10. Wholeness and Health
To develop a holistic approach to health that will be consistent with the new physics and the systems view of living organisms, we do not need to break completely fresh ground but can learn from medical models existing in other cultures. Modern scientific thought - in physics, biology, and psychology - is leading to a view of reality that comes very close to the views of mystics and of many traditional cultures, in which knowledge of the human mind and body and the practice of healing are integral parts of natural philosophy and of spiritual discipline. A holistic approach to health and healing will therefore be in harmony with many traditional views, as well as consistent with modern scientific theories.
Comparisons of medical systems from different cultures should be made very carefully. Any system of health care, including modern Western medicine, is a product of its history and exists within a certain environmental and cultural context. As this context keeps changing, the health care system also changes, adapting itself continually to new situations and being modified by new economic, philosophical, and religious influences. Hence the usefulness of any medical system as a model for another society is quite limited. Nevertheless, it will be helpful to study traditional medical systems; not so much because they can serve as models for our society, but because cross-cultural studies will broaden our perspective and help us see current ideas about health and healing in a new light. In particular, we shall see that not all traditional cultures have approached health care in a holistic way. Throughout the ages cultures seem to have oscillated between reductionism and holism in their medical practices, probably in response to general fluctuations of value systems. However, when their approaches were fragmented and reductionistic, this reductionism was often very different from the one that dominates our current scientific medicine, and thus comparative studies may be very instructive.
In nonliterate cultures throughout the world, the origin of illness and the process of healing have been associated with forces belonging to the spirit world, and a great variety of healing rituals and practices have been developed to deal with illness accordingly. Among these, the phenomenon of shamanism offers a number of parallels to modern psycho-therapies. The tradition of shamanism has existed since the dawn of history and still continues to be a vital force in many cultures throughout the world.1 Its manifestations vary so much from culture to culture that it is almost impossible to make general statements about it, and there are probably many exceptions to each of the following generalizations.
A shaman is a man or woman who is able, at will, to enter into a nonordinary state of consciousness in order to make contact with the spirit world on behalf of members of his or her community. In nonliterate societies with little differentiation of roles and institutions, the shaman is usually the religious and political leader and also the doctor, and thus a very powerful and charismatic figure. As societies evolve, religion and politics become separate institutions, but religion and medicine generally stay together. The role of the shaman in those societies is to preside over religious rituals and to communicate with spirits for divination, diagnosis of illnesses, and healing. But it is also characteristic of traditional societies that most adults have some medical knowledge. Self-medication is very common and the shaman is needed only for difficult cases.
In addition to shamanistic traditions, the major cultures of the world have also developed secular medical systems that are not based on the use of trance but employ techniques passed on in written texts. These traditions usually establish themselves against the shamanistic systems. The shaman then loses his function as the leading ritual specialist and adviser to the people in power and becomes a peripheral figure often perceived as a potential threat to the power structure. In this situation the function of shamans is reduced to diagnosis, healing, and counseling at the local, village level. In spite of the widespread adoption of the Western and other secular medical systems, shamans have survived in this role throughout the world. In most countries with large rural areas shamanism is still the most important medical system, and it is also very much alive in the major cities of the world, especially in those with large populations of recent migrants.
The outstanding characteristic of the shamanistic conception of illness is the belief that human beings are integral parts of an ordered system and that all illness is the consequence of some disharmony with the cosmic order. Quite often illness is also interpreted as retribution for some immoral behavior. Accordingly, shamanistic therapies emphasize the restoration of harmony, or balance, within nature, in human relationships, and in relationships with the spirit world. Even minor illnesses and ailments such as sprains, fractures, or bites, are not seen as being due to bad luck but rather as inevitable manifestations of the larger order of things. Diagnosis and treatment of minor ailments rarely involve explanations beyond the immediate physical situation, however. Only when the patient does not get well quickly, or when the illness is more serious, are further explanations and causes sought.
Shamanistic ideas about disease causation are intimately linked with the patient's social and cultural environment. Whereas the focus of Western scientific medicine has been on the biological mechanisms and physiological processes that produce evidence of illness, the principal concern of shamanism is the sociocultural context in which the illness occurs. The disease process is either ignored altogether or is relegated to strictly secondary significance.2 A Western doctor asked about the causes of an illness will talk about bacteria or physiological disorders; a shaman is likely to mention competition, jealousy and greed, witches and sorcerers, wrongdoing by a member of the patient's family, or some other way in which the patient or his kin failed to keep the moral order.
In shamanistic traditions human beings are viewed primarily in two ways: as part of a living social group and as part of a cultural belief system in which spirits and ghosts can actively intervene in human affairs. The individual psychological and spiritual state of the patient is less important. Men and women are now viewed predominantly as individuals; their life histories and personal experiences, including illnesses, are seen as the result of being part of a social group. In some traditions the social context is emphasized to such an extent that the organs, bodily functions, and symptoms of an individual are inseparably linked to social relations, plants, and other phenomena in the environment. For example, anthropologists observing the medical system of a village in Zaire found it impossible to abstract a simple physical anatomy from the ideas about the body held in this culture, because the effective boundary of the person was consistently drawn much wider than in classical Western science and philosophy 3.
In such cultures social circumstances are assigned overwhelmingly greater importance than are psychological or physical factors in determining the causes of an illness, and these medical systems are therefore often not holistic. Searching for a cause and pronouncing the diagnosis may sometimes be more important than the actual therapy. Diagnosis often takes place in front of the whole village and may involve disputes, arguments, and feuds between one family and another, with the patient barely noticed. The entire procedure is primarily a social event, the patient being merely a symbol of the conflict within the society. Shamanistic therapies generally follow a psychosomatic*(*From the Greek psyche ('mind') and soma ('body').) approach by applying psychological techniques to physical illnesses. The principal aim of these techniques is to reintegrate the patient's condition into the cosmic order. Claude Levi-Strauss, in a classic article on shamanism, has given a detailed description of a complex Central American healing ritual in which the shaman cures a sick woman by calling upon the myths of her culture and using the appropriate symbolism to help her integrate her pain into a whole where everything is meaningful. Once the patient understands her condition in relation to this broader context, the healing takes place and she gets well. 4
Shamanistic healing rituals often have the function of raising unconscious conflicts and resistances to a conscious level, where they can develop freely and find resolution. This, of course, is also the basic dynamic of modern psychotherapies, and indeed there are numerous similarities between shaman-ism and psychotherapy. Shamans used therapeutic techniques such as group sharing, psychodrama, dream analysis, suggestion, hypnosis, guided imagery, and psychedelic therapy for centuries before they were rediscovered by modern psychologists, but there is a significant difference between the two approaches. Whereas modern psychotherapists help their patients construct an individual myth with elements drawn from their past, shamans provide them with a social myth that is not limited to former personal experiences. Indeed, personal problems and needs are often ignored. The shaman does not work with the patient's individual unconscious, from which these problems arise, but rather with the collective and social unconscious, which is shared by the whole community.
In spite of the difficulty of understanding shamanistic systems and comparing their concepts and techniques to those of our culture, such a comparison can be fruitful. The universal shamanistic view of human beings as integral parts of an ordered system is completely consistent with the modern systems view of nature, and the conception of illness as a consequence of disharmony and imbalance is likely to play a central role in the new holistic approach. Such an approach will have to go beyond the study of biological mechanisms and, like shamanism, find the causes of illness in environmental influences, psychological patterns, and social relations. Shamanism can teach us a lot about the social dimensions of illness, which are severely neglected not only in conventional medical care but also by many new organizations that claim to practice holistic medicine; and the great variety of psychological techniques that shamans use to integrate the patient's physical problems into a broader context offer many parallels to recently developed psychosomatic therapies.
Similar insights may be gained from the study of 'high-tradition' medical systems, which were developed by the major civilizations of the world and passed on in written texts for hundreds and thousands of years. The wisdom and sophistication of these traditions are illustrated in two ancient medical systems - one Western and one Eastern -whose concepts of health and illness are still extremely relevant in our time and also resemble each other in several aspects. One of them is the tradition of Hippocratic medicine that lies at the roots of Western medical science, the other is the system of classical Chinese medicine that forms the basis of most East Asian medical traditions.
Hippocratic medicine emerged from an ancient Greek tradition of healing whose roots go far back into pre-Hellenic times. Throughout Greek antiquity healing was considered to be, essentially, a spiritual phenomenon and was associated with many deities. The most prominent among the early healing deities was Hygieia, one of the many manifestations of the Cretan goddess Athena, who was associated with snake symbolism and used the mistletoe as her all-heal.5 Her curative rites were a secret guarded by priestesses. By the end of the second millennium b.c., patriarchal religion and social order had been imposed on Greece by three waves of barbarian invaders, and most of the earlier goddess myths were distorted and coopted into the new system, usually by portraying the goddess as the relative of a more powerful male god.6 Thus Hygieia was made to be the daughter of Asclepius, who became the dominant healing god and was worshiped in temples all over Greece. In the cult of Asclepius, whose name is related etymologically to that of the mistletoe, snakes continued to play a prominent role, and the serpent, coiled around the Asclepian staff, has been the symbol of Western medicine ever since.
Hygieia, the goddess of health, continued to be associated with the Asclepian cult and was frequently portrayed with her father and with her sister Panakeia. In the new version of the myth the two goddesses associated with Asclepius represent two aspects of the healing arts that are as valid today as they were in ancient Greece - prevention and therapy.7 Hygieia ('health') was concerned with the maintenance of health, personifying the wisdom that people would be healthy if they lived wisely. Panakeia ('all-healing') specialized in the knowledge of remedies, derived from plants or from the earth. The search for a panacea, or cure-all, has become a dominant theme in modern biomedical science, which often loses the balance between the two aspects of health care symbolized by the two goddesses. The Asclepian ritual involved a unique form of healing, based on dreams and known as temple incubation. Rooted in a firm belief in the healing powers of the god, it constituted an effective treatment procedure that Jungian psychotherapists have recently attempted to reinterpret in modern terms. 8
The Asclepian ritual represented only one side of Greek medicine. Besides Asclepius the god there may also have existed a human physician of that name, said to be skilled in surgery and the use of drugs, and revered as the founder of medicine. Greek physicians called themselves Asclepiads ('sons of Asclepius') and formed medical guilds that promoted a form of medicine based on empirical knowledge. Although the Asclepiads had no connection with the dream therapy of the temple priests, the two schools were not in competition but complemented each other. Out of the lay Asclepiads emerged the tradition associated with the name of Hippocrates, which represents the culmination of Greek medicine and has had a lasting influence on Western medical science.9 There is no doubt that a famous physician by that name lived in Greece around 400 b.c., practicing and teaching medicine as an Asclepiad on the island of Cos. The voluminous writings attributed to him, and known as the Hippocratic Corpus, were probably written by several authors at different times; they represent a compendium of the medical knowledge taught in various Asclepian guilds.
At the core of Hippocratic medicine is the conviction that illnesses are not caused by demons or other supernatural forces, but are natural phenomena that can be studied scientifically and influenced by therapeutic procedures and by wise management of one's life. Thus medicine should be practiced as a scientific discipline, based on the natural sciences and encompassing the prevention of illnesses, as well as their diagnosis and therapy. This attitude has formed the basis of scientific medicine to the present day, even though the successors of Hippocrates have rarely reached the breadth of vision and the depth of philosophical thought manifest in the Hippocratic writings.
