Published in JHH13.1 – Shaping the invisible
This issue of the Journal of Holistic Healthcare is devoted to a series of articles, each one about a different quality of the holistic practitioner. There are 12 of these qualities, including holistic itself, and we describe these as the dimensions of holistic practice. Of course, these are also the qualities to which we would all aspire.
The publication of this issue coincides with the launch of a major new feature on the BHMA website that begins to explore these qualities. This constitutes an important change in direction for the BHMA. We are moving away from a focus on the knowledge that underpins the care of the sick, and towards a better understanding of those who care for the sick – their ways of being and doing. By this means we may be able to reveal the true needs of the sick, and of all of us, in the mirror of those who care.
Why is the BHMA changing?
Answering this question requires knowledge of what has gone before. In the early 1980s the BHMA was launched by a small group of visionary doctors who worried about the fast-growing medical science and technology industry that was already creating a dangerous imbalance in healthcare. They believed the time had come to…
‘…replace our attempts at objectivity in the quest for further knowledge with one where the emphasis is not on subjectivity but on authenticity. We should replace our mechanistic approach to the study of health and disease with a humanistic one where aspects of human nature such as caring, sharing, loving, touching, hoping and hugging play as important a part in our endeavours to help the sick as the study of alpha feto-protein and T-suppressor cells. We should replace the reductionistic approach to the care of the sick with a holistic one.’
The quote comes from the first article in the first edition of what later became the Journal of Holistic Healthcare. It was published exactly 32 years ago. The long and beautifully written article reminds us that the cutting edge of basic science discovery (quantum mechanics, holograms, psychoneuroimmunology, complexity) actually points away from the mechanistic and towards a much more complex reality; that:
‘… the human being is a multidimensional being, possessing body, mind and spirit all inextricably connected…[extending to] an interconnectedness between human beings and their environment which includes other human beings.’
Pietroni also drew in the experimental literature of TS Eliot and James Joyce, the revolutionary new abstracted visual art of late Picasso and the beginnings of Eastern philosophy’s influence in the West – explored by The Beatles and others. He advocated many options in healthcare that are only now becoming popular, such as regular exercise, meditation, breathing and relaxation, and patient empowerment.
Sadly, since those heady days, in many ways the problems are worse. So what happened? At about the time the BHMA was launched (the early 1980s), the evidence based medicine (EBM) movement had its own beginnings. This was an attempt to ensure that treatments came with evidence of effectiveness and safety. However, the research needed to generate this evidence became increasingly expensive and large-scale. As it gradually grew in size and influence what constituted ‘evidence’ became a largely positivistic programme: only the linear, cause-andeffect of hard Newtonian science, linked to strict statistical techniques, was acceptable. Whether this shift was influenced by the increasing public popularity of the humanistic/holistic healthcare movement threatening the vested interests of the academic medical research establishment and pharmaceutical industries, it is not for me to say, but from EBM’s very sensible beginnings it had turned into a Frankenstein monster. It has enabled much ‘evidence-based treatment’ that is actually unnecessary or harmful (more below). ‘Unproven therapies’ became targets for opprobrium, even vilification in the case of homeopathy. Complementary and alternative medicine (CAM) was walled off indiscriminately and the BHMA found itself sequestrated on the wrong side of the wall. It became the ghost in the machine. The public, however, continue to look for care and attention wherever they can find it. Most people are oblivious to the mainstream’s indiscriminate marginalisation of the immeasurable. They notice only the lack of care, the lack of the human touch. Our challenge is to exploit the wonders of bioscience without sacrificing the wider and deeper needs of humanity. EBM must be tempered.
