Inner development

Medical work requires ethical capacities and an ability to work with people, in addition to professional medical competence. It is not just ethical guidelines and principles that are needed, people working in the healing profession need to be able to find the “good” in their treatment, together with their patients. While professional competence involves knowing the evidence about therapeutic efficacy, ethical competence is a moral attitude that asks about values, meaning and the spiritual dimensions of therapeutic decisions.

In Anthroposophic Medicine, patients and therapists combine the healing process with work on inner development. A therapist can only meet a patient competently if she has relationship skills and ethical-spiritual capacities in addition to professional skills. For a long time now, the study of medicine has only required a preliminary medical examination and no longer a preliminary philosophical examination. As a result, patients are seen only in a scientifically describable context and are provided with treatment based solely on this. Inner development and its connection to healing has been lost and only in the last 30 years or so is it gradually becoming more interesting to science again.

Even more remote has been the importance and necessity of inner ethical development. But here, too, new perspectives are emerging. It is becoming increasingly clear that the inner attitude of therapists and doctors is an effective factor in the treatment process. Much of what was previously dismissed as the placebo effect has now been researched as describable efficacy (1). After the shadow cast by a strictly neurologic-biologic approach to the human being, which was largely the result of a one-sided interpretation of experiments by Benjamin Libet, there is now more emphasis on self-determination and innate capacities. On the one hand this calls for the development of the self or “I” as an independent dimension of being, on the other hand it has a direct influence on health, interpersonal relationships and the quality of our actions (2).

Six qualities

Six qualities are decisive for professional encounters with patients. They have been described in detail by Rudolf Steiner (3, p. 329–337, Engl. p. 301–316) and they also represent an essential foundation for health professionals who are pursuing a meditative path of knowledge.

Concentration

How, for example, do we shape a particular conversation with a patient? Is it primarily fact-oriented, or does it have a strong associative element? Does the physician let himself be disturbed by other things, e.g., telephone calls, which signal to the patient (apart from distractedness) the high value  the physician attaches to this phone conversation, but indirectly demonstrating the lesser importance of the time with the patient? The exercise of thought control can bear rich fruit here and helps to transform time-consuming superficial conversations into concentrated ones that get right to essentials. This quality can be learned through concentration exercises focusing on simple objects and topics. New thoughts and insights can arise in such spaces of concentrated attention. Nietzsche formulated the idea that thoughts come when they want to. However, they do not come without an effort being made to address a certain topic or task. It is true that numerous outstanding inventions and discoveries have come suddenly “in the blink of an eye”, but such a “birth” is always preceded by a “pregnancy”, which consists in conducting an intensive examination of the subject. The space of concentrated attention in conversation with a patient is a suitable “birthplace” for new insights and perspectives.

“Thinking must teach itself inner stability and the ability to stick strictly to one subject. For this reason, the appropriate ‘thought exercises’ we undertake should not deal with unfamiliar and complicated objects, but with ones that are simple and familiar. Over a matter of months, if we can overcome ourselves to the point of being able to focus our thoughts for at least five minutes a day on some ordinary object (for example, a pin, a pencil, or the like), and if, during this time, we exclude all thoughts unrelated to this object, we will have made a big step in the right direction (3, p. 330–331, Engl. p. 311). You can think of a new object every day or stay with the same one for several days. 

Developing will

The same applies to the will exercise. It starts with seemingly external things. How often have you perhaps promised a patient that you would come back to his room in the evening or offered him a conversation in your practice and then simply forgotten about it for many understandable reasons! From the point of view of the patient, who may have waited a long time for this talk, the disappointment of not meeting calls the quality of your commitment into question. Doing what you have decided to do and following through on it is a very distinctive fruit of the will exercise. It also leads to a strengthening of your therapeutic commitment, and of your will to heal. This kind of therapeutic will is decisive for therapeutic relationships. The patient in turn responds with inner, health-generating forces and can continue onward, inwardly strengthened.

