3 Aims and structure of the consultation
If we state that the overarching aim of the phytotherapy consultation is to arrive at an enhanced understanding of the patient’s predicament in order to be better positioned to offer ease in coping with it – that tells us little that is distinctive about phytotherapy, since all healthcare modalities could commit to such a goal. We might go further and claim that the guiding driver of the consultation is a notion of health in its three-fold nature: prevention of deviation from health, remedy of current flaws in health and optimization of wellbeing. That is to say that the phytotherapist has her mind on these three potentials during the consultation:
Yet again, however, one is unlikely to find a healthcare approach that would not recognize the need to focus on these three personas of health, although one could debate the degree to which each actually addressed these in practice and achieved success in attaining them.
There may in fact be little that is distinctive in terms of the overall aims of the phytotherapy consultation, broadly stated, in comparison with other healthcare modalities. This should not surprise us since all such modalities will be able to subscribe to global statements about the aims, not just of the consultation, but regarding the intentions of their overall approach. Differences in emphasis and outcome emerge only when more detailed scrutiny is made of the individual therapy – its ethos, practice, scope, nature and culture. Analysis of these individual tints and twists generate the prospect not only of revealing difference but also of showing deviance from the dominant medical model. While both conventional and CAM therapies may be able to sign up to a campaign slogan summarizing the aims of ‘good healthcare’, the detail of a joint manifesto on how to deliver this might be fiercely debated.
The directional tendencies of the consultation in any healing modality will be largely shaped by the capacities and capabilities of the particular therapy being practised. This generalized orientation is then further specified by the personal beliefs and qualities of the therapist and in light of the particular expectations, wishes and predicament of the patient. In focusing on the former of these three territories we can assert that the distinguishing features of phytotherapy that influence the aims and process of the consultation have to do, in great part, with the nature and properties of herbs themselves. These include:
• The tremendous plasticity and adaptability of herbs to meet patient requirements in terms of the type of external and internal applications that can be prescribed (teas, tinctures, creams, lotions, liniments, syrups, baths, inhalations, rubs, gargles, paints, tablets, capsules, pills, compresses, poultices, plasters, etc.)
Such treatment potentialities need to be reflected and embodied in the structure and practice of the consultation so that there is a harmony and integrity between the two, and in order that the consultation process may lead to the most appropriate and effective treatment outcomes. The aims and processes of the consultation in any modality are fundamentally shaped by the therapeutic tools and strategies that the particular modality makes available. The consultation is usually directed to the possible outcomes that such tools and strategies will allow. If the therapeutic options are narrow, then this will tend to be reflected in the consideration of the patient in terms of the consultation.
A key theme here is that of complexity. There have been a number of publications by conventional medical practitioners in recent years exploring the implications of complexity and chaos theories for medical care (e.g. Plsek 2002; Holt 2004; Sweeney 2006). Although many of these publications are excellent and offer groundbreaking insights, few of the authors have noted and explored the issue of the inherently linear, non-complex nature of conventional drugs themselves. Non-linear drugs (such as antibiotics) have awesome capacities to provide rapid healing effects in specific conditions at specific points in time, yet they possess profound limitations. Conventional medicine has limited success and may be counterproductive or cause harm in many complex conditions. It is also the simple chemical nature of orthodox drugs that is their Achilles heel, e.g. in antibiotics where the absence of molecular complexity enables the development of microbial resistance. Conventional medical practitioners seeking to embrace the implications of complexity and chaos theories and to use pharmacologic agents that are complex and chaotic in nature would be well advised to train in phytotherapy since their ability to work in this way is limited by the nature and capacities of the conventional materia medica.
Herbal medicines offer genuine and exciting potentials as agents of preventive medicine and as modulators of physiological response, leading to optimizing of critical functions, as well as being effective remedies to treat many established conditions. Some key herbs can work across these three aspects, e.g. Echinacea spp. (cone flower) can modulate and enhance immune function (leading to both preventive and optimizing results) as well as being a treatment for upper respiratory tract viral infections. Other plant agents can initiate or exert broad dynamic responses in the body that lead to generalized complex and chaotic effects – the results of which are not specifically predictable but rather cause general healing trends that may produce unpredictable, yet positive, effects. An example of this would be circulatory stimulating herbs such as Zingiber officinale (ginger) which can enhance blood flow (and hence improve the rate and efficiency of gaseous exchange; delivery of nutrients, hormones, clotting factors, immune cells; removal of waste products of metabolism, etc.) to a range of tissues and organs leading to modulation of systems performance and global changes in physiology and health/illness. A second example would be within the class of herbs known as adaptogens which enhance physical and mental performance, endurance and stamina and protect from the effects of stress – whether physical, psychological or environmental. One of the most famous herbs in this category is Panax ginseng (Chinese or Korean ginseng), which is able to trigger such broad and complex consequences in part due to its propensity to increase the generation of ATP within cells, therefore modulating cellular performance. By influencing ATP generation in multiple cells complex and chaotic changes arise leading to the emergence of new properties or qualities within the body’s integrated physiological processing.