The political angle
In Dr Iona Heath’s moving essay, Love’s Labours Lost, she describes the change in the political economy of the UK starting with the Thatcher government (1979–1990) and continuing with John Major and later Tony Blair. This was a change from the post-second world war ethos of inclusiveness, social solidarity, reciprocity and public service towards an increasingly competitive market economy based on consumer consumption. This change ushers in a loss of trust and erosion of generosity which suits a consumer society, but damages public service. These consumerist changes were, of course, mirrored in the NHS – the last major bastion of post-war welfare provision. They were finally enshrined in law with the 2012 Health and Social Care Act. This makes it easier for NHS services to be provided by for-profit organisations. If the Transatlantic Trade and Investment Partnership (TTIP) is applied across Europe, these changes favouring multinational corporations may become difficult to reverse. Alongside the supremacy of the market is the new role of the NHS and the medical research industry as major drivers for the economy.
There is now public and professional unrest with the present system. This gives us a potential constituency of supporters for change. But to climb out from our closet behind the wall, we need a message of hope for the many who have received poor or unfeeling medical care, and for those many practitioners who are disillusioned with the ways of working imposed on them in the NHS. While wonderful work is still being done by those who manage to defy the system, there is widespread and deep unhappiness with contemporary healthcare. In recent years, this has been manifest in public outcries over cruel and degrading care of older people in hospitals and care homes; in poor and degrading treatment in mental health facilities; in never seeing the same doctor; and in becoming lost in impersonal bureaucratic systems. Over the last 2–3 years a large and growing medical grass roots movement has come together against overdiagnosis and overtreatment. This amounts to medicalisation of life’s travails under the guise of EBM. The current junior doctors’ industrial dispute, though ostensibly about pay and hours of work, is fuelled by the mutation of professional practice into a managerial process heavily moulded by political imperative. The resulting role ambiguity and relentless pressure are highly stressful. Finally, the perennial problem of waiting lists – the inability of the NHS to meet demand and the stress that this creates – is to a large degree ‘failure demand’. This means demand for care arising from previous failure to recognise and respond to the underlying problems, especially at a social and economic level. The roots of illness are in society.
It is clear to us that the BHMA must focus on the NHS and on the roots of illness. It is here that the holistic vision is most needed. Complementary and alternative practice is already invigorating healthcare in its own way, though in most situations these approaches are unavailable to the poor.
Reclaiming the word, holistic
To many people in the present day, holistic in a healthcare context is something to do with natural therapies and even beauty products. This is a misuse of the word. If there were an alternative English word that has not shifted its popular meaning, we would use it; but there is no such word. For us, being holistic is about how we understand the world and our place in it. This understanding will determine our relationship with everything and everyone we identify as ‘not us’. In turn, this will reflect back upon us with an impact on our day-to-day life. Holistic cannot be defined without reducing its power of meaning. There are other words like this; for instance love. Both holistic and love denote a powerful sense of connection and perhaps belonging to, even ‘being part of’. Few human beings can thrive without ‘being part of’.
In healthcare we need to reclaim our own English language word, holistic, because its meaning is so central to being human. Other (perhaps all) languages have words that mean something similar to the original meaning of holistic. For instance, German has gestalt, and Southern African speakers have ubuntu.
We are left with a crisis in our shared humanity. Canadian writer and academic Michael Ignatieff, in his 1984 book The Needs of Strangers, points to the crucial role of language (p.138): ‘Needs which lack a language adequate to their expression do not simply pass out of speech: they may cease to be felt….Of all the needs I have mentioned the one which raises this problem of the adequacy of language in its acutest form is the need for fraternity, social solidarity, for civic belonging.’ And the politicians pretend to wonder why the people do not engage with the public democratic institutions! The result is social fragmentation, dependency and socially determined illness, particularly addiction in all its forms. We in the BHMA have looked for a way of exploiting the wonders of bio-science with the right hand, without sacrificing the holistic approach assigned to the left hand.
The real voyage of discovery consists not in seeking new landscapes but in having new eyes.
So we build our strategy for transformation, not on competing scientific claims, not with arguments about which therapy, or what research evidence, but on language and the qualities of the human. Together these qualities become the dimensions of being holistic in your understanding of one another, the world around you, and in the case of practitioners, your practice. We use the qualities of the human as a way into the complexity.
