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The Nature of Healing: The Modern Practice of Medicine

by Eric J. Cassell. New York, Oxford University Press, 2013, 272 pp., $49.99.

Reviewed by Nicholas Kontos, M.D.
Am J Psychiatry 2014;171:122-123. doi:10.1176/appi.ajp.2013.13030429
View Author and Article Information

The author reports no financial relationships with commercial interests.

Boston, Mass.
Dr. Kontos is Assistant Professor in the Department of Psychiatry, Harvard Medical School, Boston.

Accepted April , 2013.

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Tremendous amounts of time, energy, and ink (perhaps less ink these days) have been expended in the pursuit of a more “human” approach to medical practice. Familiar names associated with this quest, such as Michael Balint and George Engel, are proudly claimed by psychoanalysis. However, with no direct connection to any mental health field, Eric Cassell may be the most influential living advocate for compassionate, well-rounded doctoring. Perhaps best known for the various iterations of his book The Nature of Suffering and the Goals of Medicine, Cassell’s work spans decades and has contributed to the education of generations of physicians. His latest book, The Nature of Healing: The Modern Practice of Medicine, has the feel of a summation of that work and also of its evolution and extension.

A psychiatrist approaching this book might wonder what it has to offer someone in our field. It is easy to assume that the very basis of psychiatry grounds it in the appreciation and deft handling of humanity’s passions and pains or that the field’s historical trajectory is sufficiently askew relative to the rest of medicine that it buffers us from the alleged technological monomania that afflicts other doctors. Of course, in reality, psychiatry has the same vulnerabilities as the rest of medicine—the same tendencies toward overenthusiastic diagnosis and treatment, skeptical remove, philosophical rigidity, and idealistic indulgence. There is good and bad doctoring to be found in every physician in every specialty, and any differences found in psychiatrists are more likely to be of style than of substance. The Nature of Healing thus warrants our curiosity.

Dr. Cassell locates the substance of good doctoring in removing impediments to patients living their chosen lives. In this scheme, disease is the physician’s focus but no more so than is the restoring or fostering of patients’ functioning in the service of their life goals. If this sounds like another walk down the well-trod path of “patient as person” medicine, then it is, but only to a degree. The unifying theme of The Nature of Healing is indeed that of “whole person medicine,” but the difference here is Cassell’s methodical construction of that enterprise. This is an iterative book that first establishes the author’s conceptions of sickness, personhood and patienthood, functioning, and healing before moving on to discussions of how an appropriately concerned physician addresses these things.

Cassell grounds his activities in the restoration of patients’ functioning. In doing so, he embraces definitions of functioning that involve the “achievement of goals or the realization of purposes” (p. 52). Hence, elucidating “limitations (of functioning) is a diagnostic act of clinicians and remediating them is a part of therapeutic activity” (p. 53). Dovetailing with this formulation of functioning is a not surprisingly insightful treatment of the topic of suffering, which Cassell carefully distinguishes from symptoms by linking the former to the personal meanings that people assign to their sickness experiences. One could argue the absolutism of his claim that one can only suffer from pain (or any other symptom) through the meanings one attaches to it. However, even a more measured approach to suffering through this lens opens up clinical opportunities to confront the protean and profound ways in which concretely conceived diseases express themselves in existentially situated persons.

For psychiatrists, the opportunities for engagement and intervention Cassell describes are open regardless of the frame in which one works, rooted as they are in one’s identity as a physician rather than as a “psychotherapist” or “psychopharmacologist.” Considering Cassell’s ideas invigorates the role of the psychiatrist, both in patient care and in relation to medicine at large.

That said, in this book, Cassell demonstrates a sometimes disquieting attitude toward psychiatry. While he appropriately warns against pathologizing distressing feeling states, his positing that “diagnostic words, especially psychological diagnoses, mostly obscure the problem” (p. 135) seems a simplistic and uninformed way to emphasize the point. Among the many valuable case discussions in The Nature of Healing, not a single one involves a patient with a primary psychiatric diagnosis. When one patient’s physician hastily misdiagnoses her with anorexia nervosa, the mistake is not called a mistake but rather an act that “derogated the patient” (p. 122). The benefits of this book for psychiatrists are many, but sometimes they must be extrapolated.

Another unfortunate drawback of The Nature of Healing is its employment of the standard tropes of other holistic works to prop up its argument. The usual suspects of specialization, materialist science, technology, and an almost willfully narrow-minded majority of physicians are invoked throughout the book as reasons that the kind of care it advocates has difficulty gaining traction. Ironically, these incompletely substantiated assertions are unaccompanied by mention of other social trends, economic realities, and very human desires involved. Further, the open-ended nature of “whole person care” is strongly advocated but without acknowledgment that there are legitimate, nonreductionist arguments for there being restrictions on the scope of clinical medicine.

While its shortcomings must be acknowledged, there is more baby than bathwater in The Nature of Healing. This uncommonly practical book on good doctoring conveys an abundance of clinical wisdom in a form that guides its own implementation. Cassell’s enthusiasm for the work might also inspire readers to develop their own professional wisdom and relish working in a field that affords the chances to do so.

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