What is left from the early psychosomatic movement

1
What is left from the early psychosomatic
movement?

• Wolfgang Söllner
• Dept. of Psychosomatic Medicine and Psychotherapy
• General Hospital Nuremberg

2
The psychosomatic movement

• The roots
• The early movement
• What is left?
• Open questions
• Pictures of psychosomatic researchers from
• Kindlers Psychology of the 20th Century,
  Beltz, 1979,
• or with personal consent.

3
The biomechanical paradigm

• Machine-model of the body (Lhomme machine, de la
  Mettrie, 1709-1751) Each condition and process
  of the human body may (must) be explained by
  physical and chemical methods.
• Liberation from spiritual and irrational thinking
  in medicine and biology Ist revolution in
  medicine (Foss Rothenberg 1987)
• The fascination of the machine-model is based on
  ist capacity to provide a system of spacial order
  that allows to derive an action plan for manual
  interventions in the human body. (Uexküll 1980).

4
Consequences of the biomechanical paradigm

• This modell allowed the development of modern
  technologies in medicine but reduced illness to
  an organ deficiency.
• This model had to neglect the historical, social
  and psychological perspective of the patient
  (Sarasin 2001). It expelled the soul from the
  body.
• The physician became a highly skilled mechanic
  and an interpersonal relationship with the
  patient was not regarded necessary for a
  successful treatment, any more.

5
Counter-movements I. Holistic movement in
internal medicine

• Critique of the biomechanical paradigm
• Social and psychological influences on the human
  body cannot be explained.
• Machines cannot feel nor experience anything the
  patient is seen as an object.
• Medicine is split into a soulless medicine for
  the body, and a bodyless medicine for the psyche
  (v.Uexküll)

Ludolf Krehl 1861-1937
Richard Siebeck 1883-1965
Other exponents of the holistic movement G
Jores, v. Bergmann, Christian USA Draper,
French, Putnam Other countries ........
Viktor v. Weizsäcker 1886-1957
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Aims of the holistic movement in internal medicine

• Recover the unity of body and soul
• (Re-)Introduction of the subject into medicine
• Combination of analytic-empirical science with a
  scientific approach to understand communication
  between patients and physicians.
• V. v. Weizsäcker systematically applied
  biographical interviews in medically ill patients
  (biographic- anthropological method).

• Taking time and history into account
• Health is no capital that can be CONSUMED.
  Health is present only if it is constantly
  PRODUCED. If it is not produced any more the
  human being is allready sick. (V. von Weizsäcker
  1927).

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Counter-movements II. Psychoanalytic movement in
psychiatry

• Not all bodily processes can be explained by
  somatic and even not by cognitive methods
• Freuds introduction of the psychic apparatus
  fit into the biomedical paradigm
• However, instead of treating the patient he
  talked with the patient and recognized the
  importance of the doctor-patient relationship for
  treatment

• By descibing the process of counter-transference
  he introduced the subject of the physician

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Psychoanalysis meets anthropological medicine

• Correspondence between Freud and von Weizsäcker
  (1932)
• Freud I felt obliged to keep away
  psychoanalysts from such investigations of
  psychodynamic aspects of somatic diesease
  because vascular dilatation or innervation would
  have been too much a temptation for them. They
  had to learn to restrict themselves to
  psychological thinking. However, we should be
  very much obliged to the internist for such
  amplification of scientific insight.
• Weizsäcker Psychoanalysis was created for
  psychoneuroses not for organic diseases. ..- It
  is not forseeabel which transformations of
  psychoanalysis will be necessary if it is applied
  to the medically ill.

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Development of psychosomatic medicine in the
1950ies and 1960ies The early movement?

• The holistic paradigm of medicine (Thure von
  Uexküll)

• The bio-psycho-social paradigm (George L. Engel)

• Paradigm of object relations in medicine (Michael
  Balint)

The Physician, the Patient, and his
Illness Michael Balint 1957
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Development of PM in the 1950ies and 1960ies
Empirical research

• F. Alexander

investigating the correlation of pychological
factors (intrapersonal conflicts) and organic
parameters in the context of social changes
I.A. Mirsky, H. Weiner
G. Engel A. Schmale
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Psychosomatic Medicine in Germany

• The Dührssen study (1964)
• Reimbursement of psychotherapy by health
  insurances (1967),
• Reception of psychosomatic medicine and
  psychotherapy in the curriculum of medical
  students (1972),
• Specialisation Psychosomatic Medicine (1992)
• Implementation of C-L services psychosomatic
  wards in the GH

• The legacy of the crimes of national socialism
  The perversion of the biotechnological approach
  lead to Medicine without humanity(Alexander
  Mitscherlich)

• Loss of empathy should be compensated.
• Holistic, patient-centred approaches supported.