We will return to more fully consider the ideas and assertions developing here around complexity and chaos, towards the end of this chapter. For now let us propose that phytotherapists have good cause to enter into the consultation process optimistically, with a realistic expectation that they may, on its conclusion, be able to proceed in the majority of cases to offering a herbal intervention that is capable of helping the patient to achieve greater ease at least, and frequently much more than this. Such positivity can energize the consultation and is likely to exert a healing influence in its own right (see the discussion on placebo in Ch. 2).
Let us shift focus at this stage, however, to consider a negative perspective on the question of the aims of the consultation. This would seek to identify the potentialities that are undesirable and therefore which we should consciously avoid generating within the consultation. Chief among these would be to avoid misunderstanding the patient in order to subsequently escape giving inappropriate advice and treatment that might fail to provide benefit where benefit is otherwise possible or, at worst, actually harm the patient. Awareness of the capacity for iatrogenesis (harm caused to the patient by the practitioner or by treatment) is an essential part of the make up of the advanced practitioner. The weight of this vital appreciation should not oppress the practitioner; rather a nuanced realization of its dimensions and implications can act as an anchor to provide grounding amidst the powerful currents of the flow of the consultation. While most practitioners have an understanding of the notion of clinical iatrogenesis, Illich (1976) has identified two other, less recognized, facets of the problem – social iatrogenesis and cultural iatrogenesis. By ‘social iatrogenesis’, Illich means: ‘… a term designating all impairments to health that are due precisely to those socioeconomic transformations which have been made attractive, possible or necessary by the institutional shape health care has taken’. For example, social iatrogenesis:
… obtains when medical bureaucracy creates ill-health by increasing stress, by multiplying disabling dependence, by generating new painful needs, by lowering the levels of tolerance for discomfort or pain, by reducing the leeway that people are wont to concede to an individual when he suffers, and by abolishing even the right to self-care …. when all suffering is ‘hospitalised’ and homes become inhospitable to birth, sickness, and death; when the language in which people could experience their bodies is turned into bureaucratic gobbledegook; or when suffering, mourning, and healing outside the patient role are labelled a form of deviance.
It would be an error to see this type of iatrogenesis as being limited to institutionalized mainstream medicine. CAM practitioners are not exempt from accepting particular dominant ideas, practices and values as normative and therefore the ‘correct’ or ‘right’ ways of thinking or acting. For example, women who breastfeed long-term (for years rather than months) may be considered deviant by practitioners from any field who are unaware that in ancient indigenous cultures it is usual to breastfeed for 3–5 years and that, not only does this seem to have been the norm for our species until very recent times, but additionally a number of benefits have been shown for both mother and child accruing from such a duration of feeding. It is plausible to suggest that, since CAM courses are now increasingly provided by conventional academic institutions, CAM students and graduating practitioners are likely to take on the normative values and concepts fostered by institutions of the state to a greater degree than before. We are therefore likely to see an increased blurring between so-called conventional and alternative medical thought than in recent decades. There are few signs yet that the direction of this thought is moving substantially to a more holistic take. The cries of many a disgruntled academic and social commentator that CAM courses do not properly belong in the state’s learning centres and that if they are to persist there they must be subject to the correcting influence of ‘science’ do not help to foster an environment where open philosophical discussion can occur.
… sets in when the medical enterprise saps the will of people to suffer their reality. It is a symptom of such iatrogenesis that ‘suffering’ has become almost useless for designating a realistic human response because it evokes superstition, sado-masochism, or the rich man’s condescension to the lot of the poor. Professionally organised medicine has come to function as a domineering moral enterprise that advertises industrial expansion as a war against all suffering. It has thereby undermined the ability of individuals to face their reality, to express their own values, and to accept inevitable and often irremediable pain and impairment, decline and death.
