Inborn basis for the healing doctor-patient relationship

I hypothesize that there is an inborn "hard" scientific basis for the healing doctor-patient relationship, which complements the so-called "soft" art of healing. In other words, there is an innate or archetypal basis for the healing bond, which is built upon a biology of acceptance, empathy, and hope.

Reprinted from The Pharos of the Alpha Omega Alpha, Fall, 1992, Vol. 55, No. 4, Pages 17-21.
Copyright 1992 by Alpha Omega Alpha Honor Medical Society. All rights reserved.

The author (Alpha Omega Alpha, University of Missouri at Columbia, 1970) is Frank N. McMillan Professor of Analytical Psychology, professor of psychiatry and behavioral science, and professor of humanities in Medicine at Texas A&M University, College Station, Texas. He has contributed previously to The Pharos.


 

I hypothesize that there is an inborn "hard" scientific basis for the healing doctor-patient relationship, which complements the so-called "soft" art of healing. In other words, there is an innate or archetypal basis for the healing bond, which is built upon a biology of acceptance, empathy, and hope. Support for this supposition comes from analytical psychology, ethology, and developmental psychology. I suggest that "hard" science and "soft" art are two halves of a whole, or two sides of the same coin. This presumption has immense importance for self-healing, which is fundamental to doctors successfully establishing and maintaining healing relationships with patients. Furthermore, the science and art of the doctor-patient relationship seen as a whole must be the bedrock of medical education and the healing process, which is, after all, why our profession exists.

Inborn propensities: Archetypes

Archetypes, originally conceived by Plato, are innate, affectively charged predispositions toward ideas, images, symbols, and actions. According to Carl Jung, archetype denotes, "an inherited mode of psychic functioning, corresponding to the inborn way in which the chick emerges from the egg, the bird builds its nest, a certain kind of wasp stings the motor ganglion of the caterpillar, and eels find their way to the Bermudas. In other words, it is a 'pattern of behavior.'" (1) Archetype resembles Nikolaas Tinbergen's concept of "innate releasing mechanism."(2) Konrad Lorenz's notion of an inborn basis of knowledge (and action) resembles the same theory, which is best expressed in his own words: "[M]an is still an animal and a primate ... ; and all learning is very specifically innately programmed."(3)

Anthony Stevens's book Archetypes links ethology (the scientific study of animal behavior) and analytical psychology.(4) This should not surprise us, as the primary definition of ethology is "a systematic study of the formation of human character."(5) Ethology bridges human character and animal behavior.

Healing

Some diseases can be cured, but in many more instances the doctor cannot cure a patient's disease. The physician can, however, always help the patient by being involved in a healing doctor-patient relationship.

Healing comes from the old English word haelen, which means to make or become whole. Healing has also become associated with restoring health. In addition, the word has to do with integrity, that is, making a person spiritually entire. It is closely related to the word holy, which is derived from the same root. Paradoxically, one can never be completely healed. In other words, healing is an ongoing process toward wholeness.

Doctor-patient relationship

Doctor is derived from the Latin word meaning "teacher," but it commonly refers to a practitioner of medicine. Jung clarified the term doctor by expanding it to healer. He also introduced the Greek concept of the wounded or divine physician (Asklepios), which relates to the Biblical adage "Physician, heal thyself." Jung emphasized that it is the doctor's duty "to exercise self-knowledge and to criticize his personal assumptions, whether religious or philosophical," and added, "The doctor must know his 'personal equation' in order not to do violence to his patient."(6) This statement resembles William Osler's that the M.D. degree entitles one to a lifelong education in two spheres: 1) medical knowledge and 2) knowledge of oneself.(7) Osler held that the two ought to be balanced for effective self-healing and the healing of others.

The words patient and passion derive from the same Latin root, meaning to suffer. Therefore, compassion is associated with the doctor-patient relationship. The concept of relationship involves a link or bridge between two people. Relationship is defined as "the state or character of being related or interrelated: a connection by way of relation; kinship, ... [or] affinity."(8) Two of the most meaningful relationships are the mother-child bond(9) and the doctor-patient relationship.(10)

Innate capacity for the healing relationship: Lessons from ethology

My focus on ethology will be limited to the primate and two of its representatives: the chimpanzee and the gorilla. What we are looking for is evidence of a doctor-patient or healer-patient archetype, an inborn or biological basis for the healing relationship. I contend that the doctor-patient relationship is founded on a biology of acceptance and trust; it involves feeling and love. Focusing on the archetypal foundation of the healing relationship, I refer to the work of Jane Goodall, the foremost authority on chimpanzee behavior in the wild, who has observed and photographed chimpanzees in their natural surround exhibiting a very basic healing gesture, touch."(11) This behavior relates to the expressions "I am touched," or "That is a touching comment or moment."

