Georg Ivanovas From Autism to Humanism - systems theory in medicine
2. The medical paradigm and the anomalies of ‘Normal Medicine’
A physician thinks to act, not to understand
König/Wancura, 1983: 25
Normally only neurophysiologists and philosophers are interested in the principles of cognition. But the basic mechanisms of cognition are also relevant for the medical practice. The reason is that all human communication, be it in social affairs or in medical practice follow the same pattern as found in the basic forms of perception. Thus, it is important to have a general idea of cognition before going into the details of medical practice.
We all have the natural feeling to perceive an outer objective world. But, as we know, nothing could be more wrong than that. Perception and cognition are not that simple. There is no projection of an outer world into our brains as the old neurophysiology suggested.
The fact that things are not the way we believe them to be has been a major topic in different sciences. Especially in physics exists a clear concept of how the process of observing influences the outcome. For medicine a comparable theory of perception has never been formulated. It still prevails a kind of naive naturalism maintaining that health, disease and therapeutic interventions can be judged objectively. In this chapter I will review some facts contradicting this position. Two points, although not necessarily always addressed, will be central. First, perception is theory driven from the very beginning and, second, there is always an unobserved field, an unrealised blind spot (more details in chap. 3.3).
Some fundamental principles in cognition are:
- To interpret the complex and ambiguous input, the human visual system uses prior knowledge or assumptions about the world. A 'light-from-above' prior is used to extract information about shape from shading and is modified in response to active experience with the scene. This prior is constantly adapted by interactive experience with the environment (Adams et al 2004)
- Geometric illusions are perceived by a kind of probabilistic guess according to the individual experience (Howe&Purves, 2005).
- After Sacks had lost the inner representation of his leg (see below) he had the illusion of falling when he stood on his two legs. Although standing upright, he perceived how he fell, obviously because in his inner theory only one leg existed (Sacks 1984: 140).
Inner theories organize complex and social cognition and behaviour. In family therapy they are called myths (chap 5.2). Intercultural studies show, how the feeling that things ‘are as they are’ often betray. The inadequacy of social concepts is, however, only noticed when things do not go well and the others do not behave as expected (Ivanovas 2002). In science this is called an ‘anomaly’ and occurs when an observation contradicts the paradigm (chap. 3.10). Theories and myths also organize medical cognition and give simultaneously the impression of objectivity. Thus, the perception and description of a situation is strongly connected to the basic values of the observer. This shall be demonstrated by two psychiatric cases.
The first text by Alice Miller, a known psychoanalyst, demonstrates Celsus’ ‘theoretical approach’. We learn a lot more about Miller’s theory a classical psychoanalytic approach than about the patient.
“A patient from an African family grew up alone with his mother after his father had died while he was still a very small boy. His mother insists on certain conventions and does not allow the child to be aware of his narcissistic and libidinal needs in any way, let alone express them. On the other hand, she regularly massages his penis until puberty, ostensibly on medical advice. As an adult her son leaves his mother and her world and marries an attractive European with quite a different background. Is it due to chance or to his unerring instinct that this woman not only torments and humiliates him but also undermines his confidence to an extreme degree, and that he is quite unable to stand up to her or leave her? This sadomasochistic marriage, like the other example, represents an attempt to break away from the parents' social system with the help of another one. The patient was certainly able to free himself from the mother of his adolescence, but he remained emotionally tied to the Oedipal and pre-Oedipal mother whose role was taken over by his wife as long as he was not able to experience the feelings from that period. In his analysis he encountered his original ambivalence. It was terribly painful for him to realize the extent to which he had needed his mother as a child and at the same time had felt abused in his helplessness; how much he had loved her, hated her, and been entirely at her mercy. The patient experienced these feelings after four years of analysis, with the result that he no longer needed his wife's perversions and could separate from her. At the same time he was able to see her far more realistically, including her positive sides” (Miller A: 61).
The other example is an account by Hahnemann. He treated a psychotic patient in 1792 (published 1796), to a time when mentally ill people were still held in chains, tortured and shown to the public. It was two years before Pinel in the Salpetière released the psychiatric patients from their chains, marking the beginning of a different psychiatric care. Actually, it lasted another hundred years until this approach was more generally accepted (Kraeplin 1962).
