M e d i c i n e a n d P s y c h o s o m a t i c M e d i c i n e -- N e w P o s s i b i l i t i e s in T r a i n i n g a n d P r a c t i c e

By M I C H A E L BALINT

I OOKING BACK ON 1TS A C H I E V E M E N T S in the Western world of the .d last 100 years or so, medicine can be justly proud. To mention only its

most spectacular feats: the great epidemics have disappeared, the crippling chronic infections (the real wreckers of generations) such as syphilis and tuberculosis are practically under control, infantile and puerperal mortality have been reduced to a fraction of their former frightening numbers, deficiency diseases are almost a matter of the past, and surgical operations are painless and no longer a serious threat to life. In consequence, the average expectation of life, which was about 40 years for a new-bon~ baby in the mid-nineteenth century, rose to about 45 years at the turn of the centuD, and is now about 70 vex i t s .

In the \Vestern world, medicine has thus increased the length of life avail- able to any one. Great eiforts are being made to extend these benefits to the less developed countries where the average life expectancy is still well below Oil rs.

Although spectacular advances have been made in the field of augmenting human lifo, the ultimate task can perhaps never be solved because, as far as one can see. human life is finite. At the present stage, however, another prob- lem has already appeared: \Viii it now become the duty of medicine to improve the quality or the value of life available to anyone? Some people might say, on first thought, that this is a task for philosophy, theology, or sociology, or even for politics, but not l¢or medicine. This argmnent is correct up to a point, trot it avoids the real issue, namely, whether improving the value of human life is a medical problem as well. ls it justified to demand that nov¢, in addition to the knowledge and skills that the doctor needs for increasing the amount of human life, he also acquires other knowledge and skills enabling ]aim to in- crease the value of his patients" lives?

It is my contention that this additional knowledge ~md skills ,are essential not only for helping patients to preserve or increase the value of their lives but for the understanding and treatment of many well-known pathological conditions. This is a bold statement. To make it acceptable, I must ask you to survey with me briefly the present-day ways of medical thinking. A suitable

The research described in this p a p e r teas partl~ stlpported by a grant from the Smith. Kline & F'e,lch Foundation.

XhCIIA~:L BALLX'T, M.D. BUOAPEST. PI1.D. BE|~LIN, N|.Sc. NIANCIt.: Group Leader of l'ostgrad:,ate Seminars, Department of Psycholigieal Aledicine, University College Hospital, Lundon, England; VLs'itinl2 Pro/essor of ]'s~jcltiatr!f, Unit:ersit!! of Cincinnati College of Medicine, Cincinnati, Ohio.

(:().',IVm.:nENS~VE l).~'cmA'ruY, Vo'.. 9, NO. 4 (JMy), 1968 267

~ 6 S .~flC'~t~E~. B A L [ N T

star t is to obse rve h o w s tuden t s are t r a ined at mos t good t e a c h i n g hospi ta l s all over the wor ld . Fo r a b o u t the last 150 years, m e d i c a l t r a in ing has b e e n in the h a n d s of special is ts . An inev i t ab le c o n s e q u e n c e of this a r r a n g e m e n t is that m e d i c i n e has b e e n p a r c e l e d out a m o n g the special i t ies . An ins t ruc t ive e x a m p l e of this process is the t e ach ing hosp i ta l itself. In m a n y ins tances the s t uden t is fo rced to lead the l ife of a nomad , s p e n d i n g his t ime w a n d e r i n g from one specia l i s t to the other, each of w h o m tries to get ho ld of as m a n y hours of the s tudent ' s t ime as possible , s ince the i m p o r t a n c e of his speqialit3' is m e a s u r e d b y the t ime the s t uden t spends wi th h im.

Consequently, in spi te of of ten r e p e a t e d t r ibutes to who le -pe r son m e d i c i n e a n d a s incere b e l i e f in it b y all concerned , the p ic tu re of m e d i c i n e that forces i tself upon the s tuden t is tha t of a mosa i c cons is t ing of some large a n d impor- tan t p ieces a n d a n u m b e r of sma l l e r and a p p a r e n t l y less i m p o r t a n t ones. More- over, the re la t ive i m p o r t a n c e or size of the pieces seems neve r to be se t t led or p e r h a p s is even i n c a p a b l e of ever b e i n g set t led logical ly , except by a series of compromise s l e a d i n g at t imes to su rp r i s ing results.

