one's own orchestra performing one's (musical) composition of life. .... love'. In 1986 the WHO introduced the term 'Health promotion' to emphasize and to.
Joke de Vries, M.D., Ph.D., Rudy Rijke, M.D., Ph.D. The self in health and healing Introduction One of the important themes in the writings of Roberto Assagioli was the centrality of the 'I', the personal self (1, 2) as the base of consciousness and of (the development of) will, or, put more expressively, seen as the director of the orchestra performing a musical composition. Since 1978 we have been investigating in various research projects in health care how people with a range of illnesses went through processes in which they developed ways to play an active role in their health and healing. These projects included working with people with hypertension (who managed to normalize their blood pressures), 'exceptional cancer patients' (people with cancer with an ‘infaust prognosis’ who had a complete or temporary remission), health promotion for health care professionals with 'burnout', and the nature and meaning of the therapeutic relationship in the healing processes of people who underwent sexual, physical and psychological forms of violence in their youths (3-‐6). Attitude to life: inner experience and outer behavior In confrontation with ill health, people have various ways of dealing with their problems or complaints, which depend on different attitudes to life. We developed a model of seven different attitudes to life. The puppet The attitude to life of the 'puppet' is characterized by an unconscious fear of death (and of life) and by the experience of being at the mercy of and of being determined by others and/or the circumstances of life. This results in closing off the world of inner experience and no consciousness and experience of what is happening to the person. The person lives according to fixed patterns, does not have real problems, and life ‘goes its own way’. This can easily result in being misused or abused by others. The victim The 'victim' also feels to be determined by others (‘external authorities’) and/or the circumstances, but he or she experiences this as something has happened to him or her, that is felt as being painful. The inner experience usually is one of helplessness and loneliness, and he or she feels not able to do anything about it. The experience of powerlessness often stimulates people to take up a dependent position and sometimes to cling to others with the question to resolve the problem. The fighter The attitude to life of the 'fighter' is based on an inner rage/anger that something has been done to him or her by others, by the circumstances or by whatever. The person will revolt against this: ‘this should never happen again.’ The person will fight the feeling of being vulnerable, of being dependent, and of being powerless by trying to find a rational solution of the situation to gain control again over one's reality. This will give a feeling of independence and of power: ‘I do not need anyone.’
The similarity in these three attitudes is that one feels one’s life being determined by others (external authorities) and/or circumstances. The difference lies in how one reacts to reality: the 'puppet' denies the problem being a problem, the 'victim' asks others to solve the problem, and the 'fighter' will fight the problem him-‐ or herself. These three attitudes, in the simplistic way that they are presented here, basically say ‘no’ to reality that they are confronted with. These three attitudes, sometimes called 'survival mechanisms', are ways to protect one from pain and from possible disintegration in confrontation with the possibly threatening reality of one's existence. There is a reduction of consciousness leading to a limited or no contact with the inner self or inner experiences. The next attitude to life (‘wounded warrior’) is a transitional stage between these former three of saying ‘no’ to reality and the following attitudes which are relating to life, and of saying ‘yes’ to life, as it is: the 'participant', the ‘investigator’ and ‘inner authority’. These attitudes to life are based on the experience of having choice and of being increasingly able to make choices that are important and meaningful. There is a development of consciousness that makes more space for inner experiences and of the inner self. The wounded warrior The attitude to life of the 'wounded warrior' is saying ’no’ to mere survival, which one experiences incresasingly as limiting and, in that way, violent to themself and to others. There is an acknowledging of being wounded and of being conscious of that. The person feels a desire for growth, development and meaning and motivated to fight the survival mechanisms, although with no idea how to act in a different way. This is an inner fight to face. It means to let go off of old life patterns, to let go off control and to accept the uncertainty of going into and being in the unknown, where one has to face one’s wounds and pain. The participant The characteristic of the attitude to life of the 'participant' is an open relationship with reality and the willingness to experience it, especially the painfulness of the wounds from the present or the past. From this base experiences may be investigated and meaningful choices can be made, given the realities of the inner and the outer world. In this stage the process of acceptance of life as it is starts. The investigator The attitude of life is characterised by a conscious way of investigating one’s experiences as it is now in the present. That means finding new ways to deal with reality, which are based on an increasing sense of acceptance. Choices are made which give meaning to one’s life. Inner authority The attitude to life of ‘inner authority’ is based on experiencing oneself to be the director of one’s own orchestra performing one’s (musical) composition of life. The individual is conscious of being part of bigger systems, with influences both the way one experiences responsiblity for how one lives and how one deals with reality of life. Purposeful choices are made, trusting one’s intuition or inner knowing. It is the opposite of the experience of being ‘dominated by (external) authorities or circumstances’. This 'inner authority' may come up in all other attitudes by way of intuitions, visions and the like. In the attitude of 'inner authority' it may become a more conscious connection.
