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.

 

In Category: Brian Broom, Uncategorized

Brian Broom

Dr Brian Broom is a Consultant Physician (Clinical Immunology) and Psychotherapist in the Department of Immunology in Auckland City Hospital; and Adjunct Professor, Department of Psychotherapy, Auckland University of Technology.

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