The self in health and healing

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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.  

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