That Hahnemann had a totally different idea of diagnosis and therapy can be already seen in how he described his patient:
We will only give selections from the most striking parts relating to mental science, especially such as give the reader an idea of the gifted and comprehensive mind now distorted by the violence of the disease, but which, disordered as it was, yet aroused admiration. Hahnemann devoted the first weeks to observation only, without giving any medical treatment to his patient. The latter spent day and night having a series of attacks; at one minute he spoke as a judge and delivered sentence; at another, he would recite as Agamemnon, or as Hector in the actual words of the Iliad, sung in the middle of a stanza of Pergolese's Stabat Mater; or he quoted passages from the Old Testament in the original Hebrew, or sought for an old Greek melody to a song of Anacreon or the Anthology; and again changed over to passages from Milton's " Paradise Lost " or Dante's " Inferno"; and from these again he would turn to algebraic formulae. Nothing was ever quite completed, but the new idea displaced the former with violent haste. "The marvellous part," says Dr. Hahnemann, " was the correctness of expression of all that his memory recalled from writings in many languages, especially of all that he had acquired in his youth." This mixture bears testimony to his extraordinary and manifold knowledge, but perhaps also to his eager desire to be brought into prominence by it, as he did when he boasted of his intimate acquaintance with distinguished personages ; he was not free from this characteristic in his normal state. He smashed everything that came to hand at that period, even his piano, and this he put together again in a peculiar manner in order, as he said, to find a complementary note, the Proslambanomenon. This man, who ordinarily knew nothing of bodily ailments, once wrote out for himself a prescription to be immediately dispensed, the rare ingredients of which, according to Hahnemann's deposition, were so well chosen and arranged, and so correctly calculated for the treatment of a maniac of his type, that it could easily have been accepted as the work of a learned physician; had it not been that the absurd signature and directions for administering it were proof of a disordered mind. By what means did the spirit in the midst of the fog of a storm-tossed imagination, without chart or rudder, find its way to so excellent a remedy for insanity, and one unknown to many a doctor, seeing that he had no books in his possession? How did he manage to prescribe it for himself in the most appropriate form and dose? Almost as astonishing was the fact that during the worst period of his mental disorder, on being questioned, he would not only know the date (this perhaps was comprehensible, although he had no calendar) but also the correct hour by day or night with great exactitude. As he began to improve, this power of divination became more uncertain and unreliable until with the complete return of his reason he knew neither more nor less about it than an ordinary person. When he was completely cured, I pressed him once in a friendly way to solve this riddle for me, or at least to describe the sensation that had prompted him. "My whole body shudders," he replied, " and something cold runs over me when I try to think of it; I pray you not to remind me of this thing . . ." At the beginning of his recovery he had a ravenous appetite (ten pounds of bread a day besides other food did not satisfy him); at the same time he showed a tendency to deceive and offend everybody, and yet when well again he ate moderately and behaved courteously to everyone these are symptoms previously observed in similar patients. (Haehl 2, 1922: 34)
Hahnemann was a representative of the romantic medicine which believed in the individual value of man. Thus, he had a phenomenological approach. The individual value of man had been no issue for the medical thinking before romanticism. And somehow it has been no issue for medical thinking later. As a consequence, medical literature has never been concerned with detailed and individual descriptions of psychotic processes. This was more a subject for artists.
May be the best account of a psychotic state is the autobiography of John Perceval (Bateson, 1974). He describes the development, the crisis and the recovery of his psychosis in 1830-1832 so precisely that his account helps to get a clearer concept of the disease in special, and of perception and brain function in general. He describes how the behaviour of the environment maintained and increased the disease and how a good and supporting treatment helped him to recover. Hahnemann used similar techniques as proposed by Perceval and some are even in line with the concepts of modern systemic psychotherapy (chap. 5.2).