Airs, Waters and Places, one of the most significant books of the Hippocratic Corpus, represents what we would now call a treatise on human ecology. It shows in great detail how the well-being of individuals is influenced by environmental factors - the quality of air, water, and food, the topography of the land, general living habits. The correlation between sudden changes in these factors and the appearance of disease is emphasized, and the understanding of environmental effects is seen as the essential basis of the physician's art. This aspect of Hippocratic medicine has been severely neglected with the rise of Cartesian science and is only now being appreciated again. According to Rene Dubos, 'The relevance of environmental forces to the problems of human biology, medicine and sociology has never been formulated with greater breadth and sharper vision than it was at the dawn of scientific history!'10 Health, according to the Hippocratic writings, requires a state of balance among environmental influences, ways of life, and the various components of human nature. These components are described in terms of 'humors' and 'passions,' which have to be in equilibrium. The Hippocratic doctrine of the humors can be restated in terms of chemical and hormonal balance, and the relevance of the passions refers to the interdependence of mind and body, which is strongly emphasized in the texts. Hippocrates was not only a shrewd observer of physical symptoms but also left excellent descriptions of many mental disorders that still occur in our time.
As far as healing was concerned, Hippocrates recognized the healing forces inherent in living organisms, forces he called 'nature's healing power.' The role of the physician was to assist these natural forces by creating the most favorable conditions for the healing process. This is the original meaning of the word 'therapy,' which comes from the Greek therapeuin ('to attend'). In addition to defining the role of the therapist as that of an attendant, or assistant, to the natural healing process, the Hippocratic writings also contain a strict code of medical ethics, known as the Hippocratic Oath, which has remained the ideal of physicians to the present day.
The Hippocratic tradition, with its emphasis on the fundamental interrelation of body, mind, and environment, represents a high point of Western medical philosophy that is as strong in its appeal for our time as it was twenty-five hundred years ago. As Dubos writes, paraphrasing Whitehead's remark on the debt of European philosophy to Plato, 'modern medicine is but a series of commentaries and elaborations on the Hippocratic writings.'11
The main themes of Hippocratic medicine - health as a state of balance, the importance of environmental influences, the interdependence of mind and body, and nature's inherent healing power - were developed in ancient China in a very different cultural context. Classical Chinese medicine had its roots in shamanistic traditions and was shaped by both Taoism and Confucianism, the two principal philosophical schools of the classical period.12 During the Han period (206 b.c.-a.d. 220) chinese medicine was formalized as a system of ideas and written down in the classical medical texts. The most important among the early medical classics is the Nei Ching, the Classic of Internal Medicine, which develops in a lucid and attractive way a theory of the human organism in health and illness, together with a theory of medicine.13
As in every other theoretical tradition developed in early China, the concepts of yin and yang are central. The entire universe, both natural and social, is in a state of dynamic balance, with all its components oscillating between the two archetypal poles. The human organism is a microcosm of the universe; its parts are assigned yin and yang qualities, and thus the individual's place in the great cosmic order is firmly established. Unlike the early Greek scholars, the Chinese were not deeply interested in causal relations but rather in the synchronic patterns of things and events. Joseph Needham has aptly called this attitude 'correlative thinking.' , For the Chinese,
This correlative and dynamic way of thinking is basic to the conceptual system of Chinese medicine.15 The healthy individual and the healthy society are integral parts of a great patterned order, and illness is disharmony at the individual or social level. The cosmic patterns were mapped out by means of a complex system of correspondences and associations that was elaborated in great detail in the classical texts. In addition to the yin/yang symbolism, the Chinese used a system called Wu Using, which is usually translated as the Five Elements, but that interpretation is much too static. Hsing means 'to act' or 'to do,' and the five concepts associated with wood, fire, earth, metal, and water represent qualities that succeed and influence one another in a well-defined cyclical order. Manfred Porkert has translated Wu Hsing as the Five Evolutive Phases,16 which seems to be much better suited to describing the dynamic connotation of the Chinese term. From these Five Phases the Chinese derived a correspondence system extending to the entire universe. The seasons, atmospheric influences, colors, sounds, the parts of the body, emotional states, social relations, and numerous other phenomena were all classified into five types related to the Five Phases.17 When the Five Phase theory was fused with the yin/yang cycles, the result was an elaborate system in which every aspect of the universe was described as a well-defined part of a dynamically patterned whole. This system formed the theoretical base for the diagnosis and treatment of illness.
The Chinese idea of the body has always been predominantly functional and concerned with the interrelations of its parts rather than with anatomical accuracy. Accordingly, the Chinese concept of a physical organ refers to a whole functional system, which has to be considered in its totality, along with the relevant parts of the correspondence system. For example, the idea of the lungs includes not only the lungs themselves but the entire respiratory tract, the nose, the skin, and the secretions associated with these organs. In the correspondence system the lungs are associated with metal, the color white, a piquant taste, grief and negativism, and various other qualities and phenomena.
The Chinese notion of the body as an indivisible system of interrelated components is obviously much closer to the modern systems approach than to the classical Cartesian model, and the similarity is reinforced by the fact that the Chinese saw the network of relationships they were studying as intrinsically dynamic. The individual organism, like the cosmos as a whole, was seen as being in a state of continual, multiple, and interdependent fluctuations whose patterns were described in terms of the flow of ch'i. The concept of ch'i, which played an important role in almost every Chinese school of natural philosophy, implies a thoroughly dynamic conception of reality. The word literally means 'gas' or 'ether' and was used in ancient China to denote the vital breath or energy animating the cosmos. But, neither of these Western terms describes the concept adequately. Ch'i is not a substance, nor does it have the purely quantitative meaning of our scientific concept of energy. It is used in Chinese medicine in a very subtle way to describe the various patterns of flow and fluctuation in the human organism, as well as the continual exchanges between organism and environment. Ch'i does not refer to the flow of any particular substance but rather seems to represent the principle of flow as such, which, in the Chinese view, is always cyclical.
The flow of ch'i keeps a person alive; imbalances, and hence illnesses, occur when the ch'i does not circulate properly. There are definite pathways of ch'i, called ching-mo and usually translated as 'meridians,' which are associated with the primary organs and are assigned yin and yang qualities. Along the meridians lie series of pressure points that can be used to stimulate the various flow processes in the body. From the Western scientific point of view, there is now considerable documentation to show that the pressure points have distinct electrical resistance and thermosensitivity, unlike other areas at the body surface, but there has been no scientific demonstration of the existence of meridians.
A key concept in the Chinese view of health is that of balance. The classics state that diseases become manifest when the body gets out of balance and the ch'i does not circulate properly. The causes for such imbalances are multiple. Through poor diet, lack of sleep, lack of exercise, or by being in a state of disharmony with one's family or society, the body can lose its balance, and it is at times like this that illnesses occur. Among the external causes, seasonal changes are given special attention and their influences on the body are described in great detail. Internal causes are attributed to an imbalance of one's emotional states, which are classified and associated with specific internal organs according to the correspondence system.
Illness is not thought of as an intruding agent but as due to a pattern of causes leading to disharmony and imbalance. However, the nature of all things, including the human organism, is such that there is a natural tendency to return to a dynamic state of balance. Going in and out of balance is seen as a natural process that happens constantly throughout the life cycle. Accordingly, the traditional texts draw no sharp line between health and illness. Both health and ill health are seen as natural and as being part of a continuum. They are aspects of the same process in which the individual organism changes continually in relation to the changing environment.
Since illness will at times be inevitable in the ongoing process of life, perfect health is not the ultimate goal of either patient or doctor. The aim of Chinese medicine, rather, is to achieve the best possible adaptation to the individual's total environment. In pursuing this aim the patient plays an important and active role. In the Chinese view the individual is responsible for the maintenance of her own health, and to a great extent even for the restoration of health when the organism gets out of balance. The doctor takes part in this process but the main responsibility is the patient's. It is the individual's duty to keep healthy, and this is done by living according to the rules of society and taking care of one's body in a highly practical way.
It is easy to see that a system of medicine which regards balance and harmony with the environment as the basis of health will be likely to emphasize preventive measures. Indeed, to prevent any imbalance in their patients has always been an important role of Chinese doctors. It is said that doctors in China used to be paid only while their patients stayed well and that payments stopped when they became ill. That is probably an exaggeration, but Chinese doctors did refuse patients once their condition reached a certain point of severity. As the Nei Ching explains,
These concepts and attitudes imply a role of the doctor quite different from that in the West. In Western medicine the doctor with the highest reputation is a specialist who has detailed knowledge about a specific part of the body. In Chinese medicine the ideal doctor is a sage who knows how all the patterns of the universe work together; who treats each patient on an individual basis; whose diagnosis does not categorize the patient as having a specific disease but records as fully as possible the individual's total state of mind and body and its relation to the natural and social environment.
To arrive at such a complete picture the Chinese developed not only highly refined diagnostic methods of observing and questioning the patient but also a unique art of pulse taking that allows them to determine the detailed flow of patterns of ch'i along the meridians, and thus the dynamic state of the entire organism."19 Traditional Chinese practitioners believe that these methods allow them to recognize imbalances and hence potential problems before they manifest themselves in symptoms that can be detected with Western diagnostic techniques.
The traditional Chinese diagnosis is necessarily a lengthy process in which the patient must actively participate by contributing considerable information about her personal way of life. Ideally each patient is a unique case presenting a vast array of variables to be taken into account. In actual practice there was probably always a tendency to classify according to patterns of symptoms, but the desire for precise classification and labeling was never present. The entire diagnosis relies heavily on subjective judgments by doctor and patient and is based on a body of qualitative data obtained by the doctor through the use of his own senses - touch, hearing, and vision - and through close interaction with the patient.
Having determined the dynamic state of the patient in relation to the environment, the Chinese doctor then attempts to restore balance and harmony. Several therapeutic techniques are used, all designed to stimulate the patient's organism in such a way that it will follow its own natural tendency to return to a balanced state. Accordingly, one of the most important principles of Chinese medicine is always to give as mild a therapy as possible. The whole process, ideally, is one of ongoing interaction between doctor and patient, with the doctor continually modifying the therapy according to the patient's responses.
Herbal medicines are classified according to the yin/yang system and are associated with five basic flavors that, according to the Five Phase theory, will affect the corresponding internal organs. In actual practice herbal medicines are rarely given singly but are usually prescribed in mixtures reflecting the patient's pattern of ch'i. Massage therapy, moxibustion, and acupuncture all make use of the pressure points along the meridians to influence the flow of ch'i. Moxibustion consists of burning small cones of the powdered herb moxa (mugwort) on the body at the pressure points; in the case of acupuncture solid needles of varying gauges and lengths are inserted at these points. The needles can be used either to stimulate or to sedate the body, depending on how they are inserted and manipulated. What all these therapies have in common is that they are not aimed at treating the symptoms of the patient's illness. They work at a more fundamental level to counteract imbalances that are regarded as the source of ill health.
To apply our study of the Chinese medical model to developing a holistic approach to health in our culture, we need to deal with two questions: To what extent is the Chinese model holistic? And which of its aspects, if any, can be adapted to our cultural context? For the first question it is useful to distinguish two kinds of holism.20 In a somewhat narrow sense, holism in medicine means that the human organism is seen as a living system whose components are all interconnected and interdependent. In a broader sense, the holistic view recognizes also that this system is an integral part of larger systems, which implies that the individual organism is in continual interaction with its physical and social environment, that it is constantly affected by the environment but can also act upon it and modify it.
The Chinese medical system is certainly holistic in the first sense. Its practitioners believe that their therapies will not just remove the principal symptoms of the patient's illness but will affect the entire organism, which they treat as a dynamic whole. In the broader sense, however, the Chinese system is holistic only in theory. The interdependence of organism and environment is acknowledged in the diagnosis of illness and is discussed extensively in the medical classics, but is generally neglected as far as therapy is concerned. The classical texts give equal weight to environmental influences, family relationships, emotional problems, and so on, but most practitioners today make no practical attempt to deal with the psychological and social aspects of illness therapeutically. When they make their diagnosis doctors spend considerable time talking to the patients about their work situation, their families, and their emotional states, but when it comes to therapy they concentrate on dietary counseling, herbal medicine, and acupuncture, restricting themselves to techniques that manipulate processes inside the body. There is no psychotherapy and there is no attempt to give patients advice on how they could change their life situation. The role of stressful events in the psychological and social realms is clearly acknowledged as a source of illness, but doctors do not feel that it is part of the therapeutic process to bring about changes at those levels.
