By: Elliot Dacher, M.D.
There is great fervor in the health field. New ideas, innovative programs, and hope are everywhere, and today's rapid changes seem to have a momentum of their own. States are providing licensure to new categories of health practitioners, medical schools are offering programs in holistic healing and the NIH's Office of Alternative Medicine is funding research on complementary therapies. Insurance carriers are offering reimbursement for more and more of these therapies.
Confronted with the complexities of lifestyle and stress-related degenerative diseases, addictive disorders, anxiety, depression, over-use of pharmacological and interventionist therapies, and a rising antipathy toward professional arrogance and authority, along with a growing demand for high level health, conventional health care has finally reached its limitations. There is now a broad-based consensus that change is necessary and desirable.
The current pace of change has allowed both practitioners and the general public little opportunity for reflection and evaluation. As a result, there has been a lack of significant discourse in regard to the extent and the direction of change. Motivated by very real concerns yet conditioned by old patterns of thought, fired up with enthusiasm and hope yet compelled by complex professional and financial interests, we simply assume that our current initiatives are taking us in a beneficial and innovative direction. As a result, we have failed to ask the critical questions whose answers can either reassure us about our current efforts, or cause us to reconsider them. Consider these two simple but basic questions:
I. What perspectives do we wish to see expressed in a reconfigured approach to health and healing?
II. Do our current initiatives reflect and support the development of these perspectives?
PAST AND FUTURE GATHERED TOGETHER
Today we find ourselves living in an extraordinary in-between time, a sort of gap in time that has been created by the decline of our previously unquestioned optimism and faith in the 500-year tenure of modernism, and the slow and as yet uncertain emergence of a new post modern viewpoint.
As westerners, our cultural history can largely be traced to Hellenistic Greece. This meeting of the ancient mythological world and the emerging world of rational inquiry gave rise to an extraordinary culture which sustained, for a brief period of time, a precarious yet highly creative balance between sensory and intuitive knowledge. Several centuries later this union of rational and intuitive knowledge was sundered apart with the rise of the monotheistic Christian mythos. Independent intellectual exploration of the human experience and the natural world was surrendered to the absolute authority of the Church. The dominance of the Christian era eventually declined giving way to the Copernican revolution and the modern era, an extraordinary epoch which was to last for 500 years and is only now beginning its decline.
This paradigm shift engaged the western world in a compensatory, yet equally monotheistic world view, one that was sensory-based, factual, and mechanical. This powerfully pragmatic perspective has been highly successful in elucidating the mechanistic aspects of nature, but it has left us with a disenchanted and devitalized world, one that is devoid meaning, spirit, and faith. We have deconstructed the individual, turning the immense experience of humanity into a mechanistic collection of biological parts. We have alienated ourselves from the natural world, preferring to control and manipulate it rather than to learn from and be nurtured by it. We have de-legitimized the poetic, imaginative, and aesthetic realms. And as a result, we are losing our centuries old faith and hope that an objectified and technological understanding of life acquired through reason alone would provide us with a progressive and endless improvement in the quality of our lives.
It is in this gap between world-views that we live. Both our disillusionment with the existing medical model and our efforts to revitalize and reconfigure our approaches to health and healing, emerge from this pregnant historical moment. For the purpose of seeking guidance in our efforts to reconfigure our approach to health and healing within the context of the larger cultural movements of our times I would like to set forth four perspectives that now appear to be critical elements of the emerging post modern world view, perspectives that must be central structural supports for a post modern medicine.
MULTIDIMENSIONAL REALISM
The modern world-view requires that reality be objectified, sensory-based, impersonal, measurable, quantifiable, opaque, and collectively experienced and validated. The post-modern view of reality is far more complex. It rejects the view that reality is limited to the receptive capacities of our five senses, and validates the legitimacy of non-sensory, intuitive knowledge. Reality is extended, revitalized, and personalized. It is seen as a multidimensional amalgam of sensory and non-sensory knowledge.
INTENTIONALITY
The modern world-view, postulates that unchanging universal laws that exist independently of human consciousness cause all phenomena. In essence, causality is seen as physically based and upward in its direction. The post-modern perspective validates and legitimized the causal nature of consciousness that is individually willed and downward in direction.