Lewis Thomas has maintained that "touching [is our] real professional secret" and that it "is the oldest and most effective act of doctors."(12, p. 56) Thomas has also sounded an alarm:

The close-up, reassuring, warm touch of the physician, the comfort and concern ... are disappearing from the practice of medicine, and this may turn out to be too great a loss for the doctor as well as for the patient. This uniquely subtle, personal relationship has roots that go back into the beginnings of medicine's history, and needs preserving. To do it right has never been easy; it takes the best of doctors, the best of friends. Once lost, even for as short a time as one generation, it may be too difficult a task to bring it back again. If I were a medical student or an intern, just getting ready to begin, I would be more worried about this aspect of my future than anything else. I would be apprehensive that my real job, caring for sick people, might soon be taken away, leaving me with the quite different occupation of looking after machines. I would be trying to figure out ways to keep this from happening.(12, pp. 59-60)

In correspondence with Guido Majno, author of one of the best books on healing, Goodall wrote, regarding self-care of wounded chimpanzees in the wild, "A chimpanzee will pick leaves, dab at a fresh bloody wound, lick the blood off the leaves, and then dab again. A sore on the back, or side, or head will often be pressed with the fingers, which are then licked, then pressed again to the wound." Goodall added, "On one or two occasions, one chimpanzee [would] lick the wound of another."(13)

I shall cite four more examples of chimpanzees' involvement in healing "doctor-patient" relationships. The first involves ocular first aid between a pair of captive chimpanzees, Pan and Wendy, in their early thirties, as observed and photographed in Florida by Walter R. Miles. After Wendy signaled that something was in her eye, Pan crouched before her and pulled down her lower eyelid. Wendy pulled her head back a little, as most patients would; Pan stabilized it with one hand, while removing the object from her eye with the other hand."(14, p. 841).

In the second example, Wolfgang Kohler, who studied "ape first aid," observed that

the chimpanzee likes to pay attention to wounds or injuries received by his fellows.... To handle such things gives him pleasure, and there is sometimes a helpful and beneficial result. Once an enormous abscess had appeared on the lower jaw of one of our chimpanzees. When it became noticeable through the extent of the inflamed surface and secretion of pus, another of the apes would not stir from the patient's side, but pressed and kneaded the injured jaw, until the pus was removed, revealing a raw, gaping wound. The animal thus treated made no objection .... [W]onderful to relate, the wound ... healed rapidly and completely.

Kohler continued, "Chimpanzees also like very much to remove splinters from each other's hands or feet, by the method in use among the ordinary human laity. Two finger-nails are pressed down on either side and the splinter levered upwards, to be caught and removed by the teeth."(15) Kohler also described how a chimpanzee successfully removed one of his own splinters.

The third example of healing among chimpanzees comes from the Delta Regional Primate Center in Louisiana, where William C. McGrew and Caroline E. G. Tutin studied dental grooming. They recorded a female chimpanzee performing dental care on a young male chimpanzee. To clean teeth the female used a tool, a twig of red cedar, but her major feat was the removal of a deciduous molar with the help of a pine twig.(16)

A final example, again from Goodall's work in the wild, is that of a depressed young chimpanzee who was bereaved at having lost its mother and was comforted by a surrogate mother. This caring behavior seems related to a healing relationship."(17)

Gorillas, as studied in the wild by Dian Fossey, also exhibit healing behavior.(18) Like Goodall, Fossey gained the trust and confidence of the primates she investigated. Likewise, she documented healing "doctor-patient" relationships. For instance, a mother gorilla, Effie, was injured in an intergroup skirmish; she was suffering from bite injuries of her neck, head, and shoulders, and her daughter became her healer. Fossey recorded this incident as follows:

Within a week her bite wounds were draining badly and, had it not been for Effie's five-year-old daughter Tuck, the injuries would have taken far longer to heal than they did. Tuck appointed herself Effie's attentive ... groomer, pushing away other animals who interfered with her ministrations. Tuck even pushed away the hands of Effie, who, possibly because of discomfort, wanted only to be left alone. Tuck licked and probed stubbornly at the bite injuries until all had healed six weeks after their infliction.(18, p. 89)

