A PARADIGM OF WELL-BEING

John Heron

First published by British Postgraduate Medical Federation, University of London,  December, 1981. And later in British Journal of Holistic Medicine, 1: 2, 1984.

I suggest we abandon the distinction between conventional and alternative medicine and adopt a comprehensive new medical paradigm for modelling changes in human well-being. It is a model that can encompass (a) therapy and cure, (b) prevention, (c) positive development.

The model sees well-being, physical and/or mental, as the product of four relatively independent factors which are as follows:

1. Who is responsible? Who takes the responsible well-informed decision about how my well-being is to be restored or maintained or improved? This factor is concerned with the degree of self-direction

in generating the strategies that affect my well-being. There are three main degrees. (i) I am fully responsible for deciding what strategies I shall adopt. (ii) I share the responsibility with one or more others on some kind of co-operative basis. (iii) I accept someone else's authority to be fully responsible for deciding on the strategies. I will call these three degrees, respectively, self-directed, co-operative, other-directed.

We may note in passing that both conventional and alternative medicine often rely strongly on the other-directed degree of responsibility. It is assumed and expected that the patient will hand over full authority for medical decision-making to the expert practitioner.

2. What sort of agency is involved? By what sort of agency is the strategy that affects my well-being expressed? The fundamental distinction here is between internal agency and external agency. My internal agency refers to my ability to control my mind and body. Thus it includes purely mental acts such as meditation, concentration, reflection, change of attitude and belief-system, etc. It includes mental acts intended to have some desired physiological effect, as in autogenic training (Luthe, 1969-73) and related methods. And, of course, it includes my ability to change my overt behaviour - to change my diet, take up physical exercise, alter the way I interrelate with other persons, etc.

External agency refers to a person, or a physical process or substance or piece of equipment, that acts on some aspect of my being from outside. Combined agency involves both internal and external agencies: such as visualization combined with radiation treatment; mental regulation of bodily states through interaction with biofeedback equipment; changing eating habits on the basis of a prescribed diet; etc. Agencies, then, are (i) internal, (ii) combined, (iii) external.

Again, both conventional and alternative medicine have traditionally relied strongly on external agencies. Conventional medicine on drugs, surgery, radiation, resuscitation; alternative medicines on herbal remedies, homoeopathic remedies, acupuncture needles, osteopathic leverages, and so on. Of course, there are important exceptions such as autogenic training, biofeedback and related methods; prescriptions that the patient change dietary and other habits. Nevertheless, in both schools there has been a strong emphasis on something being done to the patient from outside. The full range of potency centred in the patient's agency has not been used very much.

The first two factors, responsibility and agency, as here defined are relatively independent factors. Responsibility is concerned with who is accountable for making a well-informed decision about what strategy for changing my well-being is to be applied. Agency is concerned with what sort of strategy - whether it is centred in my agency and power, or whether it is centred in the agency and power of something or someone else. Thus if I take up some form of autosuggestion (internal agency) or take a pill (external agency) - it may be because I have made a well-informed decision to do so off my own bat (self-directed responsibility; or because it has been prescribed to me by some practitioner who makes decisions about my well-being on my behalf (other-directed responsibility).

By including the factor of responsibility, the paradigm includes self-help and peer self-help approaches to well-being, as well as practitioner-determined approaches. By including the factor of agency, and distinguishing internal from external agencies, the paradigm draws attention to the potency of patient-centred internal actions - the various forms of consciousness training and mind control, self-regulation of physiological states (Green and Green, 1977; Pelletier, 1977) - and self-regulation of overt behaviour and habits.

3. What sort of process is involved when the selected agency is at work? The basic distinction here seems to me to be between a catalytic process and a confronting process. By a catalytic process I mean one that facilitates and elicits self-regulatory processes in mind and/or body. The process is one that triggers self-healing, that harmonizes, realigns, restores self-generated wholeness of being. It intervenes in the body-mind with a location, deftness and timing that elicits normal functioning. By contrast, a confronting process is one that assaults the disordered part or process directly, seeking to subdue it, eliminate it, reconstruct it or whatever. A catalytic process seeks to encourage the body-mind to deal with its disorder from within its own resources. A confronting process deals with the disorder directly instead of and on behalf of the body-mind, leaving the latter simply to tidy up the aftermath. Again, both processes may be combined, used simultaneously. The use of both together I will call conjunctive. Thus, for different sorts of process we have: (i) catalytic, (ii) conjunctive, (iii) confronting.

