Do not invent anything

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.

Forging Stories

What really counts is the heart of a story. We forge our own stories into ‘wholes’ by choosing particular and special details, linking them together in the ‘present moment.’ A story pivots on crucial meanings, making sense of a life, and matching the story to an occasion or the audience.  It is never a complete whole in its telling. We give it definition by creating beginnings and endings, and putting important stuff in between. Ultimately, a story is really a continuum, a living fusion of an ever-extending past, through the present moment, into possible futures. There is much room for honesty and authenticity, but also for self-deception and manipulation. Stories impel, define, confine and consume us. And the story told is not exactly the story heard, because it is always digested through another story, the listener’s story.

But whatever else they are and do, our stories influence the beginning, the triggering, and the perpetuation of our illnesses, diseases and sufferings. I have written much in previous articles and books about the effects of personal stories in health and illness, and how a response to them can transform clinical care and influence outcomes. Nevertheless, it remains that in medicine and the allied health disciplines, the patient’s story material is typically pushed aside in favour of the biomedical task at hand. For many generations of clinicians, this biomedical pattern of working has been privileged beyond all other considerations. It is a general state of clinical consciousness, that stories are regarded unconsciously or consciously as irrelevant noise, time-wasting impedimenta, and eroding of a clinician’s desire for practical therapeutic clarity.

But what about the patient? In this and other articles to come I offer a set of personal reflections regarding a new kind of medicine, which embraces the patient as a whole person, by valuing the story of the patient properly integrated with the best of biomedicine. We get little guidance in becoming whole person-oriented clinicians by seeking for resources in the articles and papers that are published in the journals of our clinical disciplines. Some of the pieces that I will post here were written years apart in bursts of inspiration or frustration. A few were specifically prompted as I chanced on writings and observations by authors well outside healthcare disciplines. In a more systematic way, my work has been hugely enriched by writings across a wide spectrum–medicine, psychotherapy, philosophy, spirituality, general literature, and more. Just about any field we read has something relevant to say about the ‘lived life’ simply because everything is connected. Whether sought out or stumbled upon, I have been looking at what these sources have to say in the light of what I was seeing day by day at the ‘coal-face,’ in my work with suffering persons.  Some of the pieces to come are very storied and others more philosophical in tone. They tumble naturally together because that is the way life is.

Everywhere I emphasise relationship and connection. Nothing exists on its own. ‘Relationship’ is a fundamental condition of all life, and a proper practice of medicine should reflect this. Most illness-inducing-and-maintaining stories are actually about relationships with one’s self, family, other humans, workplaces, groups and communities, culture, the world, matters of life and death, and existence itself. Clinical recognition of these stories of illness, and a good response to them, can give rise to new stories of healing and recovery–if the suffering persons successfully face the relevant relational issues emerging before, in, and around the presenting illnesses. It follows too that the relationship between the storied sufferer and the storied clinician is a crucial factor in recovery. I have written much about that in previous papers and books.[1]

An important element of this project is a storied integration of my own personal experience and development within a fifty-five year career in clinical biomedicine, psychotherapy and towards whole person-centred healthcare. Woven into all this are themes of life very important me, particularly matters of meaning and spirituality, which I have not written about previously

Whenever I seek a starting point for my career as a doctor-psychotherapist-whole person-centred clinician, I reflexively begin with a boyhood moment in the 1950s, at the ‘kitchen sink’ in our small house at the Harewood Aerodrome in Christchurch, New Zealand, when I announced my desire to become a doctor (much more on that in the next instalment). From there I drift automatically to memories of physical symptoms of asthma and abdominal pain experienced during those high school years which were heavily coloured by the effort, anticipation, apprehension and excitement around getting into medical school. Medical school itself entailed a long and often tedious swim through an ocean of information. Facts, facts and more facts.  But not just facts.  The first day in the dissection room, twenty cadavers on stainless steel benches. The very first patient I was assigned to, to take a novice history and nervously examine, like reading a book with my elbows. And the time, as a fourth-year student, I volunteered to interview a psychiatric patient in front of a one-way screen, knowing that I would be scrutinised by a psychiatrist and nineteen fellow students. And survived. A complex notion of life–as the next first moment, with its ‘not-yet-knowing’ intrigue, enduring the initial clumsiness, the lure of challenge, excitement and forward movement, the awkwardness and satisfactions of being or getting near enough to the ‘other’–has been with me all my life. Being on the edge, looking outwards, curious and hopeful, knowing that the world is always more than we know. Despite all the uncertainties and stresses.

During that long swim through an ocean of facts, two islands of significance appeared. The first was a tantalising (and, sadly, titillating for many) lecture by Harold Bourne, who saw the world through a Freudian psychoanalytic lens, a perspective dominant in the Department of Psychiatry at that time. I am no Freudian, but that lecture was important, because, in my immaturity, it hailed the possibility of new and diverse narratives regarding the internal worlds of persons. The second island was a one-off lecture by Tom Highton, a rheumatoid arthritis researcher. Bored by many lecturers, I was captivated by the imaginative creativity of his thought processes as he explored with us the possible future of this disease and its treatment. Though vastly different in approach, these two experiences resonated with my internal impulses towards new horizons, discovery and freedoms. They also aligned with the beginnings of my journey to resolve conflicts I was experiencing between science, biomedicine, the meanings of life as thrown up by illness and suffering, and my own religious background and personal spirituality.

The real doctoring that began after graduation dominated the next ten years. In the early junior hospital doctor roles, bouncing from discipline to discipline, the joys and challenges of testing my capacities in new and often complex clinical scenarios were all absorbing. On the way, torn between general practice, paediatrics, psychiatry and internal medicine as careers, I chose the latter, and somewhat fell into the specialisation of clinical immunology. I was attracted to the newness of this clinical field, so new that there were few training positions globally. A well-funded opportunity arose to stitch together a training in the United Kingdom, and ultimately Canada. My internal impulse towards the exploration of new or different horizons played an important role in the choice. Our years overseas as a family were full, three children were born, and I gradually accumulated my training. Ultimately, this led to an academic appointment in the School of Medicine in Christchurch, where I set up a Clinical Immunology department.

All that post-graduate work and my new departmental responsibilities meant that over a longish period my other psychological, intellectual, philosophical and spiritual interests were more difficult to attend to. I became concerned at the prospect of a very long-term entanglement with biomedicine and with the clinical care of patients largely limited to pharmaceutical and technological means of treatment. This became a crisis. What to do? I needed a job to support my family.

Much to the astonishment of colleagues, I swerved into psychiatry training, looking for a way to enlarge my perspectives beyond focussing on the patient principally as a diseased body. The uncertainties involved were massively challenging because I had no fixed destination in mind. The four years in psychiatry were extremely interesting and helpful, particularly in exposing me to many aspects of the human condition. More than that it provided a training and workplace environment that daily stimulated my urge to explore the human condition from a non-physical point of view.  But, as a discipline, Psychiatry was more attuned to the biochemistry of the brain, the classification of mental conditions, and treatment with drugs, than it was to persons and persons-in-relationship. I had not entered psychiatry because I had chosen the wrong career. Rather I wanted a journey towards treating people as wholes and time to gradually realise how that might happen.  What eventually arose was a formal training as a psychotherapist, a discipline devoted to the patient-as-subject. My immunology training had been largely around the patient-as-object.

