Existential Health Psychology
The neurobiologists explain the blind spot phenomenon by describing how there are no light-sensitive neurons on the retina where the optic nerve exits at the rear of the eye, and therefore no “sense-data” can be “processed” there. This is actually a pretty good way for describing how a splotch might appear on the screen of your smart phone—an absence of photon-producing pixels.
Even after many years of teaching sensation and perception to college students, I am still surprised to learn that many students are reluctant to accept that they have a blind-spot in their visual field. The reason why the visual blind-spot is seldom recognized is that they have never had reason to perceive it. Indeed, it seems that it is only useful as a gimmick in the general psychology classroom. Far more interesting than the fact of our blind-spot is that the latter is routinely ignored.
If you have ever used a smart phone with a cracked screen, or driven a car with a cracked windshield, you will remember how distracting the crack was initially. You had grown accustomed to a particular interaction between yourself and your smart phone (or car), and now this crack has inserted itself into this routine. Eventually, you learn to navigate the miniature, backlit, rectangular world of search-engines, GIFs, and videos despite the visual impediment. The impediment fades away from your awareness, and you stop noticing it.
Sunglasses tint the light in your spectral world only until you have grown accustomed to the tint—then you might even forget that you are wearing sunglasses at all. You adapt to a new routine—a new way of making sense of the world and of understanding your interactions with it.
These kinds of blind-spots can be understood by the phenomenon of sensory accommodation. This is when something is present and available to your perception in a continuous way—be it a smell, sound, or tactile sensation. While it is noticed at first, after a while it begins to fade away. A hospital room, for example, might initially smell funny, have a distracting number of whirrs and beeps, and be dimly lit. These are all noticeable at first, but after while they sort of fade away. They haven’t disappeared, but you no longer actively discriminate between them in your perception. If, for example, the beeping was to stop, then you would probably notice that something had changed even if you could not quite identify what it was that had changed. Sensory blindness due to accommodation occurs when the meaning of the perceptions (such as the funny smell in the hospital room) is insignificant.
Sometimes, however, blind spots contain information that is very significant: such as those that occur as a consequence of your position within the car and its position on the road. Seated in the driver’s seat, you have an excellent view of the direction you are heading. A sprawling windshield allows you to see nearly everything in front of the car. Three mirrors capture views in the reverse—rear, right-rear, and left-rear. Even with these four perspectives combined, there are a few views that are missed entirely—views that can be large enough to fit a minivan full of children. Unless you are diligent enough as a driver to look over your shoulder to examine this vehicular blind-spot, there is no way of knowing what is being missed.
Checking blind-spots while driving isn’t just a helpful practice, it is essential. To be sure, it is uncommon to be surprised by what you find when you do. But even if you are surprised only once out of 100 (or 1,000) times, the practice of checking will have been worth it.
I have described two kinds of blind-spots above. The first can be understood through sensory accommodation which happens when the meaning of a particular perception proves insignificant. The second has to do with the way a practice or procedure has been designed. The structure, seating, and setup of the contemporary automobile (as well as the infrastructure of the road and highway systems) makes vehicular blind-spots a reality. Engineering can go into minimizing the visibility limitations, such as with the development of rear and side-view cameras, but unless roads prohibit any kind of driving that is not single-file, there will always be the risk of blind-spot under-sight.
Modern medicine has a blind-spot. Like the vehicular blind-spot, it is enormously significant. Also like the vehicular blind-spot, the medical blind-spot is also a consequence of the way that medicine has been developed. Like side-viewing cameras on automobiles, it wouldn’t take an enormous change to notice the medical blind-spot. However, medicine has been practicing with this blind-spot for so long that it has become increasingly difficult to notice what is being left out. It amounts to trying to get college students to discover their visual blind-spot. Some students are eager to see it and understand—“how will I know when I have found it?” While others fold their arms indignantly—“I don’t have one; nobody has one; this is ridiculous.”
The medical blind-spot also shares something in common with the blind-spot of sensory accommodation. With the latter, we no longer notice something because it has proven insignificant: we have not had to understand the world by way of this phenomenological detail so it fades away. With the medical blind-spot, a particular way of viewing health, wellness, and the practice of medicine has resulted in ignoring additional aspects of health and wellness[1]. Because the latter are systematically ignored, they are understood to be insignificant. Finally, because they are understood to be significant, they have faded from view.