This deeper insight calls into question the global positive aims of the consultation that we began with. To what extent, and in which ways, is it possible and even desirable to give ease? Are we correctly oriented if our focus is on ‘health’, its optimization, and the prevention or remedying of any deviance from its true path? Such questions lead us into a critique of the notions of health and suffering which we will attempt to sketch later in this chapter. At this point it is worth pausing to consider the breadth of Illich’s conception of iatrogenesis and let sink-in the implications for practitioners if we wish to minimize the risk of causing harm to, or hindering the free-expression and development of, patients. While clinical iatrogenesis (the risk of causing harm due to medical procedures and treatments) seems a relatively clear and straightforward concept (though arguably deceptively so) for practitioners to address and work with, the social and cultural forms of iatrogenesis are much more subtle, complex and challenging to connect with. In attempting to learn about, and from, these latter two forms of iatrogenesis the practitioner is required to engage at an advanced level of scrutiny of self, environment, society and culture. A philosophical and political engagement with these territories is necessary. The exercise of reflective practice is perhaps the most powerful tool we have to work in this way but the suggestion of the need for advanced practitioners to be fully-faceted resurfaces here. The pluralist philosopher–physician may be equipped to take up the gauntlet thrown down by Illich. Any lesser intellectual engagement with the fascinating challenges of attempting to tread Illich’s iatrogenesis labyrinth limits the practitioner’s ability to make progress on the patient’s behalf and arrests development at the level of technician. This is not to denigrate the value of the technical aspects of healthcare but to flag the limits and dangers inherent when technical aspects are not informed by the broader, deeper contextualization that may be achieved by a critical engagement with influences and issues on the grandest scale. The cultivation of such a wide-ranging view may not be a goal for everyone, yet the practice of medicine is a traditional home suited to those who require a non-abstract laboratory in which to explore the meaning of life. Joseph Needham (1948) commented on the restrictions placed by conventional science on diverse intellectual exploration and got to the nub of the radical nature of those who refuse such limitations in an essay first published in 1941:
Even today there are many professional scientists who look askance at the action of a colleague who dares to speak out from time to time on general topics … The overt rationalization of this feeling is that a scientific worker can hardly be thought to have sufficient intellectual energy for his scientific work unless he is careful to use none outside it … But the real meaning of this feeling is that to enquire too curiously into the structure of the world and society and the history of society is potentially a menace to the stability of society. The innocent scientist who harbours no ‘dangerous thoughts’ is a far more wholesome member of the community (from the point of view of its de facto rulers) than the scientist who prefers to prowl … I am glad to confess that … I have always been a prowler, an explorer, among ideas.
Such prowling can only be driven by passion and desire, a hunger for knowledge and connection. In this sense the health practitioner, while striving to help the patient find meaning in their individual predicament, is simultaneously searching for meaning in her own appreciation of the world. The practice of medicine (by which I mean any type of healing modality) in this conception, is intimately part of and indeed is a central strategy in the practitioner’s own development as a person, seeking to make sense of the world and to make a helpful contribution towards suffering humanity.
We have already emphasized the extraordinary potential of herbal medicine to play a fundamental role in enabling positive patient outcomes. Yet there are limits as to the degree to which any form of medicine can help relieve and transform suffering. Each practitioner must gain an informed perspective on this if they are to cope with feeling for the suffering of their fellows and in order to be maximally useful to them in their situation. The conventional view of suffering in the modern west is an entirely negative one – suffering has no purpose or redeeming features and is always to be eliminated. This perspective stands in the shadow of the spectre of the modern western secular view of death. Death is the end, oblivion – nothing survives it. Death is the ultimate enemy of life therefore and must be resisted and fought at all costs – as must any form of suffering, which is the intimater of mortality. Of course a healthcare system or medical approach that is founded on conquering death is setting a hard target to achieve! Standing in opposition to death is a flawed ground for working with patient’s health challenges. The practitioner must therefore gain a perspective on death too.
Let us return to Ivan Illich at this point and recall that he was a Roman Catholic priest. A key feature of religions and other spiritual belief systems is that they offer a perspective on death. Illich (1976) points out that:
The major religions reinforce resignation to misfortune and offer a rationale, a style, and a community setting in which suffering can become a dignified performance. The opportunities offered by the acceptance of suffering can be differently explained in each of the great traditions: as karma accumulated through past incarnations; as an invitation to Islam, the surrender to God; or as an opportunity for close association with the Saviour on the Cross.
A large body of (contentious) research is now available on the healing influence of faith and prayer. The benefits arising from faith and related practices seem in large part to relate to the elements we can pick out from Illich’s statement above:
The particular article of faith may be less important than the act of faith itself since any belief system may potentially furnish these elements of healing which help one to make sense of and gain some control over suffering as well as decreasing the loneliness and isolation that tend to accompany suffering.
