Imagination and its Companions

Author Brian Broom

How is it possible to be whole person-oriented and still feel that our work is manageable? Surely, we can’t be all things to all people?

Biomedical diagnoses and treatments of the ‘mechanical’ (sic) body are largely grounded in recognizing typical clinical patterns, objectively measured and verifiable physical changes using reliable testing methods, and statistical evidence based on analysis of the treatment of groups of patients. We mostly act (or not) in response to ‘definite’ findings and measurements. Even modern crafts-people of the mind, the psychologists and psychotherapists, strain to work as experts in this disciplined way, according to solid, over-arching frameworks or theories, supported by a mix of consensus and formal evidence.

But there is a big problem in applying this way of working to a whole person approach. The approach requires clinicians to attend to an ill person as a unitive whole. This means both an expanded consideration of the person’s illness as multifactorial and multidimensional, and a need to take account of these elements in our clinical response.

So, does this mean that the whole person-oriented biomedical clinician should, in addition to the normative clinical requirements of his discipline, somehow become a skilled psychotherapist, psychologist, social worker, spiritual advisor or whatever, and be required to perform elaborate, expert, systematized assessments normative within each of those disciplines? This is nonsensical and impossible. Nobody can attend to all of this.

The usual solution is of course the multidisciplinary team. But many of these are pass-the-parcel scenarios where each discipline functions narrowly according to the pattern ordained by the modern biomedical model as expressed in each individual discipline. In sum it usually manifests as an additive framework of highly expert clinicians, patients seen from multiple narrow perspectives, a dualistic concept of disease, and a lack of attention to the highly nuanced individual personal life experiences and subjectivity factors or stories that contribute to the development and perpetuation of disease.

Apart from that critique, I actually value multidisciplinary teams, but believe that each of the practitioners in the team need to be functioning in a whole person way. This is possible whatever one’s discipline. By adopting a whole person approach each clinician can do a great deal to enhance healing without feeling overwhelmed. It involves seeking the story, imagination, and a few other things.

‘Windows for the Imagination’ by SidewaysSarah @ Flikr CC

Sometimes people wonder why I am so keen on the ‘story’. It is simply that we clinicians who want to practice in a whole person way need simple practical doorways into the the world of the whole person, and especially that part of the person’s world not accessed by the normal biomedical approach to disease.  The latter, as currently practised, focuses on the expertise of information-holding, the power of drugs and physical interventions, activities directed at restoring, repairing and compensating for ‘mechanical’ deficits and distortions, and so on. I greatly value the benefits of much of this.

But listening for the patient’s story opens up an entirely different world, and its power derives from quite a different set of assumptions, attitudes and relational values. Asking for a story may seem a simple matter but the implications are hugely important. And, in listening to a story, imagination is important.

An example: A clinician asks a patient for her ‘story’, about what happened in her life when her symptoms started many years ago when she was 18 years old. This question is actually asked because the clinician assumes to some degree that the patient is a unitive whole, and that the patient’s life experience (at 18) may be very relevant, and that opening this up may help the person get well in some way.  Simply asking the question rests on really serious foundations. For me it entails the conviction that mind and body co-emerge together from the beginning of life, and therefore it is natural to imagine the story being part of the illness. It follows that there may be therapeutic potential in knowing the story. This is the paradigm of whole person care. The paradigm allows the clinician to imagine ‘something’ important in the story around age 18, and to ask the simple question.

But the imagining comes with diverse companions. It requires courage to ask because there can be no expert prediction as to what will emerge. It requires self-confidence to enter this zone of uncertainty and trust that whatever emerges can be responded to adequately; even more than that, creatively.

And there has to be generosity. The unstated relational dynamic is something like this: “I am truly interested in you as a person. We all have a unique story. I want to know what happened to you. I won’t push you over the edge. Tell me as little or as much as you want, but, because we are un-separated wholes, illness inevitably emerges in a mix of physical and non-physical factors. I am charged with helping you, and so, if you are willing, it is important that we consider this together. I hope you will trust me. I will go gently. We are both humans together. You may well experience difficult emotions that are hard to contain. I am alright with that—I have them too.