Here are the twelve dimensions:
balanced, community-minded, compassionate, connected, empowered, integrated, intuitive, meaningful,resilient, self-caring, wise, holistic
These are all natural human qualities. We all have the potential for each, but none will be equally good at all. This is not about being perfect, there is no perfect in humanity.
Out of the crooked timber of humanity, no straight thing was ever made.
So we must forgive ourselves and others for being crooked. We must be compassionate. Every generation has its challenges in this respect. Ours, here, is to cope with the manifold effects of science and technology, of harnessing the power of the natural world in ways that are wise, where in foolish hands, great damage might be caused.
A virtuous, ordinary life, striving for wisdom but never far from folly, is achievement enough.
Michel de Montaigne
What is most vulnerable and must be protected is like a seed in the breeze, fragile and transient but full of promise. The essence of this fragility and of human knowing is predominantly about ourselves. Without being self-knowing and self-caring we have little hope of caring for others and the world. Much of this is about feeling part of something much bigger than us. If we can achieve this, then caring for ourselves, for others and for our wonderful planet will come to us naturally. This is community.
[People] are free when they belong to a living, organic, believing community, active in fulfilling some unfulfilled, perhaps unrealised purpose.
So to be free, we must belong; and to belong is to be empowered.
There is no more powerful way to initiate significant change than to convene a conversation. When a community of people discovers that they share a concern, change begins. There is no power equal to a community discovering what it cares about.
Here also is the importance of being resilient. There is no perfect because the energy of the world derives from change, from tension between opposites. All is change, like the leaf in a tumbling stream, fragility riding the waves of power; once beautiful, now buffeted about on an invisible shifting film of surface tension, buoyed up by air, held down by gravity. Change and agility gives us both resilience and sustainability. Just try riding a bicycle without moving the handlebars! Change also gives us stories, perhaps the most potent way of grasping our evolving reality.
Humans have a peculiar need to find meaning in all this. Meaning is the tenuous, evanescent light that draws us onward in the story of our lives; the light that if we look too hard or try to analyse, is liable to go out.
There is a light in my heart but when I try to look at it with my intellect, it goes out.
Or it is the ship’s lantern in the stormy sea that buffets us. We are grateful when it flickers on and saves us from darkness. We search for a medicine of meaning.
Our shifting world, unknowable entirely, floating in unimaginable space, gives glimpses of itself as much to our intuitive sense as to our analytic mind. Our meaning must come from integrating these glimpses and making sense as best we can, often by a story. This will mean living with uncertainty but looking for balance, coherence and resonance in a life of enquiry.
Perhaps being connected is the most essential of our natural human qualities. But so often we are lonely. This may be from being alone, but more often it is our difficulty in making meaningful connection with another sentient being.
Loneliness does not come from having no people around you, but from being unable to communicate the things that seem important to you.
So much of the modern doctor’s time is taken up with patients whose problems can be reframed as loneliness of the soul – of the inner being – manifest in diverse ways, from serious physical illness to unhappiness and lack of fulfillment. Perhaps this is the malady of our times. Of course, with a holistic view, we know that this loneliness of the soul goes deeper. Here is Jung again.
If things go wrong in the world, this is because something is wrong with the individual, because something is wrong with me. Therefore, if I am sensible, I shall put myself right first.
This is an echo of John Donne’s famous lines, their fame perhaps residing in their truth, their resonance with the depth of the human soul. That we do not, for the most part, practise this wisdom is another demonstration of our crooked timber, yet it contains the promise of better times for mankind. Before we can start building these better times, we must first have the new eyes recommended by Proust and which are promised to those with holistic vision.
No man is an island entire of itself; …any man’s death diminishes me, because I am involved in mankind. And therefore never send to know for whom the bell tolls; it tolls for thee.