A ques t ion e m e r g e s here : W h a t should the "right and fair p lace be for p sychosoma t i c m e d i c i n e ? O n e a n s w e r could b e that p sychosoma t i c m e d i c i n e is one of the m a n y special i t ies . A na tu ra l c o n s e q u e n c e of this an.v, ver has been the e m e r g e n c e of the m a n y and still m u l t i p l y i n g af fec t - labora tor ies in wh ich it is a t t e m p t e d , more or less re l iab ly , to p roduce emot ions artifieiall;¢ in the exper- i m e n t a l subjec ts in o rder to s tudy the i r effects on fhe var ious par t - func t ions of the body , such as ca rd i ac rhy thm, b lood pressure , b rea th ing , u r ine secret ion. a d r e n a l i n e output , and perspira t io i i . W h a t one tends to ignore, d u r i n g th.ese studies, is tha t the condi t ions i n h e r e n t in these expe r i men t s restr ict the choice of the ar t i f ic ia l ly p r o d u c e d emotions. T h e r e are on ly -a few emot ions that can be p r o d u c e d a n d cont ro l led fa i r ly easi ly; these are anxie ty , fright, a n d anger . • all of t h e m ra the r shor t - l ived. Yet in p sychosoma t i c m e d i c i n e we know that it is not these, b u t the long- l ived emot ions tha t r ea l ly mat ter . T h e n there is ano the r d i s a d v a n t a g e s t i l l more impor tan t . T h e dee is ion as to xvhid~ emot ion shal l b e p r o d u c e d ar t i f ic ia l ly depends , as at rule. a lmos t solely on the l eade r of the exper i r~ents and has l i t t le to do wi th the cha rac t e r or the pe r sona l i ty of the subjects .

In spi te of these i nhe ren t shortcominKs, t h i s a p p r o a c h has f o u n d inc reas ing favor in recen t decades a n d has la id the founda t ion of w h a t m a y b e ca l led expe r imen t a l p s y c h o s o m a t i c phys io logy, a lmost ce r t a in ly an i m p o r t a n t n e w b r a n c h of science. This f ield of s tudy, however , is i nev i t ab ly coming into com- pe t i t ion wi th the exis t ing b r a n c h e s of m e d i c i n e for a fa i r sl ice of the m e d i c a l s tudent ' s t ime.

I n ' w h a t follows, I shou ld l ike to show ano t he r a n s w e r to our quest ion, one wi th wh ich we h a v e b e e n e x p e r i m e n t i n g for a n u m b e r of years in a L o n d o n t e a c h i n g hospi ta l , in w h i c h it has been recogn ized that s o m e t h i n g o u g h t to be done to coun te rac t the p a r c e l i n ~ out not only of m e d i c i n e itself, the med ica l s tudent ' s t ime, and med ica l t h ink ing a m o n g the var ious special i t ies , but , unfor- tunate ly , also the pat ients . \Ve e n c o u r a g e the s tuden ts to get to knov¢ thei r patim~ts not on ly as carr iers of i l lnesses, bu t also,, as h u m a n beinKs, and then ~'e

NIEDIC1NE AND PSYCItIOSO.~.fATIC NI:t?.DICINE 269

offer the s tuden ts possibil i t ies for the discussion of the i r exper iences a n d p rob- lems in small tutor ial seminars . 1 wish to a d d tha t the fo l lowing case w a s re- por ted by a s t uden t in the first f e w mon ths of his first c]'inical year .