It is clear that getting the story is a movement into relationship. We can do this because as humans we clinicians are ‘always already’  relational. In reality, most of the stories implicated in illness ARE relational stories: of trauma, failure, loss, abuse, abandonment, manipulation, and much more. We are all fundamentally relational. Illness and disease are ‘plural events’ (using the philosopher Andrew Benjamin’s terminology).

There is more. In these invitational, relational moments between the clinician and the person there is the beginning of new possibility, hope, and repair. We are, as clinicians, with the patient, enacting (in some measure, both symbolically and literally) the reparative potential of not just being considered attentively, but deeply heard and understood, and responded to. This is why whole person care and attending to story are so powerful, because they potentially liberate into the clinical field all the elements of the person that are important and may contribute to the multifactorial trajectory towards illness or healing. Nothing is excluded, in principle. Meantime, we hold onto the good elements of the biomedical model too.

So does it become chaos? No.

Imagination helps. Assuming I have the willingness (and interest, courage, and generosity)  to ask him, another patient tells me his chronic urticaria (‘hives’) began when he returned to his job after his summer break, only to discover that his employer had decided, without any warning, that he will now be working in a very different section of the company. Do I (as a whole person-oriented practitioner) really have to wonder about everything in his life, or can I just start there? Is it possible that the important thing has floated to the surface already? Can I treat this as a doorway?

‘doorways’ by Barbara Carroll @ Flikr CC

My imagination is stirred. Few of us would have any difficulty in imagining that this employment issue could be important to him emotionally, one way or another. I imagine that the conjunction of urticaria and this work change may suggest there were some negative emotions involved. Such imagining could reasonably lead to the simple question of what did he feel about this turn of events, and so on. Perhaps he responds with: ‘Oh, I just accepted it.’ Really? What was he accepting?

I might imagine some more things: that he might not care, or that he might care and that he might be suppressing some feelings, or that he might not be used to expressing feelings, or that he might not see the point of discussing feelings because as far as he is concerned his hives is just a physical condition, or that his boss might be difficult and arbitrary and wouldn’t listen anyway, or that he felt he could not afford to upset his boss, and so on. Such imaginings reflect my experience of life.

Because we clinicians, as people, know what life is like, in its ups and downs, most of us can imagine at least some of the possibilities. This kind of imagining is based on a belief that our lives are truly and continuously grounded in a constant sequence of feelings (positive and negative) that signal to us the meanings we make of our lives and circumstances, and that often we are not clearly in contact with them, and we are not aware that they can emerge as physical symptoms or contribute to the onset of illness and disease.

But we are beyond simple story now. Relational values kick in here. It is all very well to imagine all these things. Shall I then charge in with my preferred hypothesis? No, the key is to be there and to wonder together with him, and to arrive together at a good way of seeing any connection between the illness and what happened. It may be very simple, and it may be very complicated and require help from a ‘mind’ clinician. But you and he begin to know and share together some of what he was really feeling. You have imagined there must have been some feelings. You have not imposed your story and imaginings on his. You are ready to meet him in this zone of meaning and feeling. You have let it emerge between you both.

We don’t need to be a psychologist or psychotherapist to start this process, or to make simple connections, or to give the patient permission and encouragement to consider the connections. The interaction doesn’t have to be perfect, or prolonged, or all done at once. Patients know that we are persons too, and have limits on our capacities. We can be good-enough.

In this paradigm, it will be what it is. Therefore, whatever emerges, the clinician trusts in her personal capacity to respond in some kind of way that might be fruitful. Fruitfulness often lies in kind, generous simplicity. It might be fruitful to simply say “I am glad you told me this, and I am wondering how it might be addressed from here.” More than that, the clinician trusts that in the event she doesn’t know what to do, she has a capacity to relate authentically to this person in front of her and to ‘hold’ the patient safely; and that not knowing could even be curiously and mysteriously alright. Genuine kindness can trump information.

