Faculty of Medicine Gadjah Mada University

Holistic Approach and The philosophy, mental, social, and spiritual impact of health care
Question: What is the concept of health care? What is the role of doctor as a profession in public health system?

WHAT IS HEALTH
HEALTH IS DEFINED BY THE W.H.O AS A STATE OF COMPLETE PHYSICAL, MENTAL, AND SOCIAL WELL BEING AND NOT MERELY THE ABSENCE OF DISEASE OR INFIRMITY HOWEVER, THE MENTAL COMPONENT OF HEALTH REMAINS AN AREA OF CONSIDERABLE NEGLECT IN MEDICAL PRACTICE

WHAT IS THE IMPACT OF DRUG ABUSE

MORTALITY RATE 17,16 % RESPIRATORY DISTURBANCES 53,57 % HEPAR DISTURBANCES 55,10 % HEPATITIS 56,56% ORGANIC MENTAL DISORDER PSYCHOTIC DISORDER --- PERSONALITY DIS. DEPRESSIVE DISORDER --- SUICIDE ANXIETY DISORDER RELAPS RATE 43,90% CANCER, HIV/AIDS TO DECREASE LIFE EXPECTANCY + 10 YEARS TO INCREASE CRIMINALITY ECONOMICAL IMPACT

HOW DO THE DOCTOR ASSIST PATIENTS

A BIO-PSYCHO-SOCIAL-SPIRITUAL MODEL WOULD INCLUDE THE PATIENT AS WELL AS THE ILLNESS. THE DOCTORS TASK IS TO ACCOUNT FOR DYSPHORIA AND THE DYSFUNCTION WHICH LEAD INDIVIDUALS TO SEEK MEDICAL HELP, ADOPT THE SICK ROLE, AND ACCEPT THE STATUS OF PATIENTHOOD. THE DOCTOR MUST WEIGH THE RELATIVE CONTRIBUTIONS OF SOCIAL AND PSYCHOLOGICAL AS WELL AS OF BIOLOGICAL FACTORS IMPLICATED IN THE PATIENTS DYSPHORIA AND DYSFUNCTION

WHAT IS THE REASON THAT PSYCHIATRY ONLY DEALS WITH THAT PSYCHOSIS

PATIENTS
THE REASON ARE COMPLEX BUT ONE OF THE MAIN REASONS IS THAT MOST PSYCHIATRIC WARDS WHERE PSYCHIATRY IS TAUGHT HAVE RESOURCES TO ADMIT ONLY THE MOST DISTURBED AND SEVERELY ILL PATIENTS. THIS GIVES STUDENTS THE FALSE IMPRESSION THAT PSYCHIATRY ONLY DEALS WITH THAT PSYCHOSIS COMMONLY TERMED MADNESS

THE TEACHING OF PSYCHIATRY IN MANY MEDICAL SCHOOLS TENDS TO CONCENTRATE ON THE SEVEREST OF MENTAL ILLNESS IN EXEMPLIFYING MENTAL ILL HEALTH

STRESSES OF LIFE
MANY OF THE DAILY STRESSES OF LIFE WE MUST ALL FACE BUT WITH WHICH SOME CANNOT COPE THE STRESSES OF LIFE DO NOT ALWAYS EVOKE PSYCHOSES OR DISTURBED BEHAVIOR THAT IS SO EASILY RECOGNISED PSYCHOSES THAT ARE EASILY IDENTIFIED ONLY ACCOUNT FOR 7 % OR SO OF ALL MENTAL ILLNESSES IN ANY GIVEN COMMUNITY

WHAT ARE THE COMMON MENTAL PROBLEMS?

THE MORE COMMON MENTAL PROBLEMS ARE LARGELY DUE TO ANXIETY, DEPRESSION, SLEEP DISORDERS, CHRONIC TIREDNESS, ALCOHOL OR SUBTANCE ABUSE AND UNEXPLAINED SOMATIC COMPLAINTS. THESE LESS SEVERE BUT MORE COMMON ILLNESSES ARE USUALLY SEEN IN GENERAL PRACTICE SETTINGS WHERE LESS THAN HALF ARE RECOGNISED AND ABOUT A THIRD RECEIVE DRUG TREATMENT. EVEN IF THESE CONDITIONS ARE RECOGNISED THERE IS NO GUARANTEE THAT THEY WILL BE PROPERLY UNDERSTOOD OR THAT PATIENTS WILL RECEIVE APPROPRIATE TREATMENT.