C A S E I{EPORT

Al though the pa t i en t , a w o m a n , was on ly 34, this was her fifth admiss ion, e ach one to a d i f fe ren t ward . Th is c i r c u m s t a n c e m a d e us sit up a n d take no t i ce s ince we h a v e l ea rned to re~t~gnize it as a set]oils s y m p t o m . T h e p r e sen t admiss ion s e e m e d to be qu i t e s t ra ight forward ; the pa t i en t had a respirator)" in fec t ion , p r o p e r l y d i agnosed by h e r doctor , wh ich d id not r e spond to ant ib io t ics commol t ly used, As he r cond i t i on d id no t improve , she wa-~ r e f e r r e d to the hospi ta l w h e r e her doc tor ' s diagnosis , b r o n c h o p n e u m o n i a , was conf i rmed . Af te r the p a t h o g e n i c o rgan ism was isola ted, the r igh t an t ib io t i c was se lec ted , to whitrh the p a t i e n t r e s p o n d e d wi th r ap id i m p r o v e m e n t so tha t she cou ld leave the hospital , r es to red , in a l i t t le ove r two weeks.

This co tdd be the end of her cctst~ his tory, but be fo re c los ing it. le t us cons ide r some a~te~,t~.dents. T h e stu~tent l ea rned f rom her tha t she was t he y o u n g e s t ch i ld and the b l ack sheep o~,.the f~mily. She had left school at 14 and , a f t e r t h ree yea r s o f v e r y shor t e m p l o y - ments , jo ined the x,V.A.A.F. T h e r e she m e t her h u s b a n d w h e n she was 19 a n d m a r r i e d h im wht:-n she was 21 aga ins t ve ry stroi lg oppos i t i on by h e r fami ly . She then h a d two ch i ld ren by him itl qu i ck succe.~sion bu t lef t h im and the two ch i ld ren w h e n she was 24.

At abot t t this t i the she m a d e he r first visit to t]m hospi ta l w i th a ch ron ic u lce r on he r ankle,. T h e dermato lo i : ica l d e p a r t m e n t s t rugg led wi th it for some t ime bu t t hen de- e|areal tha t it mus t be artil lcial, ve~ ' l ikely self- inf l ic ted. E v e n t u a l l y the u lce r h e a l e d uncler a p las te r of Paris dressing, l eav ing a flat scar.

She told the s t u d e n t tha t she was then l iving wi th an e lde r ly l ady w h o h a d a son. One day there was a big row in the h o m e w h i c h Upset h e r so tha t she took an o v e r d o s e of barbi t l i ra te . She was a d m i t t e d to hospi ta l bu t cou ld be d i s c h a r g e d a f t e r a f e w days . In the m e a n w h i l e h¢~r h u s b a n d s ta r t ed d ivo rce p r o c e e d i n g s aga ins t he r and got his d e c r e e absohl te , g iv ing h im the cus tody o f the ch i ld ren .

T h e n she d e v e l o p e d b lackouts wh ich were p r o p e r l y e x a m i n e d at the neuro log ica l dc'p~rtrm:nt, h~tt t ,) .sign of ep i l epsy was discx)vered. She was next r e f e r r ed to the p sych i a t r i c ward . She app t ' a r t -d ont. day , was adru i t ted , bu t f o u n d the cond i t ions the re u n p l e a s a n t and t~ns~ttisfactory, hi.t-:]lira more and rnore ag i ta ted , a n d la te in the s ame n igh t d i s cha rged ht-r.self agains t med ica l advice .

x,V¢~ d i scove red in the files a le t te r f rom this pe r i od in w h i c h he r gene ra l p r a c t i t i o n e r s ta ted that eve ry night , in o r d e r to get some sleep, she took two or t h ree T u i n a l and two or th ree Doriden: in add i t ion she took 10 rag. L i b r i u m th ree t imes a d a y for he r t remors , a'.i C m Amyta l twice a day to e(~ntrol he r h lackouts , a n d 100 rag. Nico t in ic Ac id t h r e e times a (lay for the fee l ing o f in to le rab le co ld in he r body .

