Elliott Dacher MDThere is great fervor in the health field. New ideas, innovative programs, and hope are everywhere, and today’s rapid changes seem to have a momentum of their own. States are providing licensure to new categories of health practitioners, medical schools are offering programs on holistic healing, the Office of Alternative Medicine is funding research on complementary therapies, insurance carriers are beginning to offer reimbursement for these therapies, the Internet is overflowing with information and informal dialogues, and the state of Washington has passed legislation mandating that “Every health plan after January 1, 1996 shall permit every category of provider (chiropractors, acupuncturists, naturopaths, etc.) to provide health services or care for conditions included in the basic health care services (offered by the health plan)…”
Confronted with the complexities of lifestyle and stress-related degenerative diseases, addictive disorders, anxiety, depression and their physical counterparts, dissatisfaction with the over use of pharmacological and interventionist therapies, a rising antipathy with professional arrogance and authority along with a growing demand for high level health conventional medicine has finally reached its limitations. There is now a broad based consensus that change is necessary and desirable.
But the current pace of change has allowed both practitioners and the general public little opportunity for reflection and evaluation. As a result there has been a lack of significant discourse in regard to the extent and the direction of change. Motivated by very real concerns yet conditioned by old patterns of thought, fired up with enthusiasm and hope yet compelled by complex professional and financial interests, and carried along by a seemingly unstoppable momentum, we simply assume that our current initiatives are taking us in a beneficial and innovative direction. As a result, we have failed to ask the critical questions whose answers can either reassure us about our current efforts, or cause us to reconsider them. Consider these two simple but basic questions:
• What perspectives do we wish to see expressed in a reconfigured
approach to health and healing?
• Do our current initiatives reflect and support the development of these perspectives?
Past and Future Gathered Together
The first question, one that deals with the articulation of a newly emerging world view, must be considered in the context of our unique historical moment. Today we find ourselves living in an extraordinary in-between time, a sort of gap in time that has been created by the decline of our previously unquestioned optimism and faith in the 500 year tenure of modernism, and the slow and as yet uncertain emergence of a new post modern viewpoint. As practitioners and individuals in search of a more meaningful approach to health and healing, we rarely concern ourselves with these larger cultural movements, issues we usually leave to historians, social scientists, and philosophers. Yet at times of great transformation we cannot afford to do so. Only to the extent that we can accurately comprehend the historical forces that are driving and shaping our times can we effectively embrace and empower these forces rather than oppose them with potentially misguided efforts. With this in mind it becomes incumbent on us to inform our efforts with an understanding of our extraordinary historical moment, an understanding the can enable us to best answer the two questions we have proposed.
As westerners our cultural history can largely be traced to Hellenistic Greece. This meeting of the ancient mythological world and the emerging world of rational inquiry gave rise to an extraordinary culture which sustained, for a brief period of time, a precarious yet highly creative balance between sensory and intuitive knowledge – the seemingly opposing perspectives of analysis and synthesis. Among this culture’s many achievements was the rise of Aesclepian medicine, an amalgam of the rudimentary elements of a scientific medicine, the practice of hygiene, and the active invocation of the imagination and spirit.
Several centuries later this union of rational and intuitive knowledge was sundered apart with the rise of the monotheistic Christian mythos. Faith and scripture replaced rational inquiry as the primary route to knowledge and truth, and faith, revelation, salvation, and healing became one. Independent intellectual exploration of the human experience and the natural world was surrendered to the absolute authority of the Church. But the rise of a monochromatic perspective in either personal psychology or history always empowers its counter-balancing force which in time forces the decline of the previously dominant perspective. It is in this manner that the dominance of the Christian era eventually declined, giving way to the Copernican revolution and the modern era, an extraordinary epoch which was to last for 500 years, and is only now beginning its decline.