In the following the first five attitudes will be mentioned, since these are most common. Attitude to life in health and healing In the various research projects we found that people often went through a developmental process from the experience of being a 'puppet' through the phases of 'victim', ' fighter', 'wounded warrior' towards the experience of fully participating in life. This usually was not a neat process of going from one phase to the next, but the model proved to be a good map for the process both for patients and for health care professionals. In this process that people went through, there was a change in their attitude to life which resulted in more health and vitality. This change was the result of freeing themselves, freeing the self, from the unconscious self-‐images that restricted them. This seems to make conscious experience and investigating one's experiences possible. We found that this developmental process could be initiated by various confrontations with ill health, that this could be stimulated in a health care relationship and was independent of intellectual, educational or socio-‐economic development of the person. The core of this developmental process was the development of the self, or, how we have come to call it, the development of (inner) autonomy. This seems to be the base of an attitude to life that is conducive to health and healing. Autonomy In many research projects in the health care field that are oriented towards health more than to illness and disease, autonomy is found to be one of the important factors in health and health promotion, next to physical and mental activity and meaningful relationships (7-‐ 10). In this research the concept of autonomy is usually ill-‐defined. In relating our research findings to health care professionals and to patients we discovered that it was important to make a distinction between two concepts of autonomy: 'liberal autonomy' and 'inner autonomy'. A similar distinction can be found in various philosophical works, sometimes as the distinction between 'freedom from' and 'freedom to' (3, 11-‐12). In 'liberal autonomy' it is important to be free from the influence and interference of government, others, and disease. Liberal autonomy is developed by saying "no" to (part of) reality. This is sometimes called a negative concept of freedom. Similarly, the concept of health as the absence of disease or deformity is called the negative concept of health (10). 'Inner autonomy' is developed by relating to what we do not want, what we do not like in and of reality. Inner autonomy means being free in relationship with what is and in finding a way to express our values and meaning within the limitations of reality. These two concepts reflect different ways of experiencing autonomy and they are not contrary to each other, but are in line with each other. To put is simply: the extent to which one is able to say ’no’ determines the extent to which one can ’yes.’ The development of autonomy It appears that the experience of inner autonomy is not a given: it rather seems to be a potential in each human being that can be developed during life, particularly in times of confrontations, challenges and/or crises. The core of autonomy is the conscious experience
of a self, of an experience of 'I-‐ness'. The development of this is at the base of the development of the attitude to life, as illustrated in the model mentioned earlier. It is a development from being totally determined by others (external authorities) and by the circumstances, which we called the phase of 'puppet': there is no experience of 'I-‐ness', there is no experience of choice, and no experience of will. In the phase of 'victim' a crucial point of development is the experience of ’I am victim of this‘, but there is no experience of choice nor of will. In both attitudes there is no experience of autonomy. In the phase of 'fighter' there is a (limited) experience of 'I-‐ness' and of having choices and experiencing will in fighting reality, others and the circumstances. This may be called 'liberal autonomy' as a first and important step in developing autonomy. There is a transition from 'liberal autonomy' to a certain extent of 'inner autonomy' in the phase of ‘wounded warrior’, when the acknowledgement of the reality of being wounded, also of one's own survival patterns, leads to a stronger experience of 'I-‐ness' in making choices with a growing sense of the importance of values and meaning. The experience of 'inner autonomy' becomes stronger in the phase of 'participant' when one experiences that one is able to relate to and experience the pain of reality in an new, freeing way (‘I am there and the pain is there‘). The experience of ‘inner autonomy’ continues to grow in the next phases, when the pain of reality is accepted also in a wider meaning. The development of autonomy seems to be a process of confrontations, and it seems to be a continuous process of potential development (13-‐17) confronting one with the extent to which the sense of 'liberal autonomy' keeps one from fully participating in life. Liberal autonomy and inner autonomy It seems that the transition from 'fighter' to ' wounded warrior' is a difficult process in these days. It is about the differences between liberal autonomy and inner autonomy, and this transition does not go without saying. Usually it is a big inner struggle, because it is also a struggle between the inner and the outer. The 'fighter' has a certain extent of liberal autonomy, and he or she fits the ideal of the enlightenment: rational, expressive, and living with the idea that we can 'make life'. This means that we can beat, or at least fight, diseases, suffering, death, limitations and whatever inconveniences. The 'fighter' usually has a rational viewpoint from which he or she wants to understand everything to give it a place in the whole. Inconveniences, pain and suffering will be conquered, or at least will be fought. Feelings are under control and there will be no vulnerability, sadness, unrest, nor uncertainty. And, that is exactly what the step towards inner autonomy is about. The first three phases of the model presented here are primarily about the development of will: the experience of 'no will' towards 'having will', in the phase of the 'fighter' often a so-‐ called 'strong will'. In the next phases the development of heart qualities becomes important: it is more about values and meaning. It is less about ’my will should be‘ and more about ’thy will be done‘. "My personal will" becomes secondary to ’what is happening‘ and the choice is related more to what is experienced as meaningful and purposeful.
