Anthroposophic medicine’s understanding of the human being and of illness

[This article is taken from the book: Girke M, Matthiessen PF. Medizin und Menschenbild. 2., erweit. Aufl. Bad Homburg: VAS-Verlag; 2015.]

Central ideas

Evaluation and treatment in physicians’ and therapists’ practices are shaped by the values and fundamental assumptions about the human being. Elderly patients in intensive care challenge us to choose the appropriate therapeutic measures, and patients with cancer face decisions concerning the often-limited efficacy of the systemic therapy offered to them. Therapeutically relevant questions have to do not only with “effectiveness” and “feasibility” but also with usefulness for the patient, with whether the patient assesses them as “good”. Only if the patient makes a positive assessment of a treatment’s usefulness are the three pillars of David Sacket’s evidence-based medicine complete: external evidence, individual expertise and patient preference. Basic concepts of illness and recovery, as well as the qualities of a patient-physician relationship and ethical determinations, are dependent on the respective conception of the human being and are weighted and determined accordingly.

Anthroposophic Medicine

Anthroposophic Medicine was developed by Rudolf Steiner (1861 1925) and Ita Wegman (1876 1943) at the beginning of the 20th century as an integrative form of medicine. It is implemented in medical practices, therapies and anthroposophic clinics. Its aim is to understand human beings as physical, soul and spiritual beings, and to orient diagnostics and treatment according to this comprehensive understanding of the human being. In fact, all medical systems are based on a more or less well-founded, implicitly or explicitly stated conception of the human being. Even mainstream western medicine is in no way without presuppositions, but implicates a view of the human being that determines its methodology and its understanding of illness and healing. In the historical context of one such as Du Bois-Reymond, this is a reductionist understanding of the human being which excludes soul and spiritual aspects of a human being: “… we have conspired to establish the truth – that no other forces are active in the organism than common physical and chemical ones …” (1).

Following a causal-analytical epistemology and corresponding methods based on sensory observation, the human being can only be described on the levels available to these methods. None of these analytical procedures is capable of fully recognizing the nature of human existence. No dissection of its physical body, regardless of how detailed it is, will ever lead to its soul and spiritual dimension. In this way, a form of medicine is created that does not comprehend the patient – even loses the patient. In a related context, Carl Friedrich von Weizsäcker uses the term “cultural limitation of perspective”, which lies at the root of this view and points to the necessity of extension or broadening (2): “Natural science is currently unable to say anything on the subject – not, I think, because this is impossible on principle, but because of its cultural limitation of perspective. It works exclusively from an objective standpoint – that is, it describes objects as they appear to the human subject, but it does not reflect on the subjectivity of the subject.” Anthroposophic Medicine was developed by Rudolf Steiner in collaboration with Ita Wegman as an extension of mainstream Western medicine, within the comprehensive understanding of the human being that is anthroposophy.

Medicine, as a discipline, is challenged to find an appropriate methodological approach to the physical, soul and spiritual human being. Questions regarding a conception of the human being are not answered by interchangeable models that represent only sub-areas of a complex phenomenology. Rather, the circumstances demand a methodology of gaining knowledge that corresponds to each aspect of the human being and doesn’t reduce her complex nature to a level that can be described by causal-analytical models. In some ways, the current medical view is like a concertgoer who describes the “anatomy” and the “somatic dimension” of each instrument by recording the respective vibrations, yet never discovers the real musical expression and immaterial reality of the music. We need a broadening of our understanding of the human being. For this reason, Rudolf Steiner and Ita Wegman developed Anthroposophic Medicine at the beginning of the 20th century. It is erroneous to call it “alternative medicine”, and the term “special form of treatment” also does it insufficient justice. It is a methodology that includes, in addition to the somatic dimension, the life, soul and spiritual levels of being.

Patient questions

In the patient-physician relationship, we can distinguish between four types of questions and expectations that call for an extended understanding of the human being (3, p. 1128 1132). These are asked with varying emphasis and often only implicitly expressed.

“What do I have?”

