International Journal for the Advancement of Counselling 9:47-60 (1986). © Martinus Nijhoff Publishers, Dordrecht. Printed in the Netherlands.

P S Y C H O S O M A T I C I N T E R A C T I O N S

JEAN WRIGHT

University of Reading, United Kingdom.

Abstract

'The cure of many diseases is unknown to the physicians of Hellas, because they disregard the whole, which ought to be studied also, for the part can never be well unless the whole is well'. (Plato, in his dialogue Charmides).

The links between mind and body - the psyche and the soma - have long been recognised. Current research has focussed on their interaction and interdepen- dence.

This gives rise to the need for counsellors and physicians to study the compart- mentalised and separate services that they provide. I f they believe in the concept of the ' t reatment of the whole person' - holistic medicine - it behoves them to examine their own interactions and interdependence.

The Author examines these issues and looks at the need for a change in attitude among professionals and a change in the curriculum of medical schools and counsellor training which could result in fundamental changes in Health Service provision.

Introduction

Counsellors and clinical psychologists have for over a decade been universally urging doctors to treat the cause and not the symptom of illness, the inference being that many physical symptoms come f rom psychological causes - but is this not a constraint to a full understanding of the whole problem?

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Definition

The Oxford English Dictionary lists the word 'psychosomatic' for the first time in a supplementary publication in 1982 and offers a set of its definitions.

It defines the adjective 'psychosomatic' as one involving or depending on both the mind and the body as mutually dependent entities. The term has been used to refer to the following:

a. physical diseases - those caused or aggravated by psychological factors, and less often by mental disorders, caused or affected by physical factors.

b. the branch of medicine concerned with mind-body relations. c. the field of study sometimes designated psychosomatics, concerned with the

relationship between mind and body. This connotation of the word 'psychosomatic' may be referred to as a holistic

one as it presupposes the inseparability of mind and body, as well as mutual dependence.

Psychosomatic should not be used to imply causality in any sense or context but to refer only to the reciprocal relationship between psychosocial and biological factors in health and disease.

Concern with the nature and role of the interplay of these factors in the develop- ment, cause and outcome of all diseases, remains one of the central issues in psychosomatic medicine, and can be subsumed under an holistic connotation of the word psychosomatic.

Drabkin (1965) thinks that it is not possible to separate the psychic and the somatic, which comes from the same fundamental source. This view has been well documented over the years in medical and non-medical writing.

Applied to the concept of medicine, the holistic conception affords the need for physicians to take into account both the mental or psychologic and the physical or physiologic aspects in the study of disease and the treatment of patients.

The Eighteenth Century Dutch physician Gaub (1747) referred to the way that a person's state of mind can affect the inception and progress of physical illness and that the contrasituation is also true.

Benjamin Rush, who was considered to be the father of American psychiatry, was expressing holistic conceptions in his lectures, as early as 1811.

From the evidence of Margetts (1950, 1954) it appears that the German psychiatrist Heinroth was the first person to use the term 'psycho-somatic' in writing about insomnia in 1818.

However, Freymann (1981) points out, that in the mid Nineteenth Century there was a severe set back when Virchow's research into cellular pathology and Pasteur and Koch's discoveries in bacteriology changed medical thinking from a holistic to a mechanistic approach to patients.

But during the Nineteenth Century there were physicians who were still commit- ted to the holistic concept. One such was Henry Holland, Physician Extraordinary to Queen Victoria.

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It was not until 1922 that the term 'psychosomatic medicine' was used by an author, Felix Deutsch, and this was followed in 1925 by a book that defined and discussed 'psychosomatic medicine' from a philosophical as well as a medical standpoint.

But it was not until 1935 that psychosomatic medicine as an organised field of human and scientific enquiry was announced with the publication in 1935 of Dunbar's 'Emotions and bodily changes: A survey of literature on Psychosomatic Interrelationships 1910-1933'.

I would submit that the modern meaning of the word 'holistic', which is derived from the Greek 'holos' or whole, conveys the true concept of psychosomatic medicine.