HOW ABOUT PHYSICAL ILLNESS

PHYSICAL ILLNESS OR DISTRESS IS APPROPRIATELY MANAGED BY MOST DOCTORS, MANY FEEL HELPLESS WHEN FACED WITH EMOTIONAL DISTRESS
THE FIRST STEP IN HELPING THE PATIENTS WITH EMOTIONAL DISTRESS IS TO UNDERSTAND THE CAUSES AND THE PRESENTATIONS OF THESE ILLNESSES

HOLISTIC APPROACH
IN RECENT YEARS A BIO-PSYCHOSOCIAL AND SPIRITUAL APPROACH TO MEDICINE HAS CAPTURED PUBLIC INTEREST AND, WITHIN THE MEDICAL PROFESSION, THE ATTENTION OF PRIMARY CARE PRACTITIONERS AND PSYCHIATRIST YET MOST PHYSICIANS STILL VIEW BIOLOGY AS THE BASIC SCIENCE

HOW DO THE APPLICATION OF THE HOLISTIC PRINCIPLE

THE APPLICATION OF THE HOLISTIC PRINCIPLE TO THE STUDY OF HUMAN BEINGS HAS FAR-REACHING IMPLICATIONS. WE HAVE A NUMBER OF SCIENCES RELATING TO THE PERSON, BUT NO SCIENCE OF THE PERSON. BIOLOGY, PSYCHOLOGY, AND SOCIOLOGY DEAL WITH ARTIFICIALLY SEPARATED SINGLE SCIENCE THAT STUDIES THE HUMAN PERSON IN ITS TOTALITY. FROM A HOLISTIC POINT OF VIEW THE HUMAN BEING IS MORE THAN A MERE AGGREGATION OF BIOLOGICAL, PSYCHOLOGICAL, AND SOCIAL FUNCTIONS THE PERSON AS A WHOLE HAS ATTRIBUTES THAT CANNOT BE EXPLAINED BY THE ATTRIBUTES OF ITS CONSTITUENT PARTS

CASE OF MRS.SW
A thin woman, pallid, 28 year-old teacher at a local primary school in BTL, name is SW. After consumed mogadon for more than 4 years , she has suffered from chronic headaches for the past three years and she is telling me about her symptoms: dizziness, tiredness, easy fatigue, weakness, and a ringing sound in her ears. She has been under the treatment of doctors in the internal medicine clinic for more than half a year with increasing symptoms. They refered her to the psychiatrist, though against her objection, with the diagnosis of neurasthenia. Gently, sensing a deep disquiet behind the tight lips and mask-like squint, I ask Mrs,SW if she feels depressed. Yes, I am unhappy, she replies. My life has been difficult. She quickly adds as a justification. At this point Mrs.SW looks away. Her thin lips tremble. The brave mask dissolves into tears. For several minutes she continues sobbing, the deep inhalations reverberate as a low wall.

Case Mrs.SW --- continue

After regaining her composure (literally reforming her face), Mrs. SW explains that she is the daughter of intellectuals who died during the way to office some years ago. She and her brothers and sister were dispersed to different places. Mrs. SW then a teenager, was treated harshly by both the cadres and peasants in the impoverished com- mune in the rural area to which she was sent. She could not adapt to the weather and the inadequate diet. After a year she felt that she was starving, and indeed had decreased in weight. She felt terribly lonely; in five miserable years her only friend was a fellow middle school student with a similar background from a native city, who shared her complaints. Finally, in the mid seventies she returned to Btl. She then learned that one of her sisters had committed suicide while being struggled by drug abused, and a brother had become paralyzed in a car accident. Three times Mrs. SW took the highly competitive entrance examinations for university education, and each time, to her great shame, she failed to achieve a mark high enough to gain admission. Two years before anamnesis, she married a man in her work unit. The marriage was arranged by the unit leader. Mrs. SW do not know her husband well before their mar- riage, and afterward she discovered that both he and his mother had difficult, demanding, irascible personalities. Their marriage has been characterized by frequent arguments which end at times with her husband beating her, and her mother- in-law, which whom they live, attacking her for being an ungrateful daughter-in-law and incompetent wife. Both husband and mother-in-law hold her responsible for the stillbirth of a nearly full term

male fetus one year before.