The first set of questions focuses on the level of medical findings. If a gallstone is diagnosed, the findings-oriented questions concentrate on the possible treatment options that are available to correct this situation. Similar questions will be asked, for example, in the case of coronary artery disease with the possible necessity of an angioplasty of the constricted vessel. The need for therapeutic intervention follows from knowledge of the diagnosis. Regarded in this light, the diagnosis appears to be something “external” to the patient, requiring treatment of symptoms. From the patient’s perspective, this treatment is often seen as a “contracted service” from the medical profession. A diseased hip is to be taken care of endoprosthetically; blood sugar is to be adjusted to normal levels. At this level, the patient’s own contribution to healing remains in the background.

“What will heal me?”

Besides these diagnosis-oriented questions, there are those related to the process of becoming ill and becoming healthy. For example, a patient with rheumatism soon becomes aware that corticosteroid or DMARD treatment significantly improves symptoms, but without actually influencing the quality of the underlying illness process. Cessation of the medication generally leads to a renewal of symptoms. Process-oriented patient questions have to do with treatment options that support healing. Often, the search for a salutogenesis-oriented medical treatment is at the root of these questions. From this perspective, health is not the opposite of illness. Rather, it arises through the activity of “healing forces” in the organism that work against illness-generating (pathogenic) influences. In this sense, the organism’s reaction to a splinter with inflammation is seen as a healing reaction, despite its painfulness and experienced interference, as its purpose is to restore the integrity of the organism. Health appears as a quality on the spectrum between pathogenically and salutogenically active factors. Widespread interest in integrative, complementary or alternative medicine does not arise from an undifferentiated sympathy for everything “natural” – it is motivated by this desire for salutogenic treatment options: Contemporary Western medicine is experienced as an “intervention medicine”, which influences or normalizes pathophysiologically relevant parameters through pharmaceuticals or instrument-based interventions without supporting the patient’s salutogenically effective resources. As beneficial as the interventional possibilities of medicine are, they clearly address only diagnosis-oriented levels of patient questions and leave a blank slate where salutogenic treatment needs are concerned.

What is the relationship between illness and the human soul?

A third category of patient questions relates to the soul (mental/emotional) dimension and is therefore oriented toward patients’ feeling of well-being as opposed to diagnosis. Patients ask about the relationship between their soul experiences and the illness process. Someone with atopic dermatitis experiences very clearly that changes in his skin condition occur as a result of different levels of stress in his life. The skin’s disease appears as a mirror of the soul. Clinically significant interactions between soul life and cardiovascular disease are already well documented and have implications relevant to treatment. Accordingly, patients ask for the inclusion of this soul level of being in the treatment process.

“Why me?” Biographical context and finding meaning in the illness

And finally, a fourth level has to do with the meaning of illness. Suffering without meaning is without perspective and unbearable. In palliative care, the expressed wish for actively assisted suicide is caused less often by untreatable symptoms and more often by the experience of a loss of meaning. As soon as there is no longer any perspective, the wish for death arises. Christian Morgenstern, who died at 42 of tuberculosis, expressed this question in the following words:

“Every illness has its own specific meaning, for every illness constitutes a cleansing: one only needs to discover of what and why. There are almost certainly indications; however, people prefer to read and think about hundreds of thousands of other people’s business rather than face their own. They are unwilling to learn to read the deep hieroglyphs of their illness; they are much more interested … in the toys of life than in its seriousness – than in their own seriousness. And herein lies the true incurability of their illness: not at the bacteriological level, but in the lack of, and in the unwillingness to gain, insight.” (4, p. 210)

Asking after the meaning of an illness – which occupies not only young cancer patients and is often the spiritual background for a troubled soul, hopelessness and depression – has to do not only with finding meaning but with learning to think in new ways. Patients sometimes discover new developments in their relationships with other people, discover that they possess other competences and abilities and have new experiences and perspectives, including spiritual ones. In palliative and hospice care, we are often surprised by new capacities, values and goals in the patients, which take on significance in this advanced stage of the illness and allow patients to discover or even create a previously unexpected purpose. If the illness is experienced not as a “malfunction” but rather as connected with the individual’s development, many questions relating to the biographical context arise. The biography appears not as an accidental collection of disparate life events and illnesses, but rather as one composite form. Illnesses are integrated into this time-form of a life. The symmetrical distribution of many illnesses is well known, such as rickets in childhood and osteoporosis in the elderly, asthma in youth and COPD in elderly patients, and type 1 diabetes mellitus in youth and type 2 in adulthood. In childhood, the time of spiritual “arriving in life”, inflammatory illnesses predominate, whilst in old age, the time of “loosening and letting go”, degenerative and sclerotic illnesses predominate. From this composite context of biography, further questions arise: What significance do inflammatory illnesses have in later life? Can febrile illnesses prevent the sclerosis of old age and should they therefore be treated not by suppression, but rather from the perspective of healing?