Putting all this another way, from an early age I had a penchant and passion for putting together some things that have been kept well apart. This was gradually evolving into an extended exploration and integration of medicine, science, faith and spirituality, the ‘mind,’ and a broader model of healing.  

In 1987, I initiated the Arahura Centre in Christchurch, and established a new personal and professional direction by combining my two disciplines of internal medicine (immunology) and psychotherapy, mainly in the care of people with physical conditions. All of my medical and psychotherapy colleagues at Arahura had varying backgrounds in Christian spirituality, and all were interested in integrative practice to some degree.

My personal pairing of medicine and psychotherapy was initially based on immediate practicalities, rather than on a carefully pre-conceived plan. I just wanted to extend my project of integration, whilst earning a living, and relatively free of the stifling effects of the dominant clinical and academic systems.  But the pairing proved to be auspicious. Day after day in the clinic I found myself peering into and participating in patient stories, which often seemed profoundly important to the existence of the physical conditions the patients were referred with.  A completely new clinical horizon emerged. As time went by, I referred to my work as Medicine and Story. I spent years exploring the relations between the dimensions of the patient as a physical body and as a storied subject. I experienced a gradual revision of my medical assumptions. In part, this was a step-wise process with shifts quite often occurring in response to yet another patient with an unusual or remarkable presentation, forcing me to new frameworks of understanding illness and clinical practice. More generally, this process was greatly facilitated and enriched by reading across many disciplines, especially those outside medicine and psychotherapy.

I became an advocate, teacher, and author of not just person-centred care, but of whole person-centred care, in which both the person’s story and the presenting physical disease, when held together, can be seen as doorways into the ‘whole’ of the seeking, suffering person. More than that, when we looked closely at people with many kinds of chronic conditions, and chose to go through these doorways, we found greatly enlarged opportunities and capacities for healing and treatment.

I have been privileged to hear thousands of peoples’ stories, personal experiences and events, which have accompanied the appearance of physical conditions and turned out to be significant factors in the genesis and patterns of their illnesses. Such stories do often share common themes, but in its own way each story is unique, and touches me uniquely, shaping directions in my insight and understanding of the illness, the person, and the world we live in.

It is a truism that association does not prove causality. But some of the associations between the patients’ stories and their respective illnesses are truly extraordinary. I am referring to the symbolic illnesses, in which the story and the particular kind, pattern or site of the illness, in and of the body, are so closely matched that I have been forced to think about disease causality very differently. I believe only a hardened sceptic or ideological materialist could refuse to wonder at these extraordinary conjunctions. I have written extensively about these symbolic disorders because, in grappling with them, I gradually realised that there is no intellectually respectable reason to side-line the ‘mind’, these stories, in our care of any illness in the ‘body’. It leads to one conclusion. Persons are an undivided unity, a whole, and so we can and must, in principle, expect stories to participate actively in both disease causality and outcomes.

This journey of exploration entailed an ongoing assessment of both the strengths and the weaknesses of various models and paradigms that have shaped human thinking regarding the dimensions of personhood, particularly those influencing medicine, psychotherapy and spirituality. It was not for me to simply abandon one model or paradigm and become a devotee of another. I developed a habit of probing and non-foreclosing openness, and a resistance to reductionism. There were fascinating and relevant materials in numerous disciplines, all of which could, in part, legitimately claim my attention. Questions around suffering, meaning and healing will never be adequately comprehended by any one knowledge system whether it be religion, science, medicine, psychotherapy or any other discipline. The best we can do is to straddle them, crediting and valuing them where it is justified.

Whole person-centred care requires a special valuing of uncertainty. The opening of one’s self to what can happen, not knowing beforehand what to expect, is exactly the posture required in clinicians who want to discover the storied realities relevant to a person presenting with a physical condition. Most clinicians prefer smart diagnostic and treatment routes based on the reductive biomedical paradigm. But this new kind of medicine dies, when a clinician enters a consultation with pet or preferred assumptions. We see what we want to see, rather than what is there to be seen. Exploring story requires one to not know what is coming, and in large measure not to preconceive.

I could not write this series without what has been a profound coal-face exposure to the human conditions of illness and suffering entailed in patient stories. No matter what the scientists discover by measurement, the philosophers argue from logic, the religious maintain by revelation, the psychologists categorise from mind schemata and brain scans, the politicians attempt from perceived electoral or autocratic necessity, or intellectuals of many kinds boldly proclaim concerning ‘theories of everything’, there is nothing quite like this privileged, raw exposure to individual stories, for revealing the nature of the ‘lived’ life.

When we invite a patient to reveal story material, what actually happens, under the right conditions, is exactly what we might expect. The really important threads of the story float to the surface. We really do need those threads, but we do not need every little detail of a person’s life. Harry Stack Sullivan put it this way: “If we have the wit to see it, it is all there in the first session.”  Or borrowing language from philosophy and literary discourse I would say that the core, the nub, of any patient’s story is ‘always already’ there, if we have eyes to see and ears to hear. This can be very hard for many clinicians. We have been taught to be thorough, and that this thoroughness entails having fairly complete information. This is true to a point. But it is a very different way to think, that thoroughness may be better built on an openness stripped of easy assumptions, along with very intent listening, and exploration of the little that is given in the story realm, attending to that which is ‘always already’ in the patient’s presentation. A pressured and superficial pursuit of lots of story data can foster breadth but not depth, a listening to what one wants to hear rather than what needs to heard, and silencing or rendering invisible much that is important.

I have always been intensely curious about people, persons, humans. Much later, I came to realise that a benign and caring ‘gaze’, is central to the work of a ‘healer’, and, of course, to love in general. This is important because all clinical care is profoundly conditioned by the clinician’s own story; a truism for psychotherapists, but hardly acknowledged in medicine.  

For this reason, and to preface the rest of the book, I will now trace some threads of my own story, focussing on those elements which have, or may have, helped in the development of this ‘new kind of medicine.’ I do this for several reasons. Firstly, it is difficult to be whole person-centred and relationship-based without having an honest and authentic insight into one’s own personhood, and being constantly mindful of what we bring to the clinical relationship, our strengths and flaws. Secondly, it shows that stories are normally complex and multi-thematic. Thirdly, I hope it illustrates that one’s own life experience can provide a unique and rich, albeit complex platform from which we can go on to meet and work with the ‘other’. Fourthly, I have been privileged to be able to cite and, anonymously, make public the stories of others in books and articles. It must be emphasised that clinicians are equally ‘storied,’ and that the threads of those stories contribute positively and negatively towards the capacity to work as whole person-centred clinicians. And fifthly, it means that in the subsequent chapters I can add further experiences as small discrete pieces, without lots of distracting explanation, because the pieces can easily be referenced back to the substrate provided in these earlier instalments.