It is very difficult to be an effective whole person-centred clinician without liberating one’s imagination. At the same time imagination must be disciplined, and grounded in respect and generosity, and in a relational space in which the therapeutic potential co-emerges between the two. It may be fast or slow, a moment, a session or a series of sessions. It may involve one or several clinicians, even a multidisciplinary team!

This is always a unique process. There is no algorithm for it.

 

 

*Featured Image, ‘Imagination’ by Thomas Hawk

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4 comments

  1. Argh, I’ve really felt every word you’ve said here…
    Do you think all have this capacity to be so present, so mindful, respectful and devoted to the persons cause? I really like to think all can be, however I do wonder whether working within the NHS stagnates it in many?
    I’m lucky, I have people in my life that hold that inviting, explorative space for me, which I feel enables me to pass this on. Yet, if you don’t have that, and are pressured with time, lack of support, underpaid and overworked can we get round this?
    It’s made me think of a need to nurture a change of how colleagues address one another and whether a stronger mentoring space within the NHS for clincians would be beneficial to support the ‘genuine kindness’ that I completely agree ‘can trump information’.
    Brilliant, I’ve loved reading and reflecting within this, thank you…

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    1. Thanks for the positive response. Does everybody have the capacity? The short answer is no. Are most (or many) people trainable? Yes, but some take more time than others–our own relational experience puts us ahead of or behind the pack. Are most people willing? No. Until medicine recognizes that whole person care is required the pervasive institutional dualism and neglect of ‘story’ will be the preferred position for all those who want to belong and function in the centre of things. Nevertheless the irony is that if one gets most clinicians out of professional context they have a native warmth for whole person care–because we are ‘whole’ there is a resonance that bubbles up. But get them in professional context and there is the default back to the known and the legitimised. Individuals may have the courage to change but the ‘system’ has to change as well.

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  2. What a great article and reflects eloquently my thinking around the process of caring for your client.
    Here are my caveats. I recently changed my website to offer a biopsychosocial assessment which lasts roughly 90 minutes to set the groundwork for the alliance.As yet no takers.People are schooled in a biomedical model and can find it hard to understand why you would like to know about their life, especially their emotional life.Of course the narrative will change but we are in that awkward phase of change, where we know how to improve our care (and outcomes) but find it difficult to get people to sign up to the model because it is foreign and not what they were expecting when they made an appointment with a physical therapist. A half hour appointment can be beneficial but tends to be superficial.Unless you are well known and known for a different approach, you will struggle financially ( I certainly have since taking up this approach).
    Also confidence is an issue.Despite using a BPS approach for years I find myself doing physical things because I feel the pressure of expectation and sometimes wanting to go deeper into a model (say CBT or ACT/ Mindfulness) but not being schooled enough in the area.
    So send them to a CBT’ist.But I have learnt to mistrust other therapists as they often “steal” the client or create new yellow flags or have a different view of the problem which confuses the client.
    However I do have to say I love my work and have a thirst for knowledge.

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  3. Yes, these are all good points, and we have to deal with them too. Generally speaking people won’t engage in a website unless they are extremely determined or they are warmed up relationally. We use our website resource AFTER people have seen us. It is very useful at that stage. https://wholeperson.healthcare Signing up to a model is a relational thing.
    If you look at the website you will see under ‘clinicians’ a whole lot of suggestions to make the process easier. Training (for skills and confidence) is important and that is why we developed the Masters in MindBody healthcare hear in Auckland. Learning to handle the confusing elements of other clinicians’ involvement is part of the skill set. Have a look at my books (can get cheaply on Amazon). And you will get satisfaction rather than riches in being whole person-oriented!

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