Dear Friends and colleagues

As I begin 2023, I am thinking of all the like-minded colleagues around the world, known to me or not, who are on a journey of exploration, discovering what it means in practice to be a ‘whole person-centred’ clinician. There is a recurring question in this: ‘Why is it so difficult to be whole person-centred?” While there are many opportunities, there are many hurdles. It is easy to say we are whole person-centred, but in practice it is a very different matter. The complexity entails a major renovation of concepts, skills, social conditioning, politics, and relational understanding. 

In my short essay below “Do not invent anything!” I try to capture something crucial at the heart of these difficulties which most clinicians face. I am indebted to Richard Powers’ novel Orfeo, which has nothing much to do with healthcare, but presents a powerful metaphorical framework for the problem.

I hope the clinicians reading this find it helpful. But I also know that non-clinicians, patients, people with physical illnesses poorly responsive to current treatments, will also read this newsletter. Such persons have often asked me ‘Where can I find a doctor or clinician who will take a ‘whole person’ approach to my problem?” This piece of writing, “Do not invent anything!” does not solve the very practical urgency of this question for these people, but it may help clarify why we are in this situation.

“Students came, learned, and left. Some suffered through their solfeggio exercises, masters of the taciturn eye-roll. But others he changed forever. To the best of the student composers, Els said, Do not invent anything; simply discover it. One or two of them understood him.”

Orfeo   Richard Powers[1]

What is it like to teach doctors, clinicians to see and hear in a different way? What are the hurdles that clinicians must confront to become more whole person-oriented? Let’s approach this from literary fiction, right outside the realm of healthcare.

From the very first page, Richard Powers’ magical novel, Orfeo, immerses us in the conscious experience and innocence of a maverick, experimental composer, Peter Els. The reader becomes enveloped in Els’ greatly misunderstood questing for unfathomed depth, pattern and harmony. For much of his life, the venue for searching has been musical composition, but now Els is retired and, strangely, in a home-based laboratory, he is utilizing internet-derived information and resources to genetically engineer bacteria, which of course entails another world or domain of potentials and variations.

Genetic engineering and musical composition do seem odd bed-fellows. Perhaps just as strange as blending medicine and psychotherapy. Or listening to the patient’s ‘story’ sitting invisibly, yet to be reached, behind a physical disease. Moreover, as Els’ saga unravels, we see that his explorations in both musical composition and homely biogenetic engineering are in ample measure, innocent, subversive, sophisticated, and lamentably unacceptable to wider society.

By analogy and some identification, I do feel Els’ burden. I know very well that almost instant societal scepticism or dismissal, unconsidered and frequently unspoken, that reflects a pervasive self-serving maintenance of the normal order, a kind of communal blanket ready at hand to suffocate any emerging fire.

But first things first, Els’ beloved and very musical golden retriever, Fidelio, has suddenly collapsed. In panic, Els calls 911. The arriving officers are told by Els that Fidelio was “sliding around on the floor and howling. She bit me when I tried to move her. I thought that if someone could help restrain…..”

Els’ explanation peters out. He doesn’t really expect anyone to understand him.

The diligent officers inspect the ‘scene’, and simply cannot comprehend the strange conjunction of shelves of musical equipment and thousands of CDs, with the apparatus of an active microbiology laboratory.

Something nefarious must be going on here.

The gaze of the chief responding officer, Powell, finally alights on “several sawn-off water-cooler bottles hung from the frame by bungee cords” and he does his best to make some meaning:

Powell touched his belt. Judas Priest!

Cloud chamber bowls, Els said.

Cloud chamber? Isn’t that some kind of ….?

It’s just a name, Els said. You play them.

You’re a musician.

I used to teach it. Composition.

A song-writer?

Peter Els cupped his elbows and bowed. It’s complicated.”

Yes, it certainly is complicated. Where does one start to explain how two such apparently different worlds can exist together?

The officers, in their incomprehension, conclude sinister intent, a risk of plague through laboratory escape of novel life-threatening bacteria. Els goes on the run, while the nation goes into panic.

I cannot imagine that Powers had healthcare in mind in writing Orfeo, but he provides ample metaphor for mindbody or whole person-centred care.

At the simplest level, Officer Powell symbolizes a myriad of clinicians certificated and paid to practise normative biomedicine, fine colleagues who do the clinical work that the modern State will fund. For these clinicians, our whole person-centred work can be mystifying, disorienting, suspect, unscientific, undermining or just irrelevant. And when asked to explain what I do, I often feel like Els: “It’s complicated.” It is tiring to (virtually always) have to start from the very beginning and, block by block, build a justification for why it is a very significant error to divide, inany fundamental way, persons (and patients) into bodies, minds and whatever else.[2]

In his incapacity to explain or defend himself, Els becomes someone that the aroused State must deal to.[3] One of the reasons I have for insisting that my students and supervisees have a very clear conceptual grasp of why they are working as whole person-oriented clinicians is so that they can mitigate such pressures and risks.

But my focus here is not actually the uninterested or resistant persons and institutions in wider society, but my colleagues and trainees who are really keen to practice in a whole person-centred way, many of whom find it hard to see where they are going with patients, such are the pressures of their personal backgrounds, trainings, societal and patient expectations, and much more. I will get to some specifics soon.