As far as we can tell, this attitude was characteristic of Chinese doctors in the past also. The medical classics are rich documents expounding a broad holistic view of human nature and of medicine, but these are theoretical works written by doctors who are primarily scholars and were not very involved in curing patients. In practice the Chinese system was probably never very holistic as far as the psychological and social aspects of illness are concerned. The reluctance to act therapeutically by affecting the patient's social situation was certainly a result of the strong influence of Confucianism on all aspects of Chinese life. The Confucian system was mainly concerned with maintaining the social order. Illness, in the Confucian view, could arise from inadequate adjustment to the rules and customs of society, but the only way for an individual to get well was to change himself to fit the given social order. This attitude is so deeply ingrained in East Asian culture that it still underlies modern medical therapy in both China and Japan.
Which aspects of traditional Chinese medical philosophy and practice, then, can or should we incorporate into our own framework of health care? To answer this question the study of medical practice in contemporary Japan is extremely helpful. It provides a unique opportunity to see how modern Japanese doctors use traditional East Asian medical concepts and practices to deal with diseases that are not too different from those in our society. The Japanese adopted Western medicine voluntarily about a hundred years ago but are now increasingly reevaluating their own traditional practices, which, they believe, can fulfill many functions beyond the capacities of the biomedical model. Margaret Lock has made a detailed study of traditional East Asian medicine* (*Lock and others use the term 'East Asian medicine' for the medical system that was dominant until the nineteenth century among the literate populations of China, Korea, and Japan and is often called 'classical Chinese medicine' or 'Oriental medicine.) in modern urban Japan and found that there is an increasing number of Japanese doctors, known as kanpo* doctors (*Kanpo literally means the 'Chinese method'; it refers to the entire medical system brought to Japan from China in the sixth century.) who combine Eastern and Western techniques into an efficient system of medical care. 21 Although many aspects of kanpo medicine are effective only in the cultural context of Japan, others may well be adapted for our own culture.
One striking difference between Eastern and Western approaches to health is that in East Asian society in general, subjective knowledge is highly valued. Even in modern scientific Japan the value of subjective experience is strongly acknowledged, and subjective knowledge is considered as valuable as rational deductive thinking. Thus Japanese doctors can accept subjective judgments - both their own and their patients' - without seeing them as threats to their medical competence or their personal integrity. One consequence of this attitude is a distinctive lack of concern about quantification among East Asian doctors, supported by the doctors' awareness that they are dealing with living systems in continuous flux for which qualitative measures are considered to be sufficient. For example, kanpo doctors would not measure patients' temperatures but would note their subjective feelings about having a fever; herbal medicines are measured very roughly in little boxes without the use of scales, and are then mixed together. Nor is the duration of acupuncture therapy measured - it is simply determined by asking the patient how it feels.
The proper valuation of subjective knowledge is surely something we could learn from the East. Ever since Galileo, Descartes, and Newton our culture has been so obsessed with rational knowledge, objectivity, and quantification, that we have become very insecure in dealing with human values and human experience. In medicine, intuition and subjective knowledge are used by every good physician, but this is not acknowledged in the professional literature, nor is it taught in our medical schools. On the contrary, the criteria for admission to most medical schools screen out those who have the greatest talents for practicing medicine intuitively.
Once we adopt a more balanced attitude toward rational and intuitive knowledge, it will be easier to incorporate into our system of health care some of the aspects characteristic both of East Asian medicine and of our own Hippocratic tradition. The main difference between such a new model of health and the East Asian approach will be the integration of psychological and social measures into our system of health care. Psychological counseling and psychotherapy are not part of the East Asian tradition but play an important role in our culture; nor are East Asian doctors concerned about changing the social situation, although they recognize the importance of social problems in the development of illness. In our society, however, a truly holistic approach will recognize that the environment created by our social and economic system, based on the fragmented and reductionist Cartesian world view, has become a major threat to our health. An ecological approach to health will therefore make sense only if it leads to profound changes in our technology and our social and economic structures.
Health care in Europe and North America is practiced by a large number of people and organizations, including physicians, nurses, psychotherapists, psychiatrists, public-health professionals, social workers, chiropractors, homeopaths, acupuncturists, and various 'holistic' practitioners. These individuals and groups use a great variety of approaches that are based on different concepts of health and illness. To integrate them into an effective system of health care, based on holistic and ecological views, it will be crucial to establish a common conceptual basis for talking about health, so that all these groups can communicate and coordinate their efforts.
It will also be necessary to define health at least approximately. Although everybody knows what it feels like to be healthy, it is impossible to give a precise definition; health is a subjective experience whose quality can be known intuitively but can never be exhaustively described or quantified. Nevertheless, we may begin our definition by saying that health is a state of well-being that arises when the organism functions in a certain way. The description of this way of functioning will depend on how we describe the organism and its interactions with its environment. Different models of living organisms will lead to different definitions of health. The concept of health, therefore, and the related concepts of illness, disease, and pathology, do not refer to well-defined entities but are integral parts of limited and approximate models that mirror a web of relationships among multiple aspects of the complex and fluid phenomenon of life.
Once the relativity and subjective nature of the concept of health is perceived, it also becomes clear that the experience of health and illness is strongly influenced by the cultural context in which it occurs. What is healthy and sick, normal and abnormal, sane and insane, varies from culture to culture. Moreover, cultural context influences the specific ways people behave when they get sick. How we communicate our health problems, the manner in which we present our symptoms, when and to whom we go for care, the explanations and therapeutic measures offered by the doctor, therapist, or healer - all that is strongly affected by our society and culture.22 It would seem, therefore, that a new framework for health can be effective only if it is based on concepts and ideas rooted in our own culture and evolving according to the dynamics of our social and cultural evolution.
For the past three hundred years our culture has been dominated by the view of the human body as a machine, to be analyzed in terms of its parts. The mind is separated from the body, disease is seen as a malfunctioning of biological mechanisms, and health is defined as the absence of disease. This view is now slowly being eclipsed by a holistic and ecological conception of the world which sees the universe not as a machine but rather as a living system, a view that emphasizes the essential interrelatedness and interdependence of all phenomena and tries to understand nature not only in terms of fundamental structures but in terms of underlying dynamic processes. It would seem that the systems view of living organisms can provide the ideal basis for a new approach to health and health care that is fully consistent with the new paradigm and is rooted in our cultural heritage. The systems view of health is profoundly ecological and thus in harmony with the Hippocratic tradition which lies at the roots of Western medicine. It is a view based on scientific notions and expressed in terms of concepts and symbols which are part of our everyday language. At the same time the new framework naturally takes into account the spiritual dimensions of health and is thus in harmony with the views of many spiritual traditions.
Systems thinking is process thinking, and hence the systems view sees health in terms of an ongoing process. Whereas most definitions, including some proposed recently by holistic practitioners, picture health as a static state of perfect well-being, the systems concept of health implies continual activity and change, reflecting the organism's creative response to environmental challenges. Since a person's condition will always depend importantly on the natural and social environment, there can be no absolute level of health independent of this environment. The continual changes of one's organism in relation to the changing environment will naturally include temporary phases of ill health, and it will often be impossible to draw a sharp line between health and illness.
Health is really a multidimensional phenomenon involving interdependent physical, psychological, and social aspects. The common representation of health and illness as opposite ends of a one-dimensional continuum is quite misleading. Physical disease may be balanced by a positive mental attitude and social support, so that the overall state is one of well-being. On the other hand, emotional problems or social isolation can make a person feel sick in spite of physical fitness. These multiple dimensions of health will generally affect one another, and the strongest feeling of being healthy will occur when they are well balanced and integrated. The experience of illness, from the systems point of view, results from patterns of disorders that may become manifest at various levels of the organism, as well as in the various interactions between the organism and the larger systems in which it is embedded. An important characteristic of the systems approach is the notion of stratified order involving levels of differing complexities, both within individual organisms and in social and ecological systems. Accordingly, the systems view of health can be applied to different systems levels, with the corresponding levels of health mutually interconnected. In particular we can discern three interdependent levels of health - individual, social, and ecological. What is unhealthy for the individual is generally also unhealthy for the society and for the embedding ecosystem.
The systems view of health is based on the systems view of life. Living organisms, as we have seen, are self-organizing systems that display a high degree of stability. This stability is utterly dynamic and is characterized by continual, multiple, and interdependent fluctuations. To be healthy such a system needs to be flexible, to have a large number of options for interacting with its environment. The flexibility of a system depends on how many of its variables are kept fluctuating within their tolerance limits: the more dynamic the state of the organism, the greater its flexibility. Whatever the nature of the flexibility - physical, menial, social, technological, or economic - it is essential to the system's ability to adapt to environmental changes. Loss of flexibility means loss of health.
This notion of dynamic balance is a useful concept for defining health. 'Dynamic' is of crucial importance here, indicating that the necessary balance is not a static equilibrium but rather a flexible pattern of fluctuations of the kind described above. Health, then, is an experience of well-being resulting from a dynamic balance that involves the physical and psychological aspects of the organism; as well as its interactions with its natural and social environment.
The concept of health as dynamic balance is consistent both with the systems view of life and with many traditional models of health and healing, among them the Hippocratic tradition and the tradition of East Asian medicine. As in these traditional models, 'dynamic balance' acknowledges the healing forces inherent in every living organism, the organism's innate tendency to reestablish itself in a balanced state when it has been disturbed. It may do so by returning, more or less, to the original state through various processes of self-maintenance, including homeostasis, adaptation, regeneration, and self-renewal. Examples of this phenomenon would be the minor illnesses which are part of our everyday life and usually cure themselves. On the other hand, the organism may also undergo a process of self-transformation and self-transcendence, involving stages of crisis and transition and resulting in an entirely new state of balance. Major changes in a person's life style, induced by a severe illness, are examples of such creative responses that often leave the person at a higher level of health than the one enjoyed before the challenge. This suggests that periods of ill health are natural stages in the ongoing interaction between the individual and the environment. To be in dynamic balance means to go through temporary phases of illness that can be used to learn and to grow.
The natural balance of living organisms includes a balance between their self-assertive and integrative tendencies. To be healthy an organism has to preserve its individual autonomy, but at the same time it has to be able to integrate itself harmoniously into larger systems. This capacity for integration is closely related to the organism's flexibility and to the concept of dynamic balance. Integration at one systems level will manifest itself as balance at a larger level, as the harmonious integration of individual components into larger systems results in the balance of those systems. Illness, then, is a consequence of imbalance and disharmony, and may very often be seen as stemming from a lack of integration. This is particularly true for mental illness, which often arises from a failure to evalute and integrate sensory experience.
The notion of illness as originating in a lack of integration seems to be especially relevant to approaches that try to understand living organisms in terms of rhythmic patterns. From this perspective synchrony becomes an important measure of health. Individual organisms interact and communicate with one another by synchronizing their rhythms and thus integrating themselves into the larger rhythms of their environment. To be healthy, then, means to be in synchrony with oneself - physically and mentally - and also with the surrounding world. When a person is out of synchrony, illness is likely to occur. Many esoteric traditions associate health with the synchrony of rhythms and healing with a certain resonance between healer and patient.
To describe an organism's imbalance the concept of stress seems to be extremely useful. Although it is relatively new in medical research,23 it has taken a firm hold in the collective consciousness and language of our culture. The stress concept is also completely consistent with the systems view of life and can be fully grasped only when the subtle interplay between mind and body is perceived.