For Rosenberg (1998), Illich’s thinking represents: ‘a different realm of holism, the explicitly religious and mystical’. He argues that, while this type of holistic approach is shared by some of those involved in biomedical work and has shaped some branches of conventional medicine, it is not integral to it:
Spiritual commitment is not explicitly a part of medical thought – even though it has been a fundamental component in the shaping of modern health care institutions and a significant factor in the determining of individual medical careers and worldviews.
Impulses and insights of a ‘religious, mystical, spiritual’ nature are accorded value as influences on medical thought and practice but they are far from being seen as central. One calls to mind the little hospital chapel, lost somewhere within the brutal maze of medical architecture.
Illich has been criticized for the alleged extremism of his position in placing individual autonomy and self-care at the centre of ‘medicine’ and for according little space to modern technological biomedicine. Greaves (1996) asserts that:
Imbuing the individual with a vital autonomy sufficient to ensure his own health is not only implausible, but confers grave disadvantages … Most notably the endurance of suffering and pain becomes viewed by Illich as ennobling in itself, even forming part of the definition of a healthy life: and death is seen as better than a life lived through reliance on medicine. While Illich may hold such personal values, there would seem no good reason for claiming that others should share them.
This is a (uncharacteristically for Greaves) crude analysis, since there lies implicit within it the suggestion that biomedicine has the capacity to relieve all types of suffering and pain and that the notion of living through reliance on medicine is generally non-contentious. The first of these implicit suggestions is obviously unsustainable and the second palls when we consider, e.g. the debate about euthanasia in the aspect of the withdrawal of life-perpetuating medical treatment. For most people, the matter for reflection is not a stark choice between absolute rejection or total acceptance of biomedicine but rather a nuanced consideration of the available options and how they might be combined, including self-care, community care, conventional medical services and CAM approaches.
Certainly, some working in conventional medicine are questioning the limits of biomedicine and identifying its insufficiencies. In a Lancet Editorial (2009), the successes of the National Health Service in the UK are acknowledged before reflecting that:
Infectious diseases, seemingly conquered by antibiotics and vaccination, have resurged. The pain and decrepitude of chronic illness are widespread. Industrial injuries have largely been replaced by the illnesses of unemployment and despair – chronic pain, depression and substance abuse.
… perhaps we need to ask what health is, and how to achieve it. Do mechanical and material models adequately capture health, or care? Which suffering can clinicians alleviate, and how? And how can patients avoid suffering alone, and unconsoled?
These are key questions that demonstrate recognition of the failures (as well as the successes) of biomedical positivism and the need for a renewed meditation on first principles – examining what ‘health’ is and how it might be best achieved. Perhaps now is the time for ‘spiritual commitment’ to be shown, and to be prized, in discovering and creating solutions.
A further take on the context for such questions would be the suggestion that, precisely because conventional biomedicine has succeeded in keeping people alive for longer with conditions from which they would formerly have perished but at the cost of a permanent health deficit, the potential for prolonged suffering in the modern age has been dramatically increased. As people have been preserved and partially restored by ‘mechanical and material’ methods, they continue their lives in a society shaped by the same philosophical principles that gave rise to these methods – a materialist culture wherein community has been diminished and the search for higher meaning devalued. This is not a culture that supports or nurtures health – it is one where those who have health impairments are disadvantaged by the shift from interdependence to independence that occurred over the course of the twentieth century and now continues in the twenty-first. Illness, bereavement, profound personal challenges and losses – such experiences forcefully remind us of Donne’s insight that ‘No man is an island, entire of itself’. Yet what passes for community support today is often a sham, manufactured, institutionalized form that serves to further a personal sense of separateness from the ‘normal world’ that continues to take place elsewhere.
The general practitioner Kieran Sweeney (2006) tells of a single transforming consultation he experienced with an 85-year-old widow where, after he had explained how he could prescribe medicines to help with her diabetes, high blood pressure and raised cholesterol, she paused and said to him: ‘Well, Jack’s dead and the boys have gone’. For Sweeney this statement moved the consultation:
… from being doctor-centred to being patient-centred. It moved … from the biomedical domain to the biographical domain, or from clinical, evidence-based medicine to a consultation predicated on narrative-based evidence. But the shift was profound. When the consultation moved from its biomedical phase, it shed its parameters of p-values, absolute risk and numbers needed to treat. These were replaced by the parameters of the biographical phase of the consultation … despair, hopelessness, regret, guilt perhaps, and defeat were the parameters. Physical parameters had been replaced by metaphysical ones – two intellectual worlds seemed to have collided.