Considering these points, we can see four levels of expectations that shape the patient-physician relationship (3, p. 1128 1132):

  • findings or diagnosis-oriented level of expectations (I)
  • process-oriented level of expectations (II)
  • level of expectations oriented toward the patient’s inner well-being (III)
  • contextual-biographical level of expectations (IV)

Guidelines for an integrative medicine

These four levels of patient expectation correspond to anthroposophic medicine’s conception of the human being. Patients would like to be perceived and treated according to these different needs and corresponding levels of their being. This is why many patients ask not only for treatment with the necessary drugs or instrument-based interventions, but also for therapeutic approaches that support the healing resources in a hygiogenic fashion. Furthermore, patients expect mental/emotional (soul) support in dealing with the illness, i.e. in salutogenesis, and, finally, support in their spiritual development – autogenesis. In the context of palliative medicine and in hospice care, this is referred to as the “self-actualization” of a person. We are not only aware of the salutogenic principle of medicine through the seminal work of Aaron Antonowsky. The healing processes to be supported can be further differentiated. “Hygiogenesis”, a term coined by Gunther Hildebrandt, relates for example to the “organic healing” of a wound of fracture (5). Salutogenesis, on the other hand, includes the mental/emotional (soul) relationship with the illness – questions regarding the meaning of the illness, its ability to be understood, and its manageability. After all, it is not only severe and chronic illnesses that lead to inner development and maturity. So we can differentiate four levels of treatment in working with patients:

  • I Intervention: adjustment of illness parameters (i.e. blood sugar, blood pressure)
  • II Hygiogenesis: organic healing
  • III Salutogenesis: soul development in dealing with doubts about the meaning of the phase of life, denial and hate toward the existing affliction, fear of threatening symptoms and worsening of the illness
  • IV Autogenesis: spiritual development, self-realization

This allows us to discern the basic aspects of an anthroposophically integrative medicine. In this context, “integrative” means not the combination of all possible “best practice” approaches, but rather the meaningful composition of treatment approaches based on a bodily, soul and spiritual understanding of the human being. From the cumulative approach to treatment options arises the composite, with multimodal therapies whose indications and implementation derive from a multidimensional view of the human being.

Principles of Anthroposophic Medicine’s view of the human being

The four levels of patient questions and their therapeutic implications correspond to the constitutional elements of the human being. Access to these elements, and thereby the foundations of Anthroposophic Medicine, has varying levels of depth and begins with simple observations.

The impressive sculpture “The Reader” by Barlach shows, in its graphic dimension, the physical body of the human being. It is a realm describable by size, quantity and weight, which belongs, unlike other elements of the human being, to space. However, the form points to more than the obvious material level. Barlach could have made the facial form out of plaster, clay, bronze, or one of many other materials. Therefore, form seems to be an immaterial principle, which only requires material substance in order to appear. The pathologist Wilhelm Doerr illustrated this fact as regards the organism in the following words:

“The organism cannot be explained causally – not because it is an especially complicated chemical problem, and not because it is something metaphysical, but simply because the organism itself is an idiosyncratic form of thought – an umbrella term – which neither allows nor requires further breaking down … For order is neither power, nor energy, nor matter. But it requires the latter in order to manifest …” (6)

In a living organism, as opposed to the lifeless world, we know of no complete, static, inalterable shape or form. Rather, transformation of shape predominates. If we include the embryonic, morphogenetic, form-building processes, the constantly changing formation is especially impressive. In this context, Goethe distinguished between Gestaltung (design, formation) as that which has become spatial, and Bildung (development, generation) as those processes that transform and create shape:

“… But if we observe all forms – organic ones in particular – nowhere do we find an existing, nowhere a resting or complete form. Rather, we find that everything is in constant, fluctuating movement. This is why in our language the word Bildung [see above] can be properly used both for that which has been generated and for that which is in the process of being generated. So – if we want to introduce a morphology, we may not speak of Gestalt – form – but rather, when we need the word, at most think of the idea, of the concept, or of something that is only noted in momentary experience. That which is formed is simultaneously reforming and we must, if we want to come to some approximation of a living view of nature, be ourselves as mobile and plastic as the examples with which it precedes us …” (7)

Considering the constructive processes that lead to formation of the organism, Steiner developed the concept of the formative forces organization (Bildekräfteorganisation). This is not the same as a vitalistic or neo-vitalistic definition of life forces. In contrast to the spatial dimension of the physical body, it has to do with the temporal, formative processes of the formative forces organization (etheric body).

Medicine, in turn, must develop a differentiated view of “life” as an independent quality: Life is more than the sum of individual life processes, and requires integration at the level of the organism. Growth of single cells, for example, is ordered within the growth of the tissue, which in its turn is dependent on the corresponding organ, and this, in turn, is dependent in its growth on the whole organism. All life processes in this hierarchy of the living are oriented on the whole organism.

In the 1990’s, about 100 years after Steiner’s delineation, the US-American neurologist Alan Shewmon spoke of integration (“integrative unity”) as an innate capacity of all living beings. In his publication on what is referred to as “chronic brain death” (8), he points out that it is not the brain that executes this integration of life processes, as it also occurs in brain-dead patients and therefore cannot be dependent on the nervous system. Rather, this must be an intrinsic characteristic of living beings, which works continuously against entropic disintegration. An integrative principle actively works against disintegration and the loss of order in living beings, unlike in lifeless things. Shewmon described it as a “bubble of anti-entropy in an ocean of entropy” (9). Rudolf Steiner calls this principle the “etheric body”, which continuously counteracts the disintegration of the physical body (10). These observations lead to another anthroposophic perspective in the philosophy of brain death, which is closely connected to the concept of the etheric or the life-filled as an integrative, formative and intrinsic function of life (11).

The human soul is visible in our facial expressions. Expressions and gestures are an obvious manifestation of our soul experience. It is an inaudible language of the soul, yet clearly understandable in each and every human meeting, which is found in the lines and changing forms of the human face. Therefore, the physical appearance of a human being points not only to his anatomy or the basic formative processes, but is also a manifestation of his soul in every moment, as we can see in the contemplative, reflective soul attitude of the “Reader”.

And finally, in sensing the soul being (astral organization), we can notice a moment of intention. Our gaze can turn more inward and give the eyes a thoughtful expression, or can actively focus on another human being. Then, we notice the spiritual presence of the other person in the evidence of their “you-ness”. This inner directive entity, which is capable of directing thoughts, of experiencing feelings and of realizing itself through the will, is the individuality or entelechy, the human I. On the one hand, it manifests through permanence in that it remains through all our daily experiences and the sensations of our body as the centre of the human being; on the other hand, it manifests as able and willing to develop as the I or personality of the human being, open to the future and able to achieve new abilities.

Methodological principles

The four elements of the human being each require their own methodology. A causal-analytical method can describe simple cause and effect relationships of the physical world, but cannot nearly encompass the net-like interactions and reciprocal interdependences of the world of the living, and cannot even begin to comprehend the soul and spiritual levels of the human being. In the physical world, the contents of our sensations are connected to concepts of physical knowledge. In medicine, therefore, we summarize multiple complaints and symptoms in a patient in a syndromic conceptualization of illness and use this to come to a diagnosis. This physical knowledge does not reach the level of the living, however. The immaterial principle described above, which changes over time and leads to transformation in form, is not accessible to closed, “ready-made” thoughts. Rather, a process-oriented thought movement whose essence springs from life is the necessary methodology here. Thoughts describe what has already become – what has already fallen out of the process of becoming and forming. In contrast, mobile thinking activity approaches becoming, and therefore the world of the living etheric. Through meditative work, it can condense into imaginative knowledge (12).

Anthroposophic medicine is therefore not a closed framework of teaching derived from historical sources, but rather an independent methodology capable of development in research and in content. In this sense, it is not a traditional system that only requires evaluation – rather, it presupposes that those who are therapeutically active continually learn and develop individual capacities.