Tw(~ years a f t e r he r shor t s tay in the p sych ia t r i c ward , she was again a d m i t t e d , this t ime tc~ the surgical ward . for hav ing ctlt he r wrist in a suic idal a t t e m p t . T h e w o u n d p r o v e d to be super i lc ia l , and a f t e r hav ing it a t t e n d e d to, she was d i s c h a r g e d a day or tv¢o later; the w o n n d hea l ed p r o m p t l y w i t h o u t ~my compl ica t ions . Th i s ep i sode br ings us up- to -da te .

By c o m p a r i n g the var ious hospi ta l notes and f rom w h a t the s t u d e n t was ab le to ob- tain r Jrom her, several con t r ad i c t i ons e m e r g e d . In s o m e no tes the pa t i en t ' s h u s b a n d was desc r ibed as a "~Vest Ind ian . This fact , not m e n t i o n e d to the s tuden t , m a y ex-plain the family 's res is tance to the mar r iage . Notes m e n t i o n e d tha t tim p a t i e n t l e f t h e r h u s b a n d in ortl(:r to l ive wi th a n o t h e r man. One nt)te t h o u g h t tha t this nmn was the o ld lady 's son, while in o the r notes of admiss ion this was no t m e n t i o n e d , no r was the s t u d e n t told a b o u t it. And so on and so on.

( ; r adua l l y we f o r m e d the p i c tu r e of a w o m a n , not ve ry in te l l igent and def in i te ly depressive, who k n e w full well that she had made a mess o f her life, tha t she had b r o u g h t nnhapp ines s to e v e r y o n e nea r her ( fami ly , h u s b a n d , ch i ld ren , p e r h a p s also he r lover) bu t

.~,: (} x ~ICHAEI, t]A L~NT

w h o , in her fear, despa i r and conftlsion, resor ted to the m e t h o d of telling4 ~-~.'~:r.v {Iot:tor only bits of her h is tory b e c a u s e of her fea r that , if she were to reveal tile who le tru0~. e v e r y o n e w o u l d turn against her. \Ve r eaehed this tmde r s t and ing the day be fore th{. pa t i en t left the hospi tal and our con tac t wi th her ceased , very l ikely for good.

W e cou ld no t de te rmine , as her notes w~re si lent on this point , w h i c h of her many p rev ious doctol-s h a d r eached this diagnosis , or w h e t h e r a n y o n e had tr ied 1o treat this pa tho log ica l condi t ion and w h a t the results of such t r ea tmen t had been . Ir~stead we f o u n d p rec i se in format ion a b o u t each pa tho log ica l a l tera t ion of her part-flmctiol~s, such as the size o f the fiat scar r emain ing after the u lcer on ]at-," ank le , the length of the" self- infl icted w o u n d and the n u m b e r of s t i tches that we re n e e d e d to close it. and the exact ident if icat ion of the strain of cocci caus ing ]~er I}ronclaop~euxlaonis, a long with eqllally exact descr ip t ions of the therapeutic- measures undertake** to rern{r(]y these p~thologic-al changes a.~ld of the results achit~ved.

This no t - so -uncommon case his tory is a good i l lus t ra t ion of wha t I have cal led the mosa ic of med ic ine , consis t ing of carefu l d iagnos is and efficient t r ea tmen t o f pa tho log ica l ly c h a n g e d par t - func t ions of the b o d y with, as far as one can ascer ta in f rom the hospi ta l records, h a r d l y any a t t emp t at t rea t ing the whole pat ient . Usua l ly this is w h a t the s tuden t gets to see b u t un fo r tuna t e ly not w h a t the hospi ta l staff w a n t to teach or even hones t ly be l i eve that they teach.

N o w a d a y s , al l over the wor ld b u t espec ia l ly in the more progress ive univers i - ties, i t is i nc reas ing ly reeo~qaized that this s i tua t ion is not des i rable , and all sorts of exper imen t s are u n d e r t a k e n to c h a n g e it. The p r inc ip le diff icul ty agailx lies in specia l iza t ion. Special is ts excel in diagmosin,*. ~ and t rea t ing condi t ions w h i c h b e l o n g to the i r spec ia l ty ; w i t h some exaggera t ion , one ma,¢ say i l lnesses w h i c h are " local ized" in organs, organ systems, or par t - funct ions of the b o d y b e l o n g i n g to the i r specia l fields. '~Ve m a y call these C'Iass 1 i l lnesses. In contrast to these, there are peop le who do not have any loca l izable i l lness bu t who arc themse lves ill. W e m a y sum up these people as suffer ing from a pa tho log ica l condi t ion b e l o n g i n g to Class 2.