The medical blind-spot misses the existential dimension of human being—the structure of meaning through which experiences always unfold. This obviously doesn’t happen over the course of a year or even a decade. It takes many decades. The modern iteration of medicine did not begin by neglecting its existential dimension. The latter was merely an effect of viewing the medical subject scientifically. Moreover, the experimental handling of medicine has experienced many decades of improvements (which will be explored further in Chapter 3). As generations of providers were trained within the medical model, with no mention of the existential dimension of health and wellness, it became easy to assume that the latter was insignificant. Indeed, even the language surrounding it has come to seem awkward and unhelpful.
To trace the historical development of the medical blind-spot, I will begin by going back 100 years to WWI when German neuropsychiatrist Kurt Goldstein was noticing that the medical model had left out an essential ingredient to the understanding of health and wellness. For Goldstein, the blind-spot concerned the meaningful coherence of organic activity—a phenomenon he called self-actualization. Goldstein notices the blind-spot as an effect of the scientific practice of medicine, and warns fellow providers not to get stuck within any particular (but limiting) paradigm of medical practice. Next I will move the clock forward 25 years to WWII where a Swiss psychiatrist, Médard Boss, was realizing that something was being left out of modern medical practice. By then, the problem was becoming more and more difficult to articulate. At a loss for words, Boss consults with German existential-phenomenological philosopher Martin Heidegger, eventually asking him to come to his clinic to teach the other resident physicians.
Kurt Goldstein Identifies a Crisis in Medicine
As a German neuropsychiatrist during World War I, Kurt Goldstein was assigned to work with soldiers who had suffered closed-head injuries. In the early part of the 20th century, neuro-psychology and psychiatry had not yet been established the way that they are today. Indeed, the first neuropsychiatric department of a hospital was not developed in the United States until the 1920s at Harvard, under the direction of Karl Lashley. The lack of research into and protocol for handling closed-head injuries made the work of neuropsychiatrists during WWI exceedingly important, and few would become more influential than Goldstein[2].
When applied to closed-head injuries, the model of modern medicine suggests that deficits in behavior or cognition could be explained by deficits in the brain, even when the brain could not be seen directly. If a soldier is admitted with paralysis of his right arm, then it could be concluded that the “right-arm-area” of the primary motor cortext had been damaged. At the time, this method was called associationism (but it is now called the identity hypothesis). Associationism is the assumption that discrete brain regions are responsible for discrete cognitive and behavioral functions. If the “right-arm-area” of my brain is damaged, then I cannot rehabilitate right-hand activities, and must instead learn to go about my duties without it. If, however, I had merely torn a rotator cuff, then I could be prescribed a series of stretching and strengthening practices in order to rehabilitate full right-arm-mobility.
Goldstein’s assignment was to determine who was injured and who was malingering. Of those who were injured, he was to determine who could be rehabilitated (to return to battle) and who must be discharged. To do so, his task was to identify the presenting symptoms, and trace these to the nervous system in order to determine what neurological damage had been done. Here’s how it should have gone: 1) identify the behavioral deficits (deficit a, deficit b, and so on); 2) determine the locus of the deficits (locus a, locus b, and so on); 3) prescribe rehabilitation plan, if any.
This presents an easy-to-follow guide for understanding the newly emerging field of neuropsychiatry. It follows exactly the steps of any other diagnostic-prognostic strategy in modern medicine, whether one has found a broken leg or lung infection. Record the symptoms; identify the underlying cause of the symptoms; focus treatment on the underlying cause. This is what you attempt to do when you search for your symptoms on WebMD or Wikipedia. You compare the symptoms associated with a whole bunch of discovered diseases and compare them to your own, then follow the recommended courses of treatment.