In the next instalment I return to the ‘kitchen sink’.


[1] See https://wholeperson.healthcare/

I gave it my best shot

Recently I lunched with a younger physician colleague, who is making a significant shift in career, in his forties. Like me, though somewhat differently, he has worked hard at showing, persuading, promoting what can be done when what I call a ‘whole person-centred’ or ‘mindbody’ approach is applied to physical disease, or when we re-focus on our relationships with patients and listen to their ‘stories’.

Again like me, but in a different way, he has been stymied by the algorithmic, doctor-centred, mercantile, techno-centric emphases of modern healthcare, which is buckling to the point of widespread failure as seen from many perspectives including those focusing on inequity, financial incapacity, and the widespread reductionism to belief in tech-salvation, and more.

As I responded to him I found myself re-litigating some aspects of my own experience.

I can swing towards a simple, perhaps simplistic, optimism or hope, that somehow there will come a tipping point, and all the things we already know about healing and healthcare will surface into the consciousness of our healthcare ‘system’. Some of these include: healing as a relational activity; the fact that we are not a collection of dualistic fragments or compartments; treating the body and mind separately is craziness from philosophical, theoretical, commonsensical, epidemiological, sociological, cultural, financial and relational perspectives; our ever-bloating scientistic philosophy of technological and Artificial Intelligence ‘solutions’ will never be the whole answer to healing; epidemiological evidence shows that purpose, meaning, employment and social networks are powerful arbiters of health and longevity;  and clinicians are typical humans and follow the money, and also decide what the money gets spent on.

Yes, we hope that one day all these things and more will become clear and genuine motivators of change.

In other words, that our efforts will not have been in vain.

But I also swing back towards a more sober appraisal. What will it take to dent this blind momentum towards an unsustainable healthcare future? It seems the problem in healthcare has much in common with the problems of climate change. There is so much implicit vested professional, scientific, technological and managerial interest in carrying on in the same way that it seems likely that only severe pressure will force a re-think. This view tends towards the apocalyptic, and I dearly want to resist that.

So, all this was going on in my mind as I listened and responded to my colleague as he talked about the changes he has attempted, proposals he has formulated, little things that have changed, hopes for things that might happen, and the ways he is negotiating the past and his possible future.

I was aware of trying to be person-centred, and not to allow my own extensive experience of similar things to unnecessarily skew my response. But then, how could it not?

That night, after the lunch, I woke from a simple dream. It went something like this. There was news of a major but unspecified trauma or crisis far away across the world. On hearing this, I quickly boarded a plane, with two children in tow. I didn’t take time to prepare ourselves or even take luggage, but went precipitously. I was even conscious (in the dream) of the CO2 emissions risk involved in such a drastic move, but it seemed justifiable. I arrived at the scene of the crisis/disaster, in Sweden it seems, because the two colleagues I joined there are living Swedes who have a genuine interest in whole person approaches to health.

But despite the clear and present danger presented by the crisis they and their families seemed strangely unconcerned, disengaged, not inclined to focus on it, or act. At the end of the dream, as we were walking somewhere, still in Sweden, still occupied with the venture, one of the children said to me: “what is the purpose of this?”; which felt like “what’s the point of coming this far, if they react like this?”

I told my wife of the dream, and looked for the essential feeling elements in it. Recklessness? Disappointment? Acceptance? Resignation? Philosophical? Determined? Committed? Puzzlement? Maybe, but they didn’t quite fit. None of these really captured the sense.

She listened and after a bit she said it sounds like you are saying “I have given it my best shot”. And there it was—that is exactly what I did and do feel. And I truly feel satisfied with that.

The dream seems to capture many things. There has been a clear and present danger, within healthcare and to patients, over the three decades I have pursued, deployed and taught whole person non-dualistic approaches to physical illness. And the danger the current biomedical model poses to the overall health of the healthcare system itself is escalating.

In my late thirties, in a massive change of direction, I embarked on a long journey towards addressing this, across a huge divide—between where I was then and towards what I felt needed to be addressed. There has been a huge expenditure of energy. I had no standard equipment. I set off not really knowing what I was going to. I had a young family. I have taken various ‘juniors’ (clinicians) with me and, at times, in the face of the systemic difficulties mentioned above, they have questioned and wondered about the sense of it all. I have met with many people, clinicians, who in principle were very supportive of the need for whole person approaches, but have dissociated, disengaged, denied the realities, because clear and present danger is typically trumped by clear and present comfort.

Nevertheless, I have loved the adventure, the stimulus, the wandering over many new territories – clinical, emotional and intellectual. I feel deeply grateful for my experiences with many patients, for our shared joy in progress as we discover the roots of their suffering, diseases and healing when we consider their whole person. Such work with patients has been deeply worthwhile and satisfying. The stories that have emerged, many symbolic, and all in their own ways unique, have given rise to a novel panorama and complexity unimaginable to most clinicians: they have enriched my understanding of the world and myself, and provided a basis for understanding disease that cannot be got from biophysical measurement.  

It hasn’t been an easy journey. The ‘not knowing’ for long periods, the relative isolation from the mainstream, the difficulty of holding psychotherapy and medical forms of practice together, the ways of working that do not fit the dominant and failing template briefly described above, have all brought many stresses. But it has been worth it. I have a deep sense of vocational connection between where I am now and that decision taken at age eight or nine when I announced to my mother I was going to be a doctor.

My upbringing enabled me to set off more or less on my own into an uncertain future and relatively unexplored territories. I had learned to be self-sufficient. This helped me endure the exploration when it got really hard and there was little support. It also helped me entertain new ideas about what I was seeing without being captive to the mainstream, and stifled.

I hope the work done, and that we will yet do, will somehow filter out into the mainstream. There are many around the world who wish for something more whole person-centred in healthcare, and there are oases of activity and hope in many places. 

But, in the meantime, I feel I have given it my best, if not my last, shot.

Brian Broom MBChB, FRACP, MSc (Immunology), MNZAP
Consultant Physician (Medicine and Story; Whole Person-centred approaches to physical illness; and Clinical Immunology); Adjunct Professor, Department of Psychotherapy, Auckland University of Technologye-mail: bandabroom@xtra.co.nz

Finding meanings of illness in dark times

The Covid-19 pandemic has provoked much discussion regarding the meanings of this huge global event. The New Zealand Christians in Science organisation invited Brian Broom to speak on “Finding meaning in disease”. This video comprises his talk and his responses to the many questions coming from the audience

A plunge into the ‘whole’

I have been asking myself, yet again, ‘Where does a ‘whole person-centred’ approach fit in modern New Zealand?’ The Government has taken the plunge. Our indigenous Maori people are getting a well-funded opportunity to organise a more ‘wholistic’ healthcare system, for themselves, through the establishment of a new entity, the Maori Health Authority.

Our current health system, based almost entirely on the Eurocentric biomedical model, with its narrow focus on diseases, diagnoses, and evidence-based pharmacological and technological treatments, is certainly not working for Maori. Their health statistics are terrible.