However, today in the time of a probabilistic logic, individuality is a nuisance in research and in treatment. This had been already my first experience with a psychotic case as a student at the university, a typical lesson of the ‘hidden curriculum’ (chap.3.10). In the hospital we were demonstrated a patient hearing voices. We were excited, because until then we had only heard about such cases. We wanted to learn more about these voices, what they said, what this meant in the context of the patient, and so on. But all discussions were interrupted. It was sufficient for the diagnosis and the therapy that he heard voices. Everything else was mysticism. This is how poor observers are educated.
Bernard, also a representative of romantic medicine, came to the same conclusion for physiology. „An experimenter, who clings to his preconceived idea and notes the results of his experiment only from this point of view, fails inevitably into error, because he fails to note what he has not foreseen and so makes a partial observation“ (Bernard: 23). And: “Men who have excessive faith in their theories or ideas are not only ill prepared for making discoveries; they also make poor observations” (Bernard: 38)
Theory shapes the observation. According to the current paradigm, psychiatric diseases are seen as biological disorders. This ‘factual’ biological approach (Podvoll 1990: 9-10) reduces a phenomenon to a cause and there is no interest in the phenomenon itself (Podvoll 1990: 24). By that it is necessarily poorer in its description. The general rule says that the more theoretical a description is the less phenomenological it is (Hanson 1072: 60 - 62).
But physicians do not mainly observe or describe. They have to act and in acting they change the course of events. The physician is in a totally different position than a physicist who might smash a nucleus again and again, or as a chemist who might repeat his reactions as often as he wishes. The physician will never encounter the same situation again. By that medicine is the most nontrivial of all sciences.
The action of the physician, however, depends on his theories and observations. A physicians who treats biological causes and is not interested in the phenomena or in individuality will behave totally differently than physicians with a ‘romantic’ attitude. The physician even might induce a recursive pattern in the sense of a self-fulfilling prophecies (chap 4.2) and maintain his opinion even if it is wrong.
Known is the experiment by Rosenhan and co-workers. They asked voluntarily to be admitted to the psychiatric department. They pretended to hear voices and asked for help. Once interned they behaved totally normal, or as normal as they could. The duration of their ‘treatment’ ranged between 7 and 52 days. No one was unmasked as a fake patient by the staff (although other patients realized). Every behaviour of them was seen as confirming the diagnosis (Rosenhan 1973).
More severe was the case of a German girl who was diagnosed to be hebephrenic by a psychologist at the age of 14. Interned in psychiatry she showed resistance and was put under different drugs. She entered a cycle of resistance and ever more drugs in different institutions. Some time she was so drugged that she was hardly able to move and swallow. After more than 30 years (!) the European Court of Justice released her as it found that the first diagnose was not properly made and the further diagnoses were just a continuation of the first diagnosis. Actually the girl/women never had been ill, but showed normal reactions to drugs and a normal resistance to unfair imprisonment (Ehlers 2005). This kind of attitude which induces to some kind the behaviour it diagnoses has been called an asylum mentality in psychiatry (Foucault 1965).
That is, a certain theory produces at the same time a related action and an atmosphere, facilitating, often supporting and sometimes provoking the expected result. This is not limited to psychiatric diseases. The stress of a cardiological testing (dependent on the attitude of the cardiologist) might aggravated the condition and thus lead to a more severe diagnosis which, in turn might worsen the whole condition of the patient (Cousins 1990: 55).
As a general conclusion it can be said that an individualizing physician will perceive, behave and treat differently than a generalizing physician. This has a lot of implications.
From a ‘modern’ point of view psychiatry before the introduction of modern psycho-drugs was totally helpless. About the psychiatry of the 19th century it has been said: “As he walked the wards of the Salpetriere Hospital in 19th century Paris, Charcot allegedly gave only two prognoses, solemnly pronouncing at the end of each bed ‘Il va mourir,’ or ‘Il va mourir aujourd'hui.’… and accurate prognosis was often the only useful thing medicine could offer” (Godlee 2005). This statement might be totally wrong. We have no idea of the therapeutic means of former centuries, in how far dignity and other human forms of communication influence diseases. In today’s medicine these ‘frame’ factors are, at best, regarded as a placebo effect (chap. 5.4.b). But the accounts of Hahnemann, Perceval and in modern times Cousins (1990) demonstrate that there is much more in the healing process than the ‘specific’ treatment.