Another example among the gorillas was that of Uncle Bert, who led one of the gorilla groups. A female, Mrs. X, became ill and could not keep up with the group. Fossey recorded this poignant episode as follows:

After Mrs. X's departure from Group 4, her thirty-seven-month-old daughter Simba changed suddenly from a happy, outgoing, sociable youngster into a pathetically withdrawn and sickly infant. She spent the days and nights huddled against Uncle Bert [and] rejected all play solicitations.... The young silverback ... responded fully to Simba's helplessness. In a maternal-like manner Uncle Bert groomed her, nested with her, and scrupulously protected her from other young gorillas seeking only to [bother] the despondent youngster.(18, P. 179)

Eventually, Mrs. X meandered back to Group 4, and Fossey documented what happened.

Simba reverted to her playful self and showed no psychological effects of the two-month period when she was deprived of her mother. Simba had been almost completely weaned at the time of the separation, so the main reason for her despondency was attributed to the lack of maternal body contact rather than to deprivation of suckling.
It was obvious when Mrs. X came back to Group 4 that she was terminally ill. After twenty-three days she disappeared [again]. An extensive search for her body proved fruitless. Because of her long illness, [she was presumed] dead.(18, p. 179)

Fossey continued her observations.

With her mother's [permanent] departure, Simba again withdrew into her shell responding only to Uncle Bert, who immediately resumed his attentive guardianship. ... A year after her mother's death Simba began building her own nests by pathetically piling leaves into little mounds [but] making no attempts at rim construction. ... More often than not, she joined Uncle Bert at some point throughout the chilly nights. ... Simba's confidence under his doting attention grew to such an extent that she verged on being somewhat spoiled. If subjugated to the slightest roughhousing when playing with Augustus, Tiger, or Papoose, Simba needed only to give the smallest squeak and Uncle Bert was quick to discipline [the] bewildered playmates with pig-grunts or mock bites.(18, p. 180)

Fossey also had the experience of bringing three captive orphans back to life from near death. She was able to return the last one, Bonne Annee, to the wild. When Fossey got her, the baby had been held for six weeks in a damp, dark, potato shed belonging to poachers. She was badly dehydrated and had severe lung congestion. Fossey recorded what happened:

Six weeks of care were required before Bonne Annee was well enough to play in the meadows surrounding camp. An additional six weeks were needed for the infant to regain tree-climbing dexterity and food-preparation skills.... The transformation of the sickly captive into a typically lively young gorilla was a joy to observe. Bonne Annee's recovery was aided by Cindy [Fossey's female, part-Boxer dog], who cared for the infant exactly as she had watched over [two other captive orphans] Coco and Pucker eleven years earlier. Although considerably aged, Cindy provided Bonne Annee with cuddling or body warmth whenever the baby wanted to rest. The dog also participated in mild wrestling or chasing games during the gorilla's two-month convalescence.(18, p. 223)

When Bonne Annee was reintroduced into the wild, she was protected by Beethoven, the silverback in charge of the group that adopted her. Apparently not quite strong enough to return to the wild fully, Bonne Annee succumbed to pneumonia over a year later after a prolonged period of heavy rains and hail. "At least," Fossey recorded, providing, in a way, a quiet omen of her own fate, "Bonne Annee died free."(18, p. 228)

Developmental unfolding of the human healing relationship

I like to think of the Self (the central archetype) as an organizer in the sense that this term is used in embryology; there is an innate plan that starts to unfold at the beginning of every individual's life and that continues to do so for the rest of his or her years. One is here for a special purpose, that is, to become one's true self and to fulfill one's own personal myth. Jung called this process individuation, progress towards wholeness.

Sigmund Freud started out conceptualizing the first human instinct as a self-preservation drive, which was accurate, but subsequently abandoned this concept, replacing it with the sexual drive. Fortunately, the notion of self-preservation was later utilized in a meaningful way by others such as Jung (self-realization), Abraham H. Maslow (self-actualization), and Heinz Kohut (self-psychology).

Erik Erikson's epigenetic stages of the human life cycle elucidate many of the critical developmental issues to be resolved, the rewards of the essential human strengths, and the basic virtues, all of which characterize healing relationships.(19) (See Table.) For example, the newborn's instinct to suckle its mother's breast is based on an ancient archetypal inborn capacity to find the mother. Lorenz helped us to recognize this form of behavior as imprinting in animals, but it takes on a more evolved form in humans, leading to attachment behavior.(9, p. 220-28) Attachment is defined as "a feeling that binds a person," and its synonyms are affection and love.(20) Attachment, love, and the human bond are intricately related to trust. Once trust is in place, Erikson postulated, an essential strength, drive, is set in motion, and the basic virtue of hope (or faith) is born.