“For the sake of higher training, we must get used to strictly obeying our own commands. If we do this, we will become less and less inclined to desire nonessentials. Dissatisfaction and instability in our life of will, however, are based on desiring things without having any clear concept of realizing these desires. This dissatisfaction can disrupt our entire mental life when a higher I is trying to emerge from the soul. A good exercise is to tell ourselves to do something daily at a specific time, over a number of months: today at this particular time I will do this. We then gradually become able to determine what to do and when to do it in a way that makes it possible to carry out the action in question with great precision. In this way, we rise above damaging thoughts, such as: ‘I’d like this, I want to do that,’ which totally disregard the feasibility of what we want.” (3, p. 331–332, Engl. p. 312)

Developing feeling

Developing our feelings is also crucially important. The aim of this next exercise is to give “humane” expression to our dynamic emotional life. Every therapist knows patient communications that arouse either sympathy or antipathy. If a patient presents certain topics repeatedly and in the same detail, then impatience, anger and other emotional reactions can arise. These are humanly understandable, but the listener is then more self-occupied (experiencing his or her own emotionality and impatience) and less with the patient. In this respect, perception becomes “blinded”. Conversely, when we experience the patient’s situation in an active way it can reveal new information and messages. “It is only with your heart that you can see rightly,” Antoine De Saint-Exupéry wrote (4). Feeling can turn “inwards”, when the listener lives into his own emotional world, or orientate itself outwards like a sense organ to perceive the patient and become aware of other messages. In hospitals we like to speak of having a “gut feeling”: when considering our findings and the patient’s communications, we develop a suspicion or conviction that the clinical picture could relate to more than what was previously suspected. When a patient  reports pain in her back, her impaired general condition with weight loss and anemia will not point to an orthopedic problem but speak “a different language”. A study of palliative care shows that this “gut feeling” correlates well with a patient’s survival time. When the question “Would you be surprised if this patient died in the next 12 months?” was answered by general practitioners with ‘No’, then the hazard ratio for the actual occurrence of death during the year for these palliative care patients was 6.99 compared to the ‘Yes’ group (5).  This “gut” question thus seems to result in an assessment that often corresponds to clinical realities (though of course further evaluation is still required) (6). Our overall perception of the patient in terms of her general condition, with her verbal messages and our medical findings does result in an assessment, an “inkling” of her prognosis. In many patient encounters, this presentiment arises at several different levels when listening. It then has to be evaluated in order to become a guide for action. The search for a diagnosis, or more generally for knowledge, can be preceded by such a prescient feeling. Even in mathematics, a presentiment of a lawful connection often develops first, which then has to be proven. Steiner called it “healthy intuition”.

To develop a feeling of composure in the soul, “the soul must master its expressions of joy and sorrow, pleasure and pain. There are many prejudices that become evident with regard to acquiring this particular quality. We might imagine that we would become dull and unreceptive to the world around us if we are not meant to empathize with rejoicing or pain. However, that is not the point. The soul should indeed rejoice when there is reason to rejoice, and it should feel pain when something sad happens. It is only meant to master its expressions of joy and sorrow, of pleasure and displeasure. With this as our goal, we will soon notice that rather than becoming dulled to pleasurable and painful events in our surroundings, the opposite is true. We are becoming more receptive to these things than we were previously. Admittedly, acquiring this character trait requires strict self-observation over a long period of time. We must make sure that we are able to empathize fully with joy and sorrow without losing ourselves and expressing our feelings involuntarily. What we are meant to suppress is not our justified pain, but involuntary weeping; not our abhorrence of a misdeed, but blind rage; not alertness to danger, but fruitless fear, and so on.” (3, p. 332–333, Engl. p. 313–314)

Positivity

The fourth quality, positivity, has to do with restricted perception through emotional reactions and rejection: distance is created, and our perception of the patient is restricted when we feel disgust with the medical findings or reject unpleasant and negatively evaluated things that we hear in conversation. This can conceal essential information or positive developments. The finding of progressive tumor disease can signal powerlessness and helplessness and lead to hopelessness. This can obscure our view of positive inner development that may be occurring. Sometimes we observe admirable processes of development in the way that a patient deals with a disease—such as inner resourcefulness and a new security and outlook, even in the face of dying and death. The overriding message of tumor progression can obscure our view of the patient’s underlying development. Steiner called this quality positivity, which means to have an open sense for actual positive things. It must not be confused with the “whitewashing” of facts.

“The erroneous, the bad, and the ugly must not prevent the soul from finding the true, the good, and the beautiful wherever they are present. We must not confuse this positivity with being artificially uncritical or arbitrarily closing our eyes to things that are bad, false, or inferior. […] We cannot consider bad things good and false things true, but we can reach the point where the bad does not prevent us from seeing the good and errors do not keep us from seeing the truth.” (3, p. 334–335, Engl. p. 315)

Open-mindedness

Finally, we require open-mindedness in our encounters with patients, a constant readiness to learn something new and, for example, to refrain from holding on to the old without justification. Every clinical observation of a patient requires the practice of open-mindedness and the willingness to discover something new. Preconceived opinions hinder an unbiased view. Previous diagnoses can also lead to bias in our perception of patients.

