In technospeak that is ‘cryptanalytic’ or ‘semiotic’ rather than phenomelogical.
Ugh! More peculiar words … English please! That is my first language…
OK, though I think these are good words here. They’re about decoding and understanding unobvious signs. Another similarly useful word to characterise holism is ‘hermeneutic’, which is about attempting interpretations…
Are you provoking me?! So what have these long words got to do with holism in healthcare?
Well, those words themselves are only about addressing hidden meanings and connections. So let’s return to M’s story and see how that works. In the A&E department M received competent biodeterministic attention – the system there was not equipped to decide or contain anything else.
Fortunately for M, Dr G sensed how important it might be to enter another kind of territory with M so that – together – they might find a different kind of understanding and approach.
How is that holistic?
Well, Dr G, by inviting and evoking the invisible, subjective world of M, certainly makes for a more whole picture that the biodeterministic response. So it’s a beginning.
So holism is relative, because it cannot possibly contain everything – that’s for the Gods!
Quite. That’s important. I think of holism as a philosophy, an aspiration, or a spectrum … or a wide-angle zooming-out lens.
A spectrum? A wide-angle lens?
Yes, we can travel back and forth along it to wider or narrower pictures – more or less holistic. But as mere humans, of course, we can only see or envision just so much…
A sudden thought: BDM sees, but HH envisions what BDM cannot see.
Mm! That’s a pithy distinction. So applying mere scientific medicine to M, for example, may (by exclusion) get as far as a diagnosis of ‘anxiety’, but can get no further. The meaning of that anxiety – the (un?)consciousness and unobvious connections – requires more holistic attention.
And how do those different kinds of attention lead to different kinds of practice?
Ah! A crucial question. I think the following is broadly true: biodeterminism is the basis of treatment and intervention, holism is the basis of healing and care. BDM is the science generating our curative treatments, HH is the art suffusing our pastoral healthcare of all else.
Certainly. Well M was treated in a standard BDM fashion in the A&E department: it contained his symptoms just enough for him to get to Dr G. That doctor then looked beyond and behind the biodeterminism, searching for a more holistic picture that conveyed meaning and then opportunities for healing. Generally healing needs both holistic sense and personal knowledge. It was the offering of these by Dr G that enabled M to heal and grow beyond his dis-eased and sickened impasse.
That sounds like a fundamental distinction … Say more.
Yes, it is. Treatment is a conductive activity: we directly convey external resources into a person to change internal mechanisms. Healing, by contrast, is inductive, we awaken or activate a person’s internal resources – often capacities they are unaware of or have discounted…
Internal resources? What are these?
For healing they are mostly our near-universal abilities for immunity, growth and repair. The healer’s task is to somehow kindle and then maintain these deep (and difficult to directly evidence or measure) internal workings … these life-forces.
And healing relationships induce these?
So it’s like electrical induction, where a moving relationship between two objects produces an electrical current.
Yes, the basis for all our electrical power … That serves as an analogy – both poetic and functional – for how we enable one another to survive, heal and grow: the closeness and relationship between the two ‘objects’ is essential.
Surely; even if the relationship is imaginary…
Yes: think about placebos, particularly when self-administered.
Mm … but I imagine actual relationships are likely to be more effective, surely?
That’s true: they are. There’s now decades of research to show that relationships of positive familiarity add greatly to the effectiveness of not just pastoral healthcare but also curative treatments. Obviously that contribution will vary…
I’m losing you. I need some more examples.
Ok. Let’s say H has a massive gastrointestinal haemorrhage and needs usual emergency replenishment and intensive care. All these are BDM curative treatments in extremis, and this surely is not a time to consider meaning, relationships or world views!
However, if H recovers from this peril, her further and fuller recovery are likely to need more holistic approaches. For example, to help her re-view her alcoholic binges and dietary neglect, and beneath that her ancient and unspoken tangles of hurt, angry grief and mistrustful, bleak loneliness. This re-view is far more likely to be successful within the cradle of a ‘therapeutic relationship’ – it is almost impossible without.
And here’s a remarkable side-note: even in the operating theatre or Intensive Care Unit – the Temples of biodeterministic medicine – there is evidence that respectful and tender attunement to, and handling of, the unconscious human will help survival and recovery.
So even our most engineering-type of medical interventions may be helped by an ecological awareness and attitude.
‘Ecological’? You haven’t mentioned that before.
In my view ecology is inseparable from holism. HH must always be mindful and respectful of the infinitely complex relationships between all living things and their habitat…
That sounds rather a lot to fit into an NHS consultation!
Indeed. Our attempts at HH are always incomplete, imperfect and incompletable. But our meagre offerings can, nevertheless, be helpful – sometimes decisively so. The art of medicine is often to know what tiny part of this infinite menu to choose to probe, sample or play with. This is where the consultation becomes a complex form of intercourse, rather than an ‘intervention’. Holism then has to be imaginatively empathic; we have to sense (mostly!) accurately what is the unspoken and ‘unfinished business’ of the other. What are they ‘on’ for, and what not?
For example, Dr G intuited that M’s persona-projected statements cloaked much agitated sexual confusion and ambivalence. He conveyed this to M by (mostly) subliminal signals; M reciprocated. Then came the more explicit exchange.
Dr G’s choice of focus was accurate and hence effective. This therapeutic opportunity would have been lost if he had, for example, focused on M’s more evident shallow breathing or erratic sleep patterns.