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Models of integrated care

• Germany and Switzerland
• General medical wards organised according to
  psychosomatic principles (Ulm, Heidelberg, Bern)
• experimental approach
• Special focus on communication
• Patient-centred organisation of ward rounds
• Team-centred organisation of case-conferences
• Dual education of physicians
• Interdisciplinary co-operation

• USA
• Med-Psych units
• collaborative approach (internists and
  psychiatrists)
• Medical patients with (acute) psychiatric
  co-morbidity
• Dual education of physicians
• Interdisciplinary co-operation

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What is left from the early PSM movement?

• In medicine?
• Advances in all medical specialties based on new
  biotechnological procedures (tissue engeneering,
  genetic biomechanics, microsurgery etc.)
• General internal medicine vanishes
• Family physicians reduced to disease managers
  and referees to specialists
• Is the patient less an object? What about
  informed consent?
• Is the physician less an object? What about
  decision-making?

In Psychiatry?

• Neuroscience or psychiatry?

Did the biotechnological model finally succed?
14
What is left from the early PSM movement?

• Theoretical foundation
• Models of integrated care
• Education of medical students, physicians and
  nurses
• Research
• Clinical and scientific expertise sub-/
  specialisation in some countries
• Enthousiasm?

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What is left? (1) Theoretical foundation

• The synthesis of the holistic/systemic and the
  interactive/ralational theories (Uexküll
  Wesiack, Engel, Balint et al.) created a
  theoretical framework for the understanding of
  bio-psycho-social interdependencies in living
  systems.
• It is a new paradigm including a relational model
  (relations between individuals and between
  individual and environment) besides the models of
  biotechnology and informatics.
• As Kuhn (1973) pointed out, the change of a
  prevailing paradigm is a dialectic process
  including both
• (a) that a new theoretical paradigm already
  exists, that means that two paradigms are
  existings simultaneously and are competing with
  each other and influencing thoughts and ideas in
  society and
• (b) changes in society pointing into the same
  direction.

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What is left? (2) Models of care based on the
new paradigm (focusing on communication and the
relational aspect)

• Will they influence new integrative models?
• Integrative bio-psycho-social assessment and
  treatment (INTERMED)?
• Interdisciplinary units (e.g. in pain clinics,
  geriatric day hospitals)
• Stepped-care models in ambulatory care

• Integrative models
• Psychosomatic wards in internal medicine
• The bio-psycho-socially oriented family physician
• Collaborative models
• C-L services with a focus on LIAISON
• Psych-Med units
• Interdisciplinary work-groups (e.g. in oncology)

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What is left? (3) Education of physicians and
nurses

• Psychosocial medicine is mandatory part of the
  curriculum for med. students and nurses in many
  countries.

• In Switzerland, communication skills training is
  mandatory for oncologists

• In Austria and Germany, physicians of every
  specialisation can acquire a 2-year training in
  psychotherapeutic knowledge and skills (with a
  focus on the medically ill and somatisation).
• In Germany, 8.000 physicians have completed this
  training (2.000 family doctors, 6.000
  specialists).

• In Germany, since 2004 basic psychosomatic
  competence (30-80 hrs of seminars, communication
  skills, and supervised cases) is mandatory for
  every medical specialty.
• 65.000/320.000 German physicians have completed
  this training already.

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What is left? (5) Competence and sub-/ specialty

• Psychsomatic medicine must be both
• General basic knowledge, skills, and attitudes in
  bio-psycho-social care are needed for every
  physician
• Special knowledge, skills, and attitudes are
  needed in the treatment of the medically ill with
  psychiatric co-morbidity

• Specialty in Germany and Letvia
• Subspecialty in the USA (intended in CDN, NL,
  Spain ...)

• C-L psychiatrists are much more teachers than
  care-providers (Jim Strain, 2003)

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What is left? (4) Research

• Interdisciplinary research published in journals
  of different specialties
• PSM Journals with growing impact
• Scientific societies with regular meetings
  EACLPP, ECPR, APM, ICPM, DKPM et al.

58. Jahrestagung des Deutschen Kollegiums für
Psychosomatische Medizin (DKPM) und 15.
Jahrestagung der Deutschen Gesellschaft für
Psychosomatische Medizin und Ärztliche
Psychotherapie (DGPM)   Psycho-Somatik Medizin
zwischen Beziehung und Technik  21. 24. März
2007  Nürnberg/Erlangen   Nürnberg,
Strasse der Menschenrechte
20
We need a new psychosomatic movement in medicine
and, particularly, in psychiatry (Herbert
Weiner, 1989)

• This is subversive in the dualistic system and
  prevents the physician from perceiving and
  treating the patient as an object and denying
  that own reactions as a physician influence
  treatment.
• In this sense, both the patient and the physician
  become individual subjects and partners in the
  dyadic process of treatment.

• C-L psychiatry and Psychosomatics may contribute
  to this development
• if it does not succumb to the dualistic hydra
• if it dedicates itself as an advocate of the
  subjective experience of the patient both in
  research and patient care.