by Wayne Jonas
What helped Sarah and her husband was not the fact that the St. John’s wort worked for her depression; rather, it was the way I delivered it and the ritual and social events that followed—an ordered house, making a friend, and intimacy—that nudged her out of depression and produced the healing. I couldn’t say whether she got a lift in mood from the Gelsemium, the St. John’s wort, or the sertraline, but I could say that the way she engaged in the treatment allowed her to get out of bed and become her own healing agent. As I had seen with other patients, the treatment context and the meaning response were more important than whether the specific treatment had been proven in rigorous research for her condition.
CERTAINTY FALLS APART
Depression is one of the most common and burdensome conditions in the world. It causes a lot of suffering. And it frequently accompanies other chronic diseases. Sarah had depression after her baby was born. Bill had depression because of his back pain. Sergeant Martin was depressed after his brain injury. Depression frequently accompanies Parkinson’s disease. SSRIs have global sales of more than $11 billion a year. St. John’s wort, even with all the negative publicity from the NIH studies, still tops $50 million a year in sales. But if more than 80% of improvement in depression from any treatment is from the way it is delivered—the ritual—what are we paying for when we pay for a drug or herb or other treatment? If we are not using the treatment in a way to maximize the meaning response, we may be mostly paying for the side effects.
Proven treatments that target specific molecular pathways and so create their intended effects, usually also have effects on unintended targets, producing unwanted side effects. Thus, the very treatments that work—those producing the benefit seen in 20% to 30% in randomized studies—also produce unwanted effects. Those unwanted effects frequently impact 50% to 70% of those who take them, including when the treatment did not work. In short: in complex systems like the human body, “specific” treatments have a higher probability of causing harm than good. Judging whether the harms are worth the benefits is the challenge in all of medicine.
The figure illustrates this for one of the most common and beneficial treatments we have for preventing the number-one killer in developed countries: heart disease. That treatment is statin drugs for reducing cholesterol. For every one hundred people who take a statin, two will have their potential death from a heart attack prevented, and ninety-eight will derive no benefit. Most of those same one hundred people will experience some type of side effect, and between five and twenty of those will experience a serious side effect, like major muscle pain or the development of type 2 diabetes.
Not only was my confidence in what I had been taught under threat, but the very scientific basis on which it rested was starting to look shaky. In his 2015 book, The Laws of Medicine, Pulitzer Prize–winning author Siddhartha Mukherjee says the laws of medicine “are really the laws of uncertainty, imprecision, and incompleteness. They apply equally to all disciplines of knowledge where these forces come into play. They are the laws of imperfection.” He goes on to describe how attempts to apply rigorous science often fall short of giving us a good basis for decisions in health care. Even rigorously done experiments give us only probabilities or shifts in likelihood of benefit. And despite applying strict rules of research and critical thinking to science, decisions are still full of bias—statistical, clinical, linguistic, perceptual, regulatory, and financial bias—which can undermine our efforts at objectivity and certainty. What is more, only about one-third of what is published and “proven” using rigorous, experimental research can be replicated, leaving a two-thirds uncertainty for the gold standard—the best of the best of evidence.
Finally, the negative effects of those treatments for the whole person—with all of his or her complex reactions—are frequent, varied, and often poorly recognized. Layer upon layer of uncertainty began to pile on top of what I had based my whole medical career on, what I had taught to students, what I had used to treat patients. If only a small proportion of healing was from the treatments I dished out, and if most patients were getting side effects from those treatments, then was I throwing out most of the healing—and perhaps producing harm—by always looking for the small and particular effects? To make matters worse, this type of science is also being reinforced with money—lots of money—from companies seeking to get their products approved even when they might be doing more harm than good. Drugs get FDA-approved when they show their benefits go beyond placebo, even by a small amount. This requires very large and expensive studies. Proof now has to be purchased. A “real” treatment must separate itself from the daily processes of healing. It was patients like Aadi and Sergeant Martin who went beyond these rules of evidence and pointed me to the underlying rules of healing, prompting me to think there has to be a better way to heal.
CHAPTER 4
A Science for Healing
The science of the large and the whole.
Before science, we had only superstition or intuition to guide us to truth. Both were flawed when it came to healing. With science, we have approaches for testing our ideas in small ways and making incremental advancements in our understanding. Occasionally, these incremental advances result in a major impact—such as with the discovery of penicillin or vaccines. Before science, an epidemic was considered an act of God. After science, it became a containment challenge. We could now do more than pray. While science is a major improvement over superstition, it does not solve the uncertainty in healing. We sometimes lose sight of this. We think that by precisely defining and classifying disease, by rigorously measuring and instituting robust controls, we can determine the best treatments that will give us the most consistent results. And for many conditions this type of science does just that. When biomedical science works, it can work dramatically—especially when what ails us has a simple or a single cause—an infectious agent, a trauma, or a sudden anatomical manifestation of a chronic process, like during a heart attack. This is when the application of science in health care shines. We find miracle cures and produce magic bullets. We save millions through the application of these discoveries in public health, and we keep individuals alive when they would have died on the battlefield or on the highway or at the end of their life.