HOLISM
The modern world view assumes the distinct separateness of subjective and objective, external and internal., material and immaterial, mind and body, reason and intuition, and man and nature. At its essence, irrespective of its extraordinary accomplishments, it is an alienating perspective. The post-modern viewpoint accepts the value of an analytic methodology within a larger context that comprehends and honors the unbroken unity of all life.
PERSONAL AUTHENTICITY
The modern world view assigned great importance to the individual and his/her rights, an ideal that too often was degraded to a self-indulgent, egoistic, and aggressive quest for power and material gain accompanied by personal alienation. The post modern world view revitalizes and deepens the meaning of individualism by asserting the significance of the individual search for authenticity through self-knowledge, legitimizing the shift in authority from belief systems, institutions, and professionals to the individual (a shift in authority from external to internal), and recognizing that authentic individualism comes into being in the context of relationship.
These four perspectives underlie, inform, and drive our current process of cultural change. Together they constitute the historical imperative of our times, an elastic world-view that unlike previous religious and empirical perspectives is both pluralistic and inclusive. These essential perspectives characterize the post-modern world, and as such they can most appropriately guide and define an approach to health and healing that is unique to the needs and character of our times--an approach that I have called post-modern medicine.
A SHIFT IN WORLD VIEW OR MORE OF THE SAME
With these new perspectives in mind, let's consider our second question: Are our current efforts expressing and supporting these perspectives, the viewpoints that characterize fundamental change? Consider the following recent attempts to expand our ideas about health and healing.
*John Travis, M.D. opened the first wellness center in the late 1970's in Mill Valley, California. Influenced by Halbert Dunn's book High Level Wellness, Travis' concept of wellness sought to expand our ideas about health beyond the customary focus on preventing and curing disease to include a concern for the promotion of wellbeing. Health and healing were seen as a personal affair, a psychosocial process of education and lifestyle change.
In the 1980's alternative and complementary practices began to emerge as further expression of the rapid changes in our ideas about health care. Naturopaths, chiropractors, acupuncturist and others sought and achieved state licensure, and began the initial steps toward full integration into the mainstream of institutionalized health care, a process aimed at achieving conventional acceptability and consensual validation. The Office of Alternative Medicine was established at the National Institutes of Health to examine the efficacy and appropriateness of these diverse approaches to health and healing.
Each of these initiatives were honest attempts by sincere individuals and institutions to bring change to an entrenched health care system, one that no longer seemed effective in dealing with present day problems and sensibilities. Let's examine the results of each of these efforts.
The idea of wellness was rapidly integrated into our culture. But as it entered the mainstream of our cultural life, and particularly when it was integrated into existing health care institutions, wellness was reduced to four physically based issues: nutrition, smoking cessation, fitness, and stress management. Its fundamental emphasis on personal development and its psychosocial framework and values were largely jettisoned, and with its assimilation into the larger culture it was reshaped until it more resembled traditional preventive approaches, packaged as generic commodities carrying the "wellness" label, than the dramatic shift in perspective envisioned by Travis.
Alternative and complementary approaches to health and healing, however valuable in diversifying our treatment options, have similarly failed to significantly alter our existing world-view. Conventional and alternative practitioners, irrespective of their rhetoric or intention, generally use their specific expertise to prescribe techniques, practices, drugs, or supplements for the purpose of repairing or fixing an abnormality. The professional defines the approach solely within the context of his or her professional domain, and the prescribed treatment is external rather than internal. The individual is a more or less passive recipient of the therapeutic process gaining little in the way of personal insight or additional self-healing capacities. Because all of us are conditioned to turn to authoritarian structures and external remedies at times of adversity, we often demand and easily accommodate to the treatment model. There are always individual practitioners whose practices reflect a substantial shift in perspective (both conventional and alternative healers can access holistic principles within their traditions), but this remains an individual prerogative, as distinct from a cultural shift.
The answer to our second question is now apparent. With few exceptions, these and similar efforts ultimately failed, usually in their implementation, to explicitly and consistently express the perspectives that characterize a post- modern medicine. So why has this happened? The answer is clear. Old perspectives and parochial interests are powerful and enduring. They silently and effectively reshape our efforts to more or less conform to existing conventions, incorporating and reshaping them until they accommodate to the assumptions of the existing world-view. Because each of these initiatives explored new approaches and perspective, and in this way succeeded in expanding existing perspectives and stretching our imagination, they have been useful endeavors. But so far they have failed at fundamental change. Wellness became prevention and alternative approaches became alternative treatments. Overcoming our deeply conditioned and often unconscious assumptions is a difficult task.