Psychiatry in the 19th century with amused audience
Psychitric treatment in the 19th century
But as long as only drug therapy is considered, may be, Charcot was helpless. For physicians maintaining a biological model of mental diseases other beneficial strategies are not observable.
This reveals an important trait of complexity: Nearly every statement is true when a supporting theoretical frame is used (chap. 3.6). The influence of theory onto perception has been rarely investigated in general medicine. To exemplify the issue I would like to present another case out of the history of medicine:
When Hahnemann started his medical career bleeding and therapies as enema, artificially administering abscesses or burns to ‘draw off’ the disease, were the current paradigm. As an excellent observer he noticed that this practice did more harm than good. He did not continue his medical practice and started to write critical articles on the harming therapies of his time. His rift with the medical community came when he accused the private physician of emperor Leopold II of killing his patient by too many bleedings (1). In 1792 he wrote:
The bulletins (of Leopold’s physician) state : "On the morning of February 28th, his doctor, Lagusius, found a severe fever and a distended abdomen" he tried to fight the condition by venesection, and as this failed to give relief, he repeated the process three times more, without any better result. We ask, from a scientific point of view, according to what principles has anyone the right to order a second venesection when the first has failed to bring relief? As for a third, Heaven help us!; but to draw blood a fourth time when the three previous attempts failed to alleviate! To abstract the fluid of life four times in twenty-four hours from a man, who has lost flesh from mental overwork combined with a long continued diarrhoea, without procuring any relief for him! Science pales before this! (Haehl 1 1922: 35)
Bleeding has negative effects. This was Hahnemann’s observation that challenged the paradigm of the time. So far, this is nothing special, as there have always been physicians who understood quite early that certain practices are not for the benefit of their patients. In the frame of a study of the scientific method this episode is interesting when it is compared with a statement of Magendi. Magendi was not only one of the most famous doctors of his time. He is today considered as the founder of modern physiology and pharmacology. About 40 years after Hahnemann’s fiery accusation, Magendi made fun of his colleagues who bleeded in pneumonia on the side of the inflammation. Since Harvey (i.e., since 200 years) they should have known that both sides are connected making bleeding possible at both sides (Lichtenthaeler 1975: 447).
This example demonstrates that scientific knowledge does not enable to perceive harmful developments and therapies, even if the person is a major medical authority. We have here a typical tension between the theoretical and the pragmatical medicine. Venesection was finally abandoned in a quite modern way. In 1862 (that is 70 years after Hahnemann’s publication) Béclard proved in comparative studies that the beneficial effect of bleeding in pneumonia is an illusion (Bernard 1865: 195).
We saw in this case that Hahnemann by precise observation was able to perceive that the old paradigm was wrong. This is a typical phenomenon. Limitations and errors of an existing paradigm become conspicuous through individual observation, not through planned research. Even new diseases and rare side effects are mostly discovered by observation. Research inside a certain paradigm cannot prove its own faults (chap. 3.3). In contrary, when doubts on the correctness of a paradigm arises by observation, there is a lack of methodology to prove the deficiency of the paradigm (Kuhn 1970: 156-159).
The physician challenging most the current medical paradigm is, up to my knowledge, Oliver Sacks, an American neurologist, who became famous for his case reports. The first account of Sacks was his own case. After the immobilization due to a fracture of his leg, he developed a kind of a pseudoparesis without nerval lesion. It is impossible to define what he exactly had, as there is no neurophysiological tool to do so. Sacks described it as a somatic scotome, as a disturbance of the plan of the body. The immobilized leg was eliminated from the inner representation. It was an unbelievable situation for him and for all of the consulted doctors. Sacks’ later investigations showed, however, that this phenomenon was quite common. It was known by patients as they suffer from it. But it was overseen by doctors as they had (and have) no theory to describe it (Sacks 1984). Though, understanding the principles of recursive processes Sacks’ experience is no longer enigmatic (chap. 4.2).
