INTERNATIONAL PSYCHOLOGICAL CONSULTANT FEDERATION

Behavioral medicine is a field which as Ebbinghaus remarked about psychology in general "has a long past but a short history" (Ebbinghaus 1911). To review and comprehend the history of behavioral medicine requires an investigation into more than the just the short history of its formal inception and subsequent progress as a field. To review and comprehend the history of behavioral medicine also requires an understanding of the historical antecedents of the schools of thought represented by behavioral medicine and western medicine as practiced in the early to mid twentieth century. In this larger context we are primarily reviewing the rise and fall of two schools of medical thought dealing with the question of mind-body dualism, schools commonly represented by Hippocrates and Descartes. This paper will briefly examine both the events leading up to the formal formation of the field of behavioral medicine and some of the history of the schools of thought upon which it is built.

In 1974, two research and clinical programs were developed in behavioral medicine. The first was The Center for Behavioral Medicine formed by John Paul Brady and Ovide F. Pomerleau at the University of Pennsylvania (Pomerleau, 1982; Agras, 1982). The second was The Laboratory for the Study of Behavioral Medicine at Stanford University (Agras, 1982). Both programs had a clinical emphasis (Agras, 1982) and they were soon followed by the establishment of other research and training programs in both psychology departments and medical schools (Agras, 1982). In 1977, the first conference on behavioral medicine was held at Yale University, establishing a formal definition of behavioral medicine. The conference defined the content and involved fields of behavioral medicine. During the conference it was recognized that there was a need to pull together research previously being published in diverse journals to facilitate interdisciplinary communication and collaboration, and that the field had grown to the extent that a professional society was needed for behavioral medicine (Schwartz & Weiss, 1978). In 1978 and 1979, the Society of Behavioral Medicine, the Academy of Behavioral Medicine Research, the Journal of Behavioral Medicine, and the Behavioral Medicine branch of the National Heart, Lung, and Blood Institute were formed (Pomerleau, 1982).

There appear to be at least five major factors which converged to form the field of behavioral medicine. Three clear factors in the birth of behavioral medicine were the development and successes of behavior modification/behavioral analysis, the successes of biofeedback, and the emergence of chronic illnesses as a primary source of mortality (Blanchard, 1982). A fourth less clear factor, that is thought to have contributed to the rapid formation and development of the field of behavioral medicine, was the unprecedented escalation in health care costs during the 1970’s (Agras, 1982). This fourth factor is not just an extension of the shift from short-term care to more long-term care in the emergence of chronic illness. While the changing nature of the type of disease being treated had a significant impact on costs, the advent of expensive new technologies also contributed significantly to escalating costs. The fifth and final factor in the development of behavioral medicine was the failure of psychosomatic medicine to provide clinically relevant and useful interventions (Agras, 1982). There was a clinical need going unmet by the branch of research and medicine which was supposed to be filling it. Had psychosomatic medicine adapted its approaches and interventions to be more clinically relevant and useful it is doubtful that the field of behavioral medicine would have formed.

Three major changes occurred in behaviorism which made behavior modification a very powerful intervention and an effective initial foundation for behavioral medicine. Behaviorism and behavior modification in the 1970’s experienced a change in focus from utilizing aversive procedures to eliminate unwanted behaviors toward rewarding desired behaviors (Brown, 1987). This change in approach resulted in a qualitative increase in the effectiveness of behavioral interventions. A focus upon isolated behaviors was replaced by an interest in both the behavior and the context in which it occurred (Brown, 1987; Kazdin 1978), once more increasing the effectiveness of interventions. Most radical of all a strict adherence to the stimulus response model of behaviorism was abandoned as covert cognitive factors were recognized as mediators in human behavior. The new cognitive-behaviorists emerged on the scene with powerful and relevant interventions for obesity, smoking and other behaviorally dependent risk factors (Brown, 1987; Kazdin, 1978; Delprato & McGlynn, 1986). Michael J. Mahoney (Mahoney, 1974) was one of the central figures involved in introduction of "cognitive-behavioral" methods in behavior modification. A movement which has changed the essential nature of behavior modification and which provided a crucial basis for many subsequent interventions in behavioral medicine. The stunning successes of behavior modification and behavior analysis in the 1960’s and 1970’s as an intervention technique were a major factor in the development of behavioral medicine. These two approaches demonstrated themselves as powerful technologies in the treatment of some behavioral and mental health problems. By the mid 1960’s these techniques had moved beyond just mental health care and were being successfully applied to medically relevant behaviors such as smoking and obesity (Blanchard, 1982). The early success of behavioral medicine appears to have been largely the result of the consistency and reliability of these behavioral technologies in changing overt behaviors (Blanchard, 1982; Agras, 1975). Behavioral medicine gained attention and rapid utilization because two of its primary techniques of intervention had a consistency and reliability which conformed to the expectations of the clinicians of the time and lead to the rapid acceptance of these interventions by an empirically oriented medical community (Blanchard, 1982). Unlike psychosomatic medicine, behavioral medicine provided clinicians with objective and reliable protocols upon which to base their treatment plans. Behavioral analysis and behavior modification demonstrated in a highly scientific manner the interconnectedness of a patient’s environment and the success of their treatment.