This independent methodology of Anthroposophic Medicine becomes even clearer when we observe the soul being. Facial expressions are expressions and images of soul experience. They appear externally, of course, on the face, and are accessible to sensory observation. However, in their language of form and changes over time they show more than the physical human being who can be described using anatomical and histological methods. And observable changes in facial expression are not related to the changes in form that have to do with the development of the face from the embryo through childhood and into adulthood and that are connected to the activity of the etheric organization. Rather, facial expressions and gestures and their lively changes point to the human soul being. They appear as a “nonverbal language” that can be “heard” and understood. This gestural language plays a very important role in the patient-physician relationship: What is the patient’s posture like, his expression, his manner of speaking (loud or quiet, expressive or hesitant)? A person’s manner and appearance can be seen as a “language” that requires “learning to read”, methodologically speaking. Just as the content of a text points to more and is not identical with the chosen language or the ink itself, the soul being or astral organization of the human being points to more than just the physical and living appearance.

At this level of perception it is necessary to subordinate pictorial registering. We can only listen intently to another person if we are not distracted from the content of what she is communicating by her physical presence and facial expressions. It is only when we are able to “extinguish” the external perceptions that we can begin to understand the “inner world” of the patient. Whilst we tend to use the causal-analytical methodology of gathering knowledge in our daily life, in each form-like realization can be found the first, seed-like basis for imaginative knowing. If, instead of registering the form-like and pictorial context, we register that which is lawfully being expressed within it, the first foundations for inspired knowing develop (13).

To comprehend the beings of other people and of the world requires a fourth methodology of gathering knowledge. When we listen to a person, the spiritual content of the conversation is created for our common consciousness. This is obviously not yet identical with the being of the other person, which is only shown to us by her inner activity. If we follow her “train of thought” and in this way re-enact the activity of her being through our own activity, two intentional processes connect and combine. In this situation, there is no point in differentiating between the speaker and the listener as both activities unite in the mutually created content of the conversation or thought process. This inner attitude toward knowing, which requires letting go of our own intentions and selflessly engaging with the spiritual or mental activity of the other, connects our own being with that of the other person. Applied to understanding nature, this engagement connects our own understanding with the being of the world. This deepening process can also be taken step by step, leading from the first foundations of intuitive perception in the process of understanding daily life to the level of intuitive understanding of the real being of humanity and the world (13).

These four levels are essential for the patient-physician relationship: The person who is ill notices in a very differentiated manner how he is perceived and understood. Often, a findings-oriented view obscures understanding of the patient’s being and personality. Then, questions arise regarding the independence of a soul-spiritual being – regarding understanding of the human being. Do we recognize in the other person an independent entelechy or spiritual individual that is the bearer of autonomy and dignity, or do we see in the soul-spiritual qualities simply a surrogate or emergent neurophysiological phenomenon? The physician cannot circumvent this work toward understanding the human being. The quality and depth of this work have immediate effects on our daily practice, which is of a very different quality depending on whether the physician sees the patient as a complex mechanism which requires treatment or as a bodily-soul-spiritual being.

Four levels of illness: coronary artery disease

Four aspects of the concept of illness derive from the understanding of the human being described above. Coronary artery disease (CAD), with its typical clinical symptoms, refers to a coronary-morphological finding that consists of a stenosis of the coronary blood vessels. These are quantifiable, physical findings, distinct from the second level – the temporal dimension. Each coronary-morphological finding is also the result of a causal disease process that develops over time and cannot be described via the immediate findings. In the case of CAD, this disease process consists primarily of chronic inflammation that leads to arteriosclerosis. This is not the acute, warming febrile inflammation; it is the polar opposite – the chronic inflammation that leads to a sclerotic process. For a comprehensive description of the disease, we must now include the third, soul level. Multiple soul (mental/emotional) factors are known as influencing CAD (14, 15, 16). Anxiety and depression raise the risk, as do social isolation and a lack of biographical perspective. Treatments focused on pharmacological intervention and those which mobilize the salutogenic resources of the patient lead to very similar results (17). However, a pathogenically-oriented treatment “strategy” for CAD is currently favoured over salutogenic strategies both in what is offered to patients and in what is covered by insurance.