The Current Situation

Patients with underlying anxiety and depression present to their general practi- tioners with reoccuring ear, nose and throat problems, non-specific stomach pains, back-ache, migraine and insomnia.

The interactive links between stress and heart attacks and stress and ulcers has long been recognized. Childhood diabetes, essential hypertension, obesity, anorexia and bulimiarexia have all psychological and organic components.

Current Research

The research carried out at the Unit for Human Studies in Cancer at King's Col- lege Hospital since 1970 has suggested that psychological factors play a part in both the causation of cancer and its outcome (Pettingale, 1983, p. 9). The Unit is now conducting research studies based on the development of clearly specified methods of psychological intervention and evaluation in systematically controlled studies.

There is also evidence that psychological response can influence serum im- munoglobulin levels. In the cancer studies it was found that 'Serum lgA levels are significantly higher in patients who habitually suppressed anger than in those who were able to express it' (Pettingale, 1983, p. 9). It has also been noted that psychiatric patients have been found to have 'significantly higher levels of serum lgA and serum lgM than non-psychiatric - control patients' (Solomon et al., 1969, p. 272).

The outcome in acutely disturbed schizophrenic patients has been correlated with levels of serum immunoglobulins (Amkraut et al., 1973). Previously there have been reports, in patients with both benign and malignant breast tumours, that there were consistently higher levels of serum lgA in those women who

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habitually suppressed anger (Pettingale et al., 1977). Maguire's (1983) research showed the considerable incidence of anxiety, depres-

sion and sexual problems among cancer patients. It should, however, be noted that those psychological problems are not usually treated. This is another example of the interaction between the psychological and the organic where the psy- chological pain manifests as a physical illness which then manifests psychological symptoms.

Psychological symptoms which appear to have an organic origin are only now being subjected to research studies to the same degree as physical symptoms which derive from psychological origins. Clinically, counsellors acknowledge pre- menstrual tension, puerperal depression and the other depressions that follow viruses such as influenza. For example, they understand that patients with a highly active thyroid will show symptoms of anxiety and patients with a low active thyroid show symptoms of lethargy. Current research is, however, questioning many of these beliefs.

The Influence of the Menstrual Cycle on Emotional and Physical States

The influence of the menstrual cycle on behaviour, emotional and physical states has been extensively studied. The view that a large section of otherwise normal and healthy women experience most negative emotions pre-menstrually has been widely accepted.

Retrospective reporting of symptoms has been found to differ considerably from daily reports of symptoms. Long term retrospection tends to elicit a person's beliefs about cyclic suffering rather than represent a reasonable approximation of an individual's actual experience.

Previous studies have suffered from small samples and in most of the retrospec- tive studies women knew that the menstrual cycle was being investigated.

A recent study of young nurses showed 'peaks of psychological frequency which are not significantly greater than would occur with chance variation' (Slade, 1984, p. 4). It did, however, show fatigue and muscle stiffness in the pain category, skin blemishes, weight gain and water retention pre-menstrually and menstrually. This challenges previous accepted views: but before accepting these findings, one should note that the whole sample were young single women from a profession that has a knowledge of medical behaviour, and only 46% of them completed the study. It would seem, as other research has shown, that the design of the studies is a very real influential variable.

Research studies have also been carried out on patients in hospital.

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The Emotional Impact o f Diagnosis and Early Treatment of L ymphoma

Although many studies of lymphoma have been concerned with patients requiring surgery, the results of which are often disfiguring; other methods of treatment such as radiotherapy and chemotherapy, are also associated with emotional distress. The patients Lloyd et al. (1984) studied were suffering from malignant lymphoma and were treated with chemotherapy or radiotherapy or both.

Lloyd et al. (1984) also found that the degree to which the patient suffered anx- iety or depression following diagnosis could be correlated with the degree to which the patient's health and life expentency would be affected by the malignant disease.

It is now important to evaluate alternative methods of psychological support in patients with this type of illness.

Intervention to Alleviate Patients" Stress

Many events occuring in hospital are stressful to patients and a recent review of interventions by nurses and psychologists was carried out by Wilson-Barnett (1984).