As yet it is u n d e t e r m i n e d w h a t propor t ion of the pa t ients w h o come for adv ice and help , p resen t a pu re pic{ure of Class 1 or Class 2 condi t ions and how m a n y of t h e m are mixed cases h a v i n g s 'ymptoms b e l o n g i n g to both. A fur ther , e q u a l l y u n e x a m i n e d p r o b l e m is the correct t h e r a p y of these mixed eases; on w h i c h condi t ions shou ld the t r ea tmen t be focused or, if on several . in w h i c h order? Eve r s ince Hippocra tes , every, g rea t doctor has e m p h a s i z e d tha t i t is neve r the i l lness b u t a lways the pa t i en t w h o mus t be t reated. This a t t rac t ive p r inc ip l e ha s b e c o m e s o m e w h a t o v e r s h a d o w e d bv the s ignal suc- cesses of the "scientific" or ientat ion.

U n d e r its inf luence, p r e sen t -day m e d i c i n e has deve loped excel lent me thods for s t u d y i n g a n d t rea t ing i l lnesses b e l o n g i n g to Class 1. These are b a s e d on a close s t u d y of the pa tho log ica l changes observed , l e ad i ng to a ra t ional sys tem of these i l lnesses, the i r r e l i ab le diagnosis , and the i r h i g h l y efficient and still i m p r o v i n g the rapy . On the o ther hand , as the case r epor ted shows, p resen t -day m e d i c i n e is i l l -at-ease v¢ith condi t ions b e l o n g i n g to Class 2.

In o rde r to r e m i n d ourselves l~ever to forget these two di f ferent app roaches to the p r o b l e m s offered b y the .pat ient in recen t years we h a v e been experi- m e n t i n g w i t h the use of two concepts : the traditio;ml diagnosis, w h i c h is w h a t p re sen t -day m e d i c i n e tries to es tabl ish in eve D" case, and the ocerall diagnosis,

3 I E I ) L C I N E A N D P S Y ( . q I O S O . ~ , , f A T I C 3 I I ' ? . I ) ICINI~I 271

w h i c h shou ld c o m p r e h e n d the who le pa t i e n t w i t h a i l h i s p rob lems . W e h a v e found in o u r var ious r e sea rch seminar s tha t once the i dea of these two levels" of d iagnos i s has been accep ted , a good deal of the difficulties a n d confus ion can be c l ea red a w a y .

In p a r t i c u l a r w e h a v e f o u n d in pa t i en t s suf fer ing f r o m Class 2 condi t ions t ha t e i t he r no illness c a n be d i agnosed in t rad i t iona l terms, or t h a t a n y illness tha t can be d i a g n o s e d is e i t he r t e m p o r a r y or i r re levant . T h e case r e p o r t e d is a pa in fu l i l lus t ra t ion of this b i t t e r fact .

I f one s tudies closely w h a t h a p p e n s b e t w e e n the p a t i e n t a n d his doc to r in these ins tances , one can r ecogn ize tha t the p a t i e n t "offers" var ious s y m p t o m s , s y m p t o m complexes , synd romes , or even "'illnesses" to his doctor . T h e do c to r then " ' responds" to the pa t i en t ' s otfers b y var ious examina t ions and , on the basis of the i r results , g ives adv ice or p r e sc r ibes d rugs or a diet . T h e o u t c o m e of this in t e rac t ion b e t w e e n the pa t i en t ' s offers a n d the doctor ' s r e sponses is an " ' agreement , " F r o m n o w on, b o t h will h a v e some idea " 'what the t roub le is abou t . " In condi t ions b e l o n g i n g to Class 1, this a g r e e m e n t is b a s e d on a p r o p e r a n d t rue d iagnos i s of the illness, w h e r e a s in condi t ions be long ing to Class 2, m o r e of ten than no t the a g r e e m e n t is b a s e d on an i r r e l evan t or even a p h o n y diagnosis . Consequent ly , , w h a t is t r ea ted in condi t ions b e l o n g i n g to Class 1 is