Initiated by Copernicus and completed by Kepler, Galileo, and Descartes this paradigm shift engaged the western world in a compensatory, yet equally monotheistic world view, one that was sensory-based, factual, and mechanical. This powerfully pragmatic perspective has been highly successful in elucidating the mechanistic aspects of nature, but it has left us with a disenchanted and devitalized world, one that is devoid of meaning, spirit, and faith. We have deconstructed metaphysics, leaving ourselves with no encompassing vision of life, transcendent or immanent. We have deconstructed the individual, turning the immense experience of humanity into a mechanistic collection of biological parts. We have alienated ourselves from the natural world, preferring to control and manipulate it rather than to learn from and be nurtured by it. We have delegitimized the poetic, imaginative, and aesthetic realms. And as a result, we are losing our centuries old faith and hope that an objectified and technological understanding of life acquired through reason alone would provide us with a progressive and endless improvement in the quality of our lives.
The recognition of the limitations and dark side of the modern world view has placed us in a time of great uncertainty, one that is simultaneously filled with an unlikely mixture of personal and social nihilism and an unfettered optimism. The consequences of the former can be seen in social decay, personal despair, and the of loss meaning and hope, and the consequences of the later can be seen in a momentous surge of creativity, pluralistic thinking, and hopefulness. It is in this gap between world views that we live. And both our disillusionment with the existing medical model, and our efforts to revitalize and reconfigure our approaches to health and healing emerge from this pregnant historical moment. To understand this circumstance is to comprehend that the changes we must now envision are fundamental rather than cosmetic, and as much compelled as chosen.
Through the mist of the uncertainty of our times the elements of a post modern world view are slowly becoming evident. This new perspective, unlike those preceding it, will most assuredly be polychromatic, allowing for the inclusion of multiple perspectives while denying the dominance of any single perspective. And the individual, within the framework of community, will rediscover his or her unity with life while simultaneously maintaining an authentic sense of autonomy and transcending the alienation imposed by the modern world view. For the purpose of seeking guidance in our efforts to reconfigure our approach to health and healing within the context of the larger cultural movements of our times I would like to set forth four perspectives that now appear to be critical elements of the emerging post modern world view, perspectives that must be central structural supports for a post modern medicine.
Multidimensional Realism
The modern world view requires that reality be objectified, sensory-based, impersonal, measurable, quantifiable, opaque, and collectively experienced and validated. The post modern view of reality is far more complex. It rejects the view that reality is limited to the receptive capacities of our five senses, and validates the legitimacy of non-sensory, intuitive knowledge. Reality is extended, revitalized, and personalized. It is seen as a multidimensional amalgam of sensory and non-sensory knowledge. This amalgam denies the extremes of a purely sensory-based universe, and its antithesis a radical subjectivism.
Intentionality
The modern world view postulates that all phenomena are caused by unchanging universal laws that exist independently of human consciousness. In essence, causality is seen as physically based and upward in its direction. The post modern perspective validates and legitimizes the causal nature of consciousness which is individually willed and downward in direction.
Holism
The modern world view assumes the distinct separateness of subjective and objective, external and internal, material and immaterial, mind and body, reason and intuition, and man and nature. At its essence, irrespective of its extraordinary accomplishments, it is an alienating perspective. The post modern viewpoint accepts the value of an analytic methodology within a larger context that comprehends and honors the unbroken unity of all life.
Personal Authenticity
The modern world view assigned great importance to the individual and his/her rights, an ideal that too often was degraded to a self-indulgent, egoistic, and aggressive quest for power and material gain accompanied by personal alienation. The post modern world view revitalizes and deepens the meaning of individualism by asserting the significance of the individual search for authenticity through self-knowledge, legitimizing the shift in authority from belief systems, institutions, and professionals to the individual (a shift in authority from external to internal), and recognizing that authentic individualism comes into being in the context of relationship.
These four perspectives underlie, inform, and drive our current process of cultural change. Together they constitute the historical imperative of our times, an elastic world view that unlike previous religious and empirical perspectives is both pluralistic and inclusive. These essential perspectives characterize the post-modern world, and as such they can most appropriately guide and define an approach to health and healing that is unique to the needs and character of our times – an approach that I have called post modern medicine.