The belief that more billions of dollars invested in more science, more drugs, more technologies, will make the difference to Maori health statistics has proved to be an elaborate fantasy, energised by our (not mine, actually) biomedical model of health and illness. Our model is a pot pourri of biomedical assumptions, truth as defined by scientific measurement, a focus on the individual over communal understandings of illness, a hefty overlay of mercantilism and capitalism, a privileging of the body and medical diagnoses, permeated by a patronising and hubristic belief in our effectiveness, or potential effectiveness. This manifestly fails for Maori.

But what isn’t being said is that it isn’t working well for the rest of us either. That’s what ‘whole person-centred’ healthcare is about. We know that for all the good that the best of biomedical care does (and that’s a great deal), it is fundamentally flawed, because of its relative, and often absolute, neglect of those other aspects of our personhood, which include our ‘stories’, the un-measurable bits, our meanings, our relationships, our families, our loves and hates, our abuses and traumas, and matters of occupation, employment, cultural values, spirituality, and our attitudes to, and place in, our land, our natural world.

This adds up to a massive and scandalous inattention to what is involved in being an ill human. These elements are so obviously important in Maori concepts of wellness and illness, that not including them is a fundamental error. To its credit, the present Government has realised this failure, in respect of Maori, and thus, via the Maori Health Authority, they are provided with the opportunity to devise their own healthcare provision, for their people, according to these important wider parameters, though still accessing the benefits of the biomedical model.

They are getting the chance to expand their healthcare to encompass ill persons constituted as ‘wholes’, within larger ‘wholes’ such as family and community, and even the wider concepts of being, of spirituality, of generational influence, and culture. I look forward to seeing what transpires. There are many difficulties to overcome. But it is so interesting to me, because my concepts of whole person healthcare, derived over four decades of addressing the ‘non-whole’ emphases of the Eurocentric system, overlap in so many ways with Maori values.

In a sense the Government (or the Crown) is enabling Maori to address the ‘whole’ in their own way. What the Government is not seeing or saying is that the Eurocentric model is not working very well for Pakeha either, especially in regards to chronic disorders, because we lack an orientation to wholes. Apparently, we will trundle on trying to resolve health problems the same old biomedical way, wasting more and more billions of dollars, in the hope that these new technologies, perhaps 5-10 years away, increasingly beyond the reach of all but the wealthy, and at the expense of many other possibilities, will make all the difference. It is not going to happen. This is not the way for us. We need change too. The pot pourri is not as fragrant as we thought it would be, once upon a time.

Hopefully the new Maori Health Authority will give rise to ideas that gradually seep into the clinical work of the dominant system. And I see, amongst non-Maori clinicians, a steady rise of interest in Maori language and values, and their conceptualisation of wholes, persons, communities, the importance of place, belonging, land and sea, and spirituality.

Wouldn’t it be good if those of us who have worked to see a ‘whole person-centred’ transformation in the Eurocentric system could find a way to join hands with Maori, in our mutual desire to widen the scope and purview of all healthcare, to take in and work in a newly balanced way with the multidimensional aspects of illness and disease, health and wellness?

Brian Broom, Physician, Clinical Immunologist, Psychotherapist
February 2020

The Person-Centred Upholsterer

I discovered him by internet search–someone purporting to customise chairs for people with back problems. This sounded promising. I had fractured a vertebra six months previously, and sitting, chairs and pain had become wrestling partners. So I called him up the next day during normal office hours. He clearly wasn’t ready for customers; his name is Barry, and he explained that he had been watching the World Cup cricket over night and needed to have a shave.  

After a personable and jokey conversation we agreed a time to meet. He turned out to be very friendly, warm and somewhat loquacious. He listened very carefully to the story of the problem I was having and then began the process of deciding the right format for a chair. As this developed our confidence grew. We spent an hour or more with him, and agreed to meet again after we had chosen fabrics, and after we had returned from our visit to family in Australia, a detail that seemed curiously relevant to disclose within this personalised consultation.

He listened very carefully to the story of the problem I was having and then began the process of deciding the right format for a chair.

I had been looking for a ‘right’ chair in many shops over several months. We went away from this ‘consultation’ marvelling at the felt difference between top-down and bottom-up chair sales people. At what happens when one meets a person-centred chair person!!

At our second visit his first movement was to peer—quite literally–into both of our faces, trying to discern whether we had really had a refreshing holiday, or not; in a manner that was curiously intimate and yet appropriate. We spent more time choosing and deciding chair ‘things’. But we need to be sure, he said. Once more he got me sitting in a chair, and then very smoothly started a conversation about other things, saying it might be best if we chatted for a while.

After a time, he suggested, I might know better whether this chair really suited me, whether I needed 5, 10, or 15mm more or less in height in either the front legs or the back legs, and so on. He watched me constantly, but non-obtrusively, always waiting for me to comment, and then at that point he would add his own discernments of my comfort levels in various positions. He never once defined anything before I had given my story of what I was experiencing.

He never once defined anything before I had given my story of what I was experiencing.

In the midst of all this he wanted to know what I did, what I really did, for work. I hesitated. How does one talk about what one really does professionally in ‘whole person healthcare’ in a chair/upholstery consultation? My wife Alison was less hesitant, and stepped in, and thus I was committed. I spoke as simply as I could about working with medicine, physical symptoms and story, mind and body, and even ventured the concept of dualism. It is hard enough to talk about medical dualism with one’s colleagues!

What ensued was remarkable. I cannot remember anybody, health workers included, responding quite so intelligently and freely in a first conversation of this kind. He mused about the ‘hugeness’ of the arena that would open up if one responded to physical complaints in a ‘whole person’ way. He wondered aloud about how one would decide what was relevant in a person’s story? He noted that ‘you’ would have to listen very carefully, not like the medical ‘dicks’ he has been involved with. He quickly seized on to the idea that careful listening to what floats to the surface in a conversation would lead to centrally significant material. He does this naturally anyway.

He quickly seized on to the idea that careful listening to what floats to the surface in a conversation would lead to centrally significant material.

He recalled an orthopaedic surgeon who invited him for a consultation and quotation for chairs for his waiting room. The surgeon was determined to have tub chairs for his waiting patients, many of whom would have back and hip problems. My upholsterer told him that tub chairs were completely inappropriate for people with bad hips, and anyway a tub chair couldn’t be upholstered to work for such patients. The surgeon patronisingly rebuffed this advice. Decor was top priority. So my upholsterer got up, said he wasn’t prepared to make unsuitable chairs for him, and walked out. He wasn’t going to violate his values.

He asked what I would think of a situation where someone had had an operation which was deemed a success, but the pain was no better. So we talked about predisposing, precipitating and perpetuating factors playing a role in physical symptoms, including pain. He didn’t miss a beat. The lateral thinking and questions kept coming and coming. He pondered aloud on how hard was it to change the medical system? He reflected on his reluctance to expand his own business because he felt that it was too difficult to find someone else who had his values and approach. He even checked me out briefly for my attitude to complementary and alternative medicine by asking what did I think about chakras and iridology—he was really rather doubtful about these ideas himself, perhaps there could be something in them, possibly, but….