It is this factor, the sort of process used in restoring well-being, that has ostensibly been the main dividing issue between conventional and alternative medicine. Alternative medicines have argued that their approach is catalytic, eliciting - via homoeopathy, acupuncture, osteopathy, etc. - the vis medicatrix naturae to do the healing job from within. They have also charged conventional medicine with relying on confronting processes - via drugs, surgery, radiation - that are used excessively, often unnecessarily and inappropriately, with much resultant destructive, iatrogenic effect. Conventional medicine has charged alternative medicine that its championship of catalytic processes has never been based on adequate proof, and that the supposed catalytic effect has not been sufficiently separated out from a placebo effect, from suggestion, from unexplained spontaneous remission, or from unassisted normal recovery.

No doubt there is validity in the charges made on both sides. However, it seems more fruitful to me to sidestep the whole debate with its entrenched positions; to acknowledge that both catalytic processes and confronting processes are, qua processes, equally valid; to acknowledge that conventional medicine has used many more catalytic (and quite standard) processes than alternative medicines have noticed and that alternative medicines have used more confronting processes than they have admitted; and, finally, to acknowledge that the main issue, in this new comprehensive paradigm, is the demarcation issue. This is the issue, in some areas largely unaddressed, about when and for what to use a catalytic process, or a confronting process, or a conjunctive process.

Catalytic interventions in the physical system cover a wide spectrum. Firstly, there are interventions that are conceived to function, by some of their practitioners, in terms of energy processes. Thus high potency homoeopathic drugs, acupuncture needles are conceived as modifying the play of energy in an energy system that underlies and is the informing dynamic principle of the physical system. They regulate the balance of energies which in turn restores physical self-regulation and homoeostatic balance. This concept of an energy body, a vital body, a bio-energetic field around and throughout the physical body, which can be influenced by minimal physical interventions such as acupuncture needles or physical drugs so highly attenuated that they are scarcely physically present, is one of the main stumbling blocks for conventional medicine in its approach to the acceptance of alternative medicine. However, a bridge is being built from the conventional side with physiological studies of the regulatory control mechanisms that appear to be affected by alternative therapies (Bergsmann, 1974, 1979).

Other catalytic interventions are more obviously physical and so more conceptually accessible. Thus prescriptions for bed rest, or regular physical exercise, or a balanced diet, or a special diet, are all strategies that in their different ways enhance healthy self-regulation with the body. Certain external stimuli may well be regarded as catalytic: ultraviolet light, infra-red radiation, interferential therapy, applications of water, massage, and so on. Then there are physical interventions that make good what is missing in the body in order to maintain homoeostasis and well-balanced physical functioning: prescribing thyroid pills for someone whose thyroid gland is fibrosed and non-functional; prescribing vitamins for someone with a chronic dietary deficiency; resuscitation through the administration of oxygen, blood transfusions; the use of a saline drip; sewing up a wound; and so on. Finally, there are compensatory catalytic interventions: using a diuretic to promote the kidneys to do more work than normal in order to compensate for the effects of an irreversibly damaged heart.

4. In what dimension of being does the process produce its effect? I propose here three primary dimensions of being. (i) The transpersonal dimension: this has two aspects. First, the Source, the wellspring, the originating Act whence a person, a distinct body-mind process emerges. Second, a range of altered states of consciousness - spatio-temporal extensions, shifts of level, inner spaces, etc. - which are accessible by both physical and mental methods (Ring, 1974; Tart, 1975; Heron, 1975a; Grof, 1976). (ii) The psycho-social dimension: this covers both psychological, mental processes going on within the person, and also the individual's interactions with others. (iii) The energetic-physical dimension: the range of energy processes going on within the person, and the purely physical structures and processes.

Again, both conventional and alternative medicines have intervened largely in the energetic-physical dimension, in their different ways. There is much talk among alternative practitioners about a holistic approach to the patient. There is little evidence that they practice, or have the skills or practice, a real facilitation of growth in the psycho-social and transpersonal dimensions of their patient's lives.