Reflect for a moment. The essential strengths—drive, self-control, direction, method, devotion, affiliation, production, and renunciation—are essential strengths of the doctor/ healer. Also characteristic of the doctor/healer are the basic virtues of hope (faith), willpower, purpose, competence, fidelity, love, care, and wisdom; these virtues are necessary for the healing relationship to be effective.

Long ago Paracelsus viewed compassion as the doctor's schoolmaster. There are two more "C" words that are equally important: curiosity and courage. The forever curious, courageous, and compassionate Albert Schweitzer is a testament to the healing archetype of the doctor-patient relationship.

Adolph Guggenbuhl-Craig has forewarned all of us in the helping professions to avoid entrapment in power, negativity, and hate. If the doctor hides behind a persona or the authority of an inflated ego, he or she will not embody the human aspects of the healing relationship.(10, p. 94-101) A healing relationship is a balanced one—caring and compassion with curiosity and competence. It also helps if the doctor admits that he or she is not only a doctor, but a patient; this is the myth of the wounded healer.

Stages of Human Development
Age Freud's Psychosexual Stages Stages Critical Issues Erikson's Essential Strengths Basic Virtues
0-2 Oral Infancy Trust vs. Mistrust Drive Hope (Faith)
2-3 Anal Early Childhood Autonomy vs. Shame, Doubt Self Control Willpower
3-6 Phallic (3-5) Oedipal (5-6) Play Age Initiative vs. Guilt Direction Purpose
6-12 Latency School Age Industry vs. Inferiority Method Competence
13-18 Genital Adolescence Identity vs. Identity Diffusion Devotion Fidelity
18-25   Young Adult Intimacy vs. Isolation Affiliation Love
25-50   Adulthood Generativity vs. Self-Absorption Production Care
50+   Mature Age Integrity vs. Disgust, Despair Renunciation Wisdom

(Adapted from Erikson, EH: Identity and the Life Cycle. Psychological Issues Monograph. New York, International Universities Press, 1959.)

Healing convergence: A summing up

Just as all rivers lead to the sea, ideas and images converge; there is a blending of archetypal healing waters. One river is ethology with its two streams: animal behavior and human character. Another river has eight tributaries representing the eight stages of human development, which encompass the eight decisive issues, essential strengths, and basic virtues. In addition to the prime virtue of hope, I shall add two more wellsprings of virtue that begin with the same letter, humility and humor. Egocide (the symbolic killing of the ego and surrendering the false self, as in Buddhism), and the transformation that results, promotes humility.(21) Regarding humor, Friedrich Nietzsche said, "The most acutely suffering animal on earth invented laughter." Josh Billings said, "There ain't much fun in medicine, but there's a heck of a lot of medicine in fun." These quotes come from Norman Cousins's book Head First: The Biology of Hope, which contains a chapter called "The Laughter Connection," in which he showed that humor has healing qualities.(22) The message is, "Don't take yourself too seriously." A doctor must realize that under the mask of the competent Dr. Jekyll lurks the shadow personality of Mr. Hyde. A healing direction for the doctor is toward an increased awareness of the shadow, deflation of the doctor's ego, balanced with the identity of patient. Some of the best medicine we have is humility and humor.

Doctors and patients are the two main streams of the healing river; once they flow together, the one channel embodies both the outer and inner doctor-patient relationships. All waterways end up in the sea, so we are all in it together. We can feel for others who are in the same predicament as ourselves. Being in the same tidal river promotes empathy and compassion for suffering—with ourselves, our colleagues, and our patients.

To this flowing river of the healing relationship, I add the creative shamanic experience, which involves an inner doctor-patient relationship and death and rebirth experiences. Only through such experience can the shaman and doctor be effective in healing others. The archetype of the healing doctor-patient relationship is rooted in Shamanism. The shaman's healing ability stems primarily from self-healing techniques. The shaman heals his or her own emotional disturbance (usually a deep and severe depression due to loss of soul) by going into a trance and freeing himself or herself from it by creative artistic productions, such as paintings, songs, poems, or dances, which he or she then shares with the community. Through acts of creation, a shaman finds his or her soul and becomes a doctor by way of self-healing.

