Healing Circles: An Ethnographic Study of the Interactions Among Health and Healing Practitioners From Multiple Disciplines

Abstract

“Healing circle” is a term that has been employed by a group of Northern California integrative medicine researchers as we embarked on an 8-year ethnographic study. As a clinical medical anthropologist and registered nurse specializing in integrative practice and behavioral health, I undertook this study with colleagues from various health disciplines.

WHAT IS A HEALING CIRCLE?

“Healing circle” is a term that has been employed by a group of Northern California integrative medicine researchers as we embarked on an 8-year ethnographic study. As a clinical medical anthropologist and registered nurse specializing in integrative practice and behavioral health, I undertook this study with colleagues from various health disciplines.

The Healing Circle is a 2-hour, deep listening–and-exploring session with a volunteer client and several health practitioners from different medical and health disciplines, at one place, at one time. The client is typically someone with a history of coping with chronic conditions with little relief from conventional means. A circle is used because it is the geometry of ease and resonance, enhancing the collaborative, leader-less, democratized standing among the disciplines, which normally have been beset by long-standing politics of medical ascendancy and dominance. Healing circles provide an opportunity to sidestep the politics of difference while we recognize and gain new multidimensional knowledge in coming together.

The circle brings together about six to eight different medical or healing disciplines with the intent of providing the client a streamlined way of hearing what various healing modalities (eg, allopathy, ayurveda, naturopathic medicine, chiropractic, somatic/body-work, psychotherapy, subtle energy medicine, nutritional therapy, shamanism, traditional Chinese medicine [TCM], expressive arts therapy) have to offer in terms of information, support, relief, approaches, diagnostics, treatments, or cures.

One practitioner serves as the client-advocate (or patient navigator/facilitator). He or she takes an assertive role in facilitating the discussion. She may ask for a moment of silence or interrupt the process if the discussion or energy takes on an overwhelming or confrontational tone. She may ask some practitioners (who may be talking a lot) to recede a bit with their offerings, and others, who have not spoken yet, to come forward. The facilitator must be skilled in group dynamics and interpersonal communication within a circle of confident practitioners with healthy egos. Serving the client and being aware of his or her ability to take in the information is foremost in the facilitator's awareness. Circles run the risk of information overload, and the facilitator can bypass this overwhelm with requests for pauses or some deep breaths and more awareness (not over-talking, not interrupting, not withholding).

Practitioners in the circle are reminded to address the healthcare needs of the client, communicate with respect and dignity, and abide by the ethics and values of their respective professions. Attention is also paid to honoring a multiplicity of views, and representing and reflecting cultural diversity within circle members for the client.

WHY WERE HEALING CIRCLES INITIATED BY RESEARCHERS?

The Healing Circle serves many purposes. The presence of many disciplines in one place, at one time, is a time-saving convenience for individuals seeking solutions. Our options today in a world of complementary therapies are often confusing, especially for someone who is burdened by chronic ailments, and often at the limit of energy and expenditures.

Circles are also a cost-saving convenience. There is no charge for the circle as it is an experimental model of integrative medicine and no treatment is undertaken. In addition, the cost for all these practitioners in one place would be exorbitant.

Circles are also an energy saver. Clients with multilayered, complex chronic disease are often fatigued and frustrated and have a growing sense of despair or hopelessness. They are weary from a long journey of exploring the confusing array of complementary, alternative, and integrative medicine options. They have often embarked on this as a solo journey and feel isolated and desperate. The Healing Circle provides an opportunity to engage in a communal form of inquiry that can support the client's ongoing search with a highly efficient gathering, in one place, at one time, with many disciplines present.

The Healing Circle also gives the client an opportunity to witness a cross-dialog between practitioners of such widely different philosophies that an interesting turn occurs when conflicting opinions arise. Circles have occurred in which clients have sat back and said, “Well, I'm glad to see you two work out your differences here. Imagine what it's like for me alone when I hear one approach from one doctor and the opposite recommendation from another.” Although those contentious moments are rare, they can occur and even be helpful.