Treatment with pharmaceuticals can cause a regression of the disease, in that it leads the disease back into a manifestation of a previous stage of the illness. In this sense, the pathogenically-oriented treatment is oriented toward the past. The salutogenic treatment approach is future-oriented in that it supports the patient in changing her lifestyle and her inner soul-spiritual constitution, and allows her to have an active part in shaping her healing process. The pathogenically-oriented treatment focuses on influencing variables and risk factors – on a “causa externa” (Virchow). The salutogenic treatment concept, on the other hand, begins with the forces and resources of the human being that can be characterized as illness-overcoming, healing forces. “Healing consists of supporting that which is already present in the organism as intrinsic healing forces with external means.” (18)

And finally, the inner activity that can be called up to help shape the healing process points to the individuality, the human spiritual being. If its influence is unable to unfold, i.e. if a lifestyle marked by high levels of stress and a role-like functioning, shaped by external factors, has replaced an active taking hold of life by the individual, sclerotic diseases of the vascular system can develop. Then illness appears as a limited perspective of a patient’s future, and healing as development of a new openness to the future. For a comprehensive understanding of the illness, understanding the individuality of the patient is therefore necessary. Through these four perspectives, the patient feels that his whole being is seen and understood. A deeper quality of collaboration arises between the patient and physician, which can develop into a therapeutic relationship.

Therapeutic implications: cancer

The four levels characterized in the conception of the disease form the basis for a fourfold therapeutic approach. Thus, a mammary carcinoma diagnosed using medical imaging and a core biopsy requires a findings-oriented operative intervention on the physical level. In addition, this manifestation of a mammary carcinoma exists within the temporal dimension of a disease. Assuming a tumour diameter of 1 cm, and based on an assumed average volumetric doubling time of 100 days – the recorded extreme values for this are 23 and 209 days, respectively (19) –, the resulting tumour development span is approximately 10 years. A long segment of this person’s biography with many influence factors as yet unknown has inscribed itself on the organism. Inflammatory illnesses seem to have a special significance in this context. The inverse relationship of inflammation and carcinoma – Steiner mentioned it in 1920 (10) – has been noted for almost 100 years (20, 21, 22). It is important to note the dual character of inflammation: Whilst acute febrile inflammation presumably has a protective significance, chronic inflammation is a known risk factor for carcinoma. Based on these insights, a patient’s illnesses appear not as a random series of “malfunctions” that require correction, but rather as connected to each other and to the patient’s biography. Obviously, it is not unimportant if and how a patient underwent febrile illnesses, especially in childhood and the first half of life. Similarly, measures for “fighting” infection may not always be the most sustainably effective treatment approaches. Early on, Kienle differentiated between acute effects and longer-term effectiveness (23).

The inverse relationship of inflammation and malign disease fits into a process-oriented understanding of illness: A carcinoma, as epithelial neoplasia, develops on the surface structures of an organism that often invaginate the inside of the organism in the form of exocrine glands, such as the mamma or the gastrointestinal tract. From these surface structures, the carcinoma penetrates afferently as a malign infiltration, breaking through the basal membrane, infiltrating the surrounding tissue and finally metastasizing lymphatically as well as haematogenously. The opposite movement is found in inflammation: The inflammation process penetrates efferently outward, such as when a foreign body suppurates and is expelled from the body. If there is insufficient efferent inflammatory activity, encapsulation occurs as a foreign body granuloma. This example of process-oriented illness observation also shows the polarity between inflammation and carcinoma. And this has therapeutic implications: Steiner recommended a special preparation of whole-plant mistletoe extract for treatment of cancers. The goal, among other things, is to support the salutogenic reaction related to inflammation. Inflammatory, immune-stimulating and immune-modulating effects of mistletoe as well as apoptosis induction and neoangiogenesis inhibition have been documented in the intervening years; these are all aspects of its activity spectrum. Anthroposophic Medicine’s integrative treatment concept includes multimodal treatment options such as radiation and chemotherapy, antibody-based therapy, and use of tyrosine-kinase inhibitors   (TKI). In anthroposophic clinics, mistletoe therapy is initiated early on to complement surgery and pharmaceutical treatments. It has been shown to positively influence side effects associated with chemotherapy as well as cancer fatigue syndrome (24). In addition, it was recently shown to increase overall survival and improve multiple dimensions of quality of life in patients with pancreatic cancer as compared to “best supportive care” (25).