Case Mrs.SW --- continue

Over the past two years, Mrs. SWs physical symptoms have worsened and she has frequently sought help from physicians of both biomedicine and traditional medicine. When questioned by me, she admits to more symptoms --difficulty with sleep, appetite, and energy, as well as joylessness, anxiety, and feelings that it would be better to be dead. She has an intense feeling of guilt about the stillbirth and also about not being able to be practically helpful to her paraplegic brother. During the past six months she has developed feelings of hopelessness and helplessness, as well as self-abnegating thoughts. Mrs. SW regards her life as a failure. She has fleeting feelings that it would be better for all if she took her life, but she has put these suicidal ideas to the side and has made no plans to kill herself.

Case (discussion)
From the case the chief problem is mental disorder. The patient refuses and remarks if only she could be cured of her physical problem, headache, dizziness, fatigue and feel would be better able to adapt to her all problems. Official diagnostic--- depressive disorder The internist did not agree also the patient Neurasthenia --- a syndrome of exhaustion, weakness, and diffuse bodily complaints believed to be caused by inadequate physical energy in the central nervous system. Illness refers to the patients perception, experience, expression, and pattern of coping with symptoms Disease refers to the way practitioners recast illness in terms of their theoretical models of pathology.

THE HOLISTIC APPROACH

WE ALL AGREE THAT MAN IS THE PRIMARY OBJECT OF MEDICINE, NOT HIS SICK BODY PARTS OR HIS DISEASE MAN, AS WE ARE AWARE OF, IS A BIO-PSYCHOSOCIAL-SPIRITUAL CREATURE WHO TIGHTLY INTEGRATES ALL HIS SUBSYSTEMS AND AT THE SAME TIME IS STRICTLY INTEGRATED IN HIS SUPRASYSTEMS. DISEASE IS A DISTURBANCE OF THE BALANCE BETWEEN MAN AND HIS ENVIRONMENT, AT ALL LEVEL OF THE LIVING SYSTEM.

BARRIERS TO THE UTILIZATION OF MENTAL HEALTH SERVICES TO COMMUNITY

COMMUNITY MAY FAIL TO SEEK HELP BECAUSE

THEY DO NOT RECOGNIZE THEIR MENTAL ILLNESSES OR ARE NOT AWARE OF THE SERIOUS CONSEQUENCES OF THEIR MENTAL ILLNESSES THEY DO NOT KNOW THAT THEY COULD GET HELP TO PREVENT THESE MENTAL ILLNESSES, AND TO HAVE THEM TREATED IF THEY DO ARISE THEY DO NOT KNOW WHERE, AND UNDER WHAT CONDITIONS, MENTAL HEALTH SERVICES ARE PROVIDED THEY DO NOT WANT TO CALL ATTENTION TO THEMSELVES OR TO THEIR ACTIONS ( FOR EXAMPLE, THEIR USE OF SUBSTANCES SERVICES ARE PROVIDED IN A PLACE WHERE THEY COULD BE SEEN BY PEOPLE WHO KNOW THEM, WHICH WOULD COMPROMISE DISCRETION HEALTH WORKERS MAY ASK THEM DIFFICULT AND EMBARRASSING QUESTIONS, AND PUT THEM THROUGH UNPLEASANT AND PAINFUL PROCEDURES. THEY CANNOT AFFORD TO PAY FOR THE SERVICES THEY NEED

WHY SHOULD HOLISTIC APPROACH

TO OVERCOME THE DISTURBANCE WE SHOULD TAKE INTO ACCOUNT OR PAY ATTENTION TO ALL LINKAGES BETWEEN THOSE LEVELS IN THIS ENDEAVOUR WE SHOULD FOCUS OUR ATTENTION TO MAN AS A BIO-PSYCHO-SOCIALSPIRITUAL CREATURE, AND HENCE, HIS BIOLOGICAL AS WELL AS HIS OTHER ASPECTS. THEREFORE, MEDICAL SCIENCE AS WELL AS MEDICAL ART SHOULD BE UTILIZED, INCLUDING MEDICAL TECHNOLOGY AND MEDICAL CRAFT. THE PATIENT IS TAKEN CARE OF AS A UNIQUE PERSON (MULTICOMPLEX CREATURE), AND AT THE SAME TIME. THE PHYSICIAN SHOWS HIMSELF AS A UNIQUE INDIVIDUAL OWING TO THE ART OF MEDICINE HE APPLIES WHICH IS UNIQUE AND PERSONAL