Stress is an imbalance of the organism in response to environmental influences. Temporary stress is an essential aspect of life, since the ongoing interaction between organism and environment often involves temporary losses of flexibility. These will occur when the individual perceives a sudden threat, or when it has to adapt to sudden changes in the environment or is being strongly stimulated in some other way. These transitory phases of imbalance are an integral part of the way healthy organisms cope with their environment, but prolonged or chronic stress can be harmful and plays a significant role in the development of many illnesses. 24
From the systems point of view, the phenomenon of stress occurs when one or several variables of an organism are pushed to their extreme values, which induces increased rigidity throughout the system. In a healthy organism the other variables will conspire to bring the whole system back into balance and restore its flexibility. The remarkable thing about this response is that it is fairly stereotyped. The physiological stress symptoms - tight throat, tense neck, shallow respiration, accelerated heart rates, and so on - are virtually identical in animals and humans and are quite independent of the source of stress. Because they constitute the organism's preparation to cope with the challenge by either fighting or fleeing, the whole phenomenon is known as the Fight-or-flight response. Once the individual has taken action by fighting or fleeing, it will rebound into a state of relaxation and ultimately will return to homeostasis. The well-known 'sigh of relief is an example of such a relaxation rebound.
When the fight-or-flight response is prolonged, however, and when an individual cannot take action by fighting or fleeing to release the organism from the stressful state, the consequences are likely to be detrimental to health. The continual imbalance created by prolonged unabated stress can generate physical and psychological symptoms - muscle tension, anxiety, indigestion, insomnia - which will eventually lead to illness. The prolongation of stress often results from our failure to integrate the responses of our bodies with our cultural habits and social rules of behavior. Like most animals we react to any kind of challenge by arousing our organism in preparation for either physical fight or physical escape, but in most cases these reactions are no longer useful. In an intense business meeting we cannot win an argument by physically assaulting our opponent, nor can we run away from the situation. Being civilized, we try to deal with the challenge in socially acceptable ways, but 'old' parts of our brain often continue mobilizing the organism for inappropriate physical responses. If this happens repeatedly we are likely to get sick; we may develop a peptic ulcer or have a heart attack.
A key element in the link between stress and illness, which is not yet known in all its details but has been verified by numerous studies, is the fact that prolonged stress suppresses the body's immune system, its natural defenses against infections and other diseases. Full recognition of this fact will bring about a major shift in medical research from the preoccupation with microorganisms to a careful study of the host organism and its environment. Such a shift is now urgently needed, since the chronic and degenerative diseases that are characteristic of our time and constitute the major causes of death and disability are closely connected with excessive stress.
The sources of this overload of stress are manifold. They may originate within an individual, may be generated collectively by our society and culture, or may be present in the physical environment. Stressful situations arise not only from personal emotional traumas, anxieties, and frustrations, but also from the hazardous environment created by our social and economic system. Stress, however, comes not only from negative experiences. All events - positive or negative, joyous or sad - that require a person to adapt to profound or rapid changes will be highly stressful. It is very unfortunate for our health that our culture has produced an accelerating rate of change in all areas, together with numerous physical health hazards, but has failed to teach us how to cope with the increasing amount of stress we encounter.
Recognition of the role of stress in the development of illness leads to the important idea of illness as a 'problem solver.' Because of social and cultural conditioning people often find it impossible to release their stresses in healthy ways and therefore choose - consciously or unconsciously - to get sick as a way out. Their illness may be physical or mental, or it may manifest itself as violent and reckless behavior, including crime, drug abuse, accidents, and suicides, which may appropriately be called social illnesses. All these 'escape routes' are forms of ill health, physical disease being only one of several unhealthy ways of dealing with stressful life situations. Hence curing the disease will not necessarily make the patient healthy. If the escape into a particular disease is blocked effectively by medical intervention while the stressful situation persists, this may merely shift the person's response to a different mode, such as mental illness or antisocial behavior, which will be just as unhealthy. A holistic approach will have to look at health from this broad perspective, distinguishing clearly between the origins of illness and its manifestation. Otherwise it will not mean much to talk about successful therapies. As a doctor friend of mine put it forcefully. If you are able to reduce physical illness, but at the same time increase mental illness or crime, what the hell have you done?'
The idea of illness as a way to cope with stressful life situations naturally leads to the notion of the meaning of illness, or of the 'message' transmitted by a particular disease. To understand this message ill health should be taken as an opportunity for introspection, so that the original problem and the reasons for choosing a particular escape route can be brought to a conscious level where the problem can be resolved. This is where psychological counseling and psychotherapy can play an important role, even in the treatment of physical illness. To integrate physical and psychological therapies will amount to a major revolution in health care, since it will require full recognition of the interdependence of mind and body in health and illness.
When the systems view of mind is adopted, it becomes obvious that any illness has mental aspects. Getting sick and healing are both integral parts of an organism's self-organization, and since mind represents the dynamics of this self-organization, the processes of getting sick and of healing are essentially mental phenomena. Because mentation is a multileveled pattern of processes, most of them taking place in the unconscious realm, we are not always fully aware of how we move in and out of illness, but this does not alter the fact that illness is a mental phenomenon in its very essence.
The intimate interplay between physical and mental processes has been recognized throughout the ages. We all know that we express emotions through gestures, inflections, breathing patterns, and minute movements imperceptible to the untrained eye. The precise ways in which physical and psychological patterns interlink are still little understood, and thus most physicians tend to restrict themselves to the biomedical model and neglect the psychological aspects of illness. However, there have been significant attempts to develop a unified approach to the mind/body system throughout the history of Western medicine. Several decades ago these attempts culminated in the foundation of psychosomatic medicine as a scientific discipline, concerned specifically with the study of the relationships between the biological and psychological aspects of health. 25 This new branch of medicine is now rapidly gaining acceptance, especially with the growing awareness of the relevance of stress, and is likely to play an important role in a future holistic system of health care.
The term 'psychosomatic' needs some clarification. In conventional medicine it was used to refer to a disorder without a clearly diagnosed organic basis. Owing to the strong biomedical bias, such 'psychosomatic disorders' tended to be regarded as imagined, not real. The modern use of the term is quite different; it derives from the recognition of a fundamental interdependence between mind and body at all stages of illness and health. To single out any disorder as psychologically caused would be as reductionistic as the belief that there are purely organic diseases without any psychological components. Researchers and clinicians today are increasingly aware that virtually all disorders are psychosomatic in the sense that they involve the continual interplay of mind and body in their origin, development, and cure. In the words of Rene Dubos, 'Whatever its precipitating cause and its manifestations, almost every disease involves both the body and the mind, and these two aspects are so interrelated that they cannot be separated one from the other. ' 26 So the term 'psychosomatic disorder' has become redundant, although it is meaningful to speak of psychosomatic medicine.* (*The term 'holistic health,' which has recently become very popular, is similarly redundant, since health already implies wholeness, yet it makes sense to speak of holistic health care.)
The manifestations of illness will vary from case to case, from almost purely psychological to almost exclusively physical symptoms. When psychological aspects dominate, the illness is usually referred to as mental illness. Mental illnesses involve physical symptoms, however, and in some cases biological and genetic factors may even be dominant in the causation of the disorder. Furthermore, the origin and development of many mental illnesses depend crucially on the individual's ability to interact with his family, friends, and other social groups. Those illnesses can be fully understood only by seeing how the individual organism is embedded in its social environment.27
Moreover, it is becoming apparent that the role of the patient's personality is a crucial element in the generation of many illnesses. Prolonged stress somehow seems to be channeled through a particular personality configuration to give rise to a specific disorder. The most convincing link between personality and illness has been found for heart disease, and links are being tentatively established for other major diseases, most notably cancer.28 These results are extremely significant because as soon as the patient's personality enters into the clinical picture the illness becomes inseparably linked to his entire psyche, which suggests the unification of physical and psychological therapies.
In spite of the extensive literature on the role of psychological influences in the development of illness, very little work has been done to explore the methods of altering these influences. The key to any such attempt is the idea that mental attitudes and processes not only play a significant part in getting sick; they can also play a significant part in getting well. The psychosomatic nature of illness implies the possibility of psychosomatic self-healing. This idea is strongly supported by the recent discovery of the biofeedback phenomenon, which showed that a wide range of physical processes can be influenced by a person's mental efforts.29
The first step in this kind of self-healing will be the patients' recognition that they have participated consciously or unconsciously in the origin and development of their illness, and hence will also be able to participate in the healing process. In practice, this notion of patient participation, which implies the idea of patient responsibility, is extremely problematic and is vigorously denied by most patients. Conditioned as they are by the Cartesian framework, they refuse to consider the possibility that they may have participated in their illness, associating the idea with blame and moral judgment. It will be important to clarify exactly what is meant by patient participation and responsibility.
In the context of a psychosomatic approach, our participation in the development of an illness means that we make certain choices to expose ourselves to stressful situations and, furthermore, to react to these stresses in certain ways. These choices are influenced by the same factors that influence all the choices we make in life. They are made unconsciously more often than consciously, and will depend on our personality, on various external constraints, and on social and cultural conditioning. Any responsibility, therefore, can be only partial. Like the concept of free will, the notion of personal responsibility must necessarily be limited and relative, and neither of them can be associated with absolute moral values. The purpose of recognizing our participation in our illness is not to feel guilty about it but to adopt the necessary changes and to realize that we can also participate in the healing process.
Mental attitudes and psychological techniques are important means for both the prevention and healing of illness. A positive attitude combined with specific stress-reduction techniques will have a strong positive impact on the mind/body system and will often be able to reverse the disease process, even to heal severe biological disorders. The same techniques can be used to prevent illness by applying them to cope with excessive stress before any serious damage occurs.
An impressive proof of the healing power of positive expectations alone is provided by the placebo effect. A placebo is an imitation medicine, dressed up like an authentic pill and given to patients who think they are receiving the real thing. Studies have shown that 35 percent of patients consistently experience 'satisfactory relief when placebos are used instead of regular medication for a wide range of medical problems. 30 Placebos have been strikingly successful in reducing or eliminating physical symptoms, and have produced dramatic recoveries from illnesses for which there are no known medical cures. The only active ingredient in these treatments appears to be the power of the patient's positive expectations, supported by interaction with the therapist.
The placebo effect is not limited to the administration of pills but can be associated with any form of treatment. Indeed, it is likely to play a significant part in all therapy. In medical jargon 'placebo' has been used for any aspect of the healing process that is not based on physical or pharmacological intervention, and, like the term 'psychosomatic,' often has a pejorative connotation. Doctors have tended to classify illnesses whose origins and development could not be understood within the biomedical framework as 'psychosomatic' and to label any healing process induced by the patient's positive expectations and faith in doctor and treatment as a 'placebo effect,' while self-healings without any medical intervention were described as 'spontaneous remissions.' The real meaning of these three terms is very similar; they all refer to the healing powers of the patient's mental attitude.
The patient's will to get well and confidence in the treatment are crucial aspects of any therapy, from shamanistic healing rituals to modern medical procedures. As the writer and editor Norman Cousins has noted, 'Many medical scholars have believed that the history of medicine is actually the history of the placebo effect.' 31 On the other hand, negative attitudes of the patient, the doctor, or the family may produce an 'inverse placebo effect.' Experience has shown repeatedly that patients who are told they have only six to nine months more to live will, indeed, not live longer. Statements of this kind have a powerful impact on the patient's mind/body system - they seem to act almost as a magic spell - and should therefore never be made.
In the past, psychosomatic self-healing has always been associated with faith in some treatment - a drug, the power of a healer, perhaps a miracle. In a future approach to health and healing, based on the new holistic paradigm, it should be possible to acknowledge the individual's potential for self-healing directly, with no need for any conceptual crutches, and to develop psychological techniques that will facilitate the healing process.