The attitude to life of the 'wounded warrior' is an expression of the fight for good, for heart and soul. Standing in the reality of the acknowledgement of being wounded in the fight against reality with its limitations, wounds, suffering and death requires a strong person. The (inner) choice is between a continuous and often blind fight against reality and going on a (scary) journey into the unknown. A continous alertness is needed, because the old ways of survival are strong and they act automatically when one does not stop them. By stopping them the 'wounded warrior' paves the way for the 'participant' as the next step in the developmental process. As the 'participant' one relates to the reality as it is and one consciously relates to experiences of pain, suffering, fear, . This requires the heart and the potential to relate to reality in a broader sense. Somehow inner autonomy is developed in relationship with these aspects of concrete reality. Choices can be made then that fit one's history and values. Illnesses and diseases then become existential problems that are part of life and part of one's biography (18, 19),that one has to accept and deal with. This does not mean that one will not be dependent on others to a certain degree: sometimes the help of others is needed, and one has to accept this need, but this can be a free choice, so that one is the director of one's own life (12). Health People who have developed a certain degree of inner autonomy are vital and radiate this, sometimes in spite of disease or limitations: they have a healthy and life-‐affirming way of dealing with disease and suffering. Early on in our research projects it became clear that a distinction had to be made between the negative concept of health, health as the absence of disease and physical complaints, and a positive concept of health. Health, as a positive concept, may be influenced by disease, but not necessarily so. And there are also indications that good health may lessen the chance of falling ill and enhance recovery from disease and trauma (3, 4, 10, 20). So, what is good health? Since 1948 the World Health Organization (WHO) has been advocating a positive concept of health as 'a state of complete physical, mental and social well-‐being and not merely the absence of disease or infirmity'. But for many people, certainly in health care professions, this is read as 'health means being completely without any complaints, disease or infirmity' (21). An experience of well-‐being in spite of (chronic) disease or infirmity is usually not deemed possible. However in research projects all over the world it was found that 85-‐90% of the population said their health was good to excellent in spite of the presence of, often numerous, physical complaints and diseases. And it was also found that this subjective opinion of people was a good predictor of mortality, whereas the objective presence of disease was not (10, 22-‐24). Various positive concepts of health have been proposed over the years. One of the definitions of health that Freud gave around 1900 was 'the ability to work, to play and to love'. In 1986 the WHO introduced the term 'Health promotion' to emphasize and to operationalize their concept of health through 'the Ottawa Charter of Health Promotion' (25). In that short pamphlet some interesting things were said on health and autonomy: ’Health is created and lived by people within the settings of their everyday life; where they learn, work, play and love.’