A Shift in World View or More of the Same
With these new perspectives in mind, let’s consider our second question: Are our current efforts expressing and supporting these perspectives, the viewpoints that characterize fundamental change? Consider the following recent attempts to expand our ideas about health and healing.
• John Travis, M.D. opened the first wellness center in the late 1970s in Mill Valley, California. Influenced by Halbert Dunn’s book High Level Wellness, Travis’ concept of wellness sought to expand our ideas about health beyond the customary focus on preventing and curing disease to include a concern for the promotion of well-being. Health and healing were seen as a personal affair, a psychosocial process of education and lifestyle change.
• The idea of holism, first described by Jan Smuts in his 1920s book Holism and Evolution, was revived by individuals and practitioners seeking a broader vision of health and healing. As a concept, holism expressed the view that life at all levels is organized as a unity. Although reductionism had been successful in explaining the mechanistic workings of nature, it was increasingly seen as a limited and partial approach to knowledge, an approach which distracted us from a more comprehensive and ecological view of the human condition that offered a more meaningful, vital, and enchanted view of nature.
• In the 1980s alternative and complementary practices began to emerge as a further expression of the rapid changes in our ideas about health care. Naturopaths, chiropractors, acupuncturists and others sought and achieved state licensure, and began the initial steps towards full integration into the mainstream of institutionalized health care, a process aimed at achieving conventional acceptability and consensual validation. The Office of Alternative Medicine was established at the National Institutes of Health to examine the efficacy and appropriateness. of these diverse approaches to health and healing.
Each of these initiatives were honest attempts by sincere individuals and institutions to bring change to an entrenched health care system, one that no longer seemed effective in dealing with present day problems and sensibilities, and was at odds with the emerging post modern viewpoint. Let’s examine the results of each of these efforts.
The idea of wellness was rapidly integrated into our culture. But as it entered the mainstream of our cultural life, and particularly when it was integrated into existing health care institutions, wellness was reduced to four physically based issues: nutrition, smoking cessation, fitness, and stress management. Its fundamental emphasis on personal development, and its psychosocial framework and values were largely jettisoned, and with its assimilation into the larger culture it was reshaped until it more resembled traditional preventive approaches, packaged as generic commodities carrying the “wellness” label, than the dramatic shift in perspective envisioned by Travis.
The idea of holism suffered a similar fate. As a philosophy, holism evolved as a counterforce to atomistic and reductionistic perspectives. Sixty years after Smuts defined this concept, his vision was reduced to packaged commodities that could be bought and sold with labels such as holistic medicine, holistic dentistry, and so on. And further, it became a marketable credential that was self-applied by a diverse group of practitioners who confused humanism and an expanded repertoire of remedies and practices with holism. And even in the case of those practices that evolved from a more comprehensive framework, the “holistic” components rapidly receded in importance, or were completely discarded as they were secularized and reduced to disease-oriented treatments. As we are discovering, this is the cost of integrating into and accommodating to the institutional structures of mainstream health care whose perspectives are solidly embedded in the traditions of the modern world view. It is the price of cultural acceptability and third party reimbursement.
Alternative and complementary approaches to health and healing, however valuable in diversifying our treatment options, have similarly failed to significantly alter our existing world view. Conventional and alternative practitioners, irrespective of their rhetoric or intention, generally use their specific expertise to prescribe techniques, practices, drugs, or supplements for the purpose of repairing or fixing an abnormality. The professional defines the approach solely within the context of his or her professional domain, and the prescribed treatment is external rather than internal. The individual is a more or less passive recipient of the therapeutic process gaining little in the way of personal insight or additional self-healing capacities. Because all of us are conditioned to turn to authoritarian structures and external remedies at times of adversity, we often demand and easily accommodate to the treatment model. There are always individual practitioners whose practices reflect a substantial shift in perspective (both conventional and alternative healers can access holistic principles within their traditions), but this remains an individual prerogative in distinction to a cultural shift.