When trying to follow this 1-2-3 method, Goldstein quickly found that there was an impossible feature in the first step. The first step, you will recall, deals with the determination of symptoms. Evidently, there are many problems that accompany this step. The title of Section I, Chapter 1 of The Organism captures this: “The Problem of the Determination of Symptoms.” In this section, chapter, and throughout the book, Goldstein lists many problems with the symptom-focus, beginning with how to determine which symptom is the important one. One problem with symptom-determination approach that Goldstein observes is that a symptom can never be isolated to one aspect of the patient’s behavior. For example, a tear in the plantar fascia is not only evident when the fascia must contract, but may be seen in the global modification of the patient’s behavior—like a reluctance to put weight on that leg, or a refusal to stand. From where, then, do these symptoms emanate?
The Organism is full of such observations that Goldstein has about the then-novel modern medical approach. He operates within these discourses to a certain degree, as they had become the dominant medical discourses of that time. To this end, he writes the following of the symptom-determination, diagnosis, prognosis method: “The fundamental principle of this procedure is, of course, reasonable” (p. 34).
For Goldstein, alternatives to this always seemed just around another corner, and he was able to weave discussions of neurological and existential trauma together without contradictions or impasses. He was able to see and describe the shortcomings of the modern medical approach as it pertained to the treatment of closed-head injuries. He also recognized the danger of assuming that the modern medical model has the answers to all medical questions. To this end, he issues a powerful warning regarding the medical trend that was becoming increasingly dominant:
The real crisis arises when, even in the face of new findings, the investigator cannot free himself from the former theory; rather, the scientist attempts to preserve it and, by constant emendations, to reconcile it with these new facts instead of replacing it by a new theory fitted to deal with both the old and new facts. This error has not been avoided in the evolution of the classical doctrine. (p. 35)
Médard Boss Puzzles over Language to Describe Time, Being.
As an able-bodied Swiss man in the 1940s, psychiatrist Médard Boss was enlisted for service in the military as a battalion doctor. With the provision of a handful of hard working doctors who reported directly to him, Boss found himself gripped with boredom during his tour of duty (it was Switzerland, after all). His newfound boredom led to a growing preoccupation with the concept of time, which had suddenly become a problem for him.
The phenomenon of boredom is an interesting one. It seems as though one is oppressed by something from without—as if some thing has robbed one’s activities of purpose, direction, and meaning. Neuro-psychologists might search for which brain region is responsible for the desirability of going for a walk or mixing a vodka martini while psychoanalysts might suggest that one’s psyche or ego is being smothered by something—a past memory, trauma, or Other (person). In order to be a phenomenon in modern medicine, boredom must be something. More specifically, something that causes the familiar behavioral and motivational changes in you and me.
Of course, none of these are quite right. I do not have an ego or self to be oppressed any more than my brain can feel desire[3] (or lack thereof). What, then, was Boss to make of this newfound sense of boredom?
It was upon this backdrop that Boss came across a news item about a book titled Being and Time written by German philosopher Martin Heidegger. He ordered a copy and began reading. In Being and Time (Sein und Zeit, published in 1927), Heidegger attempts a fundamental ontology. Instead of building up “human being” by adding together blocks of chemical elements and carbon chains, the way that modern science has sought to understand the human body, Heidegger carefully described the foundation of human being.
Heidegger’s work begins with by rejecting the idea that everybody already knows what Being is. Contrary to modern thinking, Heidegger maintained that ‘human being’ and ‘existence’ are not merely the activities of an objectified body. This is the natural conclusion that must be drawn when following the steps of the scientific method, but it leaves something important out: namely, what being means. Heidegger (1962) explains: “So if it is said that ‘Being’ is the most universal concept, this cannot mean that it is the one which is clearest or that it needs no further discussion. It is rather the darkest of all” (p. 23).
Too briefly, human being (which is a gerund—an action word in the present) is translated by modern science into its past state (i.e., having been). Science cannot capture skiing, but can identify one who skis; it cannot capture mothering, but it can identify one who mothers. Being is always replaced with having been. Living beings are replaced with lifeless bodies. Boredom cannot be understood as a past-state thing, but only a present engagement in the world: only as an action.
Boss quickly learned that his training in biomedical science had not prepared him to understand Heidegger’s rendering of human existence—Dasein. Dasein, which may be translated into English as “being there,” is the quality of being that is unique to humans (at least from the perspective of humans). It is the quality of existing. For Heidegger, time is not a taken-for-granted dimension of physical universe, but an opening, a space, or a possibility of becoming. As such, it is not a physical dimension, but an existential one.