Health is created by caring for oneself and others, by being able to take decisions and have control over one’s life circumstances, and by ensuring that the society one lives in, creates conditions that allow the attainment of health by all its members’
It is clear in these statements that the health care professionals and health care scientists who developed the Ottawa Charter believed that health is not a given, but needs to be created in everyday life. Usually people in developed countries will have enough physical and mental activity, and space for autonomy and meaningful relationships to, unconsciously, create health. In the course of life the experience of health may vary, and this may be an impetus later in life for a more conscious approach to health and health promotion. In confrontation with serious disease or violence, the active development of inner autonomy, in relationships and through physical and mental activity, may greatly enhance the quality of life for people, and sometimes also help in healing and recovery from disease. References 1 Assagioli R. Psychosynthesis. A collection of basic writings. London: Turnstone Books; 1965. 2 Assagioli R. The act of will. London: Wildwood House; 1973. 3 Vries J de. Ontwikkeling van autonomie als basis van heling [Development of autonomy as a prerequisite for healing]. Ph.D. thesis, University of Humanistic Studies, Utrecht; 1998. 4 Vries J de. Geweld; het fenomeen, het trauma, en de verwerking [Violence; the phenomenon, the trauma, and the healing}. Utrecht: de Tijdstroom; 2006. 5 Rijke RPC, Vries J de, Vries MJ de. De aard en betekenis van helingsprocessen [The nature and meaning of healing processes]. Metamedica. 1983; 62:212-‐220. 6 Rijke RPC. Cancer and the development of will. Journal of Theoretical Medicine. 1985; 6:133-‐142. 7 Rowe JW, Kahn RL. Human aging -‐ usual and successful. Science. 1977; 237:143-‐149. 8 Rijke RPC. Health in medical science. In: Lafaille R, Fulder S. (eds.) Towards a new science of health. London: Routledge; 1993; 74-‐83. 9 Vaillant GE. Adaptation to life. Boston: Little, Brown and Co. 1977. 10 Rijke RPC. Op zoek naar gezondheid [In search of health]. Rotterdam: Lemniscaat; 2001. 11 Berlin I. Four essays on liberty. Oxford: Oxford University Press; 1969. 12 Agich GJ. Dependence and autonomy in old age. An ethical framework for long-‐term care. Cambridge: Cambridge University Press; 2003. 13 Vries J de. Voor heling is meer nodig dan empathie [For healing more is required than empathy]. Humanistiek. 2001; 5:41-‐49. 14 Vries J de. How should professionals treat victims of violence? European Journal of Social Education. 2004; 6:33-‐38. 15 Rijke RPC, Vries J de. Zingeving en verantwoordelijkheid -‐ de subjektieve ervaring van mensen met kanker [Meaning and responsibility -‐ the subjective experience of people with cancer]. Metamedica. 1988; 67:124-‐131. 16 Rijke RPC, Vries J de. Health promotion for health professionals. In: Kaplun A. (ed) Health promotion and chronic disease. WHO Regional Publications Copenhagen. 1992; 44:354-‐356. 17 Lebeer J, Rijke RPC. Ecology of development in children with brain impairment. Child -‐ Care, Health & Development. 2003; 29:131-‐140. 18 Pool A. Autonomie, afhankelijkheid en langdurige zorgverlening [Autonomy, dependence and long-‐lasting care]. Utrecht: Lemma. 1995.
19 Bergsma J, Thomasma DC. Autonomy and clinical medicine: renewing the health professional relation with the patient. Dordrecht: Kluwer Academic Publishers. 2000. 20 Vaillant GE. Natural history of male psychological health -‐ effects of mental health on physical health. New England Journal of Medicine. 1979; 301:1249-‐1254. 21 Huber M, Knottnerus JA, Green L, Horst H van der, Jadad AR, Kromhout D, Leonard B, Lorig K, Loureiro MI, Meer JWM van der, Schnabel P, Smith R, Weel C van, Smid H. How should we define health? British Medical Journal. 2011; 343:d4163 22 Huygen FJA, Hoogen H van den, Neefs WJ. Gezondheid en ziekte -‐ een onderzoek van gezinnen [Health and disease -‐ an investigation of families]. Nederlands Tijdschrift voor de Geneeskunde. 1983; 127:1612-‐1619. 23 Huygen FJA. Family medicine -‐ the medical life histories of families. London: Royal College of General Practitioners. 1990. 24 Appels A, Bosma H, Grabauskas V, Gostautas A, Sturmans F. Self-‐rated health and mortality in a Lithuanian and a Dutch population. Society of Scientific Medicine. 1996; 42:681-‐689. 25 Hancock T. The Ottawa Charter at 25. Canadian Journal of Public health. 2011; 102:404-‐ 406.