More often, practitioners tend to agree about what may be most helpful, and this again creates some resolution and harmony for the client. For instance, in one circle, the client was interested in pursuing an herbal remedy for chronic headaches and neck pain, and the herbalist said that he didn't think his approach would be as worthwhile for neck aches as the chiropractor's body-manipulation approach. The client was surprised at the way the herbalist conceded to another approach and felt grateful that she was going to save herself some time, money, and effort. As such, circles are a ground-floor experiment in collaborative practice and communication among inter-professional practitioners.

In more than a decade of recording the interactions in multidisciplinary circles, I've found that a sort of “Rosetta Stone” began to be revealed in the way various disciplines viewed certain chronic conditions. The Rosetta Stone was remarkable in the way three scripts (Ancient Egyptian hieroglyphs, Demotic scripts, and Ancient Greek) were carved into the stone, telling the same story. Created in 196 BC in Egypt, it provided the first clue to the modern understanding of Egyptian hieroglyphs in 1799 when it was discovered.¹

In Healing Circles, sometimes the TCM doctor states the client may have a “yin deficiency” just as the Ayurveda practitioner talks about a “dominant kapha,” and at the same time, the naturopathic medicine physician suspects a mitochondrial dysfunction. As these remarks start to converge, they point to a recognition of areas in which there may be agreement about the underlying processes that led to poor health in the first place (what the functional medicine matrix would consider environmental inputs acting on genetic predisposition), even when a discipline's language, ontology, and epistemology varies widely. The converged territories hint at certain dynamics (flow, blockage, excess) that the various healing disciplines may have in common but treat with different tools (drugs, surgery, herbs, diet, biomechanical manipulation).

QUALITY OF PRESENCE

One of the most important aspects of the Healing Circle is the quality of presence and active listening by the practitioners. Empathetic, non-judgmental, client-centered listening is the hallmark of the Healing Circle process. The facilitator generally guides the process along, gives effective feedback when needed, and later with the client, co-creates a plan of action. The entire two-and-a-half–hour session is recorded, and the client is given a CD copy. The facilitator makes an appointment within 3 days and reviews any questions the client has and then delves into a conversation that serves both to debrief the session and to develop the action plan.

The plan consists of the client's desires about whom (which practitioners) they would like to see or work with, in what order, and when. It is completely up to the client to make those appointments, but the facilitator ensures the client has the contact information. Sometimes the client wants to see someone else in a certain discipline, and the facilitator gets referrals from the appropriate practitioner. Next, the facilitator makes follow-up phone calls at agreed-upon times, usually at 6 months and 1 year.

INVITATION TO PRACTITIONERS.

DEAR __________,

Because of your experience in [discipline], you are invited to take part in a sort of multidisciplinary grand rounds, with a client (patient) present, known as the Healing Circle. This circle is for educational purposes only; no fees are charged. Confidentiality of the client's records is maintained by each of the practitioners and by all silent witnesses in a larger “fishbowl” circle. Informed consent forms will be signed beforehand, and ground agreements (below) for circle communications will be secured.

Follow-up with the client will be done by the facilitator, and a client-centered Action Plan is one output of the circle.

Thanks for letting me know as soon as possible if you can participate, and I will forward you guidelines.

Ground agreements are simple:

Stick to your discipline. If you find yourself excited by the conversation and you're anxious to contribute what you know about another practitioner's discipline, do your best to let the moment pass without interrupting. Highly educated doctors and practitioners have had to pass the test of being the best and brightest in the classroom in their field, and the urge to speak up with the right answer, revealing your knowledge, is almost irrepressible. Take a breath instead, and let the practitioner within that discipline represent his or her knowledge and lineage.

Practice conscious group talk. Measure your words, and be succinct with your offering. NO long-winded stories of how you know what you know—you're already respected for your knowledge. Share with eye toward economy. Let the gestalt of group discussion flow with a natural equanimity, not over-talking, not holding back. You will be guided by the facilitator in this regard.