The answer to our second question is now apparent. With few exceptions these and similar efforts ultimately failed, usually in their implementation, to explicitly and consistently express the perspectives that characterize a post modern medicine, perspectives that most of us would agree with and ones that would take us in the direction of fundamental change? So why has this happened? The answer is clear. Old perspectives and parochial interests are powerful and enduring. They silently and effectively reshape our efforts to more or less conform to existing conventions, incorporating and reshaping them until they accommodate to the assumptions of the existing world view. Because each of these initiatives explored new approaches and perspectives, and in this way succeeded in expanding existing perspectives and stretching our imagination, they have been useful endeavors. But so far they have failed at fundamental change. As a result, these initiatives have ultimately fallen within the hegemony of the existing values, perspectives, and practices, falling far short of taking us in the direction of a post modern medicine. Wellness became prevention, holism became an empty word, and alternative approaches became alternative treatments. The powerful influence of the existing world view subtly but surely changes us before we can change it, and our efforts fall of short of animating the perspectives of the emerging post modern viewpoint. Overcoming ourselves and our deeply conditioned and often unconscious assumptions is a difficult task.
A Post-Modern Medicine
So how do we assure fundamental change? How do we align ourselves with the future? First, we must clearly articulate the perspectives that we choose to assert, then carefully design and embed them into innovative programs, and finally, measure the success of these programs by their demonstrated capacity to foster these perspectives. To accomplish this goal these perspectives must gain priority over our conditioned thoughts and actions, and our parochial professional interests. The changes that will result from such an effort will not be an accumulation of new ideas and practices that are subtly but assuredly reshaped to resemble the past, but rather a fundamental revision of our approach to health and healing.
Because the central perspectives of the post modern world view – multidimensional realism, intentionality, holism, and personal authenticity – are activated, animated, and validated through direct personal experience guided by an inquiring consciousness, the individual (in contrast to professionals and institutions) becomes the essential focus and primary healer of post modern medicine. Health and healing – its character, symbols, and metaphors – become personal issues, ones that are uniquely defined and orchestrated by each individual. In a sense, the individual is the healer, the healee, and the healing. Directly engaged in the historical process of actively integrating and living a new world view, the individual himself is transformed. This transformation is marked by a shift in authority from professionals and institutions to the individual, a shift that is accompanied by an expansion of personal consciousness and capacity.
It follows from this that initiatives that result in an expansion and extension of professionalism and its monopoly over knowledge, conventional or alternative, expropriates power and possibility from the individual and runs counter to the values of a post modern medicine. Practitioners and their therapies will remain an important component of a person-centered post modern medicine, but not a dominant one. They will be a valuable resource to individuals who are actively engaged in composing their lives, defining their personal visions of health, and learning from and responding to life’s adversities.
Because we are still living in the gap between world views, we can only catch glimpses of what the full flowering of post modern medicine will look like. Yet there is much to gain from these glimpses. Let’s consider two programs: the Dean Ornish Lifestyle Intervention Program and the Planetree Hospital Unit and Consumer Education Program. In examining each of these programs we can measure them against the perspectives that will characterize a post modern medicine.
In 1977 Dr. Dean Ornish began to explore an alternative, non-pharmacological approach to atherosclerotic heart disease. The central elements of his program included a low fat diet, meditation, yoga, exercise, and psychological counseling and support. When I visited this program in 1990 I had an opportunity to join an evening meeting and to speak in some detail with several of the participants. What most impressed me was the extent to which these individuals had become empowered in the pursuit of their own healing. They had developed a repertoire of new skills, resources, and capacities, gained insight into their lives and relationships, cultivated a more expansive understanding of health and disease, learned to make conscious and self-directed choices in a complex and pluralistic universe, and accomplished each of these goals within the context of a community. As a result of these experiences the participants extended the scope of their personal autonomy, expanded consciousness and self-knowledge, and created new options, each of these valued outcomes was built into the ongoing program. By transforming their approach to health and healing they had simultaneously transformed themselves.
