HOLISM IN HEALTH CARE – WHAT DOES IT MEAN?
Holism can mean different things to different people, depending on past experience, perception, belief, and education. Assessing and treating holistically seems such a common sense idea – “to treat the whole person” and the concept of holism appears to be becoming increasingly popular with many health practitioners and organisations. Yet what does this actually mean? What exactly is the whole person? And do we actually practically assess and treat the whole person or just think we do? Is there a difference between concept and practice? – And, how does a holistic approach fit in with current biomedical education and practice. Is it similar or different (and if so – in what way) and can the two approaches co-exist and complement one another?
These are all interesting questions but perhaps the easiest way to answer them is to take a common sense approach and start at the beginning by brainstorming about what exactly is the whole person and gradually building our understanding from there. This is the approach I have taken in my Books and DVD series (and from which the material for this article is taken – see references) and also in my experience teaching over the years. I have found that by doing this, it does not matter who the audience is (whether Osteopaths, Naturopaths, Massage Therapists or other Medical Specialists), once the whole is discussed and then the relationship between its components is discussed, each practitioner can see quite clearly which components, and their relationships, he or she individually considers during assessment and treatment and also how each practitioner’s skills can complement each other (because each may be more specialised in assessing and emphasising certain components of the whole and their relationships more so than other components), thus allowing them to work together better for the benefit of their patients. Usually, once the anatomy of “the whole” is out in the open, it is not uncommon to realise that we are perhaps not as holistic as we first thought, but it also gives insight about how we can become more inclusive in our practice. It will also then be easier to understand how the biomedical and holistic approaches inter-relate.
This can be looked at in two board sections
- The Structure of the Whole (i.e. the Component Parts)
- The Function of the Whole (i.e. the functional Relationships between the component parts)
1. The Structure of the Whole – Components.
A. The Multi-dimensional (General) Whole;
Usually when a group is asked “what is the whole” (or “what components would most people on the planet include in their concept of the whole”), results end up being fairly consistent. It may perhaps be easy to just real off the words “Mind, Body and Spirit” but this is the easy answer (not necessarily thought deeply about) and saying does not always mean doing – with full understanding and awareness. The following general terms usually emerge; Spirit, Intuition, Mind (thoughts, beliefs, etc), Emotional, Energetic (or synchronous terms such as vital force, prana, or chi), Physical. Some might mention the word “soul” and other components not mentioned here. External components can also be added in, such as; Social, Environmental, Dietary, Planetary and Universal influences and so on (adding anything else you can think of). Basically there are what I term “internal components” (components within our beings) and “external components” (components external to our beings); with some components belonging to both categories (such as the psychological – i.e. our own mind, thoughts/feelings and how we perceive and respond internally to life events and experiences, as well as the influences externally of other people and how they impact upon us).
Questions: At this point it may be worth asking yourself – do you consider in a) assessment and b) in treatment all of the above mentioned general components? Have you thought about “how’ to assess for and recognise these components or only a few of them? Which components are included as a part of your education and training and which are not (and – what happens to them if they are actually present and not assessed for in any individual patient)?
The above mentioned general categories can then be further sub-divided in more detailed sub-categories.
B. Example Sub-category; The Physical Whole
Because the physical person is a primary emphasis in health care, let us examine the Physical Whole Person now in more detail and see if we do in fact consider (and actually treat) all of its elements in clinical practice (or again – emphasise only a few).
The Physical whole person includes the; Nervous (Somatic and Autonomic), Vascular, Immune, Endocrine, Lymphatic, Respiratory, Integumentary, Gastro-intestinal, Genito-Urinary and Musculoskeletal systems.
Questions: Ask yourselves once again, in a) assessment and b) in treatment do you consider all of the above mentioned systems? Have you thought about “how” to assess for and recognise these components or only a few of them? Note; the “how” may vary with the screening methods: Do you use, for example; special (external) testing procedures such as orthopaedic, neurological testing and medical investigations to screen for issues in these systems AND/OR ALSO feel/observe (internally/perceptively through interaction with the patients bodies/being) these systems in themselves for symmetry, texture and motion qualities for both health and imbalanced involvement during routine assessment – if so which ones do you focus more on or emphasise, or is it all of them?
C: Example Sub-division of the sub-category “Physical”: The “Musculoskeletal Whole”
Each system itself can then be investigated in even more detail to various degrees (which is what we usually do in our traditional biomedical education and training – but do we remember to put it all back together again to see their relationships and how all the puzzle pieces fit together? – see next section).
Because many manual therapists emphasise assessment and treatment of primarily the musculoskeletal components of a person, let us look at this system in more detail and see if, again, we do consider all of its components or not.
The musculo-skeletal system can be subdivided into components such as skin, fascia, muscles, ligaments, tendons, tendon sheaths, periosteum, discs, menisci, cartilage, joints and bones.