We have been building a model of illness that is both holistic and dynamic. In it illness is a consequence of imbalance and disharmony, often stemming from a lack of integration, which may arise at various levels of the organism and, accordingly, may generate symptoms of a physical, psychological, or social nature. Disease is the biological manifestation of illness, and the model clearly distinguishes between disease origins and disease processes. Excessive stress is believed to contribute significantly to the origin and development of most diseases, manifesting itself in the organism's initial imbalance and, subsequently, being channeled through a particular personality configuration to give rise to specific disorders. An important aspect of this process is the fact that illness is often perceived, consciously or unconsciously, as a way out of the stressful situation, various kinds of illness representing different escape routes. Curing the disease will not necessarily make the patient healthy, but illness may be an opportunity for introspection that will resolve the root problems.
The development of illness involves the continual interplay between physical and mental processes that reinforce one another through a complex network of feedback loops. Disease patterns at any stage appear as manifestations of underlying psychosomatic processes that should be dealt with in the course of therapy. This dynamic view of illness specifically acknowledges the organism's innate tendency to heal itself - to reestablish itself in a balanced state - which may include stages of crisis and major life transitions. Periods of ill health involving minor symptoms are normal and natural stages representing the organism's means of restoring balance by interrupting one's usual activities and forcing a change of pace. As a consequence, the symptoms associated with these minor illnesses usually disappear after a few days, whether or not any treatment is received. More serious illnesses will require greater efforts of regaining one's balance, generally including the help of a doctor or therapist, and the outcome will depend crucially on the patient's mental attitudes and expectations. Severe illnesses, finally, will require a therapeutic approach dealing not only with the physical and psychological aspects of the disorder, but also with the changes in the patient's life style and world view that will be an integral part of the healing process.
These views of health and illness imply a number of guidelines for health care and make it possible to sketch out the basic framework for a new holistic approach. Health care will consist of restoring and maintaining the dynamic balance of individuals, families, and other social groups. It will mean people taking care of their own health individually, as a society, and with the help of therapists. This kind of health care cannot just be 'provided,' or 'delivered' - it has to be practiced. Furthermore, it will be important to consider the interdependence of our individual health and that of the social and ecological systems in which we are embedded. If you live in a stressful neighborhood the situation will not be improved by raising the level of unemployment. Such actions amount to managing stress by simply pushing it around - from one family to another, from individuals to the society and back to other individuals, or from society onto the ecosystem, whence it may come back forty years later, as in the case of Love Canal. Health care at all levels will consist of balancing and resolving the stressful situations by individual and social action.
A future system of health care will consist, first and foremost, of a comprehensive, effective, and well-integrated system of preventive care. Health maintenance will be partly an individual matter and partly a collective matter, and most of the time the two will be closely interrelated. Individual health care is based on the recognition that the health of human beings is determined, above all, by their behavior, their food, and the nature of their environment." As individuals, we have the power and the responsibility to keep our organism in balance by observing a number of simple rules of behavior relating to sleep, food, exercise, and drugs. The role of therapists and health professionals will be merely to assist us in doing so. In the past this kind of preventive health care has been severely neglected in our society, but recently there has been a significant shift in attitudes that has generated a powerful grass-roots movement promoting healthy living habits - whole foods, physical exercise, home births, relaxation and meditation techniques - and emphasizing personal responsibility for health.
If acceptance of individual responsibility will be crucial to a future system of holistic health care, it will be equally crucial to recognize that this responsibility is subject to severe constraints. Individuals can be held responsible only to the extent that they have the freedom to look after themselves, and this freedom is often curtailed by heavy social and cultural conditioning. Moreover, many health problems arise from economic and political factors that can be modified only by collective action. Individual responsibility has to be accompanied by social responsibility, and individual health care by social actions and policies. 'Social health care' seems an appropriate term for policies and collective activities dedicated to the maintenance and improvement of health.
Social health care will have two basic parts - health education and health policies - to be pursued simultaneously and in close coordination. The aim of health education will be to make people understand how their behavior and their environment affect their health, and to teach them how to cope with stress in their daily lives. Comprehensive programs of health education with this emphasis can be integrated into the school system and given central importance. At the same time they can be accompanied by public health education through the media to counteract the effects of advertising of unhealthy products and life styles. An important aim of health education will be to foster corporate responsibility. The business community needs to learn much more about the health hazards of its production and its products. It should develop and demonstrate concern about public health, become aware of the health costs generated by its activities, and formulate corporate policies accordingly.33
Health policies, to be established by government at various levels of administration, will consist of legislation to prevent health hazards from being generated, and also of social policies that provide for people's basic needs. The following suggestions include a few of the many measures needed to provide an environment that would encourage and make it possible for people to adopt healthy ways of living:
A careful study of these suggested policies shows that any one of them, ultimately, requires a different social and economic system if it is to be successful. There is no way to avoid the conclusion that the present system itself has become a fundamental threat to our health. We shall not be able to increase, or even maintain, our health unless we adopt profound changes in our value system and our social organization. One physician who has recognized this quite clearly is Leon Eisenberg:
The restructuring of social institutions required by the new holistic view of health will apply, first of all, to the health care system itself. Our present institutions of health care are based on the narrow biomedical approach to the treatment of diseases and are organized in such a fragmented way that they have become highly ineffective and inflationary. As Kerr White has pointed out, "It is difficult to overemphasize the negative impact that our fragmented, disorganized, and unbalanced health care arrangements have on the adequacy of the care provided in this country and the inflationary impact this confusion has on their costs. " 36 What we need is a responsive and well-integrated system of health care that fulfills the needs of individuals and populations.
The first and most important step in a holistic approach to therapy will be to make the patient aware, as fully as possible, of the nature and extent of her imbalance. This means that her problems will have to be put into the broad context from which they arose, which will involve a careful examination of the multiple aspects of the particular illness by therapist and patient. The recognition of this context alone - of the web of interrelated patterns which led to the disorder - is highly therapeutic, as it relieves anxiety and gives hope and self-confidence, thus initiating the process of self-healing. Psychological counseling will play an important role in this process, and those administering primary health care should possess basic therapeutic skills at both the physical and the psychological level. The main purpose of the first encounter between patient and general practitioner, apart from emergency measures, will be to educate the patient about the nature and meaning of the illness, and about the possibilities of changing the patterns in the patient's life that have led to it. This, in fact, is the original role of the 'doctor,' which comes from the Latin docere ('to teach').
To assess the relative contribution of biological, psychological, and social factors to the illness of a particular person is the essence of the science and art of general practice. It requires not only some basic knowledge of human biology, psychology, and social science, but also experience, wisdom, compassion, and concern for the patient as a human being. General practitioners administering primary care of this kind need not be medical doctors, nor experts in any of the scientific disciplines concerned, but they will have to be sensitive to the multiple influences affecting health and illness, and able to decide which of these are the most relevant, best known, and most manageable in a particular case. If necessary, they will refer the patient to specialists in the relevant areas, but even when such special treatments are needed, the object of the therapy will still be the whole person.
The basic aim of any therapy will be to restore the patient's balance, and since the underlying model of health acknowledges the organism's innate tendency to heal itself, the therapist will try to intrude only minimally and keep the treatments as mild as possible. The healing will always be done by the mind/body system itself; the therapist will merely reduce the excessive stress, strengthen the body, encourage the patient to develop self-confidence and a positive mental attitude, and generally create the environment most conducive to the healing.
Such an approach to therapy will be multidimensional, involving treatments at several levels of the mind/body system, which will often require a multidisciplinary team effort. The members of the health team will be specialists in various fields but will share the same holistic view of health and a common conceptual framework that will allow them to communicate effectively and integrate their efforts systematically. Health care of this kind will require many new skills in disciplines not previously associated with medicine and is likely to be intellectually richer, more stimulating, and more challenging than a medical practice that adheres exclusively to the biomedical model.
The kind of primary patient care outlined above is being forcefully advocated today by nurses who find themselves at the forefront of the holistic health movement. Increasing numbers of nurses are deciding that they want to be independent therapists rather than assistants to doctors, and are in the process of applying a holistic approach to their practice. These highly educated and motivated nurses will be best qualified to take on the responsibilities of general practitioners. They will be able to provide the necessary health education and counseling and to assess the patients' life dynamics as a basis for preventive health care. They will keep regular contacts with their clients so that problems can be detected before serious symptoms develop, and will go out into the community to see and understand patients within the context of their work and family situations.
In such a system medical doctors will act as specialists. They will prescribe drugs and perform surgery in emergency cases, treat fractured bones, and practice the full range of medical care for which the biomedical approach is appropriate and successful. Even in those cases, however, the nurse practitioner will still play an important role, keeping the personal contact with the patient and integrating the special treatments into a meaningful whole. For example, if surgery is necessary, the nurse will stay with the patient, choose the appropriate hospital, cooperate with the hospital nurses, support the patient psychologically, and give him postoperative care. Ideally, she would know her patient well from previous consultations and would be available throughout the entire procedure, somewhat like a lawyer who guides a client through a trial.
The new holistic kind of primary care can, of course, also be practiced by physicians, and it seems that medical students have recently become more and more interested in such a career. On the other hand, a nurse may well specialize - in massage therapy, herbal medicine, midwifery, public health, or social work - in addition to her (or his) general practice. The important fact is that we now have a large number of highly qualified nurses who cannot use their full potential in the present system but are ready to carry out a holistic and humanistic approach to primary care. To incorporate nursing into a holistic framework of health care will mean to expand what already exists, and should therefore be the ideal strategy for the period of transition to the new system.
The reorganization of health care will also mean discouraging the construction and use of facilities that are inefficient and incompatible with the new view of health. 37 To change the present technology-intensive, hospital-based system, a first useful step may be, as Victor Fuchs has suggested, to impose a moratorium on all hospital construction and expansion to bring our escalating hospital costs under control. 38 At the same time hospitals will gradually be transformed into more efficient and more humane institutions, comfortable and therapeutic environments modeled after hotels rather than factories or machine shops, with good and nourishing food, family members included in patient care, and other such sensible improvements.
Drugs will be used only in emergency cases and then as sparingly and as specifically as possible. Thus health care will be liberated from the pharmaceutical industry and physicians and pharmacists will collaborate in selecting from the many thousands of pharmaceutical products the few dozen basic drugs that, according to experienced clinicians, are fully adequate for effective medical care.
These changes will be possible only with a thorough reorganization of medical education. To prepare medical students and other health professionals for the new holistic approach will require a considerable broadening of their scientific basis and much greater emphasis on the behavioral sciences and on human ecology. As Howard Rasmussen, professor of biochemistry and medicine at the University of Pennsylvania School of Medicine, has suggested, an educational program presenting a multidisciplinary study of human nature would be an ideal introductory course for health professionals.39 Such a course, to deal with various levels of individual and social health, should be based on general systems theory and study the human condition in health and illness within an ecological context. It would be the foundation for more detailed medical studies and would provide all health professionals with a common language for their future collaboration in health teams. At the same time there would be a corresponding reorientation of research priorities from an overemphasis on cellular and molecular biology to a more balanced approach.