The goal of Ornish’s program, as I view it, is to support the personal growth and development of the participants so they can assert their primary role in the healing process, recovering from illness and promoting vital and healthy lives. Ultimately, the professional fades into the background, and the individual and his or her experience becomes the central factor in health and healing. This is not a treatment program in the way we have previously conceptualized treatment. I’m not quite sure what to call it, but my sense is that it expresses the values we have discussed, and contributes to the creation of a fundamentally new and effective approach to health and healing, one that begins to engage the central elements of the post modern view.
Let’s look at another example, the Planetree model. In 1977 Angelica Thieriot, an Argentinian, was hospitalized during a visit to San Francisco. Although impressed by the technology she was appalled by her hospital care. As a result of this experience she approached the chief of medicine at the Pacific Presbyterian Medical Center in San Francisco with the idea of creating a model program, a program that would respond to the needs of the individual by supporting personal autonomy.
In 1981 the first Planetree Health Resource Center opened. This consumer library was designed to assist individuals in acquiring up-to-date medical information that would enable them to be active and informed participants in the healing process. The center maintained a library, subject files on conventional and alternative health care, access to the National Library of Medicine’s search service, selected bibliographies, and listings of national and local organizations and support groups.
In 1985 the first Planetree hospital unit was established. In each of the patient’s rooms the colors, lighting, carpeting, and other details were specifically designed so that the healing needs of individuals could be met. The patients had full access to their medical records, and were encouraged to add their observations, feelings, and responses to their files. The new unit provided kitchen facilities, flexible visiting hours, and a health educator. Alternative practitioners were permitted within the hospital setting, and patients had the option of wearing their own clothes, robes, and pajamas. In what is for most individuals a highly vulnerable circumstance the Planetree program focused on enhancing personal autonomy, expanding the individual’s knowledge and capacities, and allowing for a pluralistic approach to the healing process.
When I visited the Planetree hospital unit and consumer library the difference was clear. I did not feel I was visiting a treatment facility, but rather a healing center, one that was focused on the individual. Patients could leave the hospital more informed, aware, resourceful, empowered, and autonomous, a unique experience in health and healing. This project is another example of how postmodern perspectives when designed into the core of a program can support the emergence of a fundamentally new kind of medicine.
Each of these programs is a first step in the right direction, a movement away from the limitations of an exclusively reductionistic and professionally-centered treatment program. In each instance the advances of modern science are not discarded, in fact they are honored and then integrated into a larger, post modern world view. The result is the emergence of a post modern medicine.
It is difficult to be a midwife to a new world view. Each of us was born, socialized, and educated to live within and to honor the existing viewpoint a set of perspectives whose basic assumptions are unstated and silent yet at the same time relentlessly compelling. The science, and particularly the medicine, associated with this viewpoint have taught us to seek the remedies for our problems outside of ourselves, to distrust our inherent healing capacities, and to look towards the professional as the singular authority on issues of health and healing. As professionals we have learned our role in this drama, one, that irrespective of our rhetoric, is extremely difficult to relinquish. For this reason the impetus for fundamental change is more likely to come from an informed and conscious public than it is from current health practitioners. An understanding of our historical moment would suggest that this change will neither be defined or directed by practitioners, nor will it be characterized, as it is now, by a singular emphasis on the expansion of treatment options. Rather, it will be defined and directed by the individual.
Thomas Kuhn, in his seminal book The Structure of Scientific Revolutions, said: “The transition from a paradigm in crisis to a new one …. is far from a cumulative process, one achieved by an articulation or extension of the old paradigm. Rather it is a reconstruction of the field from new fundamentals, a reconstruction that changes some of the field’s most elementary theoretical generalizations….. When the transition is complete, the profession will have changed its view of the field, its methods, and its goals.” It is time that we step back and begin to speak about fundamentals, about the perspectives that define our lives and our work. Such a conversation will surely assist us in creating and successfully implementing the fundamental changes that are now awaiting us.
Jim Strohecker
Tom Ferguson MD
Daniel Redwood DC