There is no reason, of course, why these two worlds should not co-exist – there is no requirement to reject one in place of the other. Such a shift to a broader embracing and integrating of explanatory and experiential models does, however, require the practitioner to be able to incorporate and synthesize different perspectives. Cassell (2004) has observed that:
Since antiquity there has been a prejudice in favour of reason and against experiential knowledge. The long-standing dichotomy of medicine into its science and art is a medical expression of this bias. Knowledge, however, whether of medical science or the art of medicine, does not take care of sick persons or relieve their suffering; clinicians do in whom these kinds of knowledge are integrated.
This false dichotomy of reason/experience substantially underlies the antagonism between conventional biomedicine and CAM. Ironically (and inevitably) at the present time, just as in conventional medicine the wave of recognition of the limits and pitfalls of scientific rationalism is growing and gathering momentum, CAM professions are being exhorted to deny their experiential basis and prove themselves with reductionist science. This is partly embodied in the movement of CAM courses from independent learning centres to state academic institutions as mentioned above. If conventional medicine gets more art and CAM gets more science it may become increasingly difficult to tell the two apart, and perhaps they will meet each other halfway along their gradually developing trajectories. In the meantime it is open to individual practitioners to integrate art and science in their work right now, whatever their discipline, and in so doing to participate in an age-old project.
One approach to helping a patient such as the one just described by Sweeney would be to try to facilitate improved socialization, and thereby the development of a supportive community of care for the patient, by such means as joining a club or activity group, participating in classes or taking up volunteer work. Such solutions may not always be acceptable, practical or achievable however. Yet, there is always the capacity for the practitioner to remember and employ that most basic and powerful act – to bear witness to another’s suffering and to communicate one’s care, love and support; to be kind and to convey human warmth and integrity.
Egnew (2005) in his exploration of the meaning and definition of ‘healing’ has observed that as biomedicine became more technically successful in treating a number of diseases:
… cure, not care, became the primary purpose of medicine, and the physician’s role became ‘curer of disease’ rather than ‘healer of the sick’. Healing in a holistic sense has faded from medical attention …
The practitioner operating from the cure perspective may feel a sense of failure when full recovery is not achieved and may not feel competent in providing care since that has not been the focus of her training and ongoing development. Care takes place elsewhere – in nursing and in non-medical specialties and in CAM modalities where sceptics might assert that Egnew’s critique could be reversed: some might allow that the business of CAM practitioners is to offer care (perhaps), but that they are incapable of offering cure. Again there is a need to transcend such simplistic dichotomies. It is possible for many therapeutic approaches to offer both cure and care – to varying degrees and in differing combinations, depending on the individual case. Certainly phytotherapists, given the extended and rounded nature of the consultation; the commitment to provide continuity of care (see Ch. 7); and the flexibility of medicinal plants as complex pharmacological therapeutic tools, should feel confident in their ability to work in both territories.
Egnew (2005) concluded that healing is: ‘… associated with themes of wholeness, narrative and spirituality’. He cites Frankl (1963) who observed that: ‘Suffering ceases to be suffering in some way at the moment it finds a meaning’. Egnew asserts that:
The role of the physician-healer is to establish connexional relationships with his or her patients and guide them in reworking of their life narratives to create meaning in and transcend their suffering.
Physicians are not trained to hear patients’ stories, often fail to solicit the patient’s agenda or pick up on the patient’s clues, and often limit storytelling to maintain diagnostic clarity, support efficiency, and avoid confusion and unpleasant feelings.
While it may be tempting to suggest that CAM practitioners are more open to hearing patients’ stories and are less limited or restricted in exploring them, such an assertion is hard to sustain in light of the diversity of so-called CAM approaches, some of which may be more open and some of which may not. To many, Egnew’s description of the role of the physician–healer will seem to fit that already ascribed to the various psychological therapies. Surely the ‘reworking of … life narratives to create meaning’ belongs with those who have training in this realm – counsellors, clinical psychologists and so forth? Certainly such practitioners operate in this territory but to assign all psychological work to such specialists is to miss the opportunity for psycho-emotional-spiritual insight and development that may arise in all caring relationships, including those that develop in phytotherapy and conventional medicine. One does not have to be a qualified clinical psychologist to aid patients in exploring their narratives. On the other hand, it is important to be aware of the implications of entering into psychological dimensions with patients that may be more fully explored by the specific psychological professions. This brings us back to education and training concerns, which, though legitimate, need not overwhelm us. Simple human warmth and bearing witness are natural caring instincts that require no instruction.
