The Two Paradigms

The reductionist paradigm, on which contemporary medical thinking has been based, is attributed to Newton and Descartes. Their contribution to civilisation has influenced the philosophy and science of the last three centuries as well as medicine and psychology. The Cartesian/Newtonian system leads to a world view which is analytical and reductionist. It arrives at an understanding of the whole by looking at ever smaller parts. The body is seen as a machine; illness is the breakdown of this machine; the function of health care is to repair or replace parts.

Reductionism is the tendency to look for and focus on the parts of things and to group these parts into categories. Once this happens, things tend to seem to exist independently – a malfunction is seen affecting only a specific organ system or tissue, a drug may be thought of as affecting electrochemical activities of only certain cells, diseases sometimes seem to almost stand alone.[1]

Modern Western science categorises, objectifies and seeks the right answer. ‘Right’ can be only one truth, which results in ‘either/or’ thinking. One point of view or solution is better than the other and therefore superior. Once the right way has been decided, action is necessitated (activism). This leads to interventions to align what has been found with what is thought to be right. Just-in-case interventions are sanctioned because of projected future threats (future-time orientation). This science focuses on the presenting condition captured and frozen in a static form. If something cannot be seen, observed or measured with the five senses and the instruments available within the scientific context, it does not exist.

Holism looks at the person as a whole, recognising that individuals are unique and deserve to be allowed all their different expressions. Holism does not find one truth but allows different perspectives, which leads to ‘both/and’ thinking. One point of view or solution is not better than, but complements, the other. An aim in itself within the holistic paradigm, is simply to ‘be’ and observe the movement of the process rather than manipulate it (presentism). Reality is never static but ever changing. Present-time orientation is to be in the moment. Even if something cannot be seen or perceived, the possibility is accepted that it exists at a different level of reality, as beliefs determine what we are able to observe, and the limitation may be in our heads, not outside.

Reductionist                                                                Holistic
categorising process                                                   individualising process
objectification                                                              personification
either/or thinking                                                       both/and thinking
hierarchical approach                                                co-operative approach
opposition                                                                     complementarity
activism                                                                         presentism
future-time orientation                                              present-time orientation
focus on state                                                               focus on movement
‘seeing is believing’                                                     ‘believing is seeing’

Table 1: Opposing characteristics of the reductionist and holistic paradigms[2]

Pasteur and Koch, 200 years after Newton, demonstrated that germs cause disease. When penicillin was found, giving doctors a ‘weapon’ against these disease-causing agents, the biomedical model was complete, creating medicine as a war where experts, with ever more potent interventions, battle valiantly against disease.

This model leads to many ‘just-in-case’ interventions. The world is perceived as a hostile environment which needs to be fought and conquered. Arguments of having to be on the safe side, of protecting innocent victims, lead to interventions which are potentially harmful when there is not even a problem present. This is compounded by the increasing tendencies towards defensive medical practice.

Defensive medical practice can be defined as:

…ordering treatments, tests and procedures for the purpose of protecting the doctor from criticism rather than diagnosing or treating the patient.[3]

Defensive medicine has some positive aspects, such as taking more detailed notes in the patient’s records, giving more detailed information to the patient or taking more time to establish a stronger rapport with the patient, but this mainly stems from concern that the patient may sue if anything goes wrong.[4] With fear at its back, this type of medical help also involves increased referral rates, follow-up and diagnostic testing, which puts the patient at risk of over-intervention, that is receiving unnecessary tests and treatments with all the potential risks and side effects, and does not do much to improve authentic rapport with the doctor.

The Current Change in Emphasis

The dominance of this archetype, however, has never been total. There have always been those within Western medicine who spoke of the art in caring for the sick, the consideration for the individual, and the relevance of the soul in illness and health. Very often this point of view was heard in the caring professions, especially in nursing. This is the voice which has found reinforcement in the last two decades outwith the recognised medical system through complementary therapies becoming known and established.

Now the two paradigms are increasingly being looked at side by side, and the benefits of both are being evaluated. The choice does not have to be ‘either/or’ but can be ‘both/and’, with health professionals learning to assess when it is appropriate to deduce knowledge of the whole by looking at the parts, and categorising, and when it serves better to observe the whole process and accept the individualised approach.

For this to occur, everyone needs to have sufficient information to make clear decisions. Health professionals from both sides need to know and understand the options. In practice, this involves doctors and other medically trained professionals becoming aware of the complementary therapies and what they have to offer. It also involves complementary therapists, who already know (because they have been brought up in the Western medical system) what medicine offers, appreciating the benefits of medical interventions in appropriate situations.

Suspicion and hostility arise generally from lack of understanding and holding entrenched positions. Dualism and polarity reactions are a result of reductionist thinking from which everyone suffers, whether choosing to work in the world of holism or remaining within orthodox structures. In upholding the ideal of Medical Marriage, understanding and acceptance are the keys to co-operation. Understanding is born of education and information coupled with willingness and openness. For this reason it is worthwhile spelling out the principles of the new paradigm in detail.

The Principles of Holism

Holistic care involves:

Responding to the person as a whole (body, mind and spirit) within the context of their environment (family, culture and ecology);

A willingness to use a wide range of interventions, from drugs and surgery to meditation and diet;

An emphasis on a more participatory relationship between doctor and patient;

An awareness of the impact of the ‘health ’ of the practitioner on the patient (physician, heal thyself).[5]

Holism addresses all aspects of the human being: body, mind, psyche and spirit

A human being cannot be defined by only one level of existence; each one needs to be taken into account as all affect and are affected by one another. The interconnection of these levels is recognised, and holistic practitioners strive to address all these aspects when relating to a patient. The knowledge that one level is influenced through others opens possibilities for many different approaches to care. For example, a physical complaint can be addressed on the physical level, but this is not the only avenue available. A practitioner may choose not to act at all on the physical but to work with the emotional or mental level instead. This has been widely recognised in recent years, with counselling being observed as an effective form of treatment in stress related conditions.