Thoroughly confused by what he had read, Boss eventually built up the courage to correspond directly with the philosopher himself. This began over a decade of correspondence between the two. When he realized the value of Heidegger’s philosophy for his own practice of medicine, Boss organized a seminar format for interested physicians. They met initially at the Burgholzie Hospital, which eventually changed to Boss’s own house in Zollikon, Sweden for ten years between 1959 and 1969. The lectures and subsequent conversations were documented in the book Zollikon Seminars: Protocols—Conversations—Letters. These will be described further in Chapter 5.
The important development with this story was how Boss was incapable not only of finding the words to describe the limitations he had experienced with medicine, but also of understanding the words once they had been presented to him. Only 25 years had passed from the caution that Goldstein had given to physicians regarding the problematic limitations imposed by the modern medical model, and the latter had already snuffed out the meaning of injury and illness that Goldstein had described.
As Boss eventually became more acquainted with the existentially-oriented language of Heidegger, he began to realize that his colleagues would also benefit from these conversations. This is how the Zollikon Seminars came to be. Like Boss, the Zollikon physicians struggled and fumbled through their attempts to even describe human being, always instead trying to discuss it in terms of past states—as objects of modern science. Consider, for example, the following exchange:
Martin Heidegger: …how does bodiliness [embodiment[4]], which is undetermined, relate to space?
Seminar Participant: The body is nearest to us in space.
MH: I would say that it is the most distant. … Because you are educated in anatomy and physiology as doctors, that is, with a focus on the examination of bodies, you probably look at the states of the body in a different way than the “layman” does. Yet, a layman’s experience is probably closer to the phenomenon of pain as it involves our body lines, even if it can hardly be described with the aid of our usual intuition of space. (pp. 83-84)
Notice how Heidegger suggests these physicians might have to first unlearn their own unique way of viewing the inert body of medicine in order to understand the body existentially. By the 1960s, the medical discourses had neglected the layman’s experience of suffering for so long that it became impossible to consider it at all. Patient suffering had become irrelevant to medicine.
The seminars are full of exchanges where Heidegger asks the physicians to unlearn the medical perspective. He develops lines of reasoning that seem counterintuitive to the modern scientific mindset. “Being cannot be glimpsed by science” (2001, p. 18).
When Goldstein attempted to understand his patients using the methods of modern science, he realized that a great deal had been left out. 100 years ago, he was able to describe the blind-spot of medicine, indicating its shortcomings and advancing postulates that would address them. At that time, there was still a language for expressing these concerns and a medical audience who understood.
25 years later, and through the 1960s, we find how Boss and his colleagues similarly realized that something had been left out. This time, however, they were not quite sure what that something might be or how it could best be articulated. The medical blind-spot had been formed. There was no longer any meaningful language left with which to describe it.
The medical blind-spot is with respect to human being—that which is uniquely human. This is particularly unfortunate since medicine is in service to human being, and not just their bodies. It is as Boss describes it in his 1970 publication of Existenzgrundlage von Medizin und Psychologie (Existential Foundation of Medicine and Psychology[5]):
Assuming that the true subject matter of medicine is man, the whole reality of day-to-day human existence, we shall learn from our study that the natural scientific approach repeatedly finds itself confronting a realm to which it cannot gain access. It is precisely the essence of the way people behave among themselves in their daily lives, how they conduct themselves toward the world and other creatures, that modern medicine’s natural scientific research method fails even to approach, much less to clarify in its uniqueness. (1974, p. xxviii)
For Boss, the medical blind-spot (human existence) is very much a part of medicine. Unfortunately, the latter has become less and less accommodating of the former. It seems that today, human existence can only be addressed within a new medical sub-discipline—that of existential medicine (Aho, 2018) or, what would amount to the same thing, existential health psychology (Whitehead, 2018), as these share the same existential foundation.
Existential Medicine is not Complementary, Alternative, or Holistic. When discussing my work with medical providers, I have been asked about its relationship with complementary and alternative approaches to medicine (CAM), as well as with holistic medicine. This has been frequent enough to require brief attention at the outset. Existential medicine and existential health psychology are not synonymous with these other approaches to medicine and health, and they should not be confused.