Similarly, general medical practitioners fully acknowledge, through the pronouncements of their Royal College, the importance of psycho-social factors in primary care. But, quite apart from the pressure of limited time per patient, the skills to handle such factors are not widespread in the profession. Hence in both arenas there is acknowledgement in principle, deficiency in practice.

Of course, there are a wide variety of psychotherapies currently being practiced; and some of these include or focus strongly on the transpersonal dimension (e.g.: Jung's analytical psychology, Assagioli's psychosynthesis, varieties of Californian transpersonal therapy). But a practitioner with the skill to function comprehensively and effectively in all three dimensions of being is rare indeed.

There are some fundamental, very valid issues to be debated about these dimensions of being. The main issue, I believe, is the independence-interdependence one. On the one hand each of these dimensions appears to be relatively independent, with its own functional autonomy. It seems that a person can engage in transpersonal methods effectively without engaging in psychological or physical therapies; can receive effective psychotherapy without address to the transpersonal or physical dimensions; can effectively have the physical body treated as a self-contained system without attention being paid to psycho-social and transpersonal factors. Conversely, break-down and disorder can occur at any one level without necessarily affecting the relative functional integrity of the other two levels.

On the other hand, I think it is reasonable to believe, on the formal and informal evidence currently available, that these three dimensions are also relatively interdependent. They can have powerful effects on each other both aetiologically and therapeutically. It is sensible to believe this, but I don't think we know anywhere near enough about it. And we need a new research paradigm to improve our knowledge in this area of interdependence.

We need to know which factors promote relative functional autonomy at each level, and which factors precipitate functional interaction between the levels to the degree that procures breakdown or promotes cure.

I can now set forth the main features of the paradigm quite simply, as follows:

Sort of responsibility:	Self-directed	Co-operative	Other-directed
Sort of agency:	Internal	Combined	External
Sort of process:	Catalytic	Conjunctive	Confronting
Dimension of being:	Transpersonal	Psychosocial	Energetic-physical

Each of the four independent factors is characterized by three primary terms - two polar terms with an intermediate or bridging term. The paradigm as a whole yields 81 different basic models of ways of influencing well-being. Each model contains one of the three terms from each of the four factors. Of course, there are many more than these basic 81. Firstly, the basic 81 can be combined in many different ways. Secondly, a distinction must be made between working at one level of being to affect that level only (use of antibiotics), working at one level of being to affect another level of being (use of psychotropics), and working at one level of being to affect both that level and another level (use of iron injections for anaemia and its associated mental states). These two considerations greatly increase the number of models above the basic 81.

One way of getting a grip on this plethora of possibilities is just to consider the three vertical columns in the layout already shown. The first and the third columns, respectively, are the polar extremes of all possible models. While the second column presents a model for dealing with well-being that is intermediate between these extremes. Just taking these three models together gives a comprehensive, although still arbitrarily restricted and reduced, programme for well-being.

At one extreme (self-directed/internal/catalytic/transpersonal) the person takes full responsibility - without prescription or control by another - for practicing some form of consciousness training or mind control that elicits a shift or expansion of ordinary consciousness so that it becomes more open to its Source. The person may set aside time for practicing certain sorts of meditation, and/or use a practice like satipatthana (inner alertness, noticing) during everyday activities (Goleman, 1972).

At the other extreme (other-directed/external/confronting/energetic-physical) the person consults some expert practitioner who takes responsibility for attacking directly some disorder at the physical level -thus the person has recourse to dentistry, antibiotics, surgery, etc., as and when appropriate.

In between (co-operative/combined/conjunctive/psychosocial), the person joins with one or more peers who together share responsibility for adopting and using with each other some strategies that promote mutual wellbeing at the psycho-social level, that combine internal mental actions with external psychological interventions from each other, and that use both catalytic and confronting processes. A classic example of this is the peer self-help method of co-counselling (Heron, 1980) in which two people take turns to be counsellor and client, the client having internal skills to work on his or her own mental process, as well as responding to periodic interventions made by the counsellor. In both the client's internal actions and in the counsellor's external interventions, there are examples of both catalytic and confronting processes. Other sorts of peer support and peer self-help groups qualify as examples to the extent that they explicitly conjoin these various elements.