He pondered aloud on how hard was it to change the medical system?

Out of the blue, he aired his view that there were some people who could be ‘healers’ but actually the truth was that many didn’t have the wherewithal. By this time I was fantasising that if I was still running the MindBody Healthcare Post-Graduate program at AUT University I would offer him a place in the next intake. But, then, actually he didn’t need it. Perhaps I could send students to work on placement with him!

At the centre of his observations was the refrain ‘they don’t listen’. He knows how to listen, and better than most of the professionals I have seen since my injury. He appeared to listen out of entering my story, out of commitment to the individual person, and not out of primary commitment to his expertise, to his sales, or his ego.

He appeared to listen out of entering my story, out of commitment to the individual person, and not out of primary commitment to his expertise, to his sales, or his ego.

And the feeling of this was profound.

We have ordered two chairs.

“A rickety old shed in a haunted forest”

I figured my stories could interest him.

Many years ago my family and I were lunching with Bob, a surgical colleague, and his family. The occasion was winding down, and he and I had subsided into a corner to share work perspectives. Both of us had unusual work histories. He was an altruistic and principled man, who, out of a sense of Christian service, had devoted years of his life to medical work in a developing country. I had been an academic clinical immunologist who had turned to psychiatry in mid-life, then became a psychotherapist, and then blended my clinical immunology and psychotherapy practices together, all this reflecting a personal aspiration to integrate body, mind and spirit aspects of human reality into my clinical and healing endeavours.

I shared with him my experiences of people with diverse well-recognised physical diseases that seemed to be full of meaning, and sometimes even glaringly symbolic. I had written about many such patients.

I told him about patients with facial disorders who in one way or another had had trouble ‘facing’ the world or ‘being seen’ (and more). Yes, they would spontaneously and unconsciously use words that expressed the symbolism perfectly. (Note: I am not saying that all facial disorders are symbolic).

I then described for him:

A patient with a very long list of medically unexplained fractures and tendon injuries, occurring over several years. She was in a relationship in which she felt obliged to follow her partner in his rather excessive outdoor pursuits. The ‘injuries’ effectively prevented her participation in these activities, and during the year prior to consultation she had become an invalid and unable to work. Digging deeper there was a powerful and poignant story of leg fracture in her childhood that was experienced as a way of holding on to the attention of her father.

This injury tendency disappeared entirely and immediately once all this was acknowledged and then discussed with her partner, and she was able to become pregnant. A crucial element in the story was that he had previously fiercely resisted having a child because he did not want his outdoor activities disrupted. In sum, she was unconsciously resisting him via measureable musculo-skeletal manifestations, which effectively disrupted his life focus, whilst avoiding direct communication, conflict and threat to the relationship.

I have many such stories.

My colleague had lived and worked well outside the norms of Western medical and cultural structures. I imagined that he, being a religious person, might be open to a wider view of disease than that in which he had been trained.  I hoped he might be interested, curious, or receptive.

He was not. The conversation stopped, dead. I was disappointed but did have some understanding. All of us develop and inhabit ‘enclosures’ of mind or thought. It is unavoidable. These enclosures take many forms, but I believe he was confined by two enclosures very familiar to me. And I had experienced very significant challenges during the processes of releasing myself.

The first ‘enclosure’ is that of Western biomedicine, which affects all clinical disciplines. Biomedicine is an important part of my working life and identity, and I value its powers greatly, but in one perspective it is a system of categorising and responding to illness and disease according to several restrictive, intersecting principles and forces. I get tired of reiterating these, but they include: dualism–the separation of body from subjectivity or mind and spirit; scientific reductionismwith its exclusive privileging of quantitative measurement, the associated dominance of technological intervention, the general denial of ‘experience’ as a crucial aspect of disease causation, and the gradual decline of healing as an ‘art’ or relational form; and professionalismwith its valid focus on maintenance of standards, which can have inadvertent secondary effects of excessive conformism and suppression of knowledge outside that approved by dominant vested interests. My stories fly in the face of all this.

The second ‘enclosure’ is that of (certain forms) of Protestant Christianity. Like Western scientific medicine, and since the Reformation, it has had at its heart a desire to establish the absolute ‘truth’ of things, though its aims and means of achieving this are of course are rather different. Truth for believers generally lay in establishing the historicity of the biblical record, and in interpreting the Bible in exactly the right way, thus securing eternal facts.

In both of these enclosures there has been an accepted striving for exactitude and ‘certainty’, a conviction that we have (perhaps all) the ‘truth’ we need in our grasp if we achieve this exactitude. In a way both enclosures entail a drive towards mastery and control. I hasten to add that these drives are not confined to the two examples given here.

An unfortunate side effect or cost of this is that the softer elements, the relational dynamics and priorities at the centre of human experience and reality, the visceral experiences of living and suffering, the arts of healing, and other mysteries of life are subordinated to hard data or dogma, indeed even erased from the consciousness or awareness of (in these two instances) the science-focused clinician and the ‘absolute truth’ focused believer. In other words there is an excessive seeking of a certain kind of truth and a critical neglect of other kinds.

And, so, my friend instantly closed himself off from my stories, consideration of which might have pointed towards an uncomfortable revision of his ‘enclosures’. On further reflection, given my subsequent experience of many colleagues, a simpler narrative could be that my companion was merely settled and comfortable in his work and did not want his life complicated.

While enclosure formation is intrinsic to social formation, there is a risk that excessive closing down around a limited perspective will tend towards de-vitalisation, and even stark, cold, black-and-white places that lack heart for anything that might threaten the equilibrium and ‘safety’ achieved.

We see some vivid examples of this currently around the world.

Edmund Husserl, the father of phenomenology, might have described my friend’s reaction as an example of the ‘natural attitude’—that tendency in all of us to be inculcated, to just see what we have been taught to see. In this perspective, cultural education can be very stifling and repressive of imagination and creativity.

But his reaction seemed a bit more than this. The shutting down response was so immediate and final that I believe he must have been reacting to some kind of threat.

Jules Evans, an experientially adventurous London philosopher, in his provocative book “The Art of Losing Control. A Philosopher’s Search for Ecstatic Experience”, colourfully describes this tendency towards apparently ‘safe’ limitation as akin to dwelling in ‘a rickety old shed in a haunted forest’.  This is a powerful if somewhat homely and mystical metaphor. The haunted forest element suggests a mysterious and scary world beyond our usual perspectives, a place we would be reluctant to go. The rickety house suggests that the worlds we personally construct are limited, potentially inadequate for the job of living, and likely to collapse under pressure. There are limits to any metaphor. I know people whose world view is so rigid that a more appropriate metaphor might be ‘an unyielding fortress’.