Question: Again – if you stop here and ask yourself (out of all the above categories, subcategories and subdivisions) here “which components do you actually a) consider, then b) assess and then c) treat” in your practice (considering all that has been said so far)”; results can be quite revealing. In a past talk with Osteopathic students, for example, they all considered Osteopathy holistic but once we went through all the above anatomy and I asked them what they actually treated (and even assessed fully) in a clinical setting (with certainty) they could only answer mainly joints and muscles (which is really a small fraction of the whole person).
But – Is discussing structural components enough?: Even if all of the above mentioned general components, their sub-categories and sub-divisions are all considered – Is this sufficient to define a truly holistic practice? Let us explore this further.
- The Function of the Whole (Relationships and Balanced Function between components of the whole person):
Considering and treating a component (or even all of them) in isolation (i.e. treating a muscle, a joint, an organ, etc) is not enough to be considered holistic. Knowing a component is in trouble is fine but it gives no idea of WHY it’s in trouble. Understanding WHY comes by studying relationships (which I cover in another article on relationships more specifically – see bibliography/further reading). One must therefore also include relationships between all involved components. A little logical thought would indicate that “Health” in all tissues, organs, levels and layers of the whole person would mean that all components of the whole person are in harmonious function with one another, with the external world and with the whole in general – i.e. function as one integrated unit. Shouldn’t this be the goal of any treatment Holistic in nature (or at least be as close to it as is possible in the moment wherever a person is in their life)? To do this requires us to consider and assess the relationships between components and also the relationships between what is healthy already and what is not.
Holistic health care is not about assessing and treating parts of the person in isolation but is more concerned with assessing and treating to restore balanced relationships between the involved components so that the whole person his healthy and functioning as an integrated unit. It provides insight on how all the involved component parts all fit together.
Bio-medical education in contrast (in my experience) often breaks the whole body (often in many cases only the physical body) into parts and investigate these parts in great detail for purposes of greater knowledge and understanding. It provides the basic building blocks for understanding the human body and conditions which afflict it. It also focuses a lot on pain and symptoms and in searching for the cause of these symptoms but if we look at this relationship – this is only one relationship;
Relationship 1: Symptoms = investigating relationships between the tissues/conditions causing the symptoms and the symptoms themselves. This is only one relationship – and although it is an important part of assessment and treatment, it is usually, in my experience an effectual one (i.e. it deals with end effects and not necessarily with true causes, unless the case is a relatively straight forward one).
But – what about all the other various relationships in the human body that may be imbalanced elsewhere and contributing in some way to placing stress upon the symptomatic tissues or otherwise slowing recovery? What about all of the other individualised stresses, strains and problems elsewhere that a person has accumulated throughout their lifetime (adding time also as a component of the whole) and which can affect recovery of the symptomatic tissues?
A holistic approach therefore can enhance a bio-medical approach by considering a wider range of relationships which may not have been previously thought about but which may be contributing in some way to causing and maintaining a problem pattern or otherwise slowing recovery from a condition/injury.
Relationship 2 therefore = the relationships between other involved components of the whole and the tissues/condition causing symptoms. These other components may not directly cause the pain but can set up the symptomatic tissues, maintain them in an imbalanced state or effect optimal recovery. For example, a case springs to mind of a client (on a physical level) experiencing knee problems that had previously experienced an old bowel operation resulting in some scar tissue formation, binding up bowel motility mechanically (and possibly effecting optimal absorption of nutrients) affecting the balance in the pelvis and fluid flow to/from the legs and also through the autonomic nervous system links involved sacral and thoraco-lumbar spine restrictions. The imbalance in the pelvis, together with the effects of gravity and altered weight bearing, placed increased stress upon one knee resulting in knee pain which over time increase wear on the cartilage which was still unresolved over the previous two years despite regional treatment on the knee. This is one possible explanation which may or may not be the actual best explanation but which did link all the findings in this case uncovered from assessment. In this case results were immediate and the knee problem resolved after treating these involved areas and re-establishing a balanced relationship between these other components and the symptomatic region. Cartilage health (as is any other structure in the body), as we all are aware, is reliant upon good posture, blood supply, nutrition and drainage which in this case was compromised because of the other issues in the digestive system, pelvis and diaphragm area which needed to be open, balanced and flowing for good absorption of nutrients, fluid flow, balanced weight bearing and optimal health. None of these other findings would have been observed if other systems and areas were not investigated and issues recognised from the history and then followed up upon in clinical assessment. Symptoms may stem from local tissues but recovery (especially long term) is dependent on recognising other factors in the whole person interfering with the natural healing process. Add in mental, emotional, environmental and other components and suddenly what appears to be a simple knee issue can become a rather complex and complicated issue. These other involved patterns of dysfunction are very individualised which explains why certain treatments work for some and not others and also explains the dilemma practitioners have in dealing with chronic health issues. No symptomatic treatments or specific treatment techniques will work best for every case but a treatment which incorporates all involved components present in an individualised case (and treats to restore balanced relationships between them rather than just treating the parts alone) is more likely to work better, especially for long term health benefits.