Undergraduate education in medical schools will concentrate much more on family practice and ambulatory medicine - that is, on understanding the patient as a walking, living person. It will prepare students for working in health teams by helping them understand the multifaceted nature of health and, accordingly, the interrelated roles played by the team members. This means radical changes. Indeed, Rasmussen thinks "nothing short of revolution can restore educational balance and relevance." 40
An effective and well-integrated system of health care must be facilitated by financial incentives that will induce health professionals, health care institutions, and the general public to make appropriate choices and pursue appropriate policies. In the United States this will include, first and foremost, a system of national health insurance that is not dominated by corporate interests and provides economic incentives for holistic health care, including health education and other preventive measures.41 In conjunction with such a system licensing laws for health care professionals will have to be revised to reflect the new approach to health and give the public greater freedom of choice. 42
The paradigm shift in health care will involve the formulation of new conceptual models, the creation of new institutions, and the implementation of new policies. As far as organization and policies are concerned, there are a number of measures that can be adopted right away. With regard to therapeutic models and techniques, the situation is somewhat more complicated. As yet there is no well-established system of therapies that corresponds to the new view of illness as a multidimensional and multileveled phenomenon. However, there are at present a number of models and procedures that seem to deal successfully with various aspects of ill health. It would seem, therefore, that here too a 'bootstrap' approach may be the most appropriate strategy. It would consist of developing a mosaic of therapeutic models and techniques of limited scope that are mutually consistent. It would be the role of the general practitioner or the health team to find out which model, or which approach, is most suitable and most efficient for a particular patient. At the same time researchers and clinicians will be exploring these models further and, eventually, integrating them into a coherent system.
A number of therapeutic models and techniques are already being developed that go beyond the biomedical framework and are consistent with the systems view of health. Some of them are based on well-established Western healing traditions, others are of more recent origin, and most of them are not taken very seriously by the medical establishment because they are difficult to understand in terms of classical scientific concepts.
To begin with, numerous unorthodox approaches to health share a belief in the existence of patterns of 'subtle energies,' or life energies,' and see illness as resulting from changes in these patterns. Although the therapies practiced in these traditions, which are sometimes referred to as 'energy medicine,' involve a variety of techniques, all of them are believed to influence the organism at a more fundamental level than the physical or psychological symptoms of illness. This view is quite similar to that of the Chinese medical tradition, and so are many of the concepts used in the various healing traditions. For example, when homeopaths speak about the 'vital force,' or Reichian therapists about 'bioenergy,' they use these terms in a sense that comes very close to the Chinese concept of ch'i. The three concepts are not identical, but they seem to refer to the same reality - a reality much more complex than any of them. The main purpose of these terminologies is to describe the patterns of flow and fluctuation in the human organism. It is also believed that life energy' is exchanged between an organism and its environment, and many traditions hold that this energy can be transferred between human beings by the laying-on of hands and other techniques of 'psychic' healing.
Most approaches to 'energy medicine' were developed when science was formulated almost exclusively in terms of mechanistic concepts, and their originators cannot be faulted for using terminologies that now seem vague, simplistic, or out of date. The founders and practitioners of these healing traditions often had a remarkable intuition for the nature of life, health, and illness, and many of their concepts are likely to be extremely useful when reformulated in the language of the new systems approach. When self-organization is seen as the essence of living organisms, one of the main tasks of the life sciences will be to study the patterned processes of self-organizing systems, as well as the energies involved in these processes. The processes of physical and chemical systems have been studied extensively, and the energies associated with them are well understood. By contrast, the processes of self-organizing systems, together with their associated energies, are just beginning to be explored and may well reveal phenomena that have so far not been considered by orthodox science.
However, the term 'energy,' as used in the unorthodox healing traditions, is rather problematic from the scientific point of view. 'Life energy' is often thought of as some kind of substance which flows through the organism and is transferred between organisms. According to modern science, energy is not a substance but rather a measure of activity, of dynamic patterns.44 To understand the models of 'energy medicine' scientifically it would seem, therefore, that one should concentrate on the concepts of flow, fluctuation,' vibration, rhythm, synchrony, and resonance, which are fully consistent with the modern systems view. Concepts like 'subtle bodies,' or 'subtle energies' should not be taken to refer to underlying substances but as metaphors describing the dynamic patterns of self-organization.
One of the most intriguing approaches to the fundamental dynamic patterns of the human organism is that of homeopathy. The roots of homeopathic philosophy can be traced back to the teachings of Paracelsus and Hippocrates, but the formal therapeutic system was founded at the end of the eighteenth century by the German physician Samuel Hahnemann. Although vigorously opposed by the medical establishment, homeopathy spread steadily during the nineteenth century and became especially popular in the United States, where 15 percent of all doctors were homeopaths around 1900. In the twentieth century the movement could not hold its ground against modern biomedical science and has only very recently found a certain renaissance.
In the homeopathic view, illness results from changes in an energy pattern or 'vital force,' which is the basis of all physical, emotional, and mental phenomena and is characteristic of each individual. The aim of homeopathic therapy, like that of acupuncture, is to stimulate a person's energy levels. The traditional homeopathic approach is purely phenomenological and, unlike Chinese medicine, does not have a detailed theory of energy patterns, but in recent years George Vithoulkas, perhaps the most articulate leader of the modern homeopathic movement, has formulated the beginnings of a theoretical framework. 35 Vithoulkas has tentatively identified Hahnemann's vital force with the body's electromagnetic field and uses the term 'dynamic plane' for the fundamental level at which illness originates. In his theory the dynamic plane is characterized by a pattern of vibrations which is unique for each individual. External or internal stimuli affect the organism's rate of vibration, and these changes generate physical, emotional, or mental symptoms.
Homeopaths claim to be able to detect imbalances of the organism before any serious disturbances occur by observing a variety of subtle symptoms: changes in behavior patterns such as sensitivity to cold, desire for salt or sugar, sleeping habits, and so on. These subtle symptoms represent the organism's reaction to imbalances on the dynamic plane. Homeopathic diagnosis aims to establish a total pattern, or gestalt, of symptoms that mirrors the personality of the patient and is a reflection of that person's vibrational pattern. This is consistent with a key idea in modern psychosomatic medicine, the idea that an initial imbalance of the organism is channeled through a particular personality configuration to produce specific symptoms.
Homeopathic therapy consists of matching the pattern of symptoms that is characteristic of the patient with a similar pattern characteristic of the remedy. Vithoulkas believes that each remedy is associated with a certain vibrational pattern that constitutes its very essence. When the remedy is taken its energy pattern resonates with the energy pattern of the patient and thereby induces the healing process. The resonance phenomenon seems to be central to homeopathic therapy, but what exactly resonates and how this resonance is brought about is not well understood. Homeopathic remedies are substances derived from animals, plants and minerals, and are taken in highly diluted form. The selection of the correct remedy is based on Hahnemann's Law of Similars- 'Like Cures Like' - which gave homeopathy* (*From the Greek homeo ('similar') and pathos ('suffering').) its name. According to Hahnemann, any substance that can produce a total pattern of symptoms in a healthy human being can cure those same symptoms in a sick person. Homeopaths claim that literally any substance can produce, and cure, a wide spectrum of highly individualized symptoms known as the 'personality' of the remedy.
The first and perhaps most important part of the homeopathic practice is 'taking the homeopathic case.' Each interview is a unique process demanding of the interviewer a high degree of intuition and sensitivity. The purpose is to experience the personality of the patient as an integrated, living entity, and to match its very essence with that of the remedy. Vithoulkas says this experience should emerge from an intimate human encounter between therapist and patient, which will deeply affect both of them:
This description of the homeopathic interview, with its strong emphasis on the mutual interaction between therapist and patient, is quite reminiscent of an intense session of psychotherapy as described, for example, by Jung.47 Indeed, one is tempted to wonder whether the crucial resonance in homeopathic therapy is not the one between the patient and the homeopath, with the remedy merely a crutch.
The lack of any scientific explanation of homeopathic therapy is one of the main reasons why it has remained a highly controversial healing art. However, further development of psychosomatic medicine and the systems approach to health will help to clarify many of the homeopathic principles and may well encourage the medical profession to re-examine its position. Homeopathic philosophy, with its general view of illness, its emphasis on individualized treatment, and its basic trust in the human organism, exemplifies many important aspects of holistic health care.
A school of 'energy medicine' that is of more recent origin than homeopathy and has had a strong influence on a variety of therapies is Reichian therapy.48 Wilhelm Reich started out as a psychoanalyst and disciple of Freud, but while Freud and the other analysts concentrated on the psychological contents of mental disorders, Reich became interested in the ways these disorders manifest themselves physically. As the emphasis of his treatment shifted from the psyche to the body he developed therapeutic techniques that involved physical contact between therapist and patient - a sharp break with traditional psychoanalytic practice. From the very beginning of his medical research, Reich was keenly interested in the role of energy in the functioning of living organisms, and one of the main goals of his psychoanalytic work was to associate the sexual drive, or libido, which Freud saw as an abstract psychological force, with concrete energy flowing through the physical organism. This approach led Reich to the concept of bioenergy, a fundamental form of energy that permeates and governs the entire organism and manifests itself in the emotions as well as in the flow of bodily fluids and other biophysical movements. Bioenergy, according to Reich, flows in wave movements and its basic dynamic characteristic is pulsation. Every mobilization of flow processes and emotions in the organism is based on a mobilization of bioenergy.
One of Reich's key discoveries was that attitudes and emotional experiences can give rise to certain muscular patterns which block the free flow of energy. These muscular blocks, which Reich called 'character armor,' are developed in nearly every adult individual. They reflect our personality and enclose key elements of our emotional history, locked up in the structure and tissue of our muscles. The central task of Reichian therapy is to destroy the muscular armor in order to reestablish the organism's full capacity for the pulsation of bioenergy. This is done with the help of deep breathing and a variety of other physical techniques aimed at helping patients express themselves through their bodies rather than with words. In this process past traumatic experiences will emerge into conscious awareness and will be resolved, together with the corresponding muscular blocks. The ideal result is the appearance of a phenomenon that Reich called the orgasm reflex, and which he regarded as central to the dynamics of living organisms, far transcending the usual sexual connotation of the term. In the orgasm,' writes Reich, 'the living organism is nothing but a part of pulsating nature.' 49
It is evident that Reich's concept of bioenergy comes very close to the Chinese concept of ch'i. Like the Chinese, Reich emphasized the cyclical nature of the organism's flow processes and, like the Chinese, he also saw the energy flow in the body as the reflection of a process that goes on in the universe at large. To him bioenergy was a special manifestation of a form of cosmic energy that he called 'orgone energy.' Reich saw this orgone energy as some kind of primordial substance, present everywhere in the atmosphere and extending through all space, like the ether of nineteenth-century physics. Inanimate as well as living matter, according to Reich, derives from orgone energy through a complicated process of differentiation.
This concept of orgone energy is clearly the most controversial part of Reich's thinking and was the reason for his isolation from the scientific community, his persecution, and his tragic death. 50 From the perspective of the 1980s it seems that Wilhelm Reich was a pioneer of the paradigm shift. He had brilliant ideas, a cosmic perspective, and a holistic and dynamic world view that far surpassed the science of his time and was not appreciated by his contemporaries. Reich's way of thinking, which he called 'orgonomic functionalism,' is in perfect agreement with the process of thinking of our modern systems theory, as this passage shows:
Unfortunately, the language of modern systems biology was not available to Reich, so he sometimes expressed his theory of living matter and his cosmology in terms which were rooted in the old paradigm and rather inappropriate. He could not conceive of orgone energy as a measure of organic activity, but had to see it as a substance that could be detected and accumulated, and in his attempts to verify such a notion he cited numerous atmospheric phenomena that are more likely to be explained in terms of conventional processes, such as ionization or ultraviolet radiation. 52 In spite of these conceptual problems, Reich's basic ideas about the dynamics of life have had a tremendous influence and have inspired therapists to develop a variety of new psychosomatic approaches. If Reichian theory were reformulated in modern systems language, its relevance to contemporary research and therapeutic practice would become even clearer.