The ability to join with the patient in the moment and to ‘feel’ alongside them is key. Clinical abstraction detracts from this ability to experience what Gendlin has called ‘the felt presence of the moment’ – to participate phenomenologically with the patient. Yet clinicians who aim to contextualize and diagnose must attain a perspective from which those twin aims can be realized, hence the ability to step back at the same time as stepping in needs to be cultivated. Again, we need to beware the suggestion from scientific positivism and classical dualism that it is only possible to operate in one state at any given time. The therapeutic practitioner is able to be with the patient in the felt presence of the moment but also, simultaneously, to contextualize, calculate, diagnose and attempt to make sense of what the patient is communicating. To operate deeply, smoothly and effectively across these overlapping zones of emotional and intellectual activity requires practice, and facility in doing so increases over time and with experience. Students and novice practitioners commonly struggle with this synthesis and need to be reassured that time and persistence will bring rewards as well as being taught and trained in ways that facilitate working in this multidimensional way – which should be one of the key goals of practitioner education and ongoing development.
It might be timely to pause at this point and consider some of the aims of the consultation in phytotherapy that are emerging from the foregoing discussion. I will now attempt to state the case concisely.
The phytotherapy consultation is a locus or method that has the potential to realize a number of aims, depending on the predicament and preferences of the patient and the dynamics of the interactions between patient and phytotherapist that occur on any given occasion on which they meet and engage together. The aims and outcomes of particular consultations will shift in response to the varying needs of the patient and the changing dynamics of the relationship between patient and phytotherapist. A general list of potential aims would include to:
‘Health’ and ‘illness’ may be contrasted as poles reflecting the degree to which the individual is able to flexibly adapt to the changes and challenges of life and to weave their experiences into a fabric or text that can be made sense of and which has meaning. This ability to dance with the flux of life, retaining a perspective of meaning may be considered to apply across physical, emotional, mental and spiritual aspects of the individual. Illness in one of these personal dimensions may be contrasted with wellness in another. A person may be said to be physically well yet emotionally in turmoil, whereas another may be said to be physically ill yet to possess a serenity of spirit. Properties of health and illness then are not mutually exclusive and they need not be seen as opposing forces. They have been envisaged by some as points along a continuum from an extreme of ease (comfort and dynamic wellbeing) to an extreme of ‘dis-ease’ (pain and helpless suffering). An alternative perspective would be to see health, illness and disease as overlapping and intersecting fields which commonly co-exist, e.g. patients with some types of cancer may consider themselves to be ‘well despite the disease’.
‘Disease’ can be conceived as a concrete manifestation of illness showing clear breeches in the physical integrity or organization of the body (e.g. something abnormal can be seen in a blood test or MRI scan). Disease then can be equated with organic medical conditions where a lesion or disturbance in physiology of some type can be demonstrated. In contrast illness may be considered a collection of symptoms that exist in the absence of physical correlates such as changes in biochemical values or abnormalities revealed by imaging techniques. Disease therefore acquires legitimacy within the positivist worldview, whereas illness may not. Those who are ill but have no demonstrable lesion may sometimes be dismissed as ‘the worried well’. For Kleinman (1988), disease is essentially a medical biological phenomenon that is the concern of medical practitioners whereas illness relates to the experience of, and response to, disease on the part of the ill person, their family and wider community of associates. Conventional medical practice is predicated on treating disease but it is not as comfortable with, or competent in remedying, the state of illness.
Fowler and Christakis (2008) contend that ‘people are embedded in social networks and … the health and wellbeing of one person affects the health and wellbeing of others. This fundamental fact of existence provides a conceptual justification for the specialty of public health. Human happiness is not merely the province of isolated individuals’. Indeed the authors found that: ‘Happiness is a network phenomenon, clustering in groups of people that extend up to three degrees of separation (for example, to one’s friends’ friends’ friends)’.
The fields of health, illness and disease are ones of essential human concern and experience that are at the core of our self-image and self-understanding. They are also commercial territories to be exploited by the provision of products and services.
Foucault (2007) suggests that:
The natural locus of disease is the natural locus of life – the family: gentle, spontaneous care, expressive of love and a common desire for a cure, assists nature in its struggle against the illness, and allows the illness itself to attain its own truth.
