Positive Health Online

That the health of the mind and body are linked is generally seen as obvious, almost beyond question. The belief is part of our folk-lore: clichés such as "healthy body, healthy mind" and "dying of a broken heart" express the physical-mental connection in opposite directions.

Our art also reinforces the belief that states of mind can express themselves as disease or relief therefrom. Perhaps the most explicit example is Solzhenitsyn's "Cancer Ward" in which patients speculate about a chemical secreted by the brain which enters the blood circulation and cures disease. Susan Sontag's "Illness as metaphor" gives many similar examples. In a typical story, the hero gets tuberculosis because he repressed his true sexual nature; when he accepts life, he recovers.

The mind-body link has a long history in health care. In this essay, I will criticise some of the ways in which it has been articulated in complementary medicine (CM). This criticism is constructive in intent.

It is offered because I believe that the mind - a term which, for convenience, will be used to include spirit and soul - has often been undervalued in health care. Yet, as has been the theme of recent editorials in this journal, an important part of promoting your beliefs is to subject them to critical analysis. In the words of Janet Radcliffe Richards, they will emerge with "firmer foundations, less vulnerability to attack [and] more general acceptability."

Mind-body medicine in CM

CM practitioners interest in the mutual interdependence of mind and body stems from a laudable holistic intuition. It is said that CM treats people who have disease rather than diseases which have people: mind and body are diagnosed and treated together as part of the whole person in need of care. In many CM therapies, the mind-body link is codified in coherent theories with practical applications. In massage therapies, for example, anxiety and stress are seen to lead to increases in muscular tension which then feed back into greater psychological arousal. Massage techniques work to release tension in muscle tissue and therefore bring about both physical and mental relaxation.

Similarly, homoeopaths take information about both physical and mental characteristics in order to choose an appropriate remedy.

If that is as far as CM practitioners take mind-body medicine, then there may be little grounds for criticism. The problem starts with the adoption of certain theories, which typically originate outside the main CM theoretical traditions. An example is the claim that mental state is the direct cause of specific physical ailments, in other words, that disease is a reflection of the psyche. Such theories have been popularised by writers such as Louise Hay. In You can heal your life, Hay gives psychological causes for a wide range of diseases. For example, rheumatoid arthritis is seen to be caused by criticism of authority and by feeling "put upon"; leukaemia is said to be caused by the "killing of inspiration" and the feeling of "what is the use?" and cystitis by the holding on to old ideas. Hay's works are popular amongst CM practitioners and patients and her books are sold alongside standard CM texts. An associated set of theories cluster around cancer.

Typically, these invoke unresolved conflict or repression and inadequate expression of feelings as the cause of malignant disease.

In one famous public articulation of these beliefs, a well-known novelist explained a violent outburst by stating that he would rather express his anger than get cancer.

Such theories are often "bolted on" to existing CM therapies. It could be argued that aromatherapists, for example, have a relatively coherent method of treating eczema: a patient's eczema might be diagnosed as resulting from accumulation of toxic metabolites caused by improper functioning of the elimination systems brought about by stress; treatment might consist of a blend of sedative and anti-inflammatory oils as well as those thought to improve kidney function.

But, seemingly out of the blue, authors of aromatherapy texts introduce ideas of psychological causation: eczema, according to one author, is related to emotional hypersensitivity. Similarly, a homoeopath recently gained notoriety by appearing on television and claiming that cancer was a matter of choice, that an individual could choose whether to hold on to their cancer or to let it go. This is despite such a belief being outside conventional homoeopathic understanding and homoeopathy providing a reasonable framework for understanding the relationship between mind and body.

What is interesting about some of these articulations of mind-body medicine is that, rather than the mind and body having equal weight, the mind is given primacy as being the driving force in determining health. This results in claims such as that "90% of disease" is caused by psychological factors or that "all disease comes from a state of unforgiveness".

Against mind-body medicine

One of the main criticisms of some forms of mind-body medicine is that so many claims are made with such great certainty in the virtual absence of evidence. Certainly, there have been studies which have examined the effects of psychological stress on disease. It has been shown empirically that bereavement can suppress the immune system, that chronic, long-term stress can lead to some diseases and that coping styles predict survival in cancer. But this is a long way from linking particular psychological states to particular physical disorders or claiming that all or nearly all disease is psychological. What is the evidence, for example, that cystitis is about holding on to old ideas? Have cystitis patients been systematically compared to those without a bladder infection? Alternatively, is there good evidence that the one-third of the population who are affected at some point in their lives by cancer are more emotionally repressed than the two-thirds who are not?

