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April 28, 1998

[Editor's Note: The following essay forms part of the presentation by Charles B. Rodning, MD, Ph.D., FIGS, FACS, at the Harbinger symposium "Healing and the Spoken/Written Word" on April 23, 1998. Dr. Rodning is Professor and Vice-Chair of the Department of Surgery at the University of South Alabama.]

Patient-Physician Interaction:
Healing Power of a Covenant Relationship

[The following essay, which Dr. Rodning co-authored with Danielle Aunay, was first published in Humane Medicine in November, 1988.]

The covenant relationship is a valuable concept in the context of healing -- independent of the classification of a disease process. This concept implies a reintegration of the individual or self to achieve a state of wholeness. This integration is achieved within a covenant relationship with individuals who explicitly and implicitly communicate caring and hope. This healing relationship is effected at the mental/spiritual level by faith -- "the circle of the spirit." Patient-physician relationships are interdependent: physicians function as ministers (servants), perceiving a patient's needs and responding with a demeanor of integrity and candid hopefulness -- offering the gift, if not of healing, at least of wholeness. A physician's realistic and goal-directed responses, commensurate with a patient's specific philosophy of life, reduce the angst associated with the clinical situation and facilitates recovery of a patient's self.

I have come to tell you of the Way
And the Way is the Circle
And the Circle is the Source
And the Source is Life
And Life is the Light
Therefore, Those of the Circle shall
Drink of the Source and become as the
Light that lives and nourishes.

-- J.W. Anglund
The Circle of the Spirit

A pervasive spirit of contemporary society is wholism. In the context of health-care delivery, it is exemplified by the word "cure," which denotes restoration of an individual's total self. Supplemental terms for cure include salvation, salutary, and even shalom ("peace," "unity," "completeness," "being at one with reality," "being at one with the universe"). Each connotes a "well-being of the total self" in relation to his/her community.

The concept of wholeness is derived from Western traditions and from cultural and linguistic patterns developed from several Judeo-Christian concepts. In the orthodox use of these terms, the individual self was never seen without an awareness of the community of which he/she was an integral part. All understood that people found completeness, curing, healing, totality, and wholeness within a covenant relationship, and that caring, community, and harmony derived from the covenant. Throughout the societies of antiquity, health, health care, and related ethical concerns were a function of covenants.

TABLE 1. Specialization
Subdivision of The SelfSpecialist: ProfessionalNon-Professional
Physical/CorpusPhysician/Surgeon
Nurse
Other caregiver
Family
Mental/MensPsychiatrist
Psychologist
Social Worker
Family
Spiritual/AnimusClergyFamily
When human beings "belong together" (for instance, when they have common blood), they also share a common life, common responsibility, and common will. The personal community of the blood family was only one expression of the common life and wholeness pervading ancient societies. In its antecedent forms, this unity was a result of blood -- either of kin or of covenant. As it appeared in ancient Hebrew, "covenant" was something that was "cut," and its ratification involved the shedding of blood. As a consequence of a covenant, individuals became a unity of self, system, and society that possessed one goal: healing, wellness, wholeness -- of the total self.

However, later occidental Socratic, Platonic, and Cartesian philosophical systems took a reductionistic approach to the self. They divided the self into the physical (L. corpus, "body"), mental (L. mens, "mind"), and spiritual (L. animus, "spirit") components. Subsequently, this trichotomy fostered professional divisions, and therapists were educated to intervene at their respective levels of expertise (Table 1).

Figure 1: Integrative Omnidirectional Continuum
Corpus (Body); Mens (Mind); Animus (Spiritus, Spirit)
Although the trichotomy provides useful definitions, a reintegration of the self provides a more appropriate foundation for human healing. Consequently, the following recommendations apply:

There are historical precedents for the resurgence of interest in the concept of wholism. Before modern scientific approaches to the description and treatment of disease, ancient societies used psychosociological diagnostic and therapeutic systems. Within those communities, prophets, priests, shamans, medicine men, philosophers, and wise men assumed the role of healers. They analyzed and manipulated relationships between the individual and his/her family and community to achieve healing. These relationships played a central role in "curing the soul."

It must also be acknowledged that despite considerable scientific advancements, knowledge regarding many diseases remains incomplete. Furthermore, because much disease is not amenable to cure, patients must often accept and cope with physical and psychological pain, dysfunction, and disfigurement. As a consequence, because cure is never assured, patients may experience anger, anxiety, denial, fear, frustration, insecurity, isolation, loss of control, helplessness, and hopelessness. Furthermore, if patients are devoid of hope, they withdraw and become passive and non-manipulable; healing may be delayed or negated, and morbidity and mortality may increase.

The healing dynamic implied in the theological precepts of faith and hope has special relevance in the settings of kinships or relationships integrated at the mental and spiritual levels within "the circle of the spirit." Animus (total person or animating spirit) connotes pneuma (breath, will); essence of human personality; expression of corporeal life; and temporarily independent possibilities of blessedness and goodness, capable of vast ranges of experience, but also susceptible to anguish, disorder, injury, and pain. In these contexts, the communication of hope is a dynamic educational process. Hope for complete restoration may not be realistic, but hope for the recovery of maximal achievable function must prevail. In this regard, goals are fundamental, because they provide focus, meaning, and purpose to the continuing struggle. Any individual who establishes a covenant with a patient and who conveys hope functions as a minister (L. minister, "servants," "service") because he/she educates a patient regarding the unknown and unexpected, and thereby promotes healing.

Indeed, for the patient, hope may be possible only because of the covenant relationship with agents of healing and the community that results. In this context, the concept of shalom is relevant. When and where shalom is in effect, partners exchange gifts to strengthen the psychic community that develops. In this setting, a gift is not an expression of sentiment; it is a required consequence of a relationship between those individuals. The gift itself creates and/or strengthens that relationship. Healing (or curing) connotes the transmission of particular gifts -- caring, hope, kindness, peace of mind or body. A gift outside a covenant relationship is discretionary; within such a relationship, it is a requirement, a duty, an obligation. Therefore, a fundamental component of "curing the soul" is a covenant relationship between a patient and others (professional and/or non-professional).

In this communicative and educative process, the demeanor of the healer is of profound import. The demeanor of the caregiver is characterized by consistency, equanimity, honesty, humility, perceptiveness, sensitivity, and thoughtfulness. A caregiver engages a patient by eye contact, listening, speech, and touch; she/he communicates healing by establishing a covenant, acknowledging individuals' integrity, and promising to involve them in all decision-making processes. Only the establishment of a sense of community or covenant will allay a patient's fears of abandonment, extinction, loss of self-esteem, loss of modesty, victimization. The physician or other caregiver thereby embodies someone who cares -- an ultimate reality that brings hope, healing, salvation. A caregiver becomes a "curer of soul."

In summary, the "circle of the spirit" emphasizes the continuity of the self and the interrelationship among the three subdivisions. "Curing of the soul," reintegration of self, and restoration of health take place at the mental and spiritual levels when a caring covenant is established between patients and physicians or other caregivers who mirror reality and educate patients regarding options and probable outcomes. The covenant promises the voluntary establishment of an ethical obligation on the basis of and in response to transcendent powers beyond the control of individuals or society. The covenant provides a framework within which healing can occur. Thus it is that caregivers mediate healing.


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