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Chiropractic Journal of Australia : CJA June 2012
48 Chiropractic Journal of Australia Volume 42 Number 2 June 2012 Jennifer Jamison had another perspective. She considered that “chiropractic holism” was the effect of “skillful patient- practitioner interaction:” “Despite the reductionist nature of musculoskeletal assessment and therapy, practice observation would suggest that the patient-chiropractor encounter is an overwhelmingly holistic experience.” 27 Jamison stressed further: “The notion of a structural intervention having a global effect has certainly contributed to the personalised and interactive focus of chiropractic care. It is furthermore this patient-centredness rather that any deliberately multifactorial approach which makes chiropractic holistic.” 27 Indeed, patients frequently discovered a thorough anamnesis and physical examination, as well as personalised counselling. They soon realised that the “structural intervention” might result in profound modifcations even after years of suffering. Chiropractic adjustment, mediated through skin contact, had multiple neurological and psychological reverberations, sometimes unpredictable. They involved patients’ most intimate sensations: local pain relief, harmonised posture, kinesthetic and proprioceptive adaptation, improved visceral function, mood and voice timbre changes, general well-being, subtle body awareness, etc. While chiropractic principles have been discussed over decades, innate intelligence remained a fundamental for many chiropractors, thus creating a specifc cultural background for their practices. This original chiropractic language is now often overlooked for (chiropractic) vitalism, or vital force, or energy, to keep up with trendy denominations.28 It is however questionable whether these denominations may actually support holistic perspectives. The Biopsychosocial Model In the 1950s a theory originated in psychiatry on factors that may infuence health and healing; it was developed in the 1970s by psychiatrist George L. Engel. The theory appeared to be an outgrowth of various conceptions of disease processes and of mind-body interactions; it was also infuenced by general system theory. Structured as the biopsychosocial model it encompassed three possible dimensions of etiological processes -- biological, psychological, and societal -- since a disturbance of any of these dimensions might overfow on the others.29 The model participated both in holistic and analytical approaches and might be diffcult to apply to the varied circumstances of daily practice. Although it marked contemporary psychiatry and garnered interest in many felds of health care, it did not replace the biomedical model and remained controversial in several respects. Interestingly, this model parallels the domain of public health policies, as well as the defnition of health by the World Health Organisation (1948): “A state of complete physical, mental, and social well-being and not merely the absence of disease or infrmity.” It also parallels to a certain extent the nuances of disease, illness and sickness established by medical anthropology. In 2000 the Conference on Philosophy in Chiropractic Education (Fort Lauderdale, Florida) discussed this model, as well as “metaphysical principles” of complementary and alternative medicines such as holism, vitalism, naturism, humanism, and therapeutic conservatism.30 Chiropractic research projects now investigate the role of psychological and societal factors in chronic conditions (e.g. fbromyalgia, irritable bowel syndrome) where biological factors would not be the only determinants.31 Chiropractic practice is complex. Alan Breen stressed the diffculty of diagnosing common conditions such as musculoskeletal disorders. These were “a mixture of many subgroups of conditions – a few dominated by specifc and objectively identifable pathologies, but most with no verifable diagnosis at all.” Moreover, “objective support” for the use of spinal manipulative therapy was still missing. For these reasons the biopsychosocial model should be an asset in clinical practice: “In this scenario, to be optimally effective, chiropractors, in common with all other health professions who see patients with musculo-skeletal disorders will need be able deploy all of the strategies for patient assessment and intervention that the evidence supports. A bio-psychosocial approach will therefore remain sensible for most patients in the foreseeable future.” 32 It may well be that many chiropractors adopted this model long ago as a matter-of-course extension of the chiropractic adjustment, thus constituting the chiropractic treatment.33 A UNIQUE INTERPERSONAL ENCOUNTER Traditionally based on trust and dialogue, the practitioner- patient relationship nowadays stages various styles of knowledge and partnership, together with anxiety and expectations. These are intertwined beyond scientific considerations so that the encounter may be strained, even in a subdued manner. Knowledge and Partnership As the interpretation of practitioners is not fully scientifc, the experience of patients is not entirely fctitious. Over the last four decades patients’ participation was encouraged, whereby they should become responsible, a form of autonomy, at least in chronic conditions. First came the principle of informed consent; then patients were made aware of their rights and groups of patients were organized; fnally patients were expected to question their role in pathological and therapeutic processes. Many patients were active in this evolution and took advantage of increasingly available medical knowledge. With various motivations they eagerly adopted the internet and its extensive supply of information, so that it may intrude as a third party in practitioner-patient partnership. Patients’ discourse has always been a source of knowledge in and of itself; it may now be well documented, yet rarely fully accurate or exhaustive; it is a narrative that should be deciphered and complemented.11 This is the frst step of an idealized holistic partnership. Then practitioners should show concern, respect patients’ autonomy, and personalise therapeutic programs. Many factors and circumstances should be appreciated such as infuences from the environment; particularly a large variety of diffcult situations and hardship. Patients’ attitudes infuence the style of partnership that may be quite different depending on their ability to express HOLISM IN HEALTH CARE JOLLIOT
CJA March 2012
CJA September 2012