The selection of these three models highlights their differences in time management. Normally, a person's visits to the dentist or doctor for the treatment of physical disorders will be infrequent, the time between visits being measured in months or years. People who use co-counselling or peer support groups as a means of maintaining and enhancing psychological well-being, measure the time between sessions in days or a small number of weeks. Those who use consciousness training such as meditation methods to enhance their well-being may measure the time between sessions in hours; may indeed use such methods intermittently as part of and during everyday life.

The differences in time management reflect differences in the exercise of responsibility. Maximum time is devoted to self-directed responsibility; shared responsibility is fairly frequent; other-directed responsibility is very infrequent.

Returning now to the paradigm as a whole, it puts much more emphasis on education and training than it does on therapy and treatment. Therapy and treatment are being applied to me typically when I am being other-directed, when a well-informed, skilled expert takes decisions for me and on behalf of my well-being. But only one third of the total number of models for dealing with well-being fall within the other-directed sort of responsibility. The other two thirds involve either self-help or peer self-help. Persons who are sufficiently knowledgeable, skilful and responsible to help themselves and each other have been well educated - in the most comprehensive (and today not at all prevalent) sense of the term - and are engaging in a process of continuing education. A learning/ skills building/skills development account is appropriate, not a therapy or treatment account.

As well as a shift from treatment to education and training, the paradigm also encourages a shift from cure or attempted cure of ills to prevention of illness and to positive enhancement and development of well-being. Of course, it doesn't eliminate the notions of other-directed treatment and of cure of illness. In fact it gives very comprehensive account of the range of possibilities for treatment and cure. But it does complement them with an equally comprehensive range of possibilities for preventing disorders, for maintaining and enhancing well-being.

If the paradigm as a whole were to be used as a basis for medical education there would be a revolution in practice on an unprecedented scale. Firstly, practitioners would be educated and trained to be open to the possibility of treating people at the energetic-physical, psycho-social and transpersonal levels of being, dealing with these levels both independently and interdependently. Secondly, practitioners would also be educated and trained to educate and enable their patients to acquire competencies in self-help and peer self-help. Thirdly, practitioners would be educated and trained to abandon defensive chauvinism with respect to any one sort of practice; and this, among other things, by a grasp of various research paradigms, both old and new. For it is important to acknowledge that classical experimental research paradigms need to be complemented by experiential research paradigms involving co-operative enquiry, in any comprehensive plan of research on the well-being of persons (Reason and Rowan, 1981).

The idea of setting up a pilot postgraduate medical training programmes based on this model is not at all fanciful. The sorts of ideologies and competencies required to initiate it and staff it are available in various domains of enquiry and practice in our culture. Some parts of such a programme would be conjectural, provisional, tentative, experimental. Others would rest on a mass of solid, but so far generally neglected and unnoticed, data that has great potency for change in our approach to human well-being. Nor does all the research data have to come in before such a programme can be legitimated. For once the model of co-operative enquiry is accepted as a valid new research paradigm, practitioner and patient can together chart out new territories in our understanding, for example, of how the different levels of being can affect each other therapeutically (Heron, 1981). The practitioner simply needs to learn how to run a co-operative enquiry project with selected patients.

I would like now to extract some parts of the whole paradigm for more systematic description. But first of all we need a simple coding device. I shall designate the sorts of responsibility by roman numerals, thus: I self-directed; II co-operative; III other-directed or practitioner-determined.

The dimension of being at which the intervention occurs will be represented by capital letters, thus: A transpersonal; B psycho-social; C energetic-physical. The addition of a lower case letter indicates which level the intervention is intended to affect. Thus Cc indicates an intervention at the physical level to affect that level. Cb indicates an intervention at the physical level to affect the mental level. And so on.

This simply leaves the core of the paradigm: the nine sorts of agency-cum-process, which I shall designate by ordinary numerals, thus: 1 external agency - confronting process; 2 external agency-catalytic process; 3 external agency-conjunctive process; 4 internal agency-confronting process; 5 internal agency-catalytic process; 6 internal agency-conjunctive process; 7 combined agency-confronting process; 8 combined agency-catalytic process; 9 combined agency-conjunctive process.

Thus III Clb indicates, for example, a practitioner prescribing a drug to interrupt a disabling state of mind in the patient. III C4c indicates, for example, a practitioner prescribing that the patient visualize the direct reduction of some disease process. I C5b might indicate a person, fully on their own responsibility, using a simple mental induction of physical relaxation in order to resolve an anxious, agitated state of mind.