Two themes are especially interesting here – first, that illness and disease are an intimate, and natural, part of family life and second, the assertion that illness may be able to ‘attain its own truth’. This intriguing latter point may be interpreted in at least two ways. First, that by making sense of and discovering meaning in the illness, the ‘truth’ of the illness is constructed by the ill person and their family and wider group of friends and associates. Second, though related to the first point, a teleological interpretation may be made – that the illness has a life of its own and a purpose for being; the condition arises for a reason and towards a goal. People’s perception of where illness comes from and to what end are commonly expressed in the consultation, especially where such reflection is requested and welcomed by the practitioner. Questions around this area are in fact essential in a holistic consultation and may be posed along the lines of: ‘Tell me why do you think you have this condition?’ ‘Do you think there is a point to your condition? Is it there for a particular purpose do you think?’ Replies to these types of questions are frequently highly revealing and insightful. Common responses include such expressions as:
Herzlich (2004) has suggested that notions of the cause of illness fall between two extremes:
On the one hand, illness is endogenous in man, and the individual carries it in embryo; the ideas of resistance to disease, heredity and predisposition are here the key concepts. On the other hand, illness is thought of as exogenous; man is naturally healthy and illness is due to the action of an evil will, a demon or sorcerer, noxious elements, emanations from the earth or microbes …
Interestingly, these two extremes can be viewed from a Christian perspective as being consistent with worldviews pertaining after and before the fall. Endogenous causes relate to the concept of original sin, with exogenous causes prevailing in the garden of Eden – before the fruit of the tree of the knowledge of good and evil (an archetypal dual noxious/healing element presided over by a demon/teacher) was consumed. These two extremes can be posited as ‘naturephobic’ and ‘naturephilic’ standpoints. To be naturephobic is to distrust nature; to see it as something that must necessarily be controlled and contained lest it cause harm. Here the universe is a dangerous, purposeless place. This is consistent with the dominant scientific–positivist paradigm and is a perspective that allows the justification of the manipulation of nature in aggressive and invasive ways such as the development of conventional drugs, genetic modification and nuclear energy. The naturephilic position is that nature is inherently good and wise and can be trusted, the universe is a safe and purposeful place, we should aim to learn from and live in harmony with nature and not harm it. Such positions can be contrasted with modern and aboriginal relationships with the planet – in the modern view land can be owned, bought and sold; in the aboriginal view, the people belong to the land, are owned by the land if you will, therefore it is impossible for land to be bought and sold. Kingsley (2009) has explored the enduring importance of the relationship that indigenous people have with the land in Victoria, Australia, concluding that it is a ‘key determinant of the health and wellbeing of Indigenous people’. These are the words of the Native American leader Smohalla (c.1815–1895) presenting a traditional view of the sacred nature of the land:
Such a worldview is compatible with the notion among some CAM practitioners and patients that the human body is similarly sacred and inviolable and which interprets such interventions as surgery, radiotherapy, conventional drug therapy and vaccination as aggressive and unnatural assaults to be resisted.
Such deep trends and convictions underlie the differences between conventional medicine (essentially naturephobic) and CAM (essentially naturephilic). These currents also underlie the antagonism that occurs when a naturephobic practitioner meets a naturephilic patient, and vice-versa, as we shall see below.
Concepts relating to health, illness and disease have been created throughout time and across cultures. Both religious and secular explanations have been proffered to explain their presence – particularly the suffering that arises with illness and disease. Utopian visions of a world without suffering also have a long history. The project of biomedicine can be seen as utopian, especially because it is essentially set up in opposition to disease and death. There are no more extreme utopian visions than those seeking immortality, however, with the powerful effects of conventional drugs such as antibiotics and corticosteroids in the mid- to late-twentieth century, along with advances in surgical techniques and social measures such as improved water hygiene, such a vision may have seemed to be finally materializing. In companion with delivery from our physical ills, perhaps Freudian psychoanalysis and newer approaches to the mind would reveal ourselves to ourselves and open the door to permanent joy. Expectations of attaining a higher degree of health in any case had been raised to a new level – which was not sustained for very long. Even as statistics showed improved health-related outcomes for first-world populations, individuals continued to suffer. In an article entitled ‘The paradox of health’, Barsky (1988) set out four factors (summarized below) that he saw as influencing the perception of a gap between individual health and the health of the group:
Although sound and important, Barsky’s list is open to an alternative reading as an apologia for biomedicine as it hits the barrier and fails to deliver year-on-year growth in health achievements. Nonetheless, Barsky helps to clarify the limits to medical expansion and the generation of new territories for suffering that accompany medical ‘progress’. Other authors have explored the notion of ‘healthism’ – an excessive and misguided preoccupation with health that is unrealistic, unhelpful and perhaps irrational. Herman (1996) discussed institutional healthism and considered that it has: ‘… almost become a new morality’ that is coercive in nature such that: ‘submitting to preventive measures, diagnosis and therapy is part of what the upstanding citizen owes himself, his family, the State and even his God’. Herman questions the validity of equating longevity with health and calls for discussion of the motives that underlie biomedicine’s ‘war on death’. He proposes that: ‘Perhaps we should be using what have been slightingly referred to as our “pastoral skills” to make peace with the inevitable’. By contrast, Greenhalgh and Wessely (2004) see healthism embodied in certain perspectives and behaviours of the individual. They maintain that: ‘Healthism in the consultation … is a common source of irritation and stress to health professionals’. What then might the characteristics of the healthist be? They are (adapted from Greenhalgh & Wessely 2004):
