11.1 Health Care in oscillation

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The Health Care System (HCS) is, as all living systems, constantly adapting to changing demands. Of the numerous subsystems of which an HCS consists each is governed by it's own laws, and is at the same time responding to challenges from outside. By mutually influencing each other the subsystems form together a more or less coherent aggregate. As the lumbering HSC slowly moves forward, feeling it's way, moving around political obstacles, it resembles the slug consisting of amoeba cells that has been J.T.Bonner's object of study. Remember how the chemical call of AMP brought the dispersed cells together to form one body? This has now happened to the practises, hospitals, nursing homes, health-insurances; they are all connected by inescapable rules, regulations and buzzing communication lines.

Forty years ago I set out, determined to understand the how and why of communication disorders. It is now the time to sum up what has changed and what is going on in this section of health care, and in what relation it stands to human communication in general. We see the ceaseless struggle between the Old and the New, a dispute in undulating motion. The New ventures into unknown territory, it reports novel encounters. Subsequently it is called back by the Old which puts forth its traditional wisdom. The oscillatory period ends when together they reconcile their differences and incorporate newly won territory.

I'll be more specific about the disputes that have enlivened the scene of communication disorders and health care in general. The set of subsystems, represented as "old", is a traditional form of medicine. It is visually oriented and focussed on matter and organic pathology. Its way of thinking is causal, "objectivity" is very much in the foreground. A patient's complaint is explained by an organic disorder or it is not explained. In the latter case it is called a functional disorder and the patient is sent away with a pleasant "we haven't found anything wrong". The "old" has a paternalistic attitude and instantly closes it's eyes for anything that is not strictly medical.

Another set of subsystems in the HCS, represented as "new" has developed more recently and is mainly derived from the behavioural and social sciences. It focusses on mind and function, has a listening attitude, takes into account subjective experiences and the perspective of the life history. Its way of thinking is goal-directed, it respects the individuality and the autonomy of the patient. The "new" therapist relates to the patient as an equal and is not afraid to expose his personal limitations and uncertainties. A summary is given in the figure below.

The "old" and the "new" have at times had a difficult relationship, alternately abusing and ignoring each other. However, when they have communicated and in turn have listened and spoken to each other, this has led to considerable improvements. We have seen for instance that child abuse and incest were rarely noticed by the "old" until close observation and unprejudiced attention to life histories revealed that such trauma's in childhood and their harmful effects on development into adulthood are not at all rare. Since "new" and "old" have worked together, attending to these family tragedies has now begun to become a part of health care. Every year thousands young victims of family violence are seen. The next stage in this development will hopefully be that by proper education and counselling a potential perpetrator will be prevented from committing brutal acts.

I mention the instance of child abuse because among the victims are people who, at an early or a late stage in their lives develop a disorder of voice, speech or language. The remote cause of the dysfunction has often gone unnoticed, especially when the medical consultant or the clinician in charge has been attracted by the interesting acoustic, speech-motor or linguistic aspects of the disorder and was blinded by those to its remote origins and to the factors that maintain it. For the patient of course a blind alley without prospect of a cure. This brings me to another potentially growth-stimulating dispute, that will also go on forever.

The rift between research and clinical work is a controversy that is even harder to reconcile than that between the Old and the New. To those, attracted to the crystal clear world of science on the sixth floor, the drudgery of clinical practice in the basement is so remote that they will never set foot in it, unless they are in need of subjects for tests and measurement. Even then they prefer to deal with it by telephone. Clearly the dialogue is a struggle, a battle of unequal opponents, unequal kinds of intelligence, unequal temperaments. The outcome however may be good if, despite of frequent clashes, neither party has the intention of damaging the other. If, after every clash at least one of the parties has learned something, the dialogue has been successful. Conjunction of parties in oscillating struggle will increase knowledge and improve the quality of therapy. In the case the upstairs scientists in dispute with the downstairs clinicians, as well as when the "old" encounter the "new".

The word "therapy" is derived from a stem meaning help, support or heal. Therapy in the "old" sense includes the application of drugs, diet, surgery and counsel. By the renewal discussed above, therapy now also includes deliverance from emotional and mental damage, and reeducation with emphasis on the deep layers of the personality (psychotherapy). Human motivation is governed by expectations based on past experience. An idea or construct that has been an adaptive response when the person was coping with his environment as a child, will later mould an adult's outlook on life and influence his habitual life style. By then, the idea may have become obsolete and be maladjusted in the then prevailing circumstances. Under skilful therapeutic guidance a person can prepare himself to replace old prejudices by new interpretations of meaningful elements in his environment.

Principles of behavioural analysis and treatment should be taught in the medical curriculum because they are not yet incorporated in daily medical practice. Such training is indispensable in order to prevent medicine becoming an island of stagnant conservatism in a dynamic society. Medical schools where these subjects are being taught sometimes experience them as foreign bodies in an otherwise homogeneous curriculum of biomedical topics. The gap between a biomedical and a social-psychologic approach is not yet closed. As long as the two different scientific cultures are not on one continuum, they will remain strangers to each other. The clues given in this book to clear up the body and mind relationship should be of help to bridge the scientific rift. A health culture which includes both, will probably not come in one bright flash, but by gradual illumination of both the physical and the mental aspects.

Map 11.1 Area's open for reconciliation in medical and behavioural cultures

A short note explaining why the word re-education is appropriate for the kinds of therapy discussed here. The prefix re- does not mean a repetitive action or a return to a preexisting condition; it indicates a purposeful direction. Like the Greek ana-, it can mean: (carrying something) up to the desired place. That is: goal-directed education. In some cultures reeducation is a form of remedy for persons with a criminal past. Such connotation is of course not applicable here. We think of people who have been emotionally bruised in the past, very few of whom resort to criminal behaviour.

A complete program of therapy and reeducation involves any or all of the spheres of the personality. When a surface structure is being worked on and the therapist meets stagnation or resistance, this is a reason to proceed to a more central level or sphere. In the review that follows we shall discuss each personality sphere as it appears in its mature form, we'll also note certain weaknesses and their consequences. Because therapy is an interactive process, weakness in the therapist or counsellor is as important as it is in the patient. Fortunately it is possible that during the interactive process the therapist conquers his weaknesses and misconceptions at the same time as the patient. The condition for this to happen is that the therapist is authentic in his responding to the patient and ready for change.

11.2 The personality spheres.