On a personal note, painting has been central to my own healing process. When I become very depressed, I paint, and this activity invariably helps resolve my melancholic state. Observing this pattern of behavior, a poet friend recommended the book Shamanism: The Beginnings of Art.(23) In it, I found that shamans repeatedly had to free themselves from deep depressions by creative acts. The shamanic journey has become an important one for me.(24)

Notably, Philip Tumulty saw healing as involving four imponderables: hope, faith, compassion, and empathy.(25) Jerome Frank pointed out that the most powerful healing emotion is "expectant faith."(26) Eighty-five years ago Osler admonished doctors not to try to "mix the waters of science with the oil of faith." By keeping them separate, doctors could have "a great deal of both."(7, p. 365) The ancient biblical adage that doctors heal themselves before attempting to heal others is a truism. The most effective healers, "wounded healers," are aware of their own wounds and know that healing is a lifelong process. Always to be in pursuit of self-healing and in contact with the soul and spirit—this is the individuation process, an integrity-full journey. True healing is in tune with intrinsic healing qualities of nature. The Self represents an inner healing force with the potential for growth, creativity, and wholeness.


References

1. Jung, CG: Collected Works, vol. 18, The Symbolic Life. Princeton, New Jersey, Princeton University Press, 1976, p. 518.
2. Tinbergen, N: Social Behavior in Animals: With Special Reference to Vertebrates. New York, John Wiley & Sons, 1953.
3. Lorenz, KZ: Innate bases of learning. In: Pribram, KH, ed.: On the Biology of Learning, pp. 13-93. New York, Harcourt, Brace & World, 1969, pp. 20-21.
4. Stevens, A: Archetypes: A Natural History of the Self, New York, Quill, 1983.
5. Webster's Third New International Dictionary, s.v. "ethology."
6. Jung, CG: Collected Works, vol. 10, Civilization in Transition, 2nd ed. Princeton, New Jersey, Princeton University Press, 1978, p. 163.
7. Osler, W: Aequanimitas: With other Addresses to Medical Students, Nurses and Practitioners of Medicine, 3rd ed. Philadelphia, Blakiston, Co., 1943.
8. Webster's Third New International Dictionary, s.v. "relationship."
9. Bowlby, J: Attachment. New York, Basic Books, 1969.
10. Guggenbühl-Craig, A: Power in the Helping Professions. Dallas, Texas, Spring Publ., 1982.
11. van Lawick-Goodall, J: In the Shadow of Man. Boston, Houghton Mifflin Co., 1971.
12. Thomas, L: The Youngest Science: Notes of a Medicine-Watcher, New York, Viking Press, 1983.
13. van Lawick-Goodall, J: Excerpts of letters to Majno, G, April 13, 1969; November 30,1973. Quoted in: Majno, G: The Healing Hand: Man and Wound in the Ancient World. Cambridge, Massachusetts, Harvard University Press, 1975, p. 10.
14. Miles, WR: Chimpanzee behavior: Removal of foreign body from companion's eye. Proc Nat Acad Sci 49:840-43, 1963.
15. Kohler, W: The Mentality of Apes, Winter, E, trans., from 2nd rev. ed. London, Routledge & Kegan Paul, 1973, p. 310.
16. McGrew, WC, and Tutin, CEG: Chimpanzee tool use in dental grooming. Nature 241:477-78, 1973.
17. Tudge, C: Murder most foul on the planet of the apes. Independent on Sunday, September 9, 1990, p. 40.
18. Fossey, D: Gorillas in the Mist. Boston, Houghton Mifflin, Co. 1983.
19. Erikson, HE: Identity and the life cycle. Monograph, Psychological Issues l(l), New York, International Universities Press, 1959.
20. Webster's Third New International Dictionary, s.v. "attachment."
21. Rosen, D: Suicide survivors: Psychotherapeutic implications of egocide. Suicide and Life-Threatening Behavior 6(4):209-15, 1976.
22. Cousins, N: Head First: The Biology of Hope, New York, E.P. Dutton, 1989, p. 125.
23. Lommel, A: Shamanism: The Beginnings of Art, Bullock, M, trans. New York, McGraw-Hill Book Co., 1967.
24. Rosen, D: The pursuit of one's own healing. Am J Psychoanalysis 37:37-41, 1977.
25. Tumulty, PA: The art of healing. Johns Hopkins Med J, 143:140-43, 1978.
26. Frank, JD: The faith that heals. Johns Hopkins Med J, 137:127-31, 1975.

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