Evidence was given that the support of a significant person at a time of stress may have a significant effect. She refers to the work of Lorenson (1983) on the use of TOUC H on women in labour and Mayou et als' study (1981) with coronary patients in which the patients who had counselling with their spouse felt more satisfied with their recovery and overall adjustment while those assigned to a physical exercise program simply became fitter.

Cohen and Lazarus (1979) showed that further research could profitably in- vestigate patients' methods of coping with stress - the results would be a learning experience for the medical profession.

Intervention by one profession does not give such promising results as those from multidisciplinary teams, which would really have a holistic approach.

Recent research studies have tried to assess the benefit of self-help programmes.

Relaxation Therapy for Essential Hypertension

Studies by Braus et al. (1979) and Luborsky et al. (1982) showed that the doctor 's provision of reassurance and positive treatment expentency may reduce blood pressure in some individuals. It raises issues as to whether the effect of relaxation therapy is due to specific decreased muscle tension as Jacobson (1939) originally proved which has been subsequently disproved by Godring et al. (1956) or is in- stantly attributable to general factors such as expentency of therapeutic benefit

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and increased feelings of sufficiency in coping with problems. Whether specific or non-specific treatments are more effective is not the real

point. The issue is that the medical profession is prepared to try behavioural as well as pharmacological treatments for essential hypertension.

The Attitude of Physicians

Psychosomatic illness is now recognised by increasing numbers of general practi- tioners, particularly young doctors, who want to offer more than just repeat prescriptions for pain relieving drugs or tranquillizers. There is also a change in the attitude and thinking of official bodies. World Health Organization reports, and international conferences, all acknowledge psychosomatic medicine but it has not generally penetrated the curriculum in medical schools. In the library of the Royal Society of Medicine will be found the ' Journal of Psychosomatic Medi- cine', (the journal of the American Psychosomatic Society, first published in 1939), 'Psychosomatics ' and the ' Journal of Psychosomatic Research' . The British Holistic Medical Association formed last year consists of doctors who practise holistically. So far the association has nearly 300 members and is growing at a rate of 15 to 20 new members a month. There is now a British Journal of Holistic Medicine which was first published in April, 1984. Pioneers in this new concept of treatment were Enid and Micheal Balint who founded the Balint Socie- ty at the Tavistock Clinic, London in 1970 to encourage General Practitioners to look at the Doctor /Pat ien t relationship. It has trained groups of General Practi- tioners throughout Europe to really listen to what their patients are saying and to be aware of their patients ' underlying feelings. Sadly after fifteen years, their members only number one in a thousand of the medical profession.

The Attitude of Counsellors

Counsellors are trained to listen to what the clients are saying and to create an environment as confidential as the doctor 's surgery. In the counselling consulta- tion, feelings of anxiety and depression can be explored, change in the client's attitude and perception can take place and there can be the development of per- sonal growth and maturity. Counsellors are, however, not trained to recognize the symptoms of organic illness any more than the physician is trained to recognize the symptoms of psychological illness.

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The Development of Separate Medical and Counselling Services

Antagonism between doctors and counsellors/psychotherapists stem from many factors: - the longer history of the medical profession, Medical practices which were established a long time before counsellor/psychological services, the mis- conception that medicine takes longer training than psychology, and that medicine is a purer science, with a higher academic reputation.

This is the age of specialization, and community doctors, whether or not they have time in their busy surgeries, are expected to refer their patients' skin rash or stomach pains to the local hospital, their psychological problems to one clinic and their family planning problems to another. This results in a lessening of their total knowledge of the patients in their care, which is an ultimate loss to both patients and doctors.

Counselling services have developed as a response to the changing attitude to psychological ill health and the stress of living in a developed society.

Over the last hundred years in the West we have changed from viewing the psy- chologically and psychiatrically sick as someone to be punished to viewing even criminal hehaviour as a 'sickness of the mind'. We have progressed from looking at psychological neurosis and psychiatric behaviour as the work of the devil an burning the sufferers as witches, to treatment in humane open plan hospital or out patients' clinics.