In accompanying patients with cancer, working on the soul level is indispensable and psycho-oncology is now widespread. In the patient’s soul life, reactive changes as a result of dealing with the disease and preexisting, potentially illness-specific issues mix. The significance of mental and emotional factors in relation to cancer has been mentioned and discussed, sometimes controversially, for many years. In the 19th century, London surgeon Sir James Paget expressed it like this: “The cases in which appearance or worsening of cancer follows deep-seated fears, unfulfilled hopes and great disappointments are so common that depression must be listed in those influences that promote cancer.” (26) Lawrence LeShan has further observations. Of the many subsequent studies, the prospective study by Brenda et al. (27), which found an increased incidence of cancer in elderly people with a history of longer-term depression, stands out. The review by Oerlemans et al. showed a small and marginally significant association between depression and overall cancer risk and a significant increase in risk of mammary carcinoma in patients with a history of longer-term depression (28). A meta-analysis by Satin et al. (29) on the prognostic significance of depression in cancer patients documented an association with mortality but not with progression of the disease. (However, only three studies could be included; in animal trials, corresponding relationships were documented (30).) In the Scottish Health Survey, psychological distress was associated with higher mortality in a multi-regression analysis (31). In their meta-analysis, Pinquart and Duberstein report that patients with symptoms of depression had a 20 % higher mortality rate as compared with patients without relevant symptoms of depression (32). Therefore, psycho-oncology does not limit itself to how patients deal with the disease; it has an important place in the context of a complete, multimodal cancer treatment.

The human soul experience can be visualized as a breathing process: a receptive soul attitude corresponds to a mental and emotional “inhale”, whilst expressive, externally-oriented soul activity corresponds to an “exhale”. For each person there seems to be an individual “breathing equilibrium”, which sometimes skews toward inhalation and sometimes exhalation. In accompanying patients with cancer, there is often the impression of increased “soul inhalation”. Much is taken in, and little is directed into the emotionally expressive “exhalation”. In this, we see that a person with cancer seems to develop an inward-directed soul gesture corresponding to the organic process of the disease, which contrasts with the soul “capacity for inflammation” as efferent activity (33). We can see this quality of receptivity/ perceptivity on many levels, similar to the quality of a sensory organ. For this reason, Steiner characterizes cancer as a “tendency to build sensory organs in the wrong place” (34).

The artistic therapies and eurythmy therapy that are a part of Anthroposophic Medicine can also be used to treat this third level of the illness to support the patient as collaborator in her treatment process. For example, if the patient is vulnerable – “thin-skinned” on a soul level – certain movements in eurythmy therapy can help build this “skin” and be a significant help. Painting therapy has also been assessed by patients as extremely helpful. The effectiveness of anthroposophic artistic therapies in various illnesses was documented in what is known as the Amos Study (35).

The fourth level of treatment has to do with direct meeting and conversation with the patient. Significant topics include the patient’s biographical situation, help in dealing with the current phase of the illness, and aspects of inner development through and with the illness. Illness is not only a result of a past process; it is also the “labor pains” of future development. Some patients in advanced stages of illness speak meaningfully of gratitude for their illness. They see its wearing and strength-robbing shadow side, but also the light to whose existence every shadow points. Some patients then ask about meditative work. The inner attitude that is described in the following poem by Christian Morgenstern (36), who was ill for many years, can become a source of strength in overcoming inner challenges:

Thou, wisdom of my higher self
which spreads its wings over me
accompanied me from the beginning
as was best for me, –

When ill-humor often challenged me:
It was the ill-humor of a boy!
The mature gaze of the man has
strength to rest on you with gratitude.

Du Weisheit meines höhern Ich,
die über mir den Fittich spreitet
und mich vom Anfang her geleitet,
wie es am besten war für mich, –

Wenn Unmut oft mich anfocht: nun
– Es war der Unmut eines Knaben!
Des Mannes reife Blicke haben
die Kraft, voll Dank auf Dir zu ruhen.