In order to demonstrate the comprehensiveness of the paradigm I will describe only III Cc, III Cb, and III Bb. These are three sorts of practitioner-determined ranges of treatment: at the physical level to affect the physical level; at the physical level to affect the mental level; and at the mental level to affect the mental level. The examples given for each entry do not claim to be exhaustive.

III Cc: practitioner-determined interventions at the physical level to affect that level. In every case, the practitioner prescribes the treatment.

1. External agency-confronting process: dentistry, surgery, many sorts of chemotherapy, radiation, anaesthetics.
2. External agency-catalytic process: many standard medical procedures to support homoeostasis; massage, osteopathy, acupuncture, homoeopathy, some naturopathic treatments, laying on of hands.
3. External agency-conjunctive process: combinations of the previous two, such as surgery together with acupuncture, antibiotics together with massage, chemotherapy and homoeopathy to deal with different aspects of the same complaint.
4. Internal agency-confronting process: prescription that the patient practice visualization of the disease process being directly interrupted and reduced; or that the patient interrupt a self-destructive physical habit.
5. Internal agency-catalytic process: prescription that the patient practice autogenic training, or some form of physical relaxation through auto-suggestion, to promote general physical well-being; or that the patient adopt some physical habit that promotes physical well-being.
6. Internal agency-conjunctive process: prescription that the patient practice both visualization of the direct reduction of a disease process and autogenic training for general physical well-being; or that the patient both interrupts a self-destructive physical habit, and adopts a health promoting physical habit.
7. Combined agency-confronting process: radiation or chemotherapy for a cancer combined with a prescription that the patient practice visualizing its direct reduction.
8. Combined agency-catalytic process: prescription that the patient practice mental control of physiological states by the use of biofeedback equipment; or that the patient practice autogenic training combined with acupuncture treatment.
9. Combined agency-conjunctive process: the practitioner prescribes all the following: antibiotics, visualization of reduction of the infected area, massage, autogenic training for general physical wellbeing.

Only one or two possibilities are indicated under several of the nine sorts of intervention; in each of these cases there are, of course, many other possibilities. But each of the items cited, on the evidence currently available, is worthy of serious consideration for enquiry and controlled application. The use of internal agency in relation to the physical level already applied the principle of functional interdependence between the mental and physical levels, here working therapeutically from the mental to the physical. The evidence for this is by now far too extensive for any well informed practitioner to disregard it.

III Cb: practitioner-determined interventions at the physical level to affect the mental level. This is working on the mind via the body. "Confronting process" here means that the process directly blocks, interrupts, alters, some mental state. "Catalytic process" means that the process restores satisfactory mental functioning without any direct blocking or interrupting effect.

1. External agency-confronting process: some psychotropic drugs; hallucinogens such as LSD; deep friction or pressure applied directly to muscular armouring (as in Reichian therapy to release denied archaic emotional distress); sleeping pills.
2. External agency-catalytic process: homoeopathy, acupuncture and herbalism where these are applied for a supposed mental effect; soothing massage to calm the mind; gentle physical contact for relaxation to elicit catharsis; a prescription that makes good dietary deficiencies that undermine mental well-being.
3. External agency-conjunctive process: combinations from examples of the two previous sorts of strategy, such as the use of psychotropics with acupuncture; deep friction on muscular armouring alternating with light massage - to elicit catharsis.
4. Internal agency-confronting process: prescribing that the patient use hyperventilation or other forms of active body work, to interrupt the somatic controls on archaic emotional distress - to elicit catharsis; prescribing that the patient interrupt physical habits that lead to mental distress.
5. Internal agency-catalytic process: prescribing that the patient use deep relaxation methods through autosuggestion to the body - to reduce mental anxiety and agitation; prescribing that the patient adopt physical habits that promote mental well-being.
6. Internal agency-conjunctive process: prescribing that the patient alternate the use of hyperventilation with autogenic deep physical relaxation - to uncover and discharge buried mental contents.
7. Combined agency-confronting process: psychotropic assisted psychotherapy, with instruction to the patient to use hyperventilation or some other form of active body work, to elicit buried mental contents and catharsis.
8. Combined agency-catalytic process: acupuncture assisted psychotherapy, with instructions to the patient to use autogenic deep physical relaxation - to elicit buried mental contents and catharsis.
9. Combined agency-conjunctive process: psychotropic assisted psychotherapy, soothing massage, patient use of hyperventilation, active body work and autogenic deep physical relaxation - integrated to elicit buried mental contents.