Let’s first see what Els faces when, later in Orfeo, and after many and often harrowing experiences, he is now teaching students musical composition:

(Els) “moved back down to the Mid-Atlantics and took up the gristmill work of an adjunct professor. He taught five courses a semester: a mix of ear training, sight singing, and basic theory and harmony. His days were a gauntlet of Fixed-Do slogs, with him as tonality’s drill sergeant. Like every adjunct, he was a stone-dragging serf helping to build a very wide pyramid. But exploitation suited his need for penitence.

He threw himself into the crushing routine. A few semesters of teaching the rudiments of music made him realise how little of the mystery of organised vibrations he had ever understood. The whole enigma unfolded in front of him, and he stood back from it as baffled as a beginner. He tried to tell his freshmen the simplest things—why a deceptive cadence makes a listener ache or how a triplet rhythm create suspense or what makes a modulation to a relative minor broaden the world—and found he didn’t know.

Not knowing felt good. Good for his ear.

He still composed sometimes, at his desk between student conferences, or sitting in the thick of the college commons, although he never bothered to put any notes to paper. Tiny haiku microcosms spilled out of him, five-finger exercises that fragmented into lots of beautiful, fermata-held rests.

Students came, learned, and left. Some suffered through their solfeggio exercises, masters of the taciturn eye-roll. But others he changed forever. To the best of the student composers, Els said “Do not invent anything; simply discover it.” One or two of them understood him.

Perhaps read that last paragraph again, and ponder: “Do not invent anything; simply discover it.” How contrary that advice is to everything that we are taught in the applied sciences. I am not suggesting that anything goes. But the clinician who wants to be whole person-centred needs to realise that a new kind, or discipline, of open-ness is required. This is because most of the difficulties we are confronted with have to do NOT with the patient or the client, but with entrained clinician habits and disciplinary norms, and conscious and unconscious prioritizing of disease orientation and diagnostic formulation. As experts of a kind, we imagine we are at our most free when we have these capacities at hand and well-polished. And we are free to a point.

But to be whole person-centred we need to free ourselves from the constraints (or closures) that such expertise entails. As Els would say, “It is complicated,” but I will try to explain this in terms of the choices we might have as pursue these freedoms.

The first choice is obvious. We start to be alert to the patient as a ‘whole,’ a whole person, and beyond, but not excluding, the benefits of diagnosis. In this state of alertness we are willing to include or at least consider ‘anything.’ At it’s most basic this means we consider a condition as multifactorial. At an attitude and skills level, we become astute listeners—we listen for ‘stuff’ that may be relevant. Meanings are not irritating ‘noise’ but crucial.

The second choice is a bit scary, and conceptually challenging. We actually invite the patient to disclose their meanings and their ‘stories.’ What do I ask? How should I ask it? What do I do with what emerges? What if it gets difficult relationally? We have to find ways of enquiry. We actually have to believe that persons are ‘wholes’ and that everything is connected. Not just say we believe this. We have to believe such connections may exist even when our clumsy questioning misfires, or when denial and defensiveness emerges, and we need to be able to hold the patient empathically when they trust us to hear.

The third choice is harder still, especially for the ‘fix-it’ professions (practically all of us), or those enamored with, or clinging to, the safety of methodologies and theories. Can we hold back our desire to ‘know,’ or ‘conclude,’ or to ’fix’? Can we avoid closing down the crucial thing or things that can emerge within the specialness of the healing relationship? Can we trust that that thing will appear sometime, in some way—that it cannot be mastered by expertise but it can be brought forth by presence? Can we understand that things are always more interesting, rich, specifically nuanced, and relevant than we hasten to suppose and impose for the sake of our own comfort? Do we have the confidence and the courage to trust the ‘process’?

The fourth thing is maybe not so much a choice but rather a freedom. It is the freedom of imagination, an expanded and open awareness of possibility. I mean here the capacity to understand and grasp, without control or reduction, that the patient, client, sufferer with whatever disorder, brings a personal and relational ‘world,’ a richness, which is for this current clinical moment concentrated in this illness presentation, in this disease, in this invitation for you to be a helper alongside. Such imagination allows you to hear, to see, to invite, to move away from your own self-absorption and to discover and move with the sufferer.

Maybe all these steps are not so much a matter of choice, but of awareness or realisation, doorways that we encounter and pass through, as we become more experienced in whole person-centred work.

Despite all, it is certainly possible to be a very good clinician in a conventional sense and do work imbued with a focus on wholes, an interest in stories, a willingness to listen astutely, a courage in asking and responding, and a joy in discovering that which needs to be discovered, with (and for the sake of) that seeking person, whom it seems forever now we have called a patient.

As Els puts it:

“Do not invent anything; simply discover it.

One or two of them understood him.”

Brian Broom, January 2023

bandabroom@xtra.co.nz

[1] 2014  WW Norton & Co  New York, USA

[2] In my books and other writings, I have written extensively about the error of divided wholes, or dualistic thinking, and the challenges of functioning as whole person-centred clinicians in our current healthcare context.

[3] Fortunately, that has not been my lot! I think a determination to maintain a high professional competence in both medicine and psychotherapy enabled me to represent whole person-centred care within mainstream medical care without persecution. But there was a price to be paid in time, energy, and restraint of creativity.