The therapeutic models discussed in the rest of this chapter do not necessarily subscribe to the notion of fundamental energy patterns, but they all see the organism as a dynamic system with interrelated physical, biochemical, and psychological aspects that must be in balance for the human being to be in good health. Some of the therapies address themselves to the physical aspects of this balance by dealing with the body's muscular system or with other structural elements; others influence the organism's metabolism; and still others concentrate on establishing balance through psychological techniques. Whatever their approach, they all recognize the fundamental interdependence of the organism's biological, mental, and emotional manifestations, and are therefore mutually consistent.
The therapies that try to facilitate harmony, balance, and integration through physical methods have recently become known collectively as bodywork. They deal with the nervous system, the muscle system, and various other tissues, and with the interplay and coordinated movement of all these components. Bodywork therapy is based on the belief that all our activities, thoughts, and feelings are reflected in the physical organism, manifesting themselves in our posture and movements, in tensions, and in many other signs of 'body language.' The body as a whole is a reflection of the psyche, and work on either one will also change the other.
Since the Eastern philosophical and religious traditions have always tended to see mind and body as a unity, it is not surprising that a number of techniques to approach consciousness from the physical level have been developed in the East. The therapeutic significance of these meditative approaches is being noticed increasingly in the West, and many Western therapists are incorporating Eastern bodywork techniques such as Yoga, T'ai Chi, and Aikido in their treatments. A major aspect of these Eastern techniques, which is also strongly emphasized in Reichian therapy, is the fundamental role of breath as a link between the conscious and unconscious levels of mind. Our breathing patterns reflect the dynamics of our entire mind/body system, and breath is the key to our emotional memories. The practice of proper breathing and the use of various breathing techniques as therapeutic tools is therefore central to many schools of bodywork, in the West as well as in the East.
The dynamic manifestations of the human organism - its continual movements and the various processes of flow and fluctuation - all involve the muscle system. Work on the body's muscular system is ideally suited for studying and influencing physiological and psychological balance. Detailed studies of the physical organism from this perspective show that the conventional distinctions between nerves, muscles, skin, and bones are often quite artificial and do not reflect the physical reality. The entire muscle system of the organism is covered by loose connective tissues that integrate the muscles into a functional whole and cannot be separated either physically or conceptually from the muscle tissue, the nerve fibers, and the skin. Segments of this connective tissue are associated with different organs, and a variety of physiological disorders can be detected and cured by special techniques of connective-tissue massage.
Since the muscle system is an integrated whole, a disturbance of any part of it will propagate through the entire system, and since all bodily functions are supported by muscles, every weakening of the organism's balance will be reflected in the muscular system in a specific way. An important aspect of this balance is the regular flow of nerve current throughout the body, which is the focus of chiropractic. Chiropractors concentrate on the structural support of the nervous system along the spine. By means of manual adjustments involving gentle manipulations of joints and soft tissues, they are able to realign dislocated vertebras and thereby eliminate obstructions in the nervous flow that may cause many different disorders. Out of chiropractic emerged a special technique of muscle testing, known as applied kinesiology,*(*Kinesiology, from the Greek kinesis ('motion'), is the study of human anatomy in relation to movement.) which has been developed into a valuable therapeutic tool that enables therapists to use the muscle system as a source of information about various aspects of the organism's state of balance. 53
Influenced by the pioneering ideas of Wilhelm Reich, by Eastern concepts, and by the modern dance movement, a number of therapists have combined various elements from these traditions to develop bodywork techniques that have recently become very popular. The principal founders of these new approaches are Alexander Lowen ('bioenergetics'), Frederick Alexander ('Alexander technique'), Moshe Feldenkrais ('functional integration'), Ida Rolf ('structural integration'), and Judith Aston ('structural patterning'). In addition, various massage therapies have been developed, many of them inspired by Eastern techniques like shiatsu and acupressure. All these approaches are based on the Reichian notion that emotional stress manifests itself in the form of blocks in the muscle structure and tissue, but they differ in the methods employed for releasing these psychosomatic blocks. 54 Some bodywork schools are based on a single idea that is translated into a single set of prescriptions and manipulations, but ideally a bodywork therapist should be familiar with each of these techniques and not use any one of them exclusively. Another problem is that many schools tend to treat muscular blocks as static entities and associate emotions with body postures in a rather rigid way, without perceiving the body as it moves through space and relates to its environment.
One of the most subtle approaches to bodywork, and one which focuses precisely on that aspect - the body moving through space and interacting with its environment - is practiced by dance and movement therapists, and in particular by a school of movement therapy based on the work of Rudolf Laban and further elaborated by lrmgard Barten-ieff.55 Laban developed a method and terminology for analyzing human movement that is relevant to many disciplines besides therapy, including anthropology, architecture, industry, theater, and dance. The therapeutic significance of this method derives from Laban's perception that all movement is functional and expressive at the same time. Whatever tasks people pursue, they will also express something about themselves through their movement. Laban's system deals explicitly with this expressive quality of movement and thus allows movement therapists to recognize many fine details of their patients' emotional and physical states by carefully watching how they move.
The Laban-Bartenieff school of movement therapy pays special attention to the ways in which individuals interact and communicate with their environment. This interplay is seen in terms of complex rhythmic patterns, flowing in and out of one another in various ways, with ill health arising from a lack of synchrony and integration. Healing, in this view, is induced by a special process of interaction between therapist and patient in which the rhythms of both are continually synchronizing. By communicating with their patients through movement, and by establishing a kind of resonance, movement therapists help these individuals to better integrate themselves, physically and emotionally, into their environment.
Another important approach to balance is through the organism's metabolism. Biochemical balance can be influenced by changing one's diet and by taking various medicines in the form of either herbs or synthetic drugs. In most medical traditions these three forms of treatment are .not sharply separated, and it would seem most appropriate to adopt this view also in the new system of holistic health care. Nutritional therapy, herbal medicine, and the prescription of drugs all affect the body's biochemical balance and are variations of one and the same therapeutic approach. Recognizing the organism's inherent tendency to regain its balance, the holistic therapist will always use the mildest possible remedy, beginning with a change of diet, moving on to herbal medicines if needed to bring the desired effect, and using synthetic drugs only as a last resort and in emergencies.
Although nutrition has always been a major factor in the development of disease patterns, it is severely neglected in today's medical education and practice. Most doctors are not qualified to give sound nutritional advice, and the articles on nutrition published in popular magazines are often extremely confusing. Yet the basic principles of nutritional counseling are relatively simple and should be known to all general practitioners.56
Nutritional counseling and therapy are closely related to a new branch of medicine known as clinical ecology, which in the late 1940s grew out of the study of allergies and is concerned with the impact of foods and chemicals on our health and our mental state. 57 Clinical ecologists have found that common foods and seemingly harmless chemical products used every day in our homes, offices, and work places can cause mental, emotional, and physical problems, from headaches and depressions to aches and pains in muscles and joints. Patients who come to see their doctors with multiple symptoms, both physical and psychological, are frequently suffering from such allergies. The treatment of these patients by clinical ecologists is a highly individualized procedure, involving nutritional therapy and various other techniques, aimed at identifying and eliminating the environmental causes of the patients' illness.
Like nutritional counseling, the art of herbal medicine has been almost totally forgotten with the rise of the biomedical model, and only very recently has there been a certain revival of the therapeutic use of natural herbs. This development is encouraging, since natural, unrefined plant material seems to be the best type of oral medication, but herbal medicine can be successful only if the purpose of the treatment is to deal with the whole organism rather than trying to cure a specific disease. Otherwise there will invariably be a tendency to refine herbal mixtures in order to isolate their 'active ingredients,' which would significantly reduce the therapeutic effect. Pharmaceutical drugs, which are often the end products of such refinements, act much faster on the body's biochemistry than herbal mixtures, but they also cause a much greater shock to the organism and thus generate numerous harmful side effects that generally do not occur when the unrefined herbal remedies are used. 58
More careful use of medical drugs illustrate the future role of biomedical therapy as a whole. The achievements of modern medical science will by no means be abandoned, but in the future holistic approach biomedical techniques will play a much more restricted role. They will be used to deal with the physical and biological aspects of illness, especially in emergencies, but always very judiciously and in conjunction with psychological counseling, stress-reduction techniques, and other methods of holistic patient care. The transition to the new system will have to be made slowly and carefully because of the tremendous symbolic power of biomedical therapy in our culture. The reductionist approach to illness, with its strong emphasis on drugs and surgery, will be supplemented and eventually replaced by the new holistic therapies in a gradual process, as our collective views of health and illness change and evolve.
The last group of therapeutic techniques to be reviewed here approach psychosomatic balance through the mind. Embracing various methods of relaxation and stress reduction, they are likely to play an important role in all future therapies.59 Current attitudes toward relaxation in our culture are quite naive. Many activities thought of as relaxing - watching television, reading, having a few drinks - do not reduce stress or mental anxiety. Deep relaxation is a psycho-physiological process that requires as much diligent practice as any other skill, and that has to be practiced regularly to be fully effective. Correct breathing is one of the most important aspects of relaxation and thus one of the most vital elements in all stress-reduction techniques.
Deep, regular breathing and profound relaxation are characteristic of the techniques of meditation developed in many cultures, but especially those of the Far East, for thousands of years. Recent interest in mystical traditions has brought an increasing number of Westerners to regular meditation, and there have been several empirical studies of the health benefits of meditative practice. 60 Because these studies indicate that the response of the human organism to meditation is opposite to its reaction to stress, meditative techniques will probably have important clinical applications in the future.
Over the past fifty years various deep-relaxation techniques have also been developed in the West and have been used successfully as therapeutic tools for stress management. They can be regarded as Western forms of meditation, not connected with any spiritual tradition but growing out of the need for dealing with stress. One of the most comprehensive and successful of these techniques is a method known as autogenic training, which Johannes Schultz, a German psychiatrist, developed in the 1930s. It is a form of self-hypnosis combined with certain specific exercises designed to integrate mental and physical functions and to induce deep states of relaxation. During the initial stages autogenic training emphasizes exercises dealing with the physical aspects of relaxation, but once these have been mastered it progresses to more subtle psychological aspects that, like meditation, involve the experience of non-ordinary states of consciousness.
When the organism is fully relaxed, one can make contact with one's unconscious to obtain important information about one's problems or about the psychological aspects of one's illness. The communication with the unconscious takes place through a highly personal, visual, and symbolic language similar to that of dreams. Mental imagery and visualization, therefore, play a central role in the advanced stages of autogenic training, as they do in many traditional techniques of meditation. Visualization techniques have recently been applied directly to specific illnesses too, and have often yielded excellent results.
The psychological approach to stress reduction and healing has received dramatic support from a new technology known as biofeedback. 61 It is a technique that helps a person to achieve voluntary control over normally unconscious bodily functions by monitoring them, amplifying the results electronically, and displaying them ('feeding them back'). Numerous applications of this technique over the past decade have shown that a wide range of autonomic, or involuntary, physiological functions - heart rate, body temperature, muscle tension, blood pressure, brain-wave activity, and others - can be brought under conscious control in this way. Many clinicians now believe that it may be possible to achieve some degree of voluntary control over any biological process that can be continuously monitored, amplified, and displayed.
The term 'voluntary control' is actually somewhat inappropriate to describe the regulation of autonomic functions through biofeedback. The idea of the mind controlling the body is based on the Cartesian division and does not correspond to the observations made in biofeedback practice. What is required for this subtle form of self-regulation is not control but, on the contrary, a meditative state of deep relaxation in which all control is relinquished. In such a state, channels of communication between the conscious and the unconscious mind open up and facilitate the integration of psychological and biological functions. This process of communication often takes place through visual imagery and symbolic language, and it was this role of visual imagery in biofeedback which led a number of therapists to use visualization techniques for the treatment of illnesses.