“If we are ready and willing to take previously unaccustomed points of view, we can learn from every current of air, every leaf, every babbling baby. Admittedly, it is easy to go too far with regard to this ability. At any given stage in life, we should not disregard all our previous experiences. We should indeed judge what we are experiencing in the present on the basis of past experiences. This belongs on one side of the scales; on the other, however, students of the spirit must place their inclination to constantly experience new things and especially their faith in the possibility that new experiences will contradict old ones.” (3, p. 335, Engl. p. 316)

Equanimity, harmonious balance between the qualities

These five exercises are not only “études” for the patient-doctor relationship (which can be supplemented by further exercises) they form a living whole in which the sequence of exercises is also important. For this reason, the sixth exercise refers to the harmonious composition of the qualities practiced. An ability to concentrate, for example, does not yet mean that the doctor has sufficient openness for the patient’s communication when listening. Conversely, cultivation of open-minded perception towards the other person does not necessarily go hand in hand with sufficient mental ability to concentrate. In this respect, a sixth exercise is needed, which focuses on the harmonious development of this organism of abilities. It consists in simultaneously practicing two exercises at a time in different combinations to bring about harmony (3, p. 336).

“We have now listed five soul qualities that students in a genuine spiritual training need to acquire: control of one’s train of thought, control of one’s will impulses, composure in the face of joy and sorrow, positivity in judging the world, and receptivity in one’s attitude toward life. Having spent certain periods of time practicing these qualities consecutively, we will then need to bring them into harmony with each other in our souls. We will need to practice them in pairs, or in combinations of three and one at the same time, and so on, in order to bring about this harmony.” (3, p. 336, Engl. p. 316).

Through these exercises our relationships with patients deepen. These exercises train our ability to listen to and understand the other’s being. They leave behind the level of external medical findings and communications and step by step cross the threshold to the other human being. His or her intentions, inner values and being shine forth to us. Without this training, much remains in the dark, we “sleep through” many implicit and explicit communications. Conversely, these exercises can lead to an “awakening” to the soul and spirit of the patient and thus to a deepened patient-doctor relationship. Steiner called it “awakening through the soul and spirit of the other human being” (7, p. 116)

These six exercises can be practiced by people in all therapeutic professions. The patient goes through existential challenges on the way through illness and often arrives at impressive steps in development. She can expect that the members of the medical profession accompanying her will also strive for development and, in addition to their professional skills, will learn therapeutic relationship management and ethical competence in listening.

1 Kienle GS. Der sogenannte Placebo-Effekt. Illusion – Fakten – Realität. Stuttgart: Schattauer Verlag; 1995.

2 Bauer J. Selbststeuerung. Die Wiederentdeckung des freien Willens. Munich: Karl Blessing Verlag; 2015.

3 Steiner R. Die Geheimwissenschaft im Umriss. GA 13. 30th ed. Dornach: Rudolf Steiner Verlag; 1989. English translation: Steiner R. Occult science. Great Barrington: Anthroposophic Press; 2009.

4 de Saint-Exupéry A. The little prince. 1st ed. Boston: Mariner Books; 2000.

5 Moroni M, Zocchi D, Bolognesi D, Abernethy A, Rondelli R, Savorani G, Salera M, Dall’Oio FG, Galli G, Biasco G on behalf of the SUQ-P Group: The ‘surprise’ question in advanced cancer patients: a prospective study among general practitioners. Palliative Medicine 2014;28(7):959–964. DOI: https://doi.org/10.1177/0269216314526273

6 White N, Kupeli N, Vickerstaff V, Stone P. How accurate is the ‘Surprise Question’ at identifying patients at the end of life? A systematic review and meta-analysis. BMC Medicine 2017;2;15(1):139. DOI: https://doi.org/10.1186/s12916-017-0907-4.

7 Steiner R. Anthroposophische Gemeinschaftsbildung. GA 257. 4th ed. Dornach: Rudolf Steiner Verlag; 1989. English translation: Steiner R. Awakening to community. Great Barrington: Steiner Books; 1975.