Again, these are only a selection of possible examples, with the same caveat and recommendation applying as before. And most of them will be combined with interventions that work directly at the psycho-social level.

III Bb: practitioner-determined interventions at the mental level to affect that level. "External agency" will, of course, be exclusively in terms of communication, verbal and non-verbal, from practitioner to patient.

1. External agency-confronting process: the practitioner gives advice to, gives interpretations to, confronts the defenses/beliefs/behaviours of, the patient. Thus the practitioner directly intervenes in the psychological processes of the patient in order to alter them.
2. External agency-catalytic process: the practitioner facilitates self-discovery in the patient, that is, elicits self-generated exploration and release of feeling, self-generated insight and understanding, self-generated problem-solving, decision-making; also affirms the worth and value of the patient.
3. External agency-conjunctive process: the practitioner both advises/ interprets/confronts and elicits self-discovery in the patient.
4. Internal agency-confronting process: the practitioner teaches and trains the patient to interrupt his own defensive processes, to interrupt his own tendencies to distorted thought/attitude/behaviour.
5. Internal agency-catalytic process: the practitioner teaches and trains the patient to elicit and foster his own self-discovery process.
6. Internal agency-conjunctive process: the practitioner teaches and trains the patient both to interrupt his own defensive and distorted mental processes and to elicit and foster his own self-discovery.
7. Combined agency-confronting process: the practitioner combines, that is, alternates Blb and B4b.
8. Combined agency-catalytic process: the practitioner combines, that is, alternates B2b and B5b.
9. Combined agency-conjunctive process: the practitioner blends together B3b and B6b.

For the sorts of interventions that the practitioner may use qua external agency see my Six Category Intervention Analysis (1975b); for the sort of techniques the practitioner may teach the patient qua internal agency see my Co-counselling Manual (1980).

The analytic framework Blb to B9b does not so much identify nine different sorts of psychotherapy, as it does bring out the range of options open to any particular psychotherapeutic endeavour. The fundamental options open to any psychotherapist are: whether to intervene directly in the psychological process of the patient, or whether to train the patient to intervene in his own process; and in either of these cases whether the intervention is a direct interruption of defensive and distorted processes, or the eliciting of positive self-realization.

Since fully developed mental well-being in a person presumably involves having the awareness and skills to interrupt one's own defensive and distorted processes and to foster one's own self-realization - albeit in interdependent relationships with others with the same sorts of awareness and skill - it seems better to abandon the notions of psychotherapy, of treatment, of cure, and replace them with notions of education, of learning and training and teaching, of skills building, in the areas of emotional and interpersonal competence, and of decision-making, life-planning competence. For even the most confused, disoriented and distressed person is not so much being cured as being educated and trained, as learning, to take increasing charge of his own mental processes. Thus the patient or "student" would eventually graduate from being at the receiving end of practitioner-determined responsibility for his mental well-being to self-help and peer self-help sorts of responsibility. I will not develop further parts of the paradigm. Long lists of different sorts of interventions organized under some scheme of categories become more and more intellectually inaccessible, simply through the tedium of following the analysis through. Anyone who has grasped the basic categories can through the exercise of both practical and creative imagination derive the many other models for restoring, maintaining or enhancing well-being which the paradigm provides. I have outlined some practitioner-determined models at the physical and psycho-social levels. There are also practitioner-determined models at the transpersonal level. And, of course, self-directed and cooperatively determined models at all the levels.

A PARADIGM OF WELL-BEING

For (a) treatment, (b) prevention, (c) positive development.

The paradigm sees well-being, physical and/or mental, as the product of four relatively independent factors, with three forms of each factor, as below.

These factors, of course, apply to the person whose well-being is under consideration.

Sort of responsibility:	Self-directed	Co-operative	Other-directed
Sort of agency:	Internal	Combined	External
Sort of process:	Catalytic	Conjunctive	Confronting
Dimension of being:	Transpersonal	Psychosocial	Energetic-physical

 

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