We love those discoveries, and we get lured into using this type of science for everything, looking for the cure in an attempt to eliminate the disease we have named. We train our scientists and practitioners to look for those cures. We structure our health care system to look for those cures and treat all diseases and illnesses as if we have found the cures. We pay for these treatments, even when the benefit of the treatment is small, the risks large, and the harms poorly understood. We love this type of science—the science of the small and particular. We love it so much that we use it when we should not. Left to our own intuitive devices, we will pick an attempt to cure over healing or prevention almost all the time. Like the fox who sees a rabbit only when it moves and not the hundred others hiding in the grass, we too tend not to see what happens in our life until something changes. Most of life remains hidden in the background, unless we initially bring those elements into our vision.
Thus the science that successfully stops infections, treats trauma, and saves our lives from acute diseases doesn’t work very well for chronic diseases. Not only does it not work well, but it can also mislead us and harm us—by giving us partial treatments for diseases and producing side effects that need to be managed. And by causing us to ignore simpler approaches that produce larger and more whole-person effects. This is why when we do apply a new discovery to chronic illness, we usually get only modest effects—on average about 20% to 30%. Yet there are health care systems and patients who get much better results than that. They have tapped into the other 70% to 80% of what is possible. There is nothing wrong with incremental science, but there is something wrong with the way we apply that science to healing.
WHOLE SYSTEMS SCIENCE
Imagine for a moment that all the chemical
, energetic, psychological, and social exchanges of a person could be visualized as a web-like ball composed of millions of interactions occurring every second. When in optimal health, the ball is perfectly round and the interactions are occurring rapidly through a network of nodes or intersections in this web of interconnected links or pathways.
The primary goal of these interactions is to maintain the web-ball’s shape—the smooth flow of interactions—even in the face of traumas from the outside and breakdowns in pathways on the inside. When the ball is resilient, whenever a stress or trauma is put on it, the ball rebounds to its established shape and function and so maintains its health and wholeness. This epitomizes resilience. The network of the web also has multiple redundant pathways internally with which to maintain the chemical, energetic, psychological, and social flows when any of the individual links slow or break. Strong pathways can compensate for the weakest links.
Each node and link in the web involves hundreds of thousands of interdependent interactions that create complex chemical and energetic exchanges—billions and billions of simultaneous interactions—all designed to keep us surviving, functioning, and flourishing within a narrow range. If flow and shape are maintained, we experience health. If they break down or are disturbed, we experience disease or illness. We experience these interactions in our life as physical sensations and responses, symptoms and dysfunctions, emotions and feelings, thoughts and perceptions, social interactions with others—and sometimes as connections to unknowable forces beyond ourselves, which give rise to spiritual feelings and insights.
When we are healthy and resilient, this web of interactions exists in dynamic balance and vibrancy. Think of a young child reaching out and playing with his environment; a growing preteen curious and learning about himself and the world; an athlete or an artist at the top of her game and in the zone. We have all seen it. We have all felt it. We have all been there. When we are a person experiencing love, appreciation, peace, joy, and awe and are fully connected in body, mind, social interactions, and spiritual purpose, we then have a taste of full health and well-being. We are in the state that our body and mind is constantly trying to maintain. That is health.
We are not just a sack of chemicals, however. If we open the ball and look inside, we see at least four dimensions that make up a whole person. Manu drew a version of a whole person with three dimensions on his whiteboard when he was explaining to me how Ayurveda approached Aadi and his Parkinson’s treatment to me. Modern science has discovered similar (and additional) dimensions that we use for healing. If we were to cut into this web-ball-person, we would see that their network consists of a physical domain on the outside (I call that the body), a set of behaviors under that, a network of social and emotional interactions and then an “inner domain”—involving our thoughts, expectations, intentions, and personal experiences—what we call the mind or spirit.
If we deal with only one aspect of a person—say, the body or the mind parts—we get only partial results, and we produce reverberations (often unwanted) throughout the rest of the person. To fully heal and be well, we need to enhance connections across all four dimensions of a human—body, behavior, social, and spiritual. Healing works by making those connections stronger and inducing us to become more whole and responsive in the world.
