Georg Ivanovas From Autism to Humanism - systems theory in medicine

6. Systemic Medicine

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6.9 Second order therapy is change

Second order therapy intends a change of the organization bringing forth the symptom. The therapist is the advocate for the change (Roberto 1991: 459). Therapy in this sense has two different aims. One is the transition from one state to another and/or the ability to maintain a good inner balance under changing circumstances. This is not achieved by compensating or correcting a sub-system.

In the social context of politics this is a well known phenomenon. Giving poor people money does not solve the problems unemployment poses. And – in long term – it is extremely costly. It is also not effective to punish drug dealers as long as the international supplies are untouched and the social climate remains the same. Such first order approaches never have any long term effects. Quite similar is the medical situation today, including its financial impact.

To improve the situation – in social and in health affaires – the structure has to be changed.

The structure, however, is not changed through lowering blood pressure or through the administration of antibiotics in recurrent tonsillitis. These interventions do not induce a change, or if, only by accident.

A change has to be a change of the operator and not of the operand (chap. 4.2). But this is hardly conceivable with a linear paradigm. Robustness and other conditions of learning of higher order are neither measurable and nor visible in simple cybernetic models (Bateson 1988: 37-46). Moreover, as rigidity does not turn out to be harmful under stable circumstances (under the circumstances of trials) the increase of robustness will seem to be less effective than forcing a patient into rigidity.


The nature of therapy, the intention to influence a living organism (an autopoietic unit) can only be understood properly when the very basis of the biological organisation is properly understood. The quintessence is that every therapy is a stimulus every therapy is a stimulus. This is true for taking a cold shower in the morning, this is true for hormone replacement therapy and this is true for the resection of parts of the intestines in cancer or obesity. Or in the systemic terminology: In order to control nonlinear dynamic systems they have to be perturbed (Ashwin 2003). Or in the words of Bernard: An inner environment reacts to an outer stimulus (Bernard: 113-114).

Fluoxetine, a selective serotonin reuptake inhibitor, does not work, because it corrects certain serotonin levels in the brain (chap. 2.3.d), but because it is a stimulus. It changes the metabolism of the brain and even its plasticity (Vetencour et al 2008).

Perturbing an autopoietic unit, respectively stimulating an organism induces always a series of reactions determined by the inner structure and organization of the treated (if the system is not rigid) (chap. 4.10). This is, of course, also true for every advice. On a basic level there is no difference between a verbal and a chemical intervention (Blech 2007a). According to the principles of equifinality they might lead to the same results.

Balneology demonstrates best how through an unspecific stimulus a rigid pattern might be perturbed, such that inner rhythms start again, leading to a series of emergent phenomena including complications. Only when the balance is restored, symptoms vanish. It might take quite a long time, if the initial disturbance is severe.

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