One possible reason why much mind-body medicine is practised in the absence of data may be that the absence of data is the direct cause of many of its theories. Sontag points out that in the eighteenth and nineteenth century, tuberculosis was seen as an expression of the passions. So the revolutionary-in-exile hero of a 19th century novel contracts the disease when he realises that he can never return home.

Now that the cause of tuberculosis is understood and effective treatment available, the disease tends not be described in these terms.

Similarly, William Osler's description of diabetes as a disease of a neurotic temperament presumably resulted from an inadequate understanding of its pathological basis. Cancer is yet to be managed as effectively as tuberculosis or diabetes and remains ripe for psychological theories of cause and treatment.

It is this attempt to make sense of the unknown, to control what cannot be controlled, that may explain the origin of some conceptions of mind-body medicine. Diseases like cancer seem to afflict and kill almost at random. They are beyond our control and our understanding. But turn to a book on mind-body medicine and suddenly cancer is no longer so frighteningly out of our control: it is said to have a known cause (emotional repression) and a known treatment (taking the choice to let go of disease). Cancer becomes tamed, no longer such a threat. It could be argued further that mind-body medicine is used to counter the spiritual malaise of increasingly secular societies. Cancer concerns life and death and so raises some spiritual and existential questions: "why am I here?" and "what has been the meaning of my life?". Mind-body medicine, with its simple arithmetic of mind and body, provides some straightforward answers.

A number of forms of mind-body medicine can also be criticised on the grounds that they are profoundly parochial. In other words, they invoke beliefs about health in general which apply, if at all, only for say, middle-class, mentally competent adults in the late twentieth century in certain industrially developed countries. When a CM journal includes a quote from a popular writer that "all that has happened to you, you have drawn to yourself" does this refer to all people with all problems throughout history? Does it apply to a child with Down's syndrome, a starving farmer in Sudan, the victim of an industrial accident such as Bhopal or a civilian burned by napalm in Vietnam? When Louise Hay claims that "all disease comes from a state of unforgiveness", and ascribes leukaemia to a lack of inspiration, does she include children living near Chernobyl? The causes of most of the diseases suffered by most of the people in the world are well known - poverty, famine, poor sanitation, pollution, war - and have very little to do with the links between mind and body.

Evidence that mind-body medicine is determined by parochialism comes from the observation that the psychological states said to cause disease mirror prevailing social concerns. In the late 19th century, cancer was said to be caused by grief, overwork and feeling overcrowded, typical adverse emotional states of the urban Victorian. In the 20th century, cancer is ascribed to emotional repression, loneliness and lack of affect, arguably the archetypal fears and concerns of the increasingly technological and socially fragmented societies found in the West.

The political, historical and cultural naiveté of much mind-body medicine also extends, ironically, to over-simplified understandings of the psyche and its effects on the body. For example, one well known complementary practitioner has written that, in order to assess whether there is an "emotional cause" for illness, patients should "search diligently" for events such as being teased at school. They should then "get to work with positive thinking". Three beliefs implied by this advice contradict current psychological theory and practice. It is not widely thought that unguided introspection is a reliable method of psychological exploration, or that physical ill-health can be caused by a single, less than traumatic, event in childhood or that "positive thinking " is an appropriate way to deal with adverse emotional events. Similar types of argument are found even in the writings of those practitioners who specialise in a psychological approach to illness. Edward Bach, inventor of the Bach flower remedies, claimed that all or nearly all disease is due to states of mind. One might have thought that Bach would have a sophisticated understanding of psychology. Yet he made statements such as "rigidity of mind will give rise to those diseases which produce rigidity and stiffness of the body." Similarly, Alexander Lowen, whose therapeutic system of "bioenergetics" is based on the proposition that the body can express the unconscious, has said that "a weakness in the backbone must be reflected in serious personality disturbance... the individual with sway back cannot have the ego strength of a person whose back is straight." One might well be prepared to understand that the health of the mind and body are linked. But the simplistic conceptions of writers such as Bach and Lowen, with mind and body simply mirroring each other, strain credibility.

It is also ironic that many theories of mind-body medicine, though promoted as part of holistic medicine, are profoundly reductionist and dualist. The idea of specific states of mind causing specific states of ill-health is no different in form from the idea of bacteria causing disease. It also involves a very Cartesian split between mind and body. There is no interaction between mind and body, no systems theory, no holistic model, in beliefs such as that rheumatoid arthritis is caused by feeling "put upon" and can be treated by an appropriate affirmation.

