The nature of mind and body, their indivisibility or disparity, their role and function in our wholeness as human beings, has long been debated and puzzled over. Classic philosophy returns to the problem time and time again, and although both Socrates and Plato are regarded as dualists on this issue (i.e., believing that mind and body are separate from one another, and that the ‘soul’ or ‘psyche’ can exist independently of the body), they do both consider their inseparability in terms of medical treatment. Socrates states that ‘the body cannot be cured without regard for the soul.’, whilst Plato laments that “The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul, although the two cannot be separated.” Even Descartes, the father of dualistic thinking, muses:
‘I am not only lodged in my body as a pilot in a vessel, but that I am besides so intimately conjoined, and as it were intermixed with it, that my mind and body compose a certain unity.’
Descartes, Meditation IV, 1641
Nonetheless, ‘Cartesian dualism’ – or the idea that body and mind are separate entities – is frequently cited as the reason that underlies the clear separation of physical and mental healthcare that we typically encounter today. However, we must also consider that in ancient and medieval times mental illness was widely regarded as being caused by possession by spirits or by Witchcraft, and that until the 19th century and the advent of modern psychiatry, those who treated such people were known as ‘alienists’. Furthermore, treatment of mental illness in asylums, which began in the 13th Century, was essentially custodial in nature, with admission (and punitive treatment) for anyone who may be considered mentally unwell or simply an inconvenience to society. It was not until the 19th century, with doctors such as Philippe Pinel, that thinking began to change and to recognise that psychological illness was a) treatable, and b) deserved compassionate treatment. Nonetheless, the public remained afraid of mental illness and, in Britain at least, psychiatry had little to do with medicine until the 1930s – unsurprising given the association with incarceration, alienation and brutality. I believe this at least partially explains the ongoing division seen between physical and psychological healthcare practice that we continue to see today.
‘The use of these two words mental and physical in describing disease leads us into trouble immediately.’
Donald Winnicott 1954
Working as a mental health nurse in an eating disorder unit attached to a large children’s teaching hospital for many years, I bore witness to multiple challenges associated with providing adequate care for young people experiencing illnesses such as anorexia and pervasive arousal withdrawal syndrome (PAWS), both of which require treatment of physical and psychological symptoms simultaneously. Unfortunately, as these illnesses present as physical in nature, those experiencing them are frequently treated by clinicians who have primarily been trained in physical treatments – and indeed, at times, appear genuinely afraid of any involvement with anything considered to be outside of this domain. This can lead to inappropriate and sometimes even harmful treatment, with symptoms exacerbated by long stays in medical wards with limited access to psychological support.
This situation is not surprising given that mental and physical health services themselves are physically separate and frequently provided by different hospitals or Trusts. Furthermore, training for health professionals in mental health remains a ‘specialty’, and rather a poor cousin. As a trainee nurse I was given grounding in the mechanisms of a range of illnesses during my foundation year (in which general, paediatric and mental health nurses were all taught the same curriculum including anatomy and physiology, pharmacology, and the sociology of health and illness). After this, once we branched off to our different specialties, the focus shifted very definitely to mental illness as a separate entity to physical illness. Yes, we were cautioned to be aware of the physical health needs of people with serious mental illness and encouraged to keep our physical health skills up to date even if not using them (common in many mental health nursing settings). But there was little or no discussion concerning the psychological causes of physical symptoms, nor the physical causes of psychological symptoms. My non-mental health nursing course-mates would complain when they had to complete the required mental health competencies (‘I didn’t do nurse training to learn about that’). And in turn, my small mental health cohort lamented the continued requirement for us to attend anatomy and physiology lessons, believing the focus of our learning should be purely on the psychological facets of health and illness. Indeed, I too held this mindset – that I had come to learn to be a mental health nurse, and that I shouldn’t have to bother too much with learning about the pesky irrelevant body and its illnesses!
‘Does the body rule the mind or does the mind rule the body? I don’t know’
Steven Patrick Morrissey, The Smiths ‘Still Ill’ 1984
But as a qualified nurse I realised how much of an error this was, as I encountered some very corporeal manifestations of psychological distress. Young people suddenly unable to walk; those who could not retain any nutrition, vomiting violently after any food or fluids; those who would faint or fit; and others who had just completely shut down, barely able to physically move at all, needing staff to complete all their personal cares and feed them via nasogastric tube. These young people had undergone numerous medical tests; no ‘organic’ (or physically locatable) explanation for their symptoms could be found. It had been concluded amongst health professionals that these were ‘functional’ symptoms; in other words, they were most likely psychological in origin or served a psychological function – a protective response to traumatic experience. I enjoyed working with these young people and being involved in their rehabilitation was extremely rewarding. The unit I worked in was highly specialist, in which the interplay between physical and mental health was a cornerstone of the approach to treatment. I believe this gave me an unusual insight, and I began to question the relationship between illness perceived as physical and that which is thought to be mental – and to explore the impact of the insistence of the world of healthcare to separate the two from one another.
‘The body keeps the score. If the memory of trauma is encoded in the viscera, in the heart-breaking and gut-wrenching emotions, in auto-immune disorders and skeletal/muscular problems, and if mind/brain/visceral communication is the royal road to emotion regulation, this demands a radical shift in our therapeutic assumptions.’
Bessel Van der Kolk, 2014
Ultimately, my experiences inspired me to pursue a career in research and am now working on a PhD project investigating the development of mental health liaison – services for children and young people which aim to integrate mental and physical treatments. My reading on the topic has led me to work by somatic practitioners, psychiatrists and psychologists such as and Bessel Van Der Kolk, Peter Levine, and Bruce Perry – all recognising and explaining the physical consequences of traumatic experience – and providing new hope for those experiencing physical symptoms for which physical treatments are ineffective – thought to be a huge proportion of people presenting to GP practices and outpatient clinics. This is now beginning to inform contemporary healthcare practice, for example in specialist chronic pain services. However, we still have a long way to go before these principles inform wider healthcare practice and professional training.
‘In the absence of any external cause of terror we find ourselves experiencing the feelings of a man in terror. From all this it is obvious that the affections of soul are enmattered formulable essences’
Aristotle, De Anima.
~This article was written by Miriam Avery on behalf of the LIVE with Scientists team. All views belong solely to the author. ~
Lisa Appiganesi, 2008. Mad Bad and Sad. A History of Women and the Mind Doctors from 1800 to Present.
Chew Graham et al 2017. Medically Unexplained Symptoms: Continuing Challenges for Primary Care. British Journal of Psychiatry.
John Cookson 2012 – A Brief History of Psychiatry, in Core Psychiatry.
Bessel Van Der Kolk, 2014 – The Body Keeps the Score.
Peter Levine, 2010. In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness. North Atlantic Books.
Peter Levine, 1997. Waking the Tiger: Healing Trauma: The Innate Capacity to Transform Overwhelming Experiences. North Atlantic Books.
Read, J., Perry, B.D., Moskowitz, A., Connolly, J., 2001. The contribution of early traumatic events to schizophrenia in some patients: a traumagenic neurodevelopmental model. Psychiatry 64, 319–345. https://doi.org/10.1521/psyc.64.4.319.18602
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