Negative Space

Barrett L. Dorko, P.T.

Lorraine’s artistic medium is dried flowers, and she has a genius for making them more attractive than nature ever did. Her airy, spare creations have made her famous in this region and I have several in my own home. Though I’ve known and admired her work for years I just met her recently in my waiting room where she sat cringing, her right arm immobilized at her side. She’s full of discomfort and fear and she made her way to me reluctantly after being told by a neighbor and former patient that I wouldn’t hurt her. I gently guided her into my treatment area.

According to a famous study by Meehl in 1954 (Meehl, Paul E. Clinical vs. Statistical Prediction: A Theoretical Analysis and Review of the Evidence University of Minnesota Press) there is no reason to believe that the information we can keep in our heads is as accurate in its predictive value as a simple statistical analysis of any complex situation. This means that when a lot of information about something is available, we should not attempt to do intuitively what might otherwise be done using a relevant statistical procedure. This study has never been refuted. Despite that, there has been a concurrent and massive rise in the modern philosophy of holism, a rather vague doctrine of medical and/or therapeutic practice that implies that clinicians should focus upon and attempt to interpret a complex and largely subjective whole rather than individual pieces of information. Jan Smuts, a South African statesman, military leader and botanist, originally coined the term and his book, Holism and Evolution, published in 1926, attempts to place the concept within the context of scientific principles. I own a copy and reasonably supposed that it would contain a concise definition of holism somewhere within it, but I have concluded after many attempts to find it that it simply does not. Here’s an example of some of the writing found on pgs. 98-99 in the chapter entitled “General Concept of Holism”: “…there is much more in the term “whole” than is covered by its popular use. In the view here presented “wholes” are basic to the character of the universe, and Holism, as the operative factor in the evolution of wholes…In the view here presented “wholes” are basic to the character of the universe…Holism is a specific tendency with a definite character and creative of all characters in the universe, and thus fruitful of results and explanations in regard to the whole course of cosmic development.”

I don’t know about you, but that doesn’t make much sense to me, and Smuts’ book is full of similar passages. Whatever holism was originally meant to be, and that is by no means clear, it has become a word associated with many sorts of theory and intervention that would not ordinarily be included in a normal medical practice. “Holistic” has become a catchword meant to imply that treatment and theory include consideration for many aspects of functioning contained within any complex system. A “holistic” practice considers as much of the patient’s life as possible before embarking upon a course of care. Intake interviews are prolonged and evaluative procedures are intricate and elaborate.

As I proceeded with Lorraine’s treatment I spoke to her about the nature of her work and how it attracts so many to her store. “I use negative space,” she said. “People like to fill the emptiness between the flowers with their own imagination, and I let them do that. It sounds easy I guess, but it took some time for me to do that well.”

Do holistic practices provide some distinct advantage for either the provider or the patient? Viewed superficially, it might seem that any philosophy of care that includes as much information as possible would be a good thing. After all, modern medicine is often derided for its reductionist and impersonal nature. Holism seems to be an attempt to counteract that by bringing to light as more personal information as possible. This is combined with an attitude toward the patient’s contribution to care that honors the patient’s wishes and concerns well beyond what is ordinarily expected. The public thinks, “Why, all this sounds positively enlightened. Surely it will result in improved care.”

But there is a basic and irrefutable problem with the consideration of numerous factors when considering the behavior of complex systems, especially when many of these factors are subjective in nature. Information that does not lend itself to statistical analysis cannot be considered a reliable part of any predictive equation and may certainly lead us astray when inductive reasoning is essential for diagnostic accuracy (as Meehl’s study points out). For this reason alone many of the findings in holistic practice must be set aside when trying to understand what might be wrong and what to do for it. In addition, the study of complex systems has taught us that “critical state universality” dictates that the vast majority of details normally integral to our ideas about a system’s activity become irrelevant once the critical state (read symptomatic state) is achieved. That is to say we can legitimately ignore many of the things that are ordinarily considered important and still understand the situation well enough to exert some control. In fact, we have to do this or else risk being confused and misled by excess information. Simply put, detailed questioning and examination, the kind of thing holism insists upon, leads to a lack of perceptual clarity on the part of the one providing care. Faced with a plethora of facts we have difficulty rating their relevance and may be mislead by exotic personal details that capture our attention but do nothing to point reliably toward the origin of the patient’s symptoms. This situation may be counterintuitive but it’s true nonetheless, and it means that the “Wholistic ideal” as it was vaguely articulated by Smuts, while arguably a reasonable way to understand the universe, was always a bad idea when it came to the practice of medicine or therapy.

Lorraine’s comment about negative space reminded me of my own practice. I sometimes refer to what I do as “minimalist physical therapy” because the method I employ is so spare and noncoercive. I make sure that the therapeutic environment includes time, opportunity and safe, adequate space for the personal and unique expression of movement that I feel is essential for pain relief. Likewise, Lorraine’s creations allow those who see them an opportunity for their eyes to wander easily from one branch or flower to the next, filling the space in between with their own ideas about the shape their borders may frame. Lorraine focuses on where not to put the flower much as I focus on where not to push or prod my patients. I got out of Lorraine’s way and she filled that space with a movement that only she knew how to create, and her pain was eased.

I don’t care for holistic philosophy. It implies that every aspect of the patient’s life carries adequate significance and thus must be considered carefully in order to understand their problem and plan their care. This is not only untrue, the amount of evaluation it entails runs the distinct risk of misleading the examiner. It is also clear that the term holistic practice is now used to describe any sort of treatment the caregiver might choose to inflict upon their patient. The craziest sort of care seems somehow excused by calling it “holistic.” Whatever Smuts intention might have been when he coined the term, I doubt this was it.

Finally there is this. I sense that many who refer to themselves as holistic practitioners are implying that there is something especially compassionate about their methods. After all, since they work so hard to know as much as possible about the lives of their patients they presume that they must care more about them. They often point out that practicing in an esoteric and nontraditional fashion requires some courage of conviction that mainstream medicine lacks. By extension, those of us who remain firmly rooted in the scientific model and hold back on our claims of success pending outcome studies don’t possess the passion of the true believer or the messianic fervor so often admired in those on the fringes. In holistic practice, personality counts for a lot. Often it is enough to cloud the issues surrounding responsible care. I reject the notion that holism necessarily be equated with an increase in either passion or compassion or that my problems with its use make me less caring for my patient as a person beyond their disability. Understanding that they are complex and often unpredictable creatures has always been a tenet of therapeutic practice and holism is not needed for those of us who already know this. While holistic practitioners might very well appear to care more about their patients there is no evidence of this and it could be argued that their evaluative form leads to less effective care. Their interest in aspects of the patient’s life in which they have no real expertise can easily be construed as intrusive and, possibly, a violation of their professional practice act.

In light of this, I feel that our profession’s attitude toward the concept of holistic practice needs careful review and, ultimately, a rejection of its theory and practice.

Negative Space

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