For the moment I will stick with the rickety shed. Given our exposure to multiple contributory forces – genetic, developmental family influence, trauma, cultural beliefs, and much more – we tend to construct confined ways of seeing. They protect us from the bigness of the wider world. But under pressure such constructions can be very vulnerable, and collapse.  We strive to keep them intact. Staying with the imagery, this means not stepping outside the shed to see what there might be in the forest, with its diverse pathways, possibilities and mysteries. Doing so could be unsettling at best and overwhelming at worst.

This tendency to hunker down inside safe but confined and restrictive frameworks is more than personal. We do it as couples, families, social and ethnic groups, organisations, cultures, and professions. We enclose ourselves in social webs of interdependent vested interests. And to keep it even safer we tend to resist and suppress elements that might demand deconstruction and rebuilding. Not uncommonly we step from one enclosure to another. It is hard to keep truly open and retain stability.

There are, of course, many other reasons why people will not or cannot look beyond their favoured or habitual perspectives.

A couple of examples will suffice.

Personality is important, and different personalities do it differently. Some people, for instance, are very ‘concrete’ and factual. Imagination is dedicated to structural modes of thought and action. Hard facts, so-called, are what they live by. Relational phenomena are a mystery to them. Feelings are shadowy, puzzling and hardly accessible realities that loose-minded and emotional people fuss about. My stories are indeed outside such a frame.

Turning to healthcare again, professionalism and power structures play a role in sustaining this particular rickety shed (or perhaps fortress). Modern medicine, and all clinical practice, is built on the importance of knowing, on being the expert who understands the right thing to do, and can be trusted to do so. As one lay friend of ours says, somewhat plaintively and despairingly, ‘but the doctor should know!’ Within the enclosure of biomedicine the doctor is ‘top-dog’.

But my stories disturb this structure which, generally-speaking, denies the role of subjectivity in disease. What happens to the clinician when the door is opened and the story is suddenly there in full view?  The biomedical, story-excluding top-dog is suddenly disempowered. Not knowing what to do with the story (nor trained to do so), his or her world suddenly becomes incoherent. Better not to open the door, or if it springs open ignore it or suppress it.

But, to sustain this, defenses must be mounted. Stories are characterised as fuzzy and subjective ‘noise’, even though their meanings and rich nuances constitute the core of living experience. Medicine must be scientific and evidence-based! Ironically experience shows that, even if evidence is produced for the role of subjectivity in disease, practice does not change. For instance, there have been hundreds of articles published over the last five decades showing the influence of mind/brain factors on the immune system, but there is no hint of this literature influencing immunology practice or clinical practice generally, and it has not figured in the many immunology conferences I have attended.

Sigmund Freud had something useful to say here. Human beings are commonly afraid of facing themselves, and will generally avoid doing so. A clinician who genuinely opens herself to the story of the patient is tacitly opening herself to her own story, to a larger call upon her own self, her relational capacity and limitations, and to a whole new arena of healing. She steps into the forest with its uncharted potential pathways. Listening properly and responding to these stories requires not just expert knowing but an open explorer mentality, a whole person model of health and disease, maintenance of professional relating, imagination and capacity for intimacy, and most importantly qualities like warmth, generosity, empathy, resilience around uncertainty, and more.

Our current enclosures in healthcare are not sufficient for whole person healing. Just outside, there are rich resources, possibilities and mysteries, and being open to these can be rewarding and vitalising for the clinician, and very helpful for ill and suffering people.

Perhaps it is easier to do another laboratory investigation, write a prescription, prescribe exercises, recommend a diet, manipulate a shoulder, get on to the next patient, and then hurry home in time to see the kids.

Good for the kids. But, in a wider perspective, costly.

And sad too.

Brian Broom 28 June 2018 Copyright

Imagination and its companions

How is it possible to be whole person-oriented and still feel that our work is manageable? Surely, we can’t be all things to all people?

Biomedical diagnoses and treatments of the ‘mechanical’ (sic) body are largely grounded in recognizing typical clinical patterns, objectively measured and verifiable physical changes using reliable testing methods, and statistical evidence based on analysis of the treatment of groups of patients. We mostly act (or not) in response to ‘definite’ findings and measurements. Even modern crafts-people of the mind, the psychologists and psychotherapists, strain to work as experts in this disciplined way, according to solid, over-arching frameworks or theories, supported by a mix of consensus and formal evidence.

How is it possible to be whole person-oriented and still feel that our work is manageable? Surely, we can’t be all things to all people?

But there is a big problem in applying this way of working to a whole person approach. The approach requires clinicians to attend to an ill person as a unitive whole. This means both an expanded consideration of the person’s illness as multifactorial and multidimensional, and a need to take account of these elements in our clinical response.

So, does this mean that the whole person-oriented biomedical clinician should, in addition to the normative clinical requirements of his discipline, somehow become a skilled psychotherapist, psychologist, social worker, spiritual advisor or whatever, and be required to perform elaborate, expert, systematized assessments normative within each of those disciplines? This is nonsensical and impossible. Nobody can attend to all of this.

The usual solution is of course the multidisciplinary team. But many of these are pass-the-parcel scenarios where each discipline functions narrowly according to the pattern ordained by the modern biomedical model as expressed in each individual discipline. In sum, it usually manifests as an additive framework of highly expert clinicians, patients seen from multiple narrow perspectives, a dualistic concept of disease, and a lack of attention to the highly nuanced individual personal life experiences and subjectivity factors or stories that contribute to the development and perpetuation of disease.

Apart from that critique, I actually value multidisciplinary teams, but believe that each of the practitioners in the team needs to be functioning in a whole person way. This is possible whatever one’s discipline. By adopting a whole person approach each clinician can do a great deal to enhance healing without feeling overwhelmed. It involves seeking the story, imagination, and a few other things.

Sometimes people wonder why I am so keen on the ‘story’. It is simply that we clinicians who want to practice in a whole person way need simple practical doorways into the world of the whole person, and especially that part of the person’s world not accessed by the normal biomedical approach to disease. The latter, as currently practised, focuses on the expertise of information-holding, the power of drugs and physical interventions, activities directed at restoring, repairing and compensating for ‘mechanical’ deficits and distortions, and so on. I greatly value the benefits of much of this.

But listening for the patient’s story opens up an entirely different world, and its power derives from quite a different set of assumptions, attitudes and relational values.

Asking for a story may seem a simple matter but the implications are huge.

And, in listening to a story, imagination is important.

An example: A clinician asks a patient for her ‘story’, about what happened in her life when her symptoms started many years ago when she was 18 years old. This question is actually asked because the clinician assumes to some degree that the patient is a unitive whole, and that the patient’s life experience (at 18) may be very relevant, and that opening this up may help the person get well in some way. Simply asking the question rests on really serious foundations. For me, it entails the conviction that mind and body co-emerge together from the beginning of life, and therefore it is natural to imagine the story being part of the illness. It follows that there may be therapeutic potential in knowing the story. This is the paradigm of whole person care. The paradigm allows the clinician to imagine ‘something’ important in the story around age 18, and to ask the simple question.