• Concerned about ‘unnatural’ substances (chemicals, vaccines, drugs, additives), especially when there is a civil liberties dimension (e.g. fluoridation of water, mass vaccination, pollution, GM foods)
Can this really be what the stress-inducing healthist looks like? Certainly this list has a lot in common with many identikit pictures of CAM users. Perhaps we just have a CAM patient entering the wrong surgery door? Let us return to our earlier contrasting of the naturephobic and naturephilic worldviews. Greenhalgh and Wessely’s upset would seem to arise from a clash of ideologies. If doctors are irritated and upset by such patients, then this surely arises from a failure to intellectually appreciate and practically accommodate the patient’s ethos and predisposition. A strange twist has taken place here. In rejecting Herman’s coercive institutional healthism the patient has been labelled a healthist for taking the trouble to pursue an alternative agenda. But could Greenhalgh and Wessely’s profile of the deviant healthist not just as readily be taken as a portrait of a well-meaning citizen trying to take some responsibility for their own health and willing to question authority? How do we understand the absence of this perspective in their article then? Clearly there continue to be differences of opinion as to which health practices and health perspectives are deemed to be legitimate and which are not. General principles may be agreed but specifics are open to controversy; yes it is good to question received wisdom, but not that particular bit of it! Indeed it is great to take responsibility for your own health, but just not in that way! Medical paternalism continues in fact but under the guise of medical rationalism – they shall be taken seriously who approach health rationally.
A similar gap in understanding may occur when a more conventionally medically-orientated patient visits a CAM practitioner. The CAM practitioner may well experience stress if the patient rejects their advice and questions the premises of their worldview: ‘That patient wasn’t prepared to take any advice or change their lives in any way, they just wanted a quick fix – I can’t work in that way!’ The suggestion is that the advanced practitioner, working in any healthcare field, should be able to work with a wide range of patients without self-inducing irritation and stress by:
Let us return once again to ‘health’. The widely known World Health Organization definition of health (WHO 1948) remains an interesting catalyst for discussion: ‘Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’. This may easily be dismissed as post-war utopianism but let us linger a moment and see if we can conceive of what such a state might look like. In doing so we might be accused of archaic romanticism if we suggest that some indigenous peoples may once have enjoyed this state. Perhaps some members of some Native American tribes, for instance, achieved this harmony within their own relatively small social groups for some extended periods of time. Perhaps we all have and shall again, a la Warhol, achieved this for 15 min or so – here and there, from time to time. Yet it is hard to imagine as a steady continuing state, and perhaps now – more than ever – we are the furthest away from this potential due to what is implicit in the word ‘social’. If we are now aware of ourselves as a global society, then how can any one person be well in one place while having knowledge of the inequalities and suffering of people in other parts of our society? Indeed how can human beings living on an ecologically disrupted planet with massive disparities in health measures between nations and facing huge challenges such as climate change and population growth achieve such a level of personal health perfection? And why should we? We need to return to where we started this discussion – the WHO definition ultimately fails to be a reliable definition of health because it is oppositional, it requires the eradication of disease and infirmity from life, which is not in the nature of things.
The great source of practical and philosophical insight that ancient peoples draw on is nature itself. As we observe nature, we see (as noted in Ch. 1) that it is in the nature of things to change – either rapidly (e.g. sudden changes in weather) or slowly (geological and cosmological change). Yet around these changes sometimes patterns may be observed – such as seasonal and lunar cycles – which help us to orient ourselves in our world. So life is to do with change and cycles and to be in tune with nature we need to be able to adapt to change and to work with cycles. In Zen philosophy and practice, the aim is for the person and their environment to ‘move together’ and one translation of Zen is just that. This is a similar insight to that provided by the sociologist Aaron Antonovsky where he associates wellbeing with the individual’s ability to establish and maintain coherency between the internal and external environment, particularly in the face of stressful situations. Antonovsky’s ideas became known as salutogenesis – the origin of health – which focuses on how health is generated rather than on the processes of pathology. For Antonovsky (1987) the key to resilience and good health lies in possessing a sense of coherence which can be defined as:
A global orientation that expresses the extent to which one has a pervasive, enduring though dynamic feeling of confidence that (1) the stimuli from one’s internal and external environments in the course of living are structured, predictable, and explicable; (2) the resources are available to one to meet the demands posed by these stimuli; and (3) these demands are challenges, worthy of investment and engagement.