Often a combination of approaches on different levels increases the effect of intervention dramatically; giving some immediate relief and improving the general life quality for the patient, as well as helping with the presenting problem. For example, a patient with asthma and eczema may need to be prescribed an inhaler and cortisone cream for emergency use and for peace of mind, but this will not address the underlying issues of their symptoms. Diet may help in the longer term and at times even provide a full cure. Stress management skills may reduce some causative factors, and will be of more significance if the patient also receives some counselling or therapy which addresses childhood emotional distortions and traumas. Inherited factors are also often a contributory influence in these symptoms and these can be counteracted with homoeopathic remedies.

Holism implies the willingness to use a wide range of care modalities

As in the previous example, holistic health care takes advantage of the full spectrum of orthodox and complementary medicine. This allows practitioner and patient together to make the best choice for the individual situation.

Many GPs have felt increasingly reluctant to prescribe drugs to all patients, especially those for whom they know drug therapy will have little or no beneficial effect on the patient’s life quality in the long run. However, the alternative, in most cases, is simply to send the patient home with no help, which is also unacceptable. Within a holistic model, especially that of multidisciplinary co-operation, a GP can make use of the complementary therapies, which have fewer (if any) side effects, which care for the patient with positive input and attention and in offering ‘listening’ services, and which are therefore particularly suited to dealing with patients who suffer from chronic or stress related diseases and conditions. In this scenario, orthodox treatments (drugs or surgery) become the backup, or last resort treatment, if the complementary health care is unable to relieve the symptoms.

Relationship-centred care is essential to holism

The partnership between practitioner and patient is crucial to the healing process and cannot be separated from the treatment given.

Practitioners’ relationships with their patients, their patients’ communities, and other health care practitioners are central to health care and are the vehicle for putting into action a paradigm of health that integrates caring, healing and community. [6]

The practitioner/patient relationship is pivotal for the well-being of the patient, as well as for that of the practitioner. For the patients, positive rapport ensures compliance to the agreed treatment regimen, a sense of empowerment and active involvement in their care and the trust that they can go to the practitioner whenever they feel the need. This trust engenders openness and sharing of intimate details, which will help patients to gain insight into the complex connections regarding their health as the practitioner assesses the relevant implications for care.

In the 1960s Michael Balint, a psychiatrist in London, asked questions regarding the one ‘drug’ applied most and studied the least: the doctor.[7] He studied the actions and interactions of this ‘drug’ and its side effects, positive and negative. He requested that doctors become more conscious of the effect they have on patients and more skilled in putting this to best use. Following his work, Balint-groups sprang up which were attended by doctors and psychotherapists who used the peer group to review cases and reflect upon their own contribution to the case.

Recent studies show that the patient relationship is one of the main sources of stress in doctors’ lives.[8] Within the holistic model, attending to this relationship with skill and care can turn the source of stress into a source of nourishment and inspiration. Further exploration of how the practitioner can help to create such positive rapport is essential. Education plays a major role here. Supervision, especially peer supervision, is another important tool which practitioners can use to reflect on their own part in the relationship and to expand their skills in communication and rapport building.

The relationship with the patient’s community includes the patient’s close family and friends, as well as the larger community. This ideal scenario makes health care an integral part of everybody’s daily life. All aspects of health care, health enhancement, health education and promotion, as well as health and safety are relevant, and disease care is available and accessible when needed. The relationship with the community has been formulated as one of the core values for the medical profession for the twenty-first century.[9] This value applies to all health care professionals whether they work in the field of mainstream medicine or in the complementary field.

A mutually respectful relationship with other health care professionals is a crucial element in providing patients with a co-ordinated service and cohesive health care.

Holistic means that the practitioners’ own health and healing processes are relevant to their work

‘Healer heal thyself’ reflects the need for an openness to change and development in practitioners. As they grow and evolve with their work, their own healing can continue to unfold. This asks a high level of personal integrity. Health care professionals need to be willing to practise themselves what they ask from their patients: self-responsibility and self-care.

References:

  1. Claire Monod Cassidy, Unravelling the ball of strings: reality, paradigms, and the study of alternative medicine, Advances: The Journal of Mind-Body Health, 1994,10:1, p9.
  2. ibid. p11.
  3. J S McQuade, The medical malpractice crisis-reflections on tbe alleged causes and proposed cure, J Royal Soc Med,
    (1991); 84: 408-11.
  4. N Summerton, Positive and negative factors in defensive medicine: a questionnaire study of general practitioners. BMJ (1995), 310: 27-9.
  5. Patrick Pietroni, Holistic medicine: new lessons to be learned, The Practitioner, 22 Oct 1987; Vol 231, p1386-90.
  6. C P Tresolini and the Pew-Fetzer Task Force, Health Professions Education and Relationship-Centred Care, Pew Health Professions Commission, 1994.
  7. M Balint, The Doctor, His Patient and the Illness, Pitman Medical, 1973.
  8. Patient demands fuel GP stress, Medical Monitor, 10 Jan 1996; p 11-2.
  9. BMA, GMC, Joint Consultants Committee, Committee of Postgrad. Deans, Council of Deans of UK Med. Schools and
    Faculties, Conference of Medical Royal Colleges and their Faculties in the UK, Core Values for the Medical Profession
    in the 21st Century, BMA, 1994, p10.

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This post was previously published as a chapter in the book Medical Marriage, the New Partnership Between Orthodox and Complementary Medicine, Dr Cornelia Featherstone and Lori Forsyth, published by Findhorn Press, 1997.