But the imagining comes with diverse companions. It requires courage to ask because there can be no expert prediction as to what will emerge. It requires self-confidence to enter this zone of uncertainty and trust that whatever emerges can be responded to adequately; even more than that, creatively.

And there has to be generosity. The unstated relational dynamic is something like this: “I am truly interested in you as a person. We all have a unique story. I want to know what happened to you. I won’t push you over the edge. Tell me as little or as much as you want, but, because we are un-separated wholes, illness inevitably emerges in a mix of physical and non-physical factors. I am charged with helping you, and so, if you are willing, it is important that we consider this together. I hope you will trust me. I will go gently. We are both humans together. You may well experience difficult emotions that are hard to contain. I am alright with that—I have them too.”

It is clear that getting the story is a movement into relationship.

We can do this because as humans we clinicians are ‘always already’ relational. In reality, most of the stories implicated in illness ARE relational stories: of trauma, failure, loss, abuse, abandonment, manipulation, and much more. We are all fundamentally relational. Illness and disease are ‘plural events’ (using the philosopher Andrew Benjamin’s terminology).

There is more. In these invitational, relational moments between the clinician and the person there is the beginning of new possibility, hope, and repair. We are, as clinicians, with the patient, enacting (in some measure, both symbolically and literally) the reparative potential of not just being considered attentively, but deeply heard and understood, and responded to. This is why whole person care and attending to story are so powerful, because they potentially liberate into the clinical field all the elements of the person that are important and may contribute to the multifactorial trajectory towards illness or healing. Nothing is excluded, in principle. Meantime, we hold onto the good elements of the biomedical model too.
So does it become chaos? No.

Imagination helps. Assuming I have the willingness (and interest, courage, and generosity) to ask him, another patient tells me his chronic urticaria (‘hives’) began when he returned to his job after his summer break, only to discover that his employer had decided, without any warning, that he will now be working in a very different section of the company. Do I (as a whole person-oriented practitioner) really have to wonder about everything in his life, or can I just start there? Is it possible that the important thing has floated to the surface already?

Can I treat this as a doorway?

My imagination is stirred. Few of us would have any difficulty in imagining that this employment issue could be important to him emotionally, one way or another. I imagine that the conjunction of urticaria and this work change may suggest there were some negative emotions involved. Such imagining could reasonably lead to the simple question of what did he feel about this turn of events, and so on. Perhaps he responds with: ‘Oh, I just accepted it.’ Really? What was he accepting?

I might imagine some more things: that he might not care, or that he might care and that he might be suppressing some feelings, or that he might not be used to expressing feelings, or that he might not see the point of discussing feelings because as far as he is concerned his hives is just a physical condition, or that his boss might be difficult and arbitrary and wouldn’t listen anyway, or that he felt he could not afford to upset his boss, and so on. Such imaginings reflect my experience of life.

Because we clinicians, as people, know what life is like, in its ups and downs, most of us can imagine at least some of the possibilities. This kind of imagining is based on a belief that our lives are truly and continuously grounded in a constant sequence of feelings (positive and negative) that signal to us the meanings we make of our lives and circumstances, and that often we are not clearly in contact with them, and we are not aware that they can emerge as physical symptoms or contribute to the onset of illness and disease.

But we are beyond simple story now. Relational values kick in here. It is all very well to imagine all these things. Shall I then charge in with my preferred hypothesis? No, the key is to be there and to wonder together with him, and to arrive together at a good way of seeing any connection between the illness and what happened. It may be very simple, and it may be very complicated and require help from a ‘mind’ clinician. But you and he begin to know and share together some of what he was really feeling. You have imagined there must have been some feelings. You have not imposed your story and imaginings on his. You are ready to meet him in this zone of meaning and feeling. You have let it emerge between you both.

We don’t need to be a psychologist or psychotherapist to start this process, or to make simple connections, or to give the patient permission and encouragement to consider the connections. The interaction doesn’t have to be perfect, or prolonged, or all done at once. Patients know that we are persons too, and have limits on our capacities. We can be good-enough.

In this paradigm, it will be what it is. Therefore, whatever emerges, the clinician trusts in her personal capacity to respond in some kind of way that might be fruitful. Fruitfulness often lies in kind, generous simplicity. It might be fruitful to simply say “I am glad you told me this, and I am wondering how it might be addressed from here.” More than that, the clinician trusts that in the event she doesn’t know what to do, she has a capacity to relate authentically to this person in front of her and to ‘hold’ the patient safely; and that not knowing could even be curiously and mysteriously alright. Genuine kindness can trump information.

It is very difficult to be an effective whole person-centred clinician without liberating one’s imagination. At the same time imagination must be disciplined, and grounded in respect and generosity, and in a relational space in which the therapeutic potential co-emerges between the two. It may be fast or slow, a moment, a session or a series of sessions. It may involve one or several clinicians, even a multidisciplinary team!

This is always a unique process. There is no algorithm for it.

How this began with symbolic illnesses

How did the whole person approach develop? All histories go endlessly backwards (and forwards). But a major marker of change occurred in 1988 when, after several years away from my internal medicine (clinical immunology) practice, I re-ignited it and amalgamated it with my newly developed psychotherapy training. In short, I put together a highly conventional biomedical discipline with the mind-oriented perspectives of psychotherapy. An odd marriage.

I began to see things which had been invisible to me in my previous immunology practice roles. The major shock was the appearance of ‘symbolic’ illness, where it seemed that the physical illness fitted the story so exactly that it looked as if the body was ‘telling’ the same story. There was the young woman with unexplained vaginal and rectal bleeding who had been vaginally and anally raped fifteen years before. The woman with five years of continuous crippling mouth ulcers who couldn’t talk to her daughter about why the latter had left the Catholic church, and who got better after she was encouraged to talk with her daughter. I have written of many such examples in my books and they involve both minor and major illnesses.

Symbolic illness was a shock because my medical training was about physical diseases being entirely physical. A symbolic illness had to be an absurdity. But the many symbolic conditions I saw with vivid stories were blatantly physical and the disturbances in the body were visible, detectable, or measurable. They could not easily be relegated to the ‘psychosomatic’ bin, which is what we tend to do when we cannot detect something physical or measurable.  I did not have a plausible medical explanation for what I was seeing.

I found that people with chronic physical illnesses tended to get better once we brought the medical condition together with the patients ‘story’. Just connecting the two, or giving permission to think that they might be connected, helped some people. Working much harder on the story aspects helped others.

In an effort to make sense of this, while continuing to work with patients in a ‘mindbody’ way,  I read widely in psychoneuroimmunology, philosophy, psychotherapy, history of medicine, theories of embodiment, consciousness literature, modern physics, the nature of experience, the nature of language and the role of symbols, cross-cultural concepts, psychosomatics, modern theories of emotional expression and development, the nature of person-hood, and critiques of modern medicine and evidence-based medicine. And more.

And what I saw (as did many others) was that in Western healthcare (and culture) we had divided the person into compartments. The mind and body were separate. In medicine we treated bodily disturbance as largely separate from the mind (except in those conditions where we could not detect much or anything in the body, and these were the psychosomatic conditions).