Bring your skills in interpersonal counseling to the fore. Whether you learned it or not, now in the circle is the time to practice it. Practice instead deep listening, attentive to body language, non-verbal cues, respect.

Practice a respectful stance toward the other disciplines. It's okay to disagree, do so with respect and dignity. We are mapping out new terrain and showing the patient/client where differences lie in our approaches. Normally, a client goes from practitioner to practitioner, gathering these conflicting statements on their own, with no open forum in which they can play out and be wrestled with by the practitioners themselves. The client gets to sit back and either watch practitioners work out their differences or continue to kick around, protecting turf.

Practice consensus building. Explore whether or not you can come to an agreement by the close of the circle on which is the most expedient, most effective, most urgent path(s) for the client to explore. The client is here to tell his or her story, and now you have the obligation of laying out a harmonized path for him/her to consider.

Confidentiality is maintained by the practitioners and by all the silent witnesses in a larger “fishbowl” circle. Informed consent forms are signed by the client, and ground agreements are secured by all in attendance.

WHAT DO THE CIRCLES ACCOMPLISH IN TERMS OF HEALTH OUTCOMES?

The ongoing ethnographic study chronicled self-reported breakthroughs in the clients' understanding of causal factors in more than half of the circles (n=54).² Having more clarity regarding triggers or causes does not always translate into a cure or resolution, however. Clients often gained an altered self-concept that proved useful as they embarked on some of the suggestions from practitioners. Future research could explore whether this was a measurable gain in self-efficacy.

A third of the circles involved a client who expressed a great deal of emotional or mental relief from carrying the burden of chronic disease. They said the Circles gave them new insight into the way they define or hold onto their own disease process. Others were content that they that they could finally make sense of or fashion some sort of meaning out of their long suffering. Whether or not that understanding or newly discovered meaning led to a change in health behavior is undetermined. A small number of clients were able to follow through with specific health recommendations and reported a resolution of their symptoms, and in even fewer cases, there were reports of spontaneous remission within a few weeks.

For the most part, the Healing Circles serve the purpose of providing a caring, sincere gathering of practitioners who can share insights and information with a client in need. The singular act of deep listening and support is often enough. It may even have a placebo effect as it is a rare thing for someone to hold the gaze of so many caring practitioners at one setting. By the time someone has accrued years of telling their story—a long, sad, entrenched tale dealing with chronic problems or disability—they often have a social relationship with their ailment that goes beyond the physical. This is not to say that the health disorders or ailments are merely psychological, but rather that there are social conditions (compensatory actions by partners, friends, spouses, family members, work relationships) that have crept around the clients and their illnesses in unintended ways, buttressing and concretizing their health problems. Psychologists in the Circle are often the ones to point out the secondary gains and attachments people with chronic conditions can sometimes have developed over the years.

Circle practitioners originally gathered out of curiosity to see if this integrative circle could crack open their most challenging cases. They wondered what another discipline would do for one of these challenging patients. Clinical practice is too often an isolated endeavor, even in so-called integrative practices. It became apparent after a few years of the ongoing ethnographic study that maybe we practitioners gather in Circle because we want to break out of the isolation of solo practices. Healing Circles also allow practitioners to experience freedom from the oppressive regulation and paperwork and jumping through hoops required for professionals of various disciplines to work together—the barriers of credentialing, licensure, reimbursement, and competition are eclipsed with this experimental, non-paid model.

In getting together once a month on a Friday from 4:00 to 6:00 pm, they we were willing to risk sitting together to find out what another would do with a particularly challenging patient or client. The ability to remove those arbitrary barriers that respective disciplines tend to reinforce is ultimately liberating. We get to explore the intricate inner workings of the human body, psyche, emotions, and spirit together, for the good of all. We get to experience a new bio-psychosociocultural-spiritual model for health and healing— an integral one. As one practitioner said, “It feels good to say to heck with the paperwork.”