A POST-MODERN MEDICINE
Because the central perspectives of the post modern world view--multidimensional realism, intentionality, holism, and personal authenticity--are activated, animated, and validated through direct personal experience guided by an inquiring consciousness, the individual (in contrast to professionals and institutions) becomes the essential focus and primary healer of post modern medicine. Health and healing--its character, symbols, and metaphors--become personal issues, ones that are uniquely defined and orchestrated by each individual. In a sense, the individual is the healer, the healed, and the healer. Directly engaged in the historical process of actively integrating and living a new world-view, the individual is transformed. This transformation is marked by a shift in authority from professionals and institutions to the individual, a shift that is accompanied by an expansion of personal consciousness and capacity.
It follows from this that initiatives that result in an expansion and extension of professionalism and its monopoly over knowledge, conventional or alternative, expropriates power and possibility from the individual and runs counter to the values of a post modern medicine. Practitioners and their therapies will remain an important component of a person-centered post-modern medicine, but not a dominant one. They will be a valuable resource to individuals who are actively engaged in composing their lives, defining their personal visions of health, and learning from and responding to life's adversities.
Because we are still living in the gap between world-views, we can only catch glimpses of what the full flowering of post-modern medicine will look like. Yet there is much to gain from these glimpses. Let's consider one program: the Dean Ornish Lifestyle Intervention Program. In examining this program we can measure it against the perspectives that will characterize a post-modern medicine.
In 1977 Dr. Dean Ornish began to explore an alternative, non-pharmacological approach to atherosclerotic heart disease. The central elements of his program included a low fat diet, meditation, yoga, exercise, and psychological counseling and support.
When I visited this program in 1990s I had an opportunity to join an evening meeting and to speak in some detail with several of the participants. What most impressed me was the extent to which these individuals had become empowered in the pursuit of their own healing. They had developed a repertoire of new skills, resources, and capacities, gained insight into their lives and relationships, cultivated a more expansive understanding of health and disease, learned to make conscious and self-directed choices in a complex and pluralistic universe, and accomplished each of these goals within the context of community. As a result of these experiences the participants extended the scope of their personal autonomy, expanded consciousness, and self-knowledge, and created new options, each of these values was built into the ongoing program. By transforming their approach to health and healing they had simultaneously transformed themselves.
The goal of Ornish's program, as I view it, is to support the personal growth and development of the participants so they can assert their primary role in the healing process, recovering from illness and promoting vital and healthy lives.
Ultimately, the professional fades into the background and the individual and his or her experience becomes the central factor in health and healing. This is not a treatment program in the way we have previously conceptualized treatment. I=m not quite sure what to call it, but my sense is that it expresses the values we have discussed and contributes to the creation of a fundamentally new and effective approach to health and healing, one that begins to engage the central elements of the post modern view. This program is a first step in the right direction, a movement away from the limitations of an exclusively reductionistic and professionally centered treatment program.
It is difficult to be a midwife to a new world-view. Each of us was born, socialized, and educated to live within and to honor the existing viewpoint--a set of perspectives whose basic assumptions are unstated and silent yet at the same time relentlessly compelling. The science, and particularly the medicine, associated with this viewpoint have taught us to seek the remedies for our problems outside of ourselves, to distrust our inherent healing capacities, and to look towards the professional as the singular authority on issues of health and healing. As professionals we have learned our role in this drama, one that, irrespective of our rhetoric, is extremely difficult to relinquish. For this reason the impetus for fundamental change is more likely to come from an informed and conscious public than it is from current health practitioners. An understanding of our historical moment would suggest that this change will neither be defined nor directed by practitioners, nor will it be characterized, as it is now, by a singular emphasis on the expansion of treatment options. Rather it will be defined and directed by the individual. It is time that we step back and begin to speak about fundamentals, about the perspectives that define our lives and our work. Such a conversation will surely assist us in creating and successfully implementing the fundamental changes that are now awaiting us.
This article was originally published in The Journal of Alternative & Complementary Medicine.
An edited version is printed here with Dr. Dacher's permission. Dr. Elliott S. Dacher has practiced internal medicine for over thirty-five years.
