Contributions of Systems - Theory to the Understanding of Therapy and Health Georg Ivanovas, Milatos Doctoral thesis at the University of Crete Medical Faculty Under the guidance of Prof. Nikolaos Paritsis Promoters Vlassis Tomaras, Athens Vassiliki Papadioti, Ioannina Georg Ivanovas – Contributions of Systems-Theory to the Understanding of Therapy Content Acknowledgement 6 Introducing aphorism 8 1. Introduction 9 2. Medical Paradigm and the Anomalies of ‘Normal Medicine’ 1. The medical paradigm 17 a) the trivial concept of medicine 18 b) measurements without semantics 25 c) the autistic-undisciplined thinking in medicine 26 d) causal connections 28 e) deficient maps 35 f) generalization and individualization 41 g) the practitioner’s paradox 43 2. Perception and Intervention 45 3. The Psychosomatic Confusion 57 a) the Cartesian split 58 b) minor concepts 60 c) mind as a kind of ‘soul’ 60 d) mind as brain function 61 e) mind as inner experience 63 f) mind as behaviour 64 g) conglomerates 65 h) environment and its limits 66 i) comorbidity and the psychosomatic complex 67 j) conclusion 69 4. The Placebo Effect 69 a) the placebo effects and their paradoxes 71 b) the semiotic approach 74 c) formalisation of the placebo effect 76 d) systems approach and individualisation 79 5. The Limits of Evidence Based Medicine 80 a) the human factor 80 b) evaluation and validity 82 c) validity and the consequences for practice 82 d) lack of significance and predictability 83 e) time and process 85 f) surrogate parameter 86 g) rare side effects 86 h) arbitrary causalisation 88 i) conclusion 90 2 Georg Ivanovas – Contributions of Systems-Theory to the Understanding of Therapy 6. The Magic of Reference Values 91 7. The Meaningless Value 94 8. Complexity 95 a) the non-trivial nature of nutrition 95 b) the bacterial flora 99 c) the viral flora 105 3. Epistemological Fundamentals 1. Formal Logic – Syntax and Semantics 112 2. Russell, the Paradox and the Therapy of Diseases 114 3. Gödel, the Blind Spot and the Illusion of Completeness 118 4. Heinz von Foerster’s Decidable and Undecidable Questions 121 5. Gotthard Günther’s Polycontextural Logic 123 6. Bateson’s Frame and Content 128 7. Watzlawick and the Communication 131 8. Korzybski’s Map and Territory 134 9. Peirce, Semiotics and the Magic of Medicine 135 10. Thomas Kuhn and the Paradigm 139 4. Systemic Basics 1. Signal and Information 143 2. Recursivity and Self-Fulfilling Prophecies 149 3. Higher Orders of Learning 158 4. Cybernetic Cycles 165 5. Trivial and Non-trivial Machines 166 6. Second-order Cybernetics in Medicine 168 7. Systems Theory 178 8. Autopoiesis 185 a. neurophysiology and the funnel of Nuremberg 188 b. the biochemical system and psychoactive drugs 189 c. the visce-neuro-muscular system 193 9. Patterns 195 10. Emergence 198 11. States and the Nature of Change 200 3 Georg Ivanovas – Contributions of Systems-Theory to the Understanding of Therapy 5. Observational medicine and systemic approaches 1. CAM and Observational Medicine 209 2. Systemic psychotherapy – from causes to solutions 213 a) structural psychotherapy 217 b) strategic psychotherapy 219 3. Hippocrates – rhythms and logic 223 a) poise and inflammation 224 b) critical days and chronomedicine 226 c) the logic of the process 229 d) processual diagnosis 232 e) changing the operator 233 4. Balneology and the Beauty of Dignity a) from pleasure to specific treatment 234 b) beauty and dignity – the ‘placebo’ of human values 241 c) hydrotherapy as structural intervention 243 d) inner cleansing and the experimental setting 244 5. Homeopathy, Observation and Research in Chronic Disease 246 a) chronic disease and miasms 248 b) atopic disease and psora 250 c) atopic disease and inflammation 252 d) other miasms and epigenetical influences 254 6. Acupuncture – Circular Relations a) from systemic thinking to barefoot medicine 255 b) analogical and semiotic thinking 257 c) the missing distinction between cause and effect 260 d) the relational aspect and circular organization 262 7. Efficacy of CAM – the Methodological Problem 264 6. Towards a systemic medicine 1. The Necessity of a Systemic Medicine 272 2. From Specific Disease to Network Pathologies 276 3. Regulation and Disease 278 4. Robustness and rigidity 279 5. Central and Distributed Control 284 6. Hardening 286 7. Network Pathologies 289 8. First Order Therapy and the Concept of Suppression 290 9. Second order therapy is change 293 4 Georg Ivanovas – Contributions of Systems-Theory to the Understanding of Therapy 10. Stimulus and Reaction – the Arndt-Schulz’ Rule 295 11. Initial Deterioration 297 12. Biological Hierarchies and the Individual Prognosis 299 13. Control and Requisite variety 303 14. The Therapeutic Attitude 312 Closing aphorism 315 Appendices I. Advice to young doctors of the BMJ's editorial board 316 II. Celsus: On medicine 318 III. The Viet Nam Veteran - a Case of Milton Erickson 322 IV. Genetical Behaviourism 327 V. A Schismogenetic Case 336 VI. Biological Hierarchies in CAM 338 References 342 Abbreviations 400 Biographical Note 401 5 Georg Ivanovas – Contributions of Systems-Theory to the Understanding of Therapy Acknowledgement This thesis is a work of many limitations. Only two shall be mentioned. Firstly, I wrote it in a foreign language. For me it had a positive effect. It made me aware of inconsistencies in my reasoning which I usually cover with a figure of speech using my mother language. This is a common tendency. We all conceal our logical gaps with certain locutions believing that thereby things are sufficiently explained and/or proved. But often, too often, this is not the case. This might be one of the reasons why Beckett, who aimed for an absolute precision in his works, did not write in his mother language. Whereas it had been of some benefit for me to use a foreign language, I am well aware that this is no longer true for an eventual reader. A second limitation is the amount of subjects dealt with. As it is already difficult to be an expert in only a sub-category of any of them, it would be presumptuous to make valid statements about all of them. The scale of issues necessary to create a picture of the systems view in medicine is beyond the possibilities of a single person not affiliated to a university. Hence, a lot is only superficially touched, and many conclusions are but provisional. Moreover, mistakes are unavoidable. But, as said in the introduction, the aim of this paper is not to provide a definite content. Its aim is to reflect on the strategies we use to come to conclusions. Anyhow, I hope the text might be of some use for a reader, especially as controversial statements are often more helpful to specify the own view than well-balanced considerations. I came across the subject during an advanced training in systemic psychotherapy by Prof. Nikolaos Paritsis at the University of Crete (Greece). The theories and strategies of the early proponents of systemic psychotherapy changed my understanding of the world within a few months. All of a sudden, everything in the realm of medicine became meaningful to me. Consequently, I proposed Prof. Paritsis this thesis about the application of systemic principles to the subjects of general medicine. This was in the year 2000. Many people supported this work during all these years. First of all, Prof. Paritsis who provided me with a totally new view of the world and went with me through all the sections of this thesis. Secondly, Prof. Vlassis Tomaras, the second appointed 6 Georg Ivanovas – Contributions of Systems-Theory to the Understanding of Therapy professor for this thesis. He helped me in many publications and was really concerned to get this thesis defended. Thirdly, Prof. Vassiliki Papadioti had been incredibly supportive and caring. She helped me to overcome several major obstacles. For some time, I had a lot of fertile, although controversy discussions with Prof. Fritz B. Simon. He had been assigned as the third professor, at first. But a new law prohibits non- Greek scientists to be in charge of a Greek PhD. I thank all the persons who reacted to my emails, provided me with articles, answered my questions, or just listened to me. This concerned especially my guests who had a hard time. They had to endure endless discussions. This is particularly true for Haik Petrossian who accompanied the project and inspired me in many ways. Rebecca Eberlein (fromer Ewert) taught me some basics of Chinese medicine and the related chapter is mainly hers.1 Thanks to those persons who made some attempt to correct my English. I am especially grateful to Gisela and Gerhard Beckmann. Without their support this work would not have been possible. My children grew up during this decade and often, too often, my time and my creativity for them had been restricted. It was a typical value decision. I still do not know, whether it was the right one. Milatos, Crete, July 2010 This work is dedicated to Nikolaos Paritsis and to all teachers extending the understanding of their students. 1 Ewert R, Ivanovas G (2005): Systemic thinking and Chinese medicine – a relational exercise, 3rd Panhellenic Conference on Systemic Therapy, Heraklion, Crete 21.-23.10.2005 7 Georg Ivanovas – Contributions of Systems-Theory to the Understanding of Therapy Life is short, the Art long, opportunity fleeting, experiment treacherous, judgment difficult Hippocrate, Aphorismes (IV: 99) 8 Georg Ivanovas – Contributions of Systems-Theory to the Understanding of Therapy 1. Introduction When I started this thesis in the year 2000 it was a pioneering work. Systemic ideas in medicine were practically non-existent. This was slowly changing when the work was first finished in 2005. From that time on articles on systemic biology and medicine mushroom.