So, having discussed all of the components and their relationships; How many of us can honestly say that we consider, then investigate, assess for and treat all of these components and their relationships? Would I be far wrong if I assumed technically speaking – very few?
However – Worry not, to be truly holistic doesn’t mean we actually have to treat all of these components and their relationships. We can’t be specialised in everything. Given the amount of time it takes to learn all of the biomedical details (anatomy, physiology, conditions, etc) of even just the physical body, to do justice in studying aspects of the multidimensional whole in detail in one lifetime is daunting at best. It takes time, patience and perseverance to be open too, learn about, experience and gradually incorporate all of these components and their inter-relationships into ones practice.
But – How are we to recognise involved components if we do not as least consider them? If we consider them, we may well recognise them, when they are present (perhaps in history or discussion at first and then later during actual clinical assessment). If we can recognise their involvement, we can begin think about their involvement and how they affect the person as a whole as well as the symptomatic picture. If we can see these components and patterns of relationship emerging, we can then perhaps start to incorporate these relationships into our treatments. Alternatively, if certain components and their relationships are recognised as being involved but are outside our specific specialty then we can refer to the appropriate health care professional who is more able to address these relationships and thus still be holistic in our management. If, for example, I noticed a mental and emotional component as being present, I might refer to a psychologist for specific attention. Meanwhile I would still treat those components I am more comfortable personally treating whilst perhaps being mindful, as I treat, of the relationships between what I am doing and their effects upon the patients psychological state – and observe what happens. This awareness opens a door and can indirectly have a positive healing effect on the whole person. Simply being mindful of a components involvement (and its relationship to what we are doing) can therefore be a big help in the success of any particular treatment.
Holistic assessment = necessary to recognise involved components
Holistic treatment = a choice to include (or increasingly include as one gains experience) or to refer to the appropriate health professional.
Holistic Management = something we all do together for the health and well being of our patients.
A Holistic Approach (in Health Care) therefore includes an understanding of following relationships between;
i. The tissues/conditions causing symptoms and the symptoms themselves
ii. Other involved components (internal and external) within the “Multidimensional Whole Person” and the tissues/condition causing symptoms (i.e. that are causing, contributing or maintaining the problem pattern or otherwise slowing optimal recovery) – this can be communicated as a Working Diagnosis inter-relating all involved components into a “pattern of dysfunction” expressing (as best as able) the relationships between cause and effect in any individual case – and sets to stage for a rational treatment process which can address as many of the involved components as possible (either within a treatment or requiring multi-modality care).
iii. The Health within the body (a topic for another time) and the above mentioned pattern of dysfunction (i.e. we can use information as a guide to observe where within the human being we need to start to support the healing process)
iv. The component parts and the whole in which they belong (to tell when the human mechanism functions as a total integrated unit of function once again in that present moment)
Treatment in a Holistic Approach is directed to restoring balanced relationships between all components of the whole such that a person functions as an integrated unit of function.
Note: I hope the above discussion has got you thinking about what exactly holism means. If you want to read more; I have spent a lot of time and energy creating resources for practitioners on holistic thinking, methodology, assessment and treatment and in developing an educational process to educate practitioners how to assess more holistically, first on a physical level and then, as the concepts unfold, to incorporate more consciously other levels of being (refer to my publications in bibliography section). This in no way replaces current biomedical education, knowledge and training. In fact – it is reliant upon bio-medical knowledge as an essential component of health education and training. But as holism deals more with the relationship and awareness elements throughout assessment and treatment (between components and the categories of knowledge previously learned), it helps to tie the whole pattern of dysfunction together and give clues as to where best to treat from (as guided by the tissues of the human mechanism – not me) in order to get longer lasting changes with patients. These resources will ultimately help to enhance traditional biomedical practice by expanding it to include a wider range of components and there potential inter-relationships.
I hope you have found this article to be helpful.
Best wishes, Paul Turner
Bibliography and Recommended Reading
- Turner, P. (2011). Bridging the Gap in Health Care 1 – the Basics of Wholistic Assessment (2nd ed.). Bloomington: Balboa Press.
- Turner, P. (2011). Bridging the Gap in Health Care 2, Multidimensional assessment. Bloomington: Balboa Press.
- Turner, P. (2010). Wholistic Integrated Assessment, A Teacher-Student Guide (12 DVD Set and Manual). Melbourne: Paul Turner Publications and Osteopathy.
Turner, P. (2011). Treating with awareness of relationships. Retrieved October 28th, 2014, from http://www.turnerpublications.com/treating-with-awarene