The heart of healing

Tolstoy on healing

Some might hold a romantic view of medical practice in bygone years, when physicians carried black bags containing the scant tools of medicine that were available at the time, made housecalls, and were familiar with patients’ families and social conditions. They were, apparently, accessible, with ample time to tend to and befriend the sick. Tolstoy’s classic story “The Death of Ivan Ilych”¹—which describes the care of Ivan, a judge in 19th-century Russia—challenges such ideas.

Ivan becomes unwell in the wake of a minor fall. Tolstoy writes, “Ivan Ilych’s life had been most simple and most ordinary and therefore most terrible,”¹ fore-shadowing a spiritual crisis. Ivan, as well as we the readers, realizes that his mental anguish is contributing to his steady decline and eventual demise. Typical of Russian writers, Tolstoy delves into Ivan’s tortured psyche as he sinks into suffering. We are privy to Ivan’s mind: “Now a spark of hope flashes up, then a sea of despair rages, and as always pain; always pain; always despair, always the same.”¹

Ivan, a man of means, seeks medical care from the most distinguished and respected doctors. None of them are able to diagnose or cure him because they fail to listen to him or understand that his symptoms are exacerbated by looming existential issues. Ivan, like his doctors, lives a conventional, proper life (comme il faut) to the point of lacking authenticity. Tolstoy describes one housecall, “The doctor put on just the same airs towards him as he himself put towards the accused person.”¹ As Ivan approached death, a doctor appeared in his sick room with a look on his face that seems to say, “There now, you’re in a panic about something, but we’ll arrange it all for you directly!” The doctor knows this expression is out of place here, but he has put it on once and for all and can’t take it off—like a man who put on a frock-coat in the morning to pay a round of calls …. Ivan looks at him as much to say, Are you really never ashamed of lying? But the doctor does not wish to understand the question.¹

If you have read enough Russian novels, you would expect this story to end tragically. What is fascinating is that Ivan does heal, but not as a result of medical interventions. Two hours before death, after beseeching his Maker, “Why, why dost Thou torment me so terribly?” he grows quiet; “it was as though he were listening not to an audible voice but the voice of his soul.”¹ Thus, he is primed. When his son, a schoolboy, kisses his flailing hand, Ivan experiences an epiphany. He understands that although his life is not what it should have been, it still could be redeemed. He realizes that he can release his loved ones and himself from suffering—by accepting persistent pain. His fear of death dissolves when he begins to believe that there is no death; death, in his mind, is replaced by Light.

Healing in the 21st century

Currently many, if not most, view optimal medical practice as evidence-based, relying on science, deliberately distancing themselves from spirituality. The reality of long, shifting work hours, changing health care systems, heavy case loads, and administrative demands might make physicians believe that they are ill prepared and too stressed to attend to life crises like Ivan’s. While open to the idea that such problems are relevant, they might refer the patient to a psychologist or chaplain to address lifestyle or existential matters. Kearney,² a palliative care physician, disagrees with this fragmented approach. He contends that clinicians (not only doctors) have a responsibility to work with both pain and suffering—the former being in the domain of problems that can be relieved or cured (with procedures, medicines), the latter being the result of damage to the whole person. He defines healing as “the process of becoming psychologically and spiritually more integrated and whole; a phenomenon which enables persons to become more completely themselves and more fully alive.”² He proposes that while it is often spontaneous, it can be fostered by creating an environment that facilitates the natural process of healing. Furthermore, he stresses the importance of a trusting relationship in which the power differential does not hinder the patient’s ability to find the inner resources needed to go with rather than against his or her experience. In essence, Kearney points to the therapeutic value of the healer who has undertaken the path of self-exploration.

Drs Mount and Cassell, 2 trailblazers in whole-person care, concur with these notions of what promotes healing. In “The 10 Commandments of Healing,”³ which is intended for those who tend to the sick as much as those who are sick, Mount also teaches that healing occurs in the present tense, in the now. That is, a person is never healed “for good.” It is a dynamic process—an adaptive response shift based on meaning. Hutchinson states, “Perhaps the real goal of medicine should be to support patients in their healing journey, to help patients move towards life with a greater sense of connection and meaning and a new relationship to wounding and suffering.”⁴

Cassell,⁵ who for decades has been educating us about the nature of sickness, suffering, and healing, published a primer in 2013 that encourages physicians to examine daily medical practice in depth. He emphasizes that “there is only one goal in medicine: the well-being of the patient.” Throughout the book he reiterates that “a person is sick who cannot achieve his or her purposes and goals because of impairments of function that are believed to be in the domain of medicine.” Cassell debunks the idea that there are 2 goals in medicine (ie, treat the disease and care for the patient). He is adamant that this dualism is passé. He reminds us that recognizing the whole person is crucial. By listening deeply and acknowledging patients’ uniqueness, their need to belong, and their desire to be a part of something larger than themselves, healers can aid patients in reaching their goals and fulfilling their purposes. Meaning is crucial and the healer is attentive to what the disease or illness signifies for the patient, as this will promote or hinder recovery of function. But, as Hutchinson and Balass point out in their review of Cassell’s book,⁶ healing might be more than a linear or mechanistic process determined by conscious purposes and goals. It is more likely an iterative progression toward integration.

Siegel, a pediatric psychiatrist, writes eloquently on “therapeutic presence” and explains that it is relevant for all clinicians.⁷ He proposes that presence may be a key state in which we bring our self as a person to the therapeutic relationship. And such presence may be the exact state in which our client/patient can find a way to have a relationship with his or her own internal and interpersonal reality. This transformed relationship may be the heart of healing.⁷

Healing moments in therapy dispel the sense of a separate self that underlies much of human suffering. Siegel defines healing moments as more than releasing dysfunction; by creating new levels of integration, the person can embrace the interconnectedness of life. Perhaps this is how Ivan was healed: his son’s kiss and his expanded consciousness might have saved him.