It is not difficult to work out how simplistic ideas about the effects of the mind on the body have developed: they arise from the tendency to try to intuit mental states from behaviour. This is something we all do as a necessary part of our everyday lives. But it is a notoriously unreliable basis for making generalisations about health. In the 1950s, it was common theory that parents of autistic children were "refrigerator parents" whose "mechanicalness of human contact" caused emotional disorder in their children. Nowadays, parents of autistic children are thought to have just as wide a spectrum of emotional behaviour as anyone else. Yet hundreds of professionals spent many years interpreting the behaviour of typical, caring parents as devoid of emotional warmth. Similarly, although "emotional repression" is often implicated in cancer, is there anyone, particularly in the UK, who does not repress their emotions to a certain degree? "Emotional repression", like so many of the mental states said to cause disease, is a term so vague as to be applicable to almost anyone. Louise Hay no doubt feels confident in the belief that cystitis is related to "holding on to old ideas" because people with cystitis, like the rest of us, no doubt do hold on to old ideas. Moreover, just about any behaviour can be interpreted as doing so. If, for example, a woman renounces her religion and leaves her job, this could be interpreted as holding on to the old idea that it is religion and career which determines happiness.

I have argued that much mind-body medicine is unsubstantiated, triumphalist, parochial, naive, dualist, reductionist, simplistic and vague. This might not matter if mind-body medicine did not have the power to harm. But I believe it does. Anatomy of an Illness is a best-selling book which includes on its cover the slogan "how one man proved [that] your mind can cure your body". A whole chapter on "Creativity and longevity" is devoted to the lives of Pablo Casals, the musician and Albert Schweitzer, the doctor who practised among the poor in Africa (predictably Dylan Thomas, van Gogh and Keats are not mentioned). The remarkable intelligence, wit, wisdom and musical ability of the two great men is described in fine detail. In another best-selling mind body text, Love, Medicine and Miracles, the author describes a patient who comes to love her body, forgive her parents, control her emotions and embrace her sexuality as a sacred and ecstatic form of self-expression.

By pointing to the physical health of those who are paragons of mental virtue, theorists of some forms of mind-body medicine set patients up for feelings of moral failure. It is possible for a patient to think that "I have disease because I am who I am, and not someone good like Albert Schweitzer" (how many Albert Schweitzers can there be?). Or "my disease has a poor course because, unlike the woman described in Love, Medicine and Miracles, I am unable to forgive my parents or come to terms with my sexuality". Can it really be argued that such thoughts are improbable or have a low risk of harm? It seems more likely that some theories of mind-body medicine double the burden of illness: not only are you physically ill, but it is your own fault for having the wrong mental states.

In the traditional Christian tale of the saint's embrace of a leper, the soul is seen as separate from privations of the flesh. In much modern mind-body medicine, disease is a reflection of the psyche: a deformed and wasting body is a function of a deformed and wasting soul. This is a harmful and retrograde belief.

For mind-body medicine

The growing awareness of the need to care for a patient's mind and spirit is, I believe, one of the most important developments in contemporary health care. In the Sixties and Seventies, when critiques of conventional medicine first gained credence, medicine was dominated by a technical focus on the alleviation of physical pathologies and symptoms. Diseases were seen not in terms of their effects on the whole person, but in terms of changes in tissue structure and function. Patients were seen to respire, digest and respond to immunological challenge, rather than to hold jobs, fall in love, dance and play music. This split between disease as viewed by the medical profession and disease as experienced was perhaps best expressed in the words of a breast cancer patient quoted in a famous self-help book: "You [my doctor] are dealing with my diseased breast tissue; I am having an existential crisis." The doctor's response to this statement from his patient was to leave the room.

Nowadays, many of the top, specialist cancer hospitals offer psychosocial care: support groups, counselling, even massage and aromatherapy. These developments reflect increasing understanding that cancer affects people and not just body cells. Moreover, there is increasing emphasis on helping patients to cope with disease, and live fulfilling lives, rather than just trying to deal with pathology. There is recognition that what influences how, say, chronic pain affects an individual's ability to work, perform social duties and enjoy themselves is not organic pathology so much as factors such as anxiety, dependency and social support.

In short, what is important about mind-body medicine starts from its recognition that we are not just bodies, but minds, hearts, spirits and souls as well. Textbooks of anatomy, physiology and pathology do not constitute a complete description of patients and their needs in health care.

We need to retain what has been positive about mind-body medicine. In order to do so, we must let some of it wither. Healing the mind and the spirit is an end in itself, not a means to the end of treating physical disease. Patients want to be treated as whole individuals. They do not want their minds separated out and treated purely as the pathological cause of bodily symptoms. It is, therefore, by abandoning some conceptions of mind-body medicine that we can best meet the needs of those suffering distress through ill-health.

This article first appeared as an editorial in Complementary Therapies in Medicine 1998;6:111-4