If we think about the development of an infant it seems obvious that physicality (body) and subjectivity (mind, and our capacity for organising our experience) emerge together from the beginning. They are co-emergent. They are not separated. This means our bodies and our life experiences are not separate but mingled, and together. We are one, unitive, a whole. It follows that patients with disorders need to be considered as wholes and that so-called physical diseases merit seroius consideration of the non-physical, the ‘story’, the events that occurred before and around the time the illness emerged or relapsed (and so on).

Treating physical disease as if separate from a person’s life as a whole is a fundamental error, and negative for patients, because it shuts the door on involving a consideration of all those other life experience things which, if addressed, may cure, improve or modify the course of a physical illness. It also means that we are more and more committed to purely technological solutions to our chronic illness problems. And we see the costliness of that.

It is true that many patients are intent on getting a technological answer, and some of that is about being educated by Western culture and healthcare that that IS the only way. Some of it is about people not wanting to address tender or hurting areas of their lives. There are many factors.

Don’t get me wrong. I do not think that all illness is symbolic but the symbolic illnesses were the catalyst for seeing patients as whole persons. I highly value technological approaches in many conditions. But we need a combined approach, a whole person approach, which allows for diagnosis, drug and technological treatments and consideration of stories. Depending on each patient the treatment may be skewed one way or the other.

The two massifs

Modern healthcare (sometimes we call it biomedicine) is a massive and dominant enterprise in which the clinical gaze (1) is largely directed at the physico-material aspect of sick persons.

In contrast, ‘whole person’ or person-centred approaches hold that people are complex multidimensional beings, in which physical, subjective, soul-ish, spiritual, creative, relational, genetic, family, cultural, and environmental elements and factors are all present, mixed up together, and active, and may be legitimately and  usefully considered in the healing enterprise.

These two systems are like huge geological land-forms confronting each other across a barely bridgeable chasm. After nearly a decade of teaching the MindBody Healthcare approach at University level it is clear that clinicians of all kinds, if prepared to commit themselves to the discipline required, can become competent ‘whole person’ clinicians.  But I am less certain it can be generalised without a massive push or demand from the general population.

The question becomes whether it is too hard for most clinicians and many patients. It may be the right way to go, but is it too idealistic, given the way the world is and the way human nature is?

Biomedicine was my first professional training and identity. By orthodox academic measures I was doing well. Senior physicians and mentors believed in me and my career was blossoming. I got caught up in the demands of specialist training in Clinical Immunology. I felt the biomedical model tightening around me, drawing my energies, and stifling my interest and search for something more capacious, something to contain the wider dimensions of life and healing.

Biomedicine is powerful and exclusive. Ultimately, it eschews mystery. It knows (sic) that with more effort, more science, more measurement, more research money, more hard data, more evidence, more control, more instruments, more drugs, more training, more information, better algorithms, more publications, and more refined diagnostic labelling, we will get on top of illness and disease.

The widespread belief in technological progress as the answer to our health problems is incorrigible. Of course, there are other factors supporting this dominant narrative of illness and disease: ‘Big Pharma’, and patient yearnings for ‘fix-it’ solutions, and just plain, ordinary human defensiveness around painful emotional dilemmas which then get preferentially expressed in the body. And there is a huge biomedical army (of which I am a member) in thrall to treating disease purely from the physical aspect.

The majority of biomedical clinicians take the road ‘most’(2) travelled.  Why not? If you want to get on in the world, it makes sense to join the dominant discourse, and make sure you understand and assimilate to business as usual.  In Edmund Husserl’s terms, what these clinicians see and hear in a clinical consultation constitutes the ‘natural attitude.’ A kind of taken-for-granted view of the world, which does not allow for other possibilities.

The biomedical ‘natural attitude’ certainly encompasses clinical safety, compliance to orthodoxy, adherence to evidence, peer approval, logic and rationality, efficacy within constrained clinical frameworks, privileging instrumentality over clinical relationships, despising placebo, avoiding emotion and mystery, and, increasingly, an inability to restrain mechanistic intervention; these are typical crags on the biomedical massif.

Of course, there is room for compassion and warmth and care beyond the call of duty, but there is precious little room for ‘whole person’ approaches beyond this, little room for the patient’s unique ‘story’. These are generally not accommodated within the biomedical ‘natural attitude’. The preoccupations of the climbers on the biomedical massif mean that there is little ‘marginal capacity’ (again calling on Husserl) for awareness of either the chasm or the massif on the other side.

Yes there will be some awareness of the psychosocial factors, for example, that cultural elements are important, or that some people may be helped by a psychologist, especially if they can be given a diagnosis of depression or anxiety disorder.

And sometimes I become aware that biomedical colleagues are far more aware of emotional factors than they had ever previously disclosed. At moments like this I am newly shocked by the power of a system to shut down knowledge or talk of things inimical to the biomedical system’s dominance.

When I do foster discussion from a ‘whole person’ perspective with other clinicians, or as I try to bring the ‘other’ massif into focus, I am commonly confronted with a variety of reactions: awkward silences, uneasiness, a rush to regain control or terminate the discussion, confusion, bewilderment, an awakening from boredom, threats to knowing and competence, and rush to assert biomedical dominance. And later, usually later, if at all, and privately, individual clinicians coming up to me to say they are glad that I spoke out, or that they did agree and are glad that I said something.

I have persisted with biomedicine. I have long felt that it is wrong to shake the dust off one’s feet and leave biomedicine for, say, complementary and alternative medicine. Not that I was ever drawn to that route. Much of complementary and alternative medicine is not whole person-oriented, but a mixture of diverse ideologies, techniques, and methodologies, distinguished significantly by the disapproval of biomedicine, and the lack of the kind of evidence approved by biomedicine.

I have also been disappointed with ‘whole person’-oriented colleagues who have turned their backs on medicine because they find it is too hard to live in the biomedical context and practise whole person care. Coping with collegial misunderstanding and disapproval, the disempowering fear of missing serious diagnoses whilst attending to the whole person, the inevitable reductions in income, the extra energies required to enact whole person care within the constraints of conventional medical appointment structures, the intellectual challenges in making sense of mind and body integration in the medical context—all of these things and more, can be too much. Disappointed I may be, but I do understand the need to keep life manageable.

Yet I remain convinced that ‘whole person’ approaches need to celebrate and retain the reality that we are physical and bodied, and that the physico-materialist, mechanistic, biomedical modelling of persons is highly effective in many circumstances, such as surgery, acute resuscitation, and many other situations. In fact it is this very success and usefulness that makes biomedicine such a huge and forbidding massif, resisting erosion, demanding our whole focus.

It is shame that we cannot have the benefits of both sides of the chasm. This resource is an attempt to give patients and clinicians at least some access to both

  1. Foucault M. The Birth of the Clinic: An Archaeology of Medical Perception. London: Tavistock; 1973.
  2. Peck MS. The Road Less Traveled: A New Psychology of Love, Traditional Values, and Spiritual Growth, New York City: Simon & Schuster; 1978.