However, with re-admission rates of 45% at psychiatric hospital's the high cost of the drugs bill to the National Health Service and a growing awareness that by the 'prescribing of benzodiazepines to one million people annually doctors create 100,000 drug dependent patients' (Medical Research Council Annual Report, 1982-83, p. 24-25) counselling services have developed to try and find more cost effective and efficient treatment.

These counselling services have proliferated with specialization such as Abortion Clinics, Family Planning Clinics, Psychosexual Clinics, Pre-retirement counselling services and Bereavement counselling. These can repeat the mistakes of the physi- cians by seeing the whole person as needing separate specialist interventions.

The referral system re-inforces the antagonism between doctors and counsellors. Doctors accept referral from a counsellor as ' to a higher authority' not ' to an equal professional colleague' and seldom accord the counsellor the courtesy of feed back that the doctor would expect from a hospital specialist. This denigration of coun- sellors by doctors arises historically from the hierarchy of the medical setting in hospitals, where the psychologist has a lower status than the physician.

In seeking to establish themselves, counsellors have often over-reacted by not referring patients to a doctor, when it is in the patients' interest for the doctor to be involved. Therefore, valuable opportunities for co-operative treatment, as in the case of anorexia nervosa, do not take place. The patient is the loser. If counsel- ling services are well established prior to medical facilities, as happened with stu- dent services in Australian Universities in the 1970's, the counsellors often

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appeared loath to refer clients to the medical centres, in order to retain the status they so clearly cherish. If this happens a student with a migraine may find himself treated with relaxation techniques, instead of having an investigation which might show a brain tumor requiring treatment.

The Patients' Choice of Treatment

The patients' choice of treatment is dependent on availability, previous ex- perience, culture expectation and class norms.

Treatment o f Stress by Physicians

In Western Society, where there is a National health service, anxiety is usually treated by the general practitioner by the prescribing of a tranquillizer by repeat prescriptions (50°7o without seeing the doctor). 'These products marketed as Valium, Ativn, Tensium only relieve anxiety for up to four months, and those marketed as sleeping pills - like Mogaden, Dalmane, Nitrodes are only affective for 3 - 1 2 days' (Lacey, 1984, p. 27-28).

There are 'side' effects from these drugs but of more concern is risk of dependency shown by Petursson and Lader (1981, p. 643-645) in their on-going research at the Institute of Psychiatry, London.

As the Medical Research Council's Annual Report ( I982-83, p. 24-25) stated, 'benzodiazepines are often prescribed in situations in which the medical problem, if it exists at all, is only a minor component of the patients' total predicament' •. . A fundamental question remains that o f prescribing practise'.

Treatment o f Stress by Counsellors

Anxiety, as treated by a counsellor/psychologist with an ecletic approach, consists of the teaching of deep relaxation, a psychological technique known as systematic desensitization and psychotherapeutic treatment of the environmental and rela- tionship factors that give rise to the stressful state.

The causes of stress may be organic, but often result from environmental fac- tors in Western society: The isolation of high rise dwellings, the loss of the extend- ed family, the increase in one parent families, the changing role and ambivalence of women, the increase in unemployment, the Welfare agencies that only meet material and not emotional needs, are all examples.

Treatment has to presuppose a universally agreed upon definition of the term 'stress'. In Engineering terms, stress could be defined as 'A force per unit area

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. . . . When a stress is applied to a body a corresponding strain is produced ' (Uvarov & Chapman, 1973 p. 408). In human terms one would say that all en- vironmental incidents would be stressful. However, Selye (1950, p. 672) showed that an individual 's character can significantly affect the result of a stressful en- vironmental incident.

The counsellor cannot remove all stress f rom a client's life but can try to help the individual to change and develop self help techniques in the control of stress, so that one can more easily cope with the strain of living in a 'developed' environment.

Untreated Stress

I f stress, usually referred to as anxiety, is untreated, it can result not only in the development of an extreme anxiety state, i.e. phobic states, such as agoraphobia or examination phobia, but also in depression and potential suicide. Usually the individual 's a t tempt to ' t reat ' the anxiety himself with increased alcohol leads to dependence; or the use of drugs and cirgarettes may lead to addiction. This results in physical illnesses such as cirrohsis o f the liver, lung cancer and with the lessen- ing of the ability to fight disease, gangrene; and always, shorter life expectancy. So the self same stress conditions can have very different outcomes depending on how and where they are treated and one again sees, pertinently, the interaction between mind and body.