In a later book The man who mistook his wife for a hat (Sacks 1998), Sacks provides a collection of cases that demonstrate that our current understanding of the function of the brain is deficient, or better: wrong. He describes how certain abilities arise in patients with brain disease or brain injury, abilities that are known only from patients with outstanding talents, something he called excesses. Such cases are rarely and superficially reported in neurological literature. For example, an artist became more talented after suffering from frontotemporal dementia and losing his ability to talk (Mell et al 2003).
Sacks describes such confusing cases in detail. He demonstrates the complex pattern of such diseases showing that these patients can only be approached when all linear assumptions are left behind.
“’Deficit’...is neurology’s favorite word its only word, indeed, for any disturbance of function. Either the function (like a capitor or fuse) is normal or it is defective or faulty: what other possibility is there for a mechanistic neurology, which is essentially a system of capacities and connections? What then of the opposite an excess or superabundance of function? Neurology has no word for this because it has no concept. A function, or a functional system, works or it does not: these are the only possibilities it allows. Thus a disease which is ‘ebulient’ or ‘productive’ in character challenges the basic mechanistic concepts of neurology, and this is doubtless one reason why such disorders common, important, and intriguing as they are have never received the attention they deserve” (Sacks 1998: 87).
An example of such ‘excesses’ are hypermnesia or hypergnosia as already described by Hahnemann with Klockenbrink’s exact feeling of time. In orthodox medicine such phenomena are normally just ignored.
The most incredible case for such an observation that challenges medical thinking is, again, by Hahnemann and it would be unbelievable, if he were not such an excellent observer in all other cases. Hahnemann maintains that that during his more than 50 years of practice he never saw Syphilis stadium II or III if the initial lesion, the chancre, remains untouched. The chancre, if not treated, might persist even for years (Hahnemann, 1835: 15).
Could it really be possible that all medical textbooks are wrong, because every physician or the patient himself will treat the initial lesion? Yes, it could be possible. We have nearly no idea how processes develop without intervention. Everything is treated with drugs, creams, surgery or whatsoever, often unnecessarily (Doust/Del Mar 2004). Rarely a disease is left to its real natural course. It is therefore possible, indeed, that our understanding of the course of diseases has major gaps or is wrong. Another example will be given later where a lack of theory and the already mentioned tendency to treat everything prevents to understand essential inner rhythms (chap. 5.3.b).
One of the main proponents of doing nothing was Bleuler. He maintained that it is much easier to harm than to help (Bleuler 1962: 11). He regarded many therapies as superfluous (Bleuler 1962: 10) only putting the patients at risk (Bleuler 1962: 15). He called his therapy of doing nothing in Latin udeno-therapy. He was very strict in what a patient and the physician are able to endure. He maintained that it is quite possible for a practitioner to practice with 40oC fever (Bleuler 1962: 11). His point was that too much treatment makes people oversensitive, such that they become more inclined to get ill.
Bleuler’s statements challenge a lot of today’s opinions. They involve two main issues. First, Bleuler was not afraid to make value decisions, a neglected subject incurrent medicine (chap. 5.4.b, 6.1). Second, Bleuler’s arguments are based on a second order thinking involving robustness (chap 6.4), also no issue in the current medical thinking.
The effect of udeno-therapy or not treating with drugs is clearly underestimated because the effect of modern drug therapy is overestimated. For example, the increase of life expectancy today is mainly due to reduced child mortality out of infectious disease (Fintch/Crimmins 2004) and the decline of mortality due to these diseases was gradual since mid of the 19th century. The introduction of antibiotics and vaccinations has not changed anything. The curves for tuberculosis and scarlet fever (Hiatt 1975: 42) are just examples. Most other infectious diseases follow the same pattern.
Death rate (per million) for tuberculoses in the years 1838 - 1970
Death rate (per million) for scarlet fever in the years 1861 - 1970
There might be a lot of reasoning to explain this decline. But one thing is sure: it was not modern medicine. This epidemiological truth contradicts all observations about the effectiveness of modern medicine. As a consequence, all conclusions based on the assumption of the effectiveness of our therapies are wrong. That is, even on the level of effectiveness medical cognition is by far not as objective as it is normally assumed.