• N the pa t ien t ' s illness, w h e r e a s in those b e l o n g i n g to Cla~s 2, m o r e of ten t han not it is the "agreement,'"

This is an o p p o r t u n e m o m e n t to r e tu rn to a cons ide ra t ion of the two tasks of med ic ine w i th w h i c h we s t a r t ed : to inc rease the l eng th of h u m a n life and to increase the va lue of h u m a n life .available. I hope i t can be seen n o w that the first task can be solved only on the basis of a reliabz~ traditional diagnosis whi le the second task d e m a n d s an e( lual ly reliable o,;era~ diagnosis. T h e r e can be no d o u b t t tmt all the medica l t r e a t m e n t our w o m a n p a t i e n t r ece ived h e l p e d he r to presern, e a n d p ro long he r life. At least on one occasion, w h e n she h a d the b r o n c h o p n e u m o n i a , h e r ]fie w a s p r o b a b l y s aved b y the r ight t r e a tmen t . \Vhen we inqtaire a b o u t the s econd task, h o w e v e r , t ha t of i nc reas ing the va lue of he r life, w e h a v e to adal(~it t h a t no overa l l d iagnos is was a t t e m p t e d in h e r case; as a result , the va lue c~f h e r l ife r e m a i n e d as pa t ho l og i c a l l y poor as i t ever " , v a s .

F u r t h e r m o r e , med ic ine canno t easi ly d e f e n d i tself aga ins t the c ha rge of no t diag~aosing the f ac t tha t severa l of this w o m a n ' s admiss ions to the hosp i t a l w e r e c o n n e c t e d w i t h the pa tho log i ca l l y poo r va lue of h e r life ( fo r ins tance , the two abor t ive su ic ide a t t empt s , p e r h a p s h e r t r e m o r a n d b lackou t s , a n d poss ib ly h e r self- int l icted skin u l ce r ) a n d possibly- cou ld h a v e b e e n p r e v e n t e d if m e d i c i n e h a d been ab le to h e l p he r w i th this pa tho log ica l pover ty . This is a good illus- t ra t ion of w h a t ~I m e n t i o n e d a t t h e beg inn ing , t h a t in a n u m b e r of cases solving the second task, to inc rease t he v a l u e of the pa t i en t ' s l ife on the basis of an overal l d iagnosis , m a y con t r i bu t e c o n s i d e r a b l y to t he solut ion of t he first task, looking a f t e r the p a t i e n t in he r va r ious p a t h o l o g i c a l cond i t ions a n d t h e r e b y inc reas ing the l eng th of he r life.

D i s q u i e t i n g ques t ions f ace us a t this point . Shou l d tiffs overa l l d iagnos is be a t t e m p t e d ? I f so, shou ld it be our responMbil i ty or even ou r du ty , w o u l d it be

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be t t e r to leave i t to psycl!ologists, psychiatr is ts , teachers, sociologists, or per- haps to min is te rs? If we accep t respons ib i l i ty for the diagnosis , w h a t is the p rope r t he r apy based on it?

I n our case, as far as can be l ea rned f rom t h e notes, no overal l d iagnos is was a t t e m p t e d by any of he r phys i c i ans or surgeons dur ing the ten y'ears she was pe r iod ica l ly a d m i t t e d to- the hosp i ta l . T he first a t t emp t at an overal l d iagnosis was m a d e b y s tudents who h a d no control over the therapy . Conse- quent ly , i f the a n s w e r to the first ques t ion is "'nb,'" we have to accept the case his to~, as~ inev i tab le . However , if we accept respons ib i l i ty for the overal l diagnosis , we also have to accept two i m p o r t a n t consequences : O n e is a n e w or ienta t ion in m e d i c a l thinl<ing and, of course, t ra ining; the o ther is a d e m a n d for a n e w the r apy based on this overal l diagnosis .