To be sure, you will find overlap between existential medicine, CAM, and holistic medicine, but not enough to justify their conflation. CAM includes those interventions that are rooted in historical, spiritual, indigenous, and regional traditions. Traditional practices—folk medicine, spiritual healing, herbal supplements, and changes to diet go back millennia. Every culture has its own set of techniques for raising children, handling conflict, and treating illnesses. As they have been lumped together into the category of CAM, these traditions have become medicalized—goods to be presided over by specialists and consumed by prospective patients. These have recently been subjected to the same kind of randomized medical trials that are the hallmark of experiment-based modern medicine. Herbal remedies, acupuncture, and energy healing, along with hundreds of others, have been subjected to placebo-controlled clinical trials in order to measure their precise therapeutic efficacy.
So too with holistic medicine. Aaron Antonovsky’s “salutogenenic model”, which will be described in more detail in Chapter 2, is a helpful example of holistic medicine. Antonovsky is careful to emphasize that health is not merely concerned with the biochemistry of the human body, but also includes aspects of lifestyle that have customarily been left out of the medical discussions—nutrition, finances, relationships, and so forth. While his data was primarily qualitative, the many aspects of health he has indicated have been individually subjected to massive clinical trials in order to determine their precise role in the mediation of health and wellness with chronic diseases. This is why you may have heard that your personal relationships influence your health, or that certain amounts of exercise and limited portions of potato chips can be helpful in ‘increasing’ your health.
Existential medicine and existential health psychology belong to a conversation that does not include measurement, control, or any other objectification of human being and existence. It begins with the latter, specifically in cases of illness where a person’s life and/or health has become a problem for them. These are not symptoms which are allegedly discrete, verifiable, and measurable. They are changes to one’s way of being—one’s routines in life.
Modern medicine, CAM, and holistic medicine are each tasked with intervention: intervening on behalf of the sick, ill, or diseased person in order to help them overcome their suffering. Existential medicine and health psychology target a non-objectifying understanding of the suffering (and existence) so that it may be accepted, and growth may continue.
Finally, and since we are on the subject, it is also important to note that you might also find overlap between existential medicine and conventional medicine. Conventional medicine has also come to include the growing field of health psychology, represented by Division 38 of the American Psychological Association. The mission of Division 38 specifies biomedicine as the preferable model of health. In the cases where overlap occurs, it is usually because the provider has left behind the strictures of modern science, departing from the evidence-based practices and procedures. At such times, it is understood that they are stepping outside of their roles as doctors, nurses, and clinicians, and they are having human interactions. The human interactions are not credentialed, certified, or otherwise mediated by the state- and federally regulated medical institutions, and are therefore not “medical.” Fortunately, with the work of figures such as Rita Charon (2018), Arthur Kleinman (1988), and Janice Morse (2016), there is a growing body of healthcare research that may be found stepping just outside of the modern medical model.
[1] particularly those that are existential in nature, or that pertain specifically to being that humans are.
[2] His influence is even more impressive when it is understood that Goldstein, as a Jewish physician, was denied professorships at major German Universities, and even arrested while seeing patients. He spent a year in jail before it was arranged for him to emigrate to the United States, which he admits never quite felt like home.
[3] Unfortunately, the latter position has become a typical one among psychologists and philosophers alike. An example of the growing popularity of the-brain-that-feels can be seen in the publication of Neuroexistentialism (Caruso & Flanagan, 2018), where a broad mixture of authors discuss how the very existential I describe is being left out of medicine may be found in the nervous system.
[4] Embodiment is the existential dimension that includes the body. You and I do not have bodies; we are embodied. Our interactions with one another and with the world can only come by way of our bodies. The body does not bump into physical things and initiate a series of neurochemical impulses that terminate at our “minds.” Our bodies are our capacity for inter-action.
[5] The original German title preserves Boss’s recognition that medicine and psychology shared the same existential foundation. There is not an existential psychology (focusing, for example, on the “psyche”) that is distinct from the existential foundation of medicine (focusing, for example, on the body). When it was translated into English
Comments
Post a Comment