For example, an investigation of traumatized soldiers of Waterloo and Trafalgar revealed that “despite the non-existence of antisepsis, antibiotics, blood transfusions, life-support machines and other paraphernalia of modern intensive care, most of these soldiers recovered, often from life-threatening injuries. Yet with all our technical advances in medicine, mortality rates from conditions such as serious infection have not improved dramatically over the past fifty years”. The main problem today in intensive care units is sepsis not seen so often in ancient times (Singer/Glynne 2005). This result, as unbelievable as it is, makes sense when it comes to questions of robustness and reagibility (chap. 6.4).
In order to understand medical cognition it is also important to realize that Bleuler was wrong in an important point: There is no udeno-therapy. It is impossible for a physician not to treat. Bleuler treated through his personality. The advise to do nothing and leave something to its natural course is a treatment in a world, where everything is treated. It is an information (chap. 4.1), an attitude (chap. 6.14). Not treating can be even a complex intervention.This shall be exemplified with the following case.
A mother came to me with her 8-year old daughter for homeopathic therapy. The child had been diagnosed with ADHD and had been treated for some time with Ritalin without effect. I found nothing special with the girl. A little cheeky, may be. So I said to the mother: “Your child is not ill”. The mother became furious. How would I dare to say this, as she had already seen the psychiatrist, had made three years therapy with a child psychologist, even went to a sanatorium with the girl which turned out to be a catastrophe. She described how the girl behaved badly, vomited into her meal with everybody present, etc.
The reaction of the mother, according to the theory of systemic psychotherapy, demonstrated that the family is in a certain balance with the child being ill (chap. 5.2). The attempt to take away even the diagnose was a threat for her. This explains according to the theory her fiercely reaction. In this situation I had two possibilities. One was to submit to the mother's will and to treat the child, or to find a solution that maintained my authority. I decided to write the following receipt:
- The girl is not ill, only a little loud
- She has the right to express her loudness
- If she violates the rights of others she has to be punished
- The parents are not allowed to fight about the behaviour of the girl.
This was only an explicit form of stating what I had said anyway in our conversation. But it was combined with a signification: the receipt. That is, every therapy has a semiotic aspect (chap 3.9), even the udeno-therapy.
In this case the intervention worked: The girl was happy, the father stayed at home more often (probably because the mother did not complain anymore about the child), the mother slowly relaxed, the results at school became better and so on. This was a very specific form of doing nothing and contained some well-defined strategies of systemic psychotherapy.
Most practitioners use similar or other tactics when doing nothing. We all have such stories.
Simon who worked on this subject theoretically describes such interactions as follows: “Whenever a person is labelled as a patient, a specific context is defined, i.e. a social situation with given rules that differ from everyday pattern of behaviour and relations. The role of the ill one and the healthy one ensure that the rules of everyday (e.g. inner familiar) interactions are no longer negotiated freely, but follow a certain cultural determined expectation” (Simon, 1995: 111, my translation).
Thus, there are possibilities to influence the structure of interaction in doing nothing, or in doing something. The idea of a neutral relation between physician and patient is absurd. Or better: A neutral stance is medically inferior as an affective one (Roberto 1991: 468). Just as it is impossible not to communicate (chap. 3.7), it is impossible for a physician not to treat. Udeno-therapy is a therapy where many things happen we never are aware of, far from any theory. This does, of course, not only happen when no treatment is intended. It happens always. This implies that there is a big difference between what we do, what we think we do and what others think we do.
The psychoanalyst Michael Balint investigated this interplay between physician, patient and medical perception (Balint 1964) and until today physicians meet in Balint groups to analyse their perception of the therapeutic relationship and their theory of their own and the patient’s behaviour. As this, as seen above, is only of interest when things do not develop as expected, Balint groups are a good tool to understand ‘difficult’ patients and cases.
(1) The same fate caught up with George Washington who also died due to repeated bleeding in 1799.