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.
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’.
 See https://wholeperson.healthcare/
I loved this Brian, especially the valuing of uncertainty. To be in the ‘don’t know’ with a client and let them reveal their reality and for us to be able to truly hear it is a courageous and humble space where insight and healing can emerge. Thank you for sharing this - I look forward to more.
Thanks Peta, being comfortable with 'not knowing,' but knowing that 'not knowing' is the place/space for creative discovery and exploration (and therefore knowing) is perhaps the hardest thing to communicate to highly trained clinicians. But more on that in a later news letter.
With warm regards