Every person has an inherent, automatic set of processes that continually seeks to maintain balance and vibrancy across all these dimensions and maintain the integrity of the entire network. The goal of a whole systems approach is to keep this in balance when we are well (in medical terms this is called prevention); to return balance when we are thrown off (this is called recovery); and to grow, interact, and flourish even if we have a chronic disease. This latter state is often referred to as well-being and can happen even when we have an incurable disease or are at the end of life. We have all experienced this sense of wholeness, vibrancy, and balance, even if only for a moment. This is health and well-being. Healing is the process that constantly strives to keep us in this state if we are healthy, and seeks to restore us to it when we are hit by trauma, stress, or illness. In medicine this view is called the “biopsychosocial” or “whole person” model of health care, and the science used to study it is called “whole systems science.” Whole systems science is the science of the large and the whole. It is the foundation for the future of health care. But you can use it now.
So what happens when things are not working properly and we cannot return to homeostasis? Chronic illness happens when something goes wrong with a person, such that their web of health and healing is distorted.
From the whole systems science perspective, disease is a distortion in the shape or in the web of pathways. When an outside disturbance like a stress or trauma occurs, symptoms are produced as the person attempts to rebound, repair itself, and restore order and harmony again. If the disturbance is from a single cause or event, such as an acute trauma or infection, removing that cause will allow the person to come back to harmony rapidly. As we saw in the last chapter, if the causes are multiple, as is usual in chronic illness, attempts to control or remove the main distortions may partially control the disease but usually produce only a small or modest response.
A specific treatment is used to control the main disease manifestation. It may do that, but it also produces unwanted side effects in other areas of the body and mind. This is what happens when we apply only specific treatments—treatments derived from the science of the small and particular. It is also why so many of us end up on multiple drugs—each one designed to produce a specific effect. This is how we usually apply science when seeking cures.
THE MEANING RESPONSE
Whole systems science and the biopsychosocial model offer a different approach to healing. It’s an approach that taps into this inherent capacity of a whole system to return to balance and maintain its integrity—and to produce the other 70% to 80% of healing. This approach stimulates and supports the person as a whole—connecting all four dimensions and nudging them to recover, rebalance, and restore the harmony that existed prior to the illness.
I call how this type of healing happens the “meaning response.” Why? The definition of “meaning” is “the intended significance of something: the gist, drift, trend, or purpose.” But this word is a bit too cerebral for what actually happens during healing. The word “response” means a reaction to a stimulus, whether that stimulus is a physical environment, a change in behavior, a social interaction, a medical or spiritual ritual, or a word. By combining the word “meaning” with the word “response,” we get closer to the dynamic nature of what my patients experienced and what well-delivered health care systems can produce. When the meaning response occurs, the whole person—not just one specific part of the person—is stimulated and supported to return to balance, health and well-being.
This is what my patients had discovered and taught me—though it went against my established knowledge and opinions at the time. Healing works through the meaning response by improving the connections across all the dimensions of a person—by stimulating their response in a meaningful way.
Given our complex, redundant web of pathways, each person’s journey to induce their meaning response can follow a different path and may use different tools and modalities. Some enter their healing journey using pills and potions, like Norma did. Some may completely change the setting in which they live, like Aadi. Some may find their journey starts with a change in attitude, like Bill. Whatever human activity is used as the entry point—through the body/external, behavior/lifestyle, social/emotional, or spiritual/mental—the pathway and processes for releasing our inherent healing capacity are similar for everyone. First, a deeply meaningful experience is found—often by engaging in a ritual of care. This helps us find the unique, best, and most enduring path for each of us. Second, all the core dimensions of a person are acknowledged—body/external, behavior/lifestyle, social/emotional, and spiritual/mental. This supports complex healing processes to the full ext
ent and helps us use as many redundant pathways as possible. Finally, we engage in some stimulus for healing—usually a stress or challenge—followed by removal of the stimulus, then rest, so that we can rebound and recover. Periodic repetition of this stimulus keeps our body and mind resilient and responsive and on a continuous healing path.
To help organize this when I work with patients, and to help you organize this in your own life, I define four dimensions of healing for a person—body/external, behavior/lifestyle, social/emotional, and spiritual/mental—within which there are many available approaches, tools, and agents. I then use three processes to activate those dimensions for healing: meaning, support, and stimulus. When a person is well and wants to keep well, or when a person is ill and wants to recover their health, or when a person is dying and wants to find well-being, their healing journey involves exploring these four dimensions and engaging in these three processes. When that happens, healing emerges spontaneously and order is restored—like a healthy child recovering from a cold or an athlete rebounding from an injury or an elder dying in peace.