The ne'*v or ienta t ion in med ica l t h ink ing ",,,'ill d e m a n d that in every case, ill add i t i on to a r e l i ab le t rad i t iona l diagnosis , the doctor should reach an equa l ly re l i ab le overal l diagnosis . I t is on this basis that he wi l l have to d e c i d e w h e t h e r his pa t i en t needs t r ea tmen t other t han that b a s e d on the t rad i t iona l d i agnos i s . - I n this way , bo th the overal l d iagnos is and the dec is ion about fu r the r t h e r a p y wil l r e m a i n the ful l respons ib i l i ty of the doctor in charge. (I shou ld like to e m p h a s i z e the phrase, "'full respons ib i l i ty ." ) Unt i l n o w , doctors h a v e been censu red only if they over looked ~_m organic condit ion. If this n e w or ienta t ion becomes accepted, doctors will be equa l ly censured for over looking a pe r sona l i ty p rob l em or for not ask ing at the appropr i a t e m o m e n t for psych ia t r i c examina t ion if they feel i n a d e q u a t e to work out a r e l i ab le overal l d iagnos is themselves .

Th i s overal l d iagnosis and the t he rapy based upon it wi l l const i tu te true p sychosoma t i c med ic ine . Th i s is t he reason I adop ted an app roach d i f ferent f rom tha t used in the affect- laboratories. T h e i r m a i n - a i m is to s tudy how part- func t ions c h a n g e u n d e r the inf luence of art if iciMly p r o d u c e d emotions. The results ob t a ined in this way wil l u n d o u b t e d l y const i tu te p roper scientif ic data, r e l i ab le and repea tab le , and of course c a p a b l e of s tat is t ical e labora t ion . In this wG¢ we w o u l d con t r ibu te impor t an t observat ions to t he s tudy of h u m a n par t funct ions , tha t is, to h u m a n phys io logy, bu t we wou ld miss the oppor tun i ty for the s tudy of the pa t i en t as a who le h u m a n b e i n g and con t r ibu te t h e r e b y to the s tudy of whole person med ic ine .

In the case of the w o m a n pat ient , we c a m e to the conclus ion tha t the who le patholog)) was ahnos t cer ta inly in causal connec t ion wi th he r inc reas ing aware- ness tha t she h a d ~ r e e k e d he r life, b r o u g h t on ly u n h a p p i n e s s to everyone w h o m a t t e r e d to her, all of w h i c h resu l ted in depress ion , s h a m e and confusion. All these emot ions are of the chronic , s tab le type, a lmos t imposs ib le to s t u d y u n d e r l abora to ry condi t ions . On the o ther hand , all of them can be s tud ied fmr ly eas i ly du r ing t r ea tmen t in m e d i c a l pract ice .

It is i m p o r t a n t to rea l ize tha t no m a t t e r h o w h a r d one tries, in this f ield it i)s p r a c t i c a l l y imposs ib le to avoid b e i n g b iased b y p reconce ived ideas. T h e only th ing one can do against-t .his diff iculty is to state one's p reconcep t ions as c lear ly as o n e can. Al though it is obvious tha t there are a n u m b e r of psy- chologica l s y m p t o m s and even i l lnesses w h i c h are la rge ly caused b y somat ic

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condit ions, I th ink that the i r i m p o r t a n c e a n d frequen%v in m e d i c i n e are over- stated. The real p roblems, espec ia l ly in p sychosoma t i c med ic ine , are the somat ic s y m p t o m s and i l lnesses that h a v e thei r or igins in psychologica l conflicts and persona l i ty problems . To be exact, these two para l l e l s t a t ements are a hypothes i s w h i c h mus t be p roved or r e fu ted b y p rope r ly c o n d u c t e d c l in ical research.