One more advantage to a healing circle involves a much overlooked need for transparency and comparative effectiveness. Fewer than 25% of patients report that they are exploring alternative or complementary modalities to their physicians. They report failing to do so out of fear of being scolded, humiliated, or told to discontinue its use. In most circles, an MD or two is present, and he or she has the advantage of hearing how patients interact with different disciplines and get to witness the caring support and rationale for seeking a complementary therapy.

But in some cases, the practitioners (usually the MDs) are further disinclined to approve an alternative therapy. They've come, they've listened, and they disbelieve even more that the modality has any value, feeling that it's nothing more than a waste of time and money for their patient. At this point, a vocal disagreement breaks out in the circle with discounting, dismissive comments. Facilitators must intercede and restore respectful communication.

When the Healing Circle is working satisfactorily, the client has the benefit of taking part in a frank discussion among practitioners, sifting through options, and receiving caring guidance and support. When the Circles are working at their best, there is an emergent quality, a presence of deep nurturance and healing that arises from the collective regard of practitioners who seek to remove old barriers and learn from each other and be honest about what may be the best approach for the problems at hand. It is crucial for the practitioners to express gratitude to the client at the end of the circle, for it is the client who has generously shared his story, a complex, emotionally-wrought medical narrative, as an educational device for the benefit of the practitioners. When the client does this in a “fishbowl” for educational purposes of graduate students (an outer circle of silent listeners), the educational benefit is truly significant.

DE-LABELING

From a medical anthropology viewpoint, the Healing Circle allows us to explore the links between health and identity. That link is fastened to labeling theory and the management of identities wrapped in chronic disease. (“I am a diabetic. I am an arthritis sufferer.”) We are what we have been labeled by the authorities. This happens in every culture where there is an allegiance to a particular type of medicine, whether it is the traditional healing systems of Ayurveda in India or African shaking medicine among the Han in the Kalahari. Stripping away labels and opening to new possibilities of vital living in non-material ways is a radical act of de-stigmatizing and requires agency and supportive alliances or community reinforcement.

In some circles, with a certain tension and disagreement among practitioners, there is a tangible moment when disabling or stigmatizing disease labels are stripped away because the doctors and practitioners are in direct opposition to one another epistemologically. They negotiate across that divide. There is both a struggle for recognizing the value in each healing lineage and an offer to reconcile and harmonize once the value of putting aside the hard-earned epistemological differences is appreciated.

SUMMARY OF FINDINGS

Inception and Mission

• The multi-modality healing circles arose out of a cultural ground characterized by (1) a steady rise in the public's interest in complementary and alternative therapies; (2) a professional criticism of the impersonal, fragmented, dehumanizing treatment with biomedicine; (3) a recognition of the ineffectiveness of conventional healthcare for the treatment of chronic illness; and (4) a desire among some biomedical and alternative practitioners to exchange ideas about treatment and resources in what they thought of as a relatively neutral ground.

• The subordination that practitioners feared was inherent in the structures of integrative medicine was not the primary obstacle to working in a successful interdisciplinary manner. Instead, the lack of skills and awareness in communicating, negotiating, and mediating among disciplines dominated the interactions. Tensions surfaced from this unbearable divergence, and the Healing Circle abandoned its multi-modality mode of operation for a circle designed to help chronically ill clients search for the meaning of their illnesses.

• The deeply embedded stakes held by the practitioners regarding the superiority of their individual traditions prevented the emergence of a discourse for integration or at least a dialogic model of multi-modality treatment. This resolve was so embedded that the stakes went far beyond differences in epistemology and touched upon ontological differences.

• The healing circles served as a starkly evident touchstone for observing just how thoroughly unknowledgeable the different disciplines are in regard to the others' educational background, training, areas of expertise, and scopes of practice.

Positive Effects and/or Influences of the Healing Circle

• Practitioners experienced enhanced camaraderie and support in working with chronically ill patients; a step towards collaborative care versus isolated practice was achieved.

• Chronically ill clients did receive a presentation of expanded array of healing options and wide range of viewpoints.