HOW DO THE HOLISM AT THE POPULATION LEVELS

HOLISM AT THE POPULATION LEVELS WILL NOT NEGLECT THE ETHICAL ASPECT OF MEDICINE, INCLUDING FOR EXAMPLE THE DISTRIBUTIVE JUSTICE IN HEALTH SERVICES AND THE BIRTH RIGHTS WHICH ARE SOMETIMES NOT CONSIDERED TO BE VERY IMPORTANT. AS REGARD TO ETIOLOGY, WE COULD OBSERVE THAT THE INSULT AT ONE LEVEL/PART OF THE LIVING STATE WILL INFLUENCE OTHER LEVELS/PARTS AS WELL, DEPENDING ON THE NATURE OF THE INSULT. IN THERAPY WE OBSERVE THAT INTERVENTION AT ONE LEVEL/PART WILL SHOW EFFECT AT OTHER LEVELS/PARTS, EITHER THE THERAPEUTIC AS WELL AS THE SIDE EFFECTS. HOLISM ALLOWS US TO REGARD MAN AS AN EVOLUTIONARY EPISODE, A PRODUCT OF HIS BIOLOGIC SYSTEM INTERACTING WITH HIS ENVIRONMENT IN TIME AND SPACE. DISEASES ARE ALSO EVOLUTIONARY PRODUCTS, THE RESULTS OF INTERACTION BETWEEN MAN AND HIS ENVIRONMENT IN TIME AND SPACE.

THE CAUSA OF DISEASES

MAN IS A MEMBER OF HIS ECOSYSTEM, VARYING IN VERTICAL AND HORIZONTAL AXES, AND HIS DISEASE IS THE DISTURBANCE IN BALANCE AND HARMONY HE EXPERIENCES. OUR OUTLOOK OF MAN AND HIS DISEASE IS NECESSARILY WIDEANGLED. DISEASE IS NOT REGARDED AS MONOCAUSAL, AND OCCURS ONLY AT ONE LEVEL/PART OF THE LIVING SYSTEM, AND CONSEQUENTLY, INTERVENTION AGAINST IT SHOULD TAKE THESE INTO CONSIDERATION. MEDICINE CANNOT BE REGARDED JUST AS AN EXACT SCIENCE, OR EVEN JUST BIOLOGY OR PHYSICAL CHEMISTRY, OR ON THE OTHER HAND, JUST AS A SOCIAL SCIENCE. MEDICINE SHOULD BE VIEWED AS A MEANS TO OVERCOME THE DISTURBANCE IN BALANCE AND HARMONY OF MAN AT VARIOUS LEVELS/PARTS OF THE LIVING SYSTEM IN THE BIO-PSYCHOSOCIAL-SPIRITUAL MATRIX, BY EMPLOYING NATURAL AND BEHAVIOURAL SCIENCES.

PREVENTION OF DISEASE AND PROMOTION OF HEALTH

PREVENTION OF DISEASE AND PROMOTION OF HEALTH IN MEDICINE ARE CARRIED OUT BY MEANS OF MAINTAINING THE BALANCE AND HARMONY IN LIFE, SUCH AS BETWEEN ACTIVITY AND REST, SLEEP AND WAKEFULNESS, PLEASURE AND UNHAPPINESS, SELF AND ENVIRONMENT, PHYSIQUE AND PSYCHE, MAN AND SUPERNATURAL POWER, INDIVIDUAL AND SOCIETY, COLD AND WARM, MODERATION IN ATTITUDE AND BEHAVIOR , ETC.

HOLISTIC APPROACH
WHAT IS CALLED A HOLISTIC VIEW OF THE PERSON, THAT IS, WE DID NOT SPLIT THE PERSON INTO SEPARATE PARTS --- WE HAVE TO VIEW THE PERSON AS AWHOLE --- BIO-PSYCHO--SOCIAL --- SPIRITUAL THE WHOLE PERSON CANNOT BE UNDERSTOOD BY AN ANALYSIS OR DISSECTION OF HIS PARTS.

HOLISTIC APPROACH
IF YOU ARE A PHYSICIAN

YOU WOULD LIKE TO HAVE AN OBJECTIVE PROCEDURE THAT WILL SHOW YOU HOW MUCH VARIOUS DRUGS AND THERAPY PROCEDURES YOU USE ARE HELPING YOUR PATIENTS.

IF YOU ARE PATIENT

YOU WOULD BE INTERESTED TO SEE HOW MUCH THE TREATMENT ARE HELPING ACCORDING TO AN OBJECTIVE MEASURE?

IN BOTH CASES, HOLISTIC APPROACH IS THE BEST SOLUTION

OBJECTIVE OF HOLISTIC APPROACH ANALYSIS EVALUATION OF INTEGRITY OF HOMEOSTASIS EVALUATION OF TREATMENT