So this kind of holism is both intimate and bespoke.
So it can’t, then, be standardised or mass-produced?
That’s right: we have to respect the ‘idiomorphic’ – we must thoughtfully heed and understand the uniqueness of each individual’s life, form and experience.
There is a guiding principle here: the more you see of someone, the more of someone you see. So, to honour that bedrock of personalised holism we need to assure and protect personal continuity of care as a guiding principle wherever this is possible and desired. And we need a governing regime and system that enables the practitioner’s autonomy and time, to free up their headspace and heartspace.
Where does social prescribing fit in to all this?
Ah! ‘Social prescribing’ – I have many mixed thoughts and feelings about this…
OK. Positives first. Yes, I’m very in favour of helping doctors and healthcarers to think, and selectively act, outside of the biomedical frame. To think of wider behaviours, social contacts and activities and forms of consciousness that might help patients. These can all be good indices and tools of holism… … …
Yet you pause, and I sense a ‘but’ coming.
I’m afraid so. OK, my doubts:
Yes, of course suggesting or providing alternative activities and affiliations to other people can be helpful, sometimes even transforming. But its success depends on accurate discrimination, and that depends on empathic attunement, and that (usually) depends on how well we know and understand people – their idiomorphism – and that (generally) depends on personal continuity of care…
And I know you see the loss of that as having decimated our NHS…
Oh, yes! Thirty years of ‘modernising’ reforms have engineered and over-systematised our healthcare to make personal continuity of care peripheral, redundant, or even discouraged. So we now have a no-one-knows-anyone-but-just-follow-the-algorithm-and-do-as-you’re-told service.
The losses to diagnostic and therapeutic opportunities are enormous…
And with social prescribing?
Well the word ‘prescription’ traditionally means ‘doctor knows best, and this will fix it’. A prescription is thus different to a co-created insight or idea.
If I suggest – say – yoga, gardening, choir-singing or literature appreciation – what will happen? If I know the person – the nature of their loneliness, or grief, or shame, or anger, or unrequited love – then my suggestion is a product of that relationship and its understanding. Coming from an empathic bond it is more likely to be taken up and to succeed. That is personal or intimate holism.
But what happens if I don’t know the person, and probably never will? Well, not only is my ‘prescription’ likely to be much less accurate, it also lacks the buttress, containment and guidance of an anchoring relationship.
Social prescribing then risks becoming yet another traffic-managing procedure to offload, outsource and deflect.
Without headspace, heartspace and adequate personal continuity of care I fear social prescribing will devalue to be a feeble bridge. Such is quick-fix and anomic holism.
What’s your view on complementary or alternative medicine and their relationship to holistic healthcare?
Well, I don’t have any particular experience or knowledge of these, so my remarks are very general. I think all practitioners – allopathic, alternative or whatever – have similar and ceaseless choices between convergence and divergence, between atomism and holism. Alternative and complementary therapists can be just as rote and procedure-bound as any conventional doctor. In which case they will be no more holistic.
But those alternative/complementary practitioners do have one great advantage in this regard – they are mostly self-employed. That gives them the freedom to ensure personal continuity of their care, and then to allocate whatever time, headspace and heartspace they and any patients wish.
In contrast, such bespoke and personal holistic healthcare is increasingly difficult for NHS doctors to pursue and deliver in a way that they or their patients wish. How can they achieve this when their working conditions have become so time-pressured, personally discontinuous, procedurally bound and bureaucratically distracted?
What of the future? What do you see for holistic healthcare?
I am full of trepidation but have enough optimism to hope that I am wrong.
Since qualification in the 1960s I have never before known a time when the need for holistic wisdom and practice was both more needed and simultaneously more imperilled. Our technology has become ever-more vigilant and powerful, but our personal care insentient and deracinated. We are now, so often, scanner-sighted yet humankind-blind.
On the positive side, there are still, thankfully, younger practitioners wanting the vocational aspiration and inspiration that holism might bring their practice. Their projects and credos make up many articles in The Journal of Holistic Healthcare.
Good seeds all these may offer us, but they can only germinate and survive in soil whose integrity and fertility are protected.
Holism is a fragile essence.
David, I think I’ll cancel my initial question: ‘Were you always holistic?’! But I am interested in the development of your ideas in holistic medicine over decades of practice.
Well, right from the beginning of my training I was thinking about the nature and limits of biomedical science, and then what was both useful and valuable beyond. I came to understand that the science of practice led to its effective treatments, but beyond that lay the art of practice: endurance, palliation and healing. The wise and skilled practitioner will titrate and weave these.
It seems to me that if we lose that skill and wisdom – if we overinvest in the biodeterministic and scientific – then we are left with healthcare that becomes procedural and commodified.
And you think this is what has happened?
Yes, definitely. This is the legacy of thirty years of neoliberal reforms … with many echoes in allied welfare services, too.
Much of this you’ve explored and published in decades of writing…
Yes, as much to clarify my thoughts as to propagate them.
If you were to choose just a couple of articles to illustrate your own personal approach to holistic healthcare and the development of your ideas, what would they be?
Um … OK. I’ll suggest one from 1976 – my first in a medical journal – and the other from 20212. They both revolve around real stories, showing how important is understanding human meaning in attempting to ‘treat’ others.
In those forty-five years I hope you’ll see I’ve tried to loosen my style a little!