Clinical biofeedback can be used in conjunction with many therapeutic techniques, both physical and psychological, to teach patients relaxation and the management of stress. It is more likely to convince Westerners of the unity and interdependence of mind and body than Eastern techniques of meditation, and it facilitates the important shift of responsibility for health and illness from the therapist to the patient. The fact that individuals are able to correct a particular symptom by themselves through biofeedback will often dramatically reduce their feeling of helplessness and encourage the positive mental attitude that is so important in healing.
These experiences have shown the great value of biofeedback as a therapeutic tool, but it should not be used in a reductionist way. Since it concentrates on the single physiological function that is monitored, biofeedback is not an alternative to more traditional meditation and relaxation techniques. Stress involves various patterns of psychosomatic functions, and the regulation of any one of them is generally not enough. Hence biofeedback has to be supplemented by more general methods of relaxation if it is to be fully effective. To establish the appropriate combination of self-regulation and relaxation techniques is quite difficult and requires a great deal of experience.
To conclude our discussion of holistic health care, it is appropriate to talk about a new way of treating cancer known as the Simonton approach, which I consider a holistic therapy par excellence. Cancer is an exemplary phenomenon, an illness characteristic of our age that forcefully illustrates many of the points made in this chapter. The imbalance and fragmentation that pervade our culture play an important role in the development of cancer and, at the same time, prevent medical researchers and clinicians from understanding the disease or treating it successfully. The conceptual framework and therapy that Carl Simonton, a radiation oncologist,*(*0ncology, from the Greek onkos ('mass'), is the study of tumors.) and Stephanie Matthews-Simonton, a psychotherapist, have developed are fully consistent with the views of health and illness we have been discussing and have far-reaching implications for many areas of health and healing.62 At present the Simontons see their work as a pilot study. They select their patients very carefully because they want to see how far they can go with a small number of highly motivated individuals to understand the basic dynamics of cancer. Once they have reached such an understanding, they will apply their knowledge and skills to larger numbers of patients. So far, the average survival time of their patients is twice that of the best institutions for cancer therapy and three times the national average in the United States. Moreover, the quality of life and levels of activity of these men and women, all of whom were considered medically incurable, are absolutely extraordinary.
The popular image of cancer has been conditioned by the fragmented world view of our culture, the reductionist approach of our science, and the technology-oriented practice of medicine. Cancer is seen as a strong and powerful invader that strikes the body from outside. There seems to be no hope of controlling it, and for most people cancer is synonymous with death. Medical treatment - whether radiation, chemotherapy, surgery, or a combination of these - is drastic, negative, and further injures the body. Physicians are increasingly coming to see cancer as a systemic disorder; a disease that has a localized appearance but has the ability to spread, and that really involves the entire body, the original tumor being merely the tip of the iceberg. Patients, however, often insist on viewing their cancer as a localized problem, especially during its initial phase. They see the tumor as a foreign object and want to get rid of it as quickly as possible and forget the whole episode. Most patients are so thoroughly conditioned in their views that they refuse to consider the broader context of their illness and do not perceive the interdependence of its psychological and physical aspects. For many cancer patients the body has become their enemy, one they mistrust and from which they feel thoroughly alienated.
One of the main aims of the Simonton approach is to reverse the popular image of cancer, which does not correspond to the findings of current research. Modern cellular biology has shown that cancer cells are not strong and powerful but, on the contrary, are weak and confused. They do not invade, attack, or destroy, but simply overproduce. A cancer begins with a cell that contains incorrect genetic information because it has been damaged by harmful substances or other environmental influences, or simply because the organism will occasionally produce an imperfect cell. The faulty information will prevent the cell from functioning normally, and if this cell reproduces others with the same incorrect genetic makeup, the result will be a tumor composed of a mass of these imperfect cells. Whereas normal cells communicate effectively with their environment to determine their optimal size and rate of reproduction, the communication and self-organization of malignant cells are impaired. As a consequence they grow larger than healthy cells and reproduce recklessly. Moreover, the normal cohesion between cells may weaken and malignant cells may break loose from the original mass and travel to other parts of the body to form new tumors - which is known as metastasis. In a healthy organism the immune system will recognize abnormal cells and destroy them, or at least wall them off so they cannot spread. But if for some reason the immune system is not strong enough, the mass of faulty cells will continue to grow. Cancer, then, is not an attack from without but a breakdown within.
The biological mechanisms of cancer growth make it clear that the search for its causes has to go in two directions. On the one hand we need to know what causes the formation of cancerous cells; on the other we need to understand what causes the weakening of the body's immune system. Many researchers have come to realize over the years that the answers to both these questions consist of a complex network of interdependent genetic, biochemical, environmental, and psychological factors. With cancer, more than with any other illness, the traditional biomedical practice of associating a physical disease with a specific physical cause is not appropriate. But since most researchers still operate within the biomedical framework, they find the phenomenon of cancer extremely bewildering. As Carl Simonton has noted, 'Cancer management today is in a state of confusion. It looks almost like the disease itself - fragmented and confused. ' 63
The Simontons fully recognize the role of carcinogenic substances and environmental influences in the formation of cancer cells, and they strongly advocate the implementation of appropriate social policies to eliminate these health hazards. However, they have also come to realize that neither carcinogenic substances, nor radiation, nor genetic predisposition alone will provide an adequate explanation of what causes cancer. No understanding of cancer will be complete without addressing the crucial question: What inhibits a person's immune system, at a particular time, from recognizing and destroying abnormal cells and thus allows them to grow into a life-threatening tumor? This is the question on which the Simontons have concentrated in their research and therapeutic practice, and they have found that it can be answered only by carefully considering the mental and emotional aspects of health and illness.
The emerging picture of cancer is consistent with the general model of illness we have been developing. A state of imbalance is generated by prolonged stress which is channeled through a particular personality configuration to give rise to specific disorders. In cancer the crucial stresses appear to be those that threaten some role or relationship that is central to the person's identity, or set up a situation from which there is apparently no escape. Several studies suggest that these critical stresses typically occur six to eighteen months before the diagnosis of cancer.64 They are likely to generate feelings of despair, helplessness, and hopelessness. Because of these feelings, serious illness, and even death, may become consciously or unconsciously acceptable as a potential solution.
The Simontons and other researchers have developed a psychosomatic model of cancer that shows how psychological and physical states work together in the onset of the disease. Although many details of this process still need to be clarified, it has become clear that the emotional stress has two principal effects. It suppresses the body's immune system and, at the same time, leads to hormonal imbalances that result in an increased production of abnormal cells. Thus optimal conditions for cancer growth are created. The production of malignant cells is enhanced precisely at a time when the body is least capable of destroying them.
As far as the personality configuration is concerned, the individual's emotional states seem to be the crucial element in the development of cancer. The connection between cancer and emotions has been observed for hundreds of years, and today there is substantial evidence for the significance of specific emotional states. These are the result of a particular life history that seems to be characteristic of cancer patients. Psychological profiles of such patients have been established by a number of researchers, some of whom were even able lo predict the incidence of cancer with remarkable accuracy on the basis of these profiles.
Lawrence LeShan studied more than five hundred cancer patients and identified the following significant components in their life histories:65 feelings of isolation, neglect, and despair during youth, with intense interpersonal relationships appearing difficult or dangerous; a strong relationship with a person or great satisfaction with a role in early adulthood, which becomes the center of the individual's life; loss of the relationship or role, resulting in despair; internalizing of the despair to the extent that individuals are unable to let other people know when they feel hurt, angry, or hostile. This basic pattern has been confirmed as typical of cancer patients by a number of researchers.
The basic philosophy of the Simonton approach affirms that the development of cancer involves a number of interdependent psychological and biological processes, that these processes can be recognized and understood, and that the sequence of events which leads to illness can be reversed to lead the organism back into a healthy state. As in any holistic therapy, the first step toward initiating the healing cycle consists of making patients aware of the wider context of their illness. Establishing the context of cancer begins by asking patients to identify the major stresses occurring in their lives six to eighteen months prior to their diagnosis. The list of these stresses is then used as a basis for discussing the patients' participation in the onset of their disease. The purpose of the concept of patient participation is not to evoke guilt, but rather to create the basis for reversing the cycle of psychosomatic processes that led to the state of ill health.
While the Simontons are establishing the context of a patient's illness, they are also strengthening his belief in the effectiveness of the treatment and the potency of the body's defenses. The development of such a positive attitude is crucial for the treatment. Studies have shown that the patient's response to treatment depends more on his attitude than on the severity of the disease. Once feelings of hope and anticipation are generated, the organism translates them into biological processes that begin to restore balance and to revitalize the immune system, using the same pathways that were used in the development of the illness. The production of cancerous cells decreases, and ^t the same time the immune system becomes stronger and more efficient in dealing with them. While this strengthening takes place, physical therapy is used in conjunction with the psychological approach to help the organism destroy the malignant cells.
The Simontons see cancer not merely as a physical problem but as a problem of the whole person. Accordingly, their therapy does not focus on the disease alone but deals with the total human being. It is a multidimensional approach involving various treatment strategies designed to initiate and support the psychosomatic process of healing. At the biological level the aim is twofold: to destroy cancer cells and to revitalize the immune system. In addition, regular physical exercise is used to reduce stress, to alleviate depression, and to help patients get more in touch with their bodies. Experience has shown that cancer patients are capable of far more physical activity than most people would assume.
The principal technique of strengthening the immune system is a method of relaxation and mental imagery that the Simontons developed when they learned about the important role of visual imagery and symbolic language in biofeedback. The Simonton technique consists of the regular practice of relaxation and visualization during which the cancer and the action of the immune system are pictured in the patient's own symbolic imagery. This technique has turned out to be an extremely efficient tool for strengthening the immune system and has often resulted in dramatic reductions or eliminations of malignant tumors. Moreover, the visualization method is also an excellent way for patients to communicate with their unconscious. The Simontons work very closely with their patients' imagery and have learned that it tells them much more about the patients' feelings than any rational explanations.
Although the visualization technique plays a central role in the Simonton '.herapy, it is important to emphasize that visualization and physical therapy alone are not sufficient to heal cancer patients. According to the Simontons, the physical disease is a manifestation of underlying psychosomatic processes that may be generated by various psychological and social problems. As long as these problems are not solved the patient will not get well, even though the cancer may temporarily disappear. To help patients solve the problems that are at the roots of their illnesses, the Simontons have made psychological counseling and psychotherapy essential elements of their approach. The therapy usually takes place in group sessions, in which patients find mutual support and encouragement. It concentrates on their emotional problems but does not separate these from the larger patterns of their lives, and thus generally includes social, cultural, philosophical, and spiritual aspects.
For most cancer patients the impasse created by the accumulation of stressful events can be overcome only if they change part of their belief system. The Simonton therapy shows them that their situation seems hopeless only because they interpret it in ways that limit their responses. Patients are encouraged to explore alternative interpretations and responses in order to find healthy ways of resolving the stressful situation. Thus the therapy involves a continual examination of their belief system and world view.
Dealing with death is an integral part of the Simonton therapy. Patients are made aware of the possibility that, sometime in the future, they may come to a decision that it is time for them to move toward death. They are assured that they have the right to make such a decision and are promised that the therapists will be as supportive and caring through their dying as they are in their struggle to regain health. In dealing with death in such a way, a major task is often getting the family to give the patient permission to die. Once this permission is given and expressed - not just verbally but through the family's behavior - the whole perspective of that death is changed. As the Simontons point out to their patients, whether or not one recovers from cancer, one can succeed in improving the quality of one's living or of one's dying.
The confrontation with death that cancer patients have to face touches on the fundamental existential problem that is characteristic of the human condition. Cancer patients are thus naturally led to consider their goals in life, their reasons for living, and their relation to the cosmos as a whole. The Simontons do not avoid any of these issues in their therapy, and this is why their approach is of such exemplary value for health care as a whole.
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