This concentrated activity of thinking can dissolve the brooding and circling of thoughts around recurring worries and lead to a deeper reflection and consciousness.

In addition to this meditative thinking activity, there are exercises that can be used for will development. Every physician knows the importance of an inner, positive will to heal. If a patient decides to “stop fighting”, deterioration often follows, and sometimes death. For this reason, a mood that opens perspectives but is also free of illusions is crucial in the patient-physician relationship, as this relationship accompanies each step in overcoming an illness. In this context, Rudolf Steiner speaks of the important and fundamental relationship between therapeutic engagement, the “will of a healer”, and the patient’s will to heal.

A next step in meditative practice relates to feeling. The life of a person with cancer is almost always marked by an intense dynamic of sensations and emotions that fluctuate between fear and worry, e.g. before an examination for restaging, and relief and hope when results are negative and joyous. The patient experiences the tension between resigned self-abandonment and illusionary misjudgements of his illness situation. This standing at the edge of the abyss with a constant, existentially experienced threat requires great strength in order to achieve the necessary inner calm and level-headedness. One exercise trains the attention to the positive which arises through the illness. Sometimes it is a positive development that gives strength, sometimes the deepening relationship to people around the patient that achieves new intensity. Or it is inwardly noticeable developmental steps that develop as fruits of the illness. Even in palliative and hospice care, we notice impressive steps in self-realization that no longer focus on a professional or other role but rather develop the authenticity of the personality.

Finally, the oft-asked questions regarding the prognosis in the different stages of the disease require a special way of engaging patients in an unbiased fashion that is capable of placing the individual progress in the context of a statistically expected life expectancy. The key task is having found one’s own way, recognizing its purpose and knowing it to be in harmony with one’s values. It is important not only to have found something “effective”, but also to recognize it as “good” and as corresponding to one’s preferences. The direction of this path then provides security even if its length is unknown.

These challenges relate to exercises that Rudolf Steiner described in a more comprehensive text as developing the “six characteristics” (“sechs Eigenschaften”) (13, 18).

In patients with cancer, questions of death and dying must be dealt with. Here, it is important to connect with the patients’ personal views and values and reflect upon them together in conversation, and to meet them with our own experience from many years of accompanying patients with cancer. Topics such as the near-death experiences researched in the remarkable study by Pim van Lommel et al. (37) can help the patient, who is still a future-oriented human individual, to develop new perspectives. In view of the above-characterized conception of the human being, finiteness is related to the physical level but not to the living, soul and spiritual being of a person. These various levels of being each have their own path of development. If we recognize the physical body as an instrument that serves the individual and allows him to appear in this world, we can see that the discontinuation of this instrument does not cause its user to cease to exist. Rather, the idea of a new realization in a new instrument can arise, as described by the 23-year-old Benjamin Franklin as follows in an epitaph for his future gravestone: “The body of B. Franklin, Printer (Like the Cover of an Old Book, Its Contents torn Out And Stript of its Lettering and Gilding) Lies Here, Food for Worms. But the Work shall not be Lost; For it will (as he Believ’d) Appear once More In a New and More Elegant Edition, Revised and Corrected by the Author” (38).

These “six characteristics” are not only for the patients, they are just as important for the attending physician: Concentration in thinking and conversing, therapeutic engagement in the sense of a will to heal, empathy as the culture of relationship building, recognizing the positive in the course of the illness, and finally, unbiased perception of each patient in his individual situation, are the pillars of the patient-physician relationship and require from the physician not only informational competence, but also inner development.

Development in illness

In his “Spirit Warrior”, Barlach created a sculpture that expresses the human ability to overcome illness. That which is not yet human but “animal-like” is not overcome by battle, but rather by the calm gestures of the angel-like figure that seems to lack any violence. Medicine has learned to suppress illness – to “block” it or antagonize it, but not to transform it. In the salutogenic forces of confronting illness, the human being can develop transformative strength in the physical, the vital, the soul and the spiritual, and through these can achieve a new step on her individual developmental path. From this perspective, illness has a close relationship to the spiritual being of a person, with her entelechy. Novalis speaks to this with the words, “The ideal of perfect health is only scientifically interesting: illness belongs to individualization.” (39)

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