Wednesday, August 25, 2010

Mind-Body Dualism

In every generation since Richard Cabot initiated medical social work at the Massachusetts General Hospital in 1905, humane physicians and medical ethicists have inveighed against mind-body dualism and mechanistic approaches to medicine. But dualism and a decidedly second class citizenship for mind have had remarkable staying power. Powerful preaching on behalf of an integrated view of our human species and elegant conceptualizations like George Engel's biopsychosocial model have not slain the dualistic dragon.

But dualism and neglect of mind may finally be on the way out. Our capacity to look inside the skull with magnetic resonance imagining is bringing about the change.

An article by Matcheri Keshavan and colleagues - "Neuroprotective Effects of Cognitive Enhancement Therapy Against Gray Matter Loss in Early Schizophrenia" - in the July issue of the Archives of General Psychiatry, reports on a two year study in which patients early in the course of schizophrenia but already significantly impaired were randomized to "cognitive enhancement therapy," an integrated approach to the remediation of cognitive impairment in schizophrenia that uses computer-assisted neurocognitive training and group-based social-cognitive exercises, or "enriched supportive therapy." All patients were treated with antipsychotic medications.

Not surprisingly, patients who received the cognitive enhancement therapy showed gains in cognitive and social function. But MRI studies over the course of two years showed significantly greater preservation of grey matter in several areas of the brain and increased grey matter in some key locations. In other words, a psychosocial intervention caused physical changes in the brain.

As an undergraduate studying philosophy and psychology I learned the riddle: "What's mind? It doesn't matter. What's matter? Never mind!" But studies like the one Keshavan reports show that words and thoughts are not wimpy ephemera compared to "the real thing" (drugs). They show up in our wiring and have the power to generate physical changes as well as emotional reactions.

Creating a better balance between mechanical intervantions with drugs, devices and other technologies and the interactive, interpersonal components of medicine won't come about easily. Too many economic interests are at stake in our worship of mechanism and contempt for mind. But the combination of a heightened understanding of the power of mind and dissatisfaction with the soul-less health system we've created will be a powerful force for change.

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