As we env i sage it, the research is s t ruc tu red in tiers. T he first tier, of course, is diagnosis . To ar r ive a t an even ly b a l a n c e d d iagnos is w h i c h is e q u a l l y con- ce rned wi th the i l lnesses ca r r ied b y .the pa t ien t and w i th the pa t i en t h imsel f , we insist tha t in each case the doctor mus t m a k e a traditional a n d an overall diagnosis. E v i d e n t l y the s tab le or bas ic emot ions and affects that in our v i ew are of p a r m n o u n t impor t ance for p sychosomat i c m e d i c i n e will find the i r p lace in the overal l diagnosis .

The second tier is that of the the rapeu t i c decis ion tha t mus t be b a s e d on, and stated in t en ns of, the t radi t ional d iagnos is a n d the overal l diagnosis .

Bight at the start of the t rea tment , the doctor m u s t state w h a t resul ts h e hopes to ach ieve in the field of each of the two d iagnoses ; this is the th i rd t ier of (mr research. The pred ic t ions m u s t be s ta ted in a .form c a p a b l e of verifi- cat ion or re fu ta t ion by object ive observa t ion; they mus t b e ex-pressed b o t h for a shor t - term and for a long- term fol low up.

All this is taken down in wri t ing, and wi th this in our hand , we i n t e n d to fol low up our cases for a sufficient l eng th of t ime to see to w h a t ex tent our predic t ions prove to be correct, T he fol low-up, in terms of the p red ic t ions m a d e in wr i t ing at the incept ion of the t rea tment , const i tu tes the four th t ier of our research.

After a few mon ths of preparator)" work, we have just s ta r ted research on these lines wi th a group of exper i enced g e n e r a l pract i t ioners . Our first a im is to work out et]]eient me thods t'or d e a l i n g w i th bas ic and s tab le emot iona l p rob l ems a n d the i r s o m a t i c consequences that can b e used in the se t t ing of genera l pract ice . T h e close compar i son of our overal l diagnmsis w i th the thera- peu t ic decis ions ba sed upon it, the predic t ions , mad the fo l low-up of results, wil l give us da ta abou t the connec t ions b e t w e e n the pa t i en t ' s s tab le or bas ic emot iona l at t i tudes, their somat ic consequences , the the rapeu t i c means n e e d e d for c h a n g i n g these a t t i tudes , and the effects of these changes on the somat ic s),rnptoms. "~Ve be l i eve tha t this stud)" will th row n e w l igh t on some of the bmsie p rob l ems of p sychosomat i c m e d i c i n e .

E v i d e n t l y any t r ea tmen t based on an overal l dia_o-nosis mus t ahvays b e conce rned wl th increas ing the va lue of the pa t i en t s life, the second task of therapy~ As the case quo ted he re shows, this second task m a y get over looked ff the pr ine ipaI a t ten t ion is focused on the t rad i t iona l d iagnos i s as m a y happen , inadver tan t ly , in a chiefly specia l is t pract ice .

Thus , the n e w or ienta t ion tha t we advoca te in m e d i c i n e wi l l n e e d a con- s ide rab ly c h a n g e d at t i tude. I w i sh to e m p h a s i z e tha t this does not m e a n tha t a n y t h i n g of p resen t -day m e d i c a l t ra in ing or t h ink ing shou ld b e a b a n d o n e d ; it means that, in add i t ion to w h a t is t augh t today, this n e w a p p r o a e h ~ t h e whole person m e d i c i n e b a s e d on a re l i ab le overal l d i a ~ m s i s ~ m u s t f ind its

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r ightful place in medical thinldng and training. I t is evident that it will not be an easy task to achieve this integration.

REFERENCES

1. Balint M.: The Doctor, His Patient and the Illness (ed. 2). London, Pitman Medical Publishing Co., 1964.

2 . - - , and Balint, E.: Psyehotherapeutic Techniques in Medicine. London, Tavistoek Publications Ltd., 1961.

3. Ball, D., and Wolff, lt. H.: An experi- ment in the teaching of psychotherapy to medical shldents. Lancet 1:2t4-217, 1965.

4. Tredgold, R. F.: The inte~ation of psychiatric teaching into the curriculum. Lancet 1:1344--1347, 1962.