• The advantages of group resonance and generous listening time may have fanned a spark of motivation, or initiated a new level of self-care in some clients.

• The unpaid, volunteer aspect may have served as a placebo effect.

Questionable and/or Negative Effects and Influences of the Healing Circle:

• The ratio of several practitioners to one client can easily impose a dominant interpretive scheme upon the client in a formidable and unwelcome way.

• The single-intervention approach (eg, only one healing circle per client) is unproven for lasting behavioral change.

Political Climate

• The level playing field that practitioners hoped to attain within the circle is possible on a philosophical basis, but more problematic on a political one. The current professional gatekeeping restrictions of biomedicine assure limited entry through licensure, credentialing, and qualifiers of insurance reimbursement. In some biomedical settings, there exists a milieu of mistrust, competition, and persistent discounting of the mounting evidence of alternative health's effectiveness in the management of chronic illness.

• As gatherings of practitioners with varying degrees of education, licensure, and credentials, Healing Circles could not be reimbursed according to the current healthcare system.

• Just to participate in a Healing Circle would require a good deal of risk taking on the part of licensed practitioners, as learning to take appropriate risks and viewing failure as frequent and survivable are not attributes of medical education.

Education and training

• The various branches of medicine (allopathy, chiropractic, osteopathy, homeopathy, naturopathic medicine), nursing schools, and allied health training programs could include training in communication and negotiation, group psychotherapy, psychology, and holistic counseling techniques.

• Courses could explore ways for healers to tolerate uncertainty, the inability to cure, the lack of resolution or consensus, and the reframing of the healing process.

• Integrative medicine curricula could include socio-cultural and medical anthropology studies in addressing diversity, different philosophies of healing, and epistemological differences.

Recommendations

• Future study of a multi-modality healing circle could provide data for a “registry of effectiveness” for chronic illness conditions and related treatments. There were many times when the practitioners did come to agreement regarding the optimum choices for someone's condition. I believe these agreements came about due to the lack of political interference, the absence of competition for reimbursement dollars, and the ability to experiment with form and structure, independent and unhindered of the biomedical healthcare system.

• If mainstreamed within the biomedical health-care system, a multi-modality healing circle could supplement the work of medical peer review boards or quality assurance and utilization review committees within hospitals. The practitioners could evaluate which type of medicine is most effective for certain ailments. A “best practice” approach to certain maladies could be defined as a result of outcome data on healing circles.

• Cost containment is another potential advantage to using a multi-modality healing circle within a hospital or clinical setting. The cost of managing chronic illness is the largest health-care expense, and it is expected to spiral upward in the next decade. Determining the most effective cost-containment measures by evaluating what treatments help patients decrease their utilization of services would help keep health-care operations stable and solvent. Health insurers could sponsor a pilot project to evaluate the Healing Circle intervention programs as a means of cost containment and better management of chronically ill patients.

CLOSING REFLECTION

I close this ethnographic discussion with a deep gratitude to the individuals who suffer with chronic illness for the ways in which they taught me that much of our current fee-for-service biomedical model is still fragmented and lacking in fully humane, ethical, and collaborative care. I soberly recognize how I joined practitioners, both alternative and biomedical, as we retreated to the margins, looking to escape the dehumanizing biomedical terrain that we all took a part in creating. A generation raised to place science on a pedestal, the material over the spiritual, has now come full circle and is hungry for other sources of healing wisdom. As a medical anthropologist, I suppose we are trying to heal the various personal, spiritual, familial, and communal factors that impact our views of health and illness.

As a practitioner in this new framework, I know the healing circle is just a start. We should not fool ourselves that we gather there solely for the sake of others. We are there to form community, to question where we have been, to ask forgiveness, and to come to terms with psychological conditioning that we have the right and privilege afforded by expert knowledge to dominate others in a fragmented system that was neither healthy nor caring. We think of ourselves as givers in the healthcare field; however, the Healing Circles teach us more about receiving. We gather to heal ourselves, and with enough humility and an act of grace, I believe when we circle, we have a chance to do just that.