Integrating Mind and Matter in Healthcare

A great article in the NYTimes illustrates a major problem in contemporary psychiatric practice–its mind/body dualism. The author Daniel Carlat, who has a book coming out on the subject next month, describes how psychiatric practice has moved over the last fifty years from an exclusive focus on the mind to an exclusive focus on the brain:

Leon Eisenberg, an early pioneer in psychopharmacology at Harvard, once made the notable historical observation that “in the first half of the 20th century, American psychiatry was virtually ‘brainless.’ . . . In the second half of the 20th century, psychiatry became virtually ‘mindless.’ ” The brainless period was a reference to psychiatry’s early infatuation with psychoanalysis; the mindless period, to our current love affair with pills.

More specifically, writes Carlan, “psychiatry has been transformed from a profession in which we talk to people and help them understand their problems into one in which we diagnose disorders and medicate them.”

This is due to a number of factors including the fact that insurance companies “pay nearly the same amount for a 20-minute medication visit as for 50 minutes of therapy” as well as the fact that patients in today’s busy culture are unlikely to want to commit valuable time to weekly therapy. But a big reason for the move to meds over therapy is that the drugs seem to work. But appearances can be deceiving. Carlat writes,

But over the past few years, research studies have shown that therapy is just as effective as medications for many conditions, and that medications themselves often work through the power of placebo. In one study, for example, researchers did a meta-analysis of studies submitted by drug companies to the F.D.A. on seven new antidepressants, involving more than 19,000 patients. It turned out that antidepressants are, indeed, effective, because on average patients taking the pills showed a 40 percent drop in depression scores. But placebo was also a powerful antidepressant, causing a 30 percent drop in depression scores. This meant that about three-quarters of the apparent response to antidepressants pills is actually due to the placebo effect.

Nobody knows exactly how the mysterious placebo effect works, but it is clear that it has impacts on the brain that can be seen as clearly as medication effects. In one study conducted by pain researchers at the University of Michigan, subjects were given an ache-inducing injection of saline into their jaws and were placed in a PET scanner. They were then told that they would be given an intravenous pain treatment, but the “treatment” was merely more saline solution, acting as a placebo. The PET scan showed that the endogenous endorphin system in the brains of the subjects was activated. The patients believed so strongly that they were receiving effective treatment that their brains followed suit. Presumably, a corresponding brain change occurs when depressed patients are given placebo pills.

Therapy, you may be surprised to discover, also leads to empirical changes in the brain.

n an experiment conducted at U.C.L.A. several years ago, with subjects suffering from obsessive-compulsive disorder, researchers assigned some patients to treatment with Prozac and others to cognitive behavior therapy. They found that patients improved about equally well with the two treatments. Each patient’s brain was PET-scanned before and after treatment, and patients showed identical changes in their brain circuits regardless of the treatment.

What this article points out is that the dualistic distinction between mind and matter does not correspond to reality. The “mind” is not some metaphysical entity distinct from and trapped inside the material trappings of the brain. Rather, the mind is matter, or perhaps more specifically, the mind is consubstantial with matter. As scientists like Steven Pinker and Antonio Damasio have illustrated, the legacy of Descartes that there is some sort of “ghost in the machine” is false. The metaphysical “mind,” complete with values, personality, and character, exists substantially in the material components of synapses, axons, and cortex.

We might consider this a development from a more Platonic to a more Aristotelian psychology and biology. Ethically, it challenges us to see how care for the soul cannot be separated from care for the body. We are not spiritual beings who can somehow transcend the trappings of the body with all of its inconveniences, but nor are we purely material beings, as transparent and obedient to the laws of nature as a stone. What is metaphysical in our nature influences and is influenced by what is material.

This new understanding of the nature of the human person, what we might call a philosophical anthropology, needs to influence the way we think of medicine. As Carlat writes,

Clearly, mental illness is a brain disease, though we are still far from working out the details. But just as clearly, these problems in neurobiology can respond to what have traditionally been considered “nonbiological” treatments, like psychotherapy. The split between mind and body may be a fallacy, but the split between those who practice psychopharmacology and those specializing in therapy remains all too real.

For him practically, this has meant a shift to what he calls “supportive therapy” which involves not only prescribing drugs, but also listening to patients, helping them solve basic problems, and offering emotional support. The implications, however, extend beyond just psychiatry to all of medicine. Carlat concludes that good doctoring “involves perfecting all the skills relevant to healing and deploying them when needed.”

This will be a challenge in upcoming years as our health care system becomes more systematized, more reliant on complex care networks dependent largely on electronic patient records rather than a simpler primary care provider/patient relationship. In an of itself, this is not a bad thing and a more efficient system will allow more patients to receive and benefit from healthcare. But doctors need not forget the value of that standard question “how are you feeling?” and most importantly, cultivating a disposition to listen to the response. They may find themselves prescribing fewer meds and getting healthier and happier patients as a result.


3 comments so far

  1. Niggardly Phil on

    Perhaps it would be better to distinguish powers of the mind, some of which (the “common sense”, imagination, et al) rely on the brain as on an organ, some of which (“nous”) do not.

    The Cartesian duality is not merely a problem of dividing mind from body, but of DIVIDING more generally. The “either/or” premise of modern science is on full display, neatly corresponding to binary code, our machine-mode of thought. But between univocity and equivocity lies analogy, something lost on logic these days, the tool of the sciences. It’s sad that such an assumption goes almost unquestioned. Analogy is the pinnacle of reason, what enables us to understand this world and ourselves.

  2. Niggardly Phil on

    I guess what I meant to say in a rambling sort of way is that the mind does not exist substantially in the material (this leads back to idealism), but formally.

    Just being niggardly.

  3. Charles on

    Here’s a relevant link to a Louis Menand book review and essay from the March 1 issue of The New Yorker:

    The books reviewed are Manufacturing Depression by Gary Greenberg, and “The Emperor’s New Drugs” by Irving Kirsch.

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