Medical Treatment in Developing Countries

Perhaps a villager f rom a less developed country is better off . He does not accept the arbitrary medical treatment that the doctor, counsellor or psychiatrist decides on; rather he chooses f rom the variety of approaches that are available to him: a. his own knowledge of herbal medicine; b. the witch doctor with his incantations; c. the techniques of meditation and massage for relaxation that may be part of

his culture;

d. the Western medicine consisting of drugs and tonics; e. the improved ideas on hygiene and nutrition he receives f rom non-formal

teachers and health education workers; f. traditional counsellors offering help to the family. These treatments are often all available to him.

By treating his psychological and physical symptoms concurrently - the villager is an example of holistic medical treatment. Whatever the interaction be- tween the physical pain and the psychological pain, he covers all eventualities.

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The Provision of Joint Physical/Psycholdgical Services

In the United Kingdom there is an increasing number of group community prac- tises where counsellors are employed to work alongside doctors. The National Health Service does not yet recognize the employment of these counsellors although 'their worth has been demonstrated' (Marsch & Barr, 1975, p. 73-75) and they have a recognized association that is a separate branch of the British Association of Counselling.

In hospital settings where hospital physicians investigate unspecified physical pain in patients referred by general practitioners, counsellors work on the psychosomatic problems diagnosed by the consultant and act as a member of a multi-disciplinary team.

The benefit to the patient and a significant drop in the prescribing of drugs, has been shown by the published research into the effectiveness of counsellors in Group Practises, carried out by the Royal College of General Practitioners (Meacher et al., 1976, p. 1 - 6 and Anderson & Hasler, 1979, p. 352-356).

Discussion

Doctors and counsellors must show proper professional responsibilities albeit on a narrow front. Until each profession totally respects the other and is more con- cerned about the patient's health than their own motives for power, status and career advancement, there will be little change and the patient will continue to lose out.

The Medical Profession

Doctors have little cause to be complacent. In 1980 40 million prescriptions for benzodiazepines, which includes 'Valium' the most profitable drug in history, were written by family doctors alone in the United Kingdom; at a cost to the Na- tional Health Service of over 30 million pounds. But the rise in psychological stress is increasing. Hospitals now deal with 100,000 overdoses a year, compared with 5,000 in 1955, and nearly a quarter of all acute medical beds are now occupied by overdose victims.

Perhaps the results of the present investigation by the Royal College of Physi- cians into 'Alternative Medicine', where the enquiry if being carried out by doc- tors who will apply their medical model of 'evaluating outcomes of treatment' , could be complimented with a similar investigation into the effectiveness of physical medicine and prescribing habits.

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The Counselling Profession

Counsellors must continue to be self-critical. Their work environment means that their clients are often special referrals or short term cases, making long term follow-up studies difficult to conduct effectively, even if they had the resources to do so. It has been said that counselling is difficult to evaluate objectively, and effectively. Perhaps one of the best methods is to see what medical help the patient has required over the three years after counselling has terminated. This would show if there had been as reduction of psychosomatic illness presented to the general practitioners.

Conclusions

During training for counselling, counsellors learn what help they can offer to pa- tients and how and where to refer psychiatric problems such as psychotic episodes, schizophrenia and endogenous depression. They do not learn about the pathology of organic illnesses and the pre and post treatment of psychological symptoms. This can and should be an essential part of counsellor training and form as much a part of the counsellor's awareness in treatment as the recognition of intercultural factors.

Perhaps this problem in counsellor training could best be overcome by a recognition of the importance of psychosomatic interactions, by the involvement of doctors in cousellor training programmes and counsellors in medical school curricula.

It may then be possible for the next generation of counsellors and general practi- tioners to work more effectively. Only then will the target group, the patients, be treated holistically and feel responsible themselves for their state of health.

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