The Need for Theory-Based Thinking in Current Psychosomatic Research
(English translation of the German introduction)
Kathrin Mörtl
In my busy congress travel years between 2005 and 2015, almost all scientific congresses included a discussion about the gap between research and practice in the psychotherapy scene. From my bases, first at a university hospital for psychosomatic medicine and psychotherapy, later at a faculty for psychotherapy science, this gap also preoccupied me: The committed empirical researchers, on the one hand, wondered why the new, sophisticated research results met with so little response from the clinicians, while the interested clinicians, on the other hand, ploughed through highly specific results, and, often disappointed, could only take away a few insights relevant to their clinical work. As a psychotherapy researcher, I thought for a while that research, and especially basic research in psychosomatic medicine and psychotherapy, did not necessarily have to serve an application-oriented purpose, but should primarily serve the further development of theory. This view persisted until one day at a congress when I became aware that even academics involved in theory building felt that empirical research had lost its capacity to connect (Mörtl, 2010): The renowned psychotherapy researcher Adam Horvath (international expert on the therapeutic alliance) spoke in a thoughtfully critical voice to the assembled audience (influential senior-career and motivated early-career scientists of the Society for Psychotherapy Research). He had noticed that in recent years many similar studies were published repeatedly to answer the very the same questions related to the research subject of the therapeutic alliance. Not only did these studies not build on each other - he compared it to building a house by throwing bricks onto a lawn, satisfied that they would certainly fall somewhere - he also had the impression that today we do not know much more about the therapeutic alliance than what was already written by Freud and Rogers. His plea for inter-disciplinary and inter-institutional research also urged, with a force that still impresses me, to engage with classical theories in all modesty (by the audience with an affinity for empiricism) and to build on them.
Emerging concepts and theories
The 'classical theories' of psychosomatics open a wide field, and for many eras of science have been at the centre of understanding the life of the soul in interaction with the body, from the definition of abnormal mental states and their physical expression, to classifications of emotional disorders and their connections with physical symptoms. For example, a clear outline of the development of conceptual explanations of psychosomatic disorders from antiquity to the 20th century is given by Franz Alexander in his mid-20th century contribution to the development of psychosomatic medicine (1962). Franz Alexander belonged to a generation of psychosomatic researchers whose thinking shaped theory and practice from the beginning to the middle of the 20th century. It was the time of the second-generation psychoanalysts who further developed Freud's teachings (among others Helene Deutsch, Otto Fenichel, Karen Horney, Erich Fromm, Wilhelm Reich) and for many it was also the time of emigration to the USA during National Socialism. Also, practitioners who developed new psychotherapeutic concepts parallel to or distinct from the psychoanalytic movement played an essential role in today's understanding of body and psyche in the Western world of psychotherapy thinking; for example, Fritz and Laura Perls (Gestalt therapy), or Jacob Levy Moreno (psychodrama).
Franz Alexander, after his emigration to the USA, continued his psychoanalytic research on specific emotional or psychogenic factors in organic diseases and, as a co-founder of modern psychosomatics, published in his 1950 work Psychosomatic Medicine: Its Principles and Applications descriptions of a range of typical psychosomatic diseases - organic diseases with a psychogenic cause (peptic ulcer, ulcerative colitis, neurodermatitis, asthma, hypertension, hyperthyroidism, rheumatoid arthritis). While Freud considered the so-called organ neuroses as not yet accessible to psychoanalytic theory and practice and devoted himself purely to the psychoneuroses with their physical aspects, Alexander expanded the spectrum in this area. In addition to the conversion symptoms described by Freud (physical symptom of hysteria or anxiety neurosis as unconscious symbolic expression of a psychogenic conflict-defence process), Alexander now postulated the emotional causes in the organ neuroses (physical symptoms as functional concomitants of emotional conflicts). This classification of psychosomatic diseases found its way into later textbooks (e. g. Textbook of Psychosomatic Medicine by Thure von Uexküll, 1979) and is still significant today. However, his attempt to attribute a specific conflict constellation to each of these psychosomatic diseases came under heavy criticism. This criticism accused him of defining certain character types ('the asthma type') through his theory of specificity, whose typical emotional and biographical constitution or vulnerability would seem to be rigidly and inevitably associated with one of the specific diseases previously mentioned. Alexander had not formulated this in such a reduced and exclusive causality; on the contrary, in his texts he pointed to very complex and individual constellations of conflict and disposition. On those issues, he could not undertake further empirical research. Although his classification of disorders is still used in theory and practice today, the psychodynamic specificity theory has hardly been empirically researched since then.
Classification, reduction, focusing
This may be related to the fact that from the mid-20th century, health care systems in Europe and America were intensively devoted to diagnostic classification systems of mental disorders (e. g. Diagnostic and Statistical Manual of Mental Disorders, DSM), including psychosomatic manifestations. Today, textbooks of psychosomatic medicine and psychotherapy are subdivided into the following areas (see Hoffmann & Hochapfel, 2009):
Somatoform disorders (conversion disorders, somatisation disorder, somatoform autonomic dysfunction [e. g. tinnitus, irritable bowel syndrome]),
Organ diseases with potentially psychosocial factors (8th edition) or psychosomatoses (up to the 6th edition) (including bronchial asthma, ulcerative colitis, rheumatoid arthritis, hypertension, and fibromyalgia)
Eating disorders (including anorexia nervosa, bulimia nervosa, obesity), and
Somatopsychic disorders (including psychological consequences of physical illnesses such as in the fields of oncology or transplantation).
In addition to the trend toward descriptive classification of mental disorders, another development of the 20th century shaped the current understanding of psychosomatics in psychotherapy discourse, namely that of comparative empirical psychotherapy research. The 20th century emergence of different schools of psychotherapy, primarily in Europe and North America, resulted in a competition over the effectiveness of certain schools of therapy. For decades, the battle between psychoanalysis and behavioural therapy captivated empirical researchers, who designed randomised-controlled studies to prove the superiority of one school over the other (later also including humanistic directions, psychopharmaceutical treatments, and other offers of the health care system). Here, a few selected symptoms of illness were measured at the beginning and end of psychotherapy. This era of psychotherapy research has been discussed with sufficient scepticism (see Tschuschke, Kächele, & Hölzer, 1994), in part because a different school of therapy always won the race depending on who directed the study, and this reductive type of comparative research did not produce results relevant to theory or practice. The conceptual research on the theory and practice of psychosomatics, which had been lively until the middle of the 20th century, stagnated here in favour of mainstream quantitative empirical research on the effectiveness of certain forms of intervention with specific diagnostic criteria.
This trend in psychotherapy research in the second half of the 20th century has left gaps between theory and research and practice. The classical theories are still taught as a central part of clinical trainings to become a psychotherapist and continue to have high practical relevance. However, in the current debate on the gap between research and practice, we find a mainstream research landscape that is impoverished - compared to the mid-20th century - and that has actually contributed little to further theory development in psychotherapy.
New discourse in psychosomatics
In the last ten to twenty years, a trend toward new conceptual work in psychosomatics (e. g. the field of psychoneuroimmunology, or genderbased psychosomatic medicine and psychotherapy) has emerged again. Public health discourse now connects mental health and physical well-being: everyone speaks of fitness, wellness, nutritional awareness, health optimisation. While the psychosomatic agents of the 20th century were predominantly located in medicine, psychology, and sociology, other disciplines now participate in the broad research discourse (such as psychotherapy science, philosophy, sinology, anthropology or ethnology, gender studies, nutrition science, and sports science). In accordance with this new...