The development of biofeedback in the 1960’s provided behavioral medicine researchers and clinicians with a third clinically useful method of treating patients. In this case through the monitoring and altering physiological responses associated with some illnesses (Blanchard 1982). Like behavior modification and behavior analysis this technology was a powerful intervention for behavioral medicine (when used appropriately with a relevant illnesses) because it was also very objective and reliable. Biofeedback demonstrated graphically the interconnectedness of the mind and the body and how an intervention with one can impact the other. Like behavior modification and behavior analysis biofeedback was a rapidly adopted treatment intervention.

The changing nature of health care was also a crucial factor in the development of behavioral medicine, providing the right time and the right place for behavioral medicine. While the development of behavior modification/behavior analysis and biofeedback represented advances in behavioral and medical knowledge and treatment modalities, the changing nature of health care represented an environmental change for medicine itself. A change which began to put pressure on non-psychiatric medicine to alter some of its conceptualizations of health and illness and develop new kinds of interventions to meet the demands of preventing and managing chronic illness (Blanchard, 1982; Agras, 1982).

Public health and medical research had effectively eliminated many of the infectious diseases that had been the primary source of mortality such as smallpox, TB, typhoid, polio etc. (Blanchard, 1982). The acute care for which the mechanistic model of twentieth century medicine is very well suited (with its focus on identifying and combating a single cause of illness) was fading as the primary kind of care being delivered. The primary source of mortality in adults was increasingly becoming diseases that were not easily identified as having a single cause or chronic illnesses without any easily identified single cause. These were diseases which were not cured in the acute care sense but which required long term management, such as cancer and cardiovascular disease. Epidemiological research was identifying specific risk factors for some chronic disease processes (Monson, 1980), many of the behavioral risk factors for which the technology of the emerging field of behavioral medicine was well adapted to treating. Behavior analysis was also identifying factors effecting compliance with medical regimens and improving compliance with management of chronic illness. The change in the kinds of illnesses medicine was faced with and the growing awareness of the contributions of behavior in chronic illness (Blanchard, 1982) created an environment where behavioral medicine and the intervention technologies of behavioral medicine were in demand.

The final factor in the development of behavioral medicine was the failure of psychosomatic medicine to provide clinically useful interventions and thus a dissatisfaction with it (Agras, 1982; Brown, 1987; Kazdin, 1978). Behavioral medicine likely would not have developed if psychosomatic medicine had been more successful in providing the clinically relevant (Osterfield, 1973) and useful studies/treatment protocols needed by the clinician (Agras, 1982). Despite psychosomatic medicine’s original goal of bridging the gap created by mind-body dualism in medicine, it returned to that dualism in its adoption of illness and treatment from a psychodynamic perspective.

Psychosomatic medicine failed because of its lack of intervention oriented research and because its primary mode of intervention was not an objective protocol, but the subjective protocol of verbal therapy (Delprado & McGlen, 1986). In general it came to be viewed by the non-psychiatric medical community as just not very relevant to general medical practice. Psychosomatic medicine was distanced from clinicians by its subjectivity in treatment approach and the use of liaison psychiatry as a mediator between behavioral scientists and non-psychiatric practitioners.

Psychosomatic medicine left clinicians with little in the way of objective assessment and treatment protocols. In a comparison of research in psychosomatic journals and behavior modification journals of the mid 1970’s Stewart Agras found that both types of articles were equally clinical in emphasis. However15% to 20% of the behavior modification articles was of a controlled intervention with a clinical problem whereas only 3% of the journal articles in psychosomatic medicine were (Agras, 1982). Despite the lack of controlled studies on clinically relevant questions psychosomatic medicine did contribute a large body of basic biobehavioral research which was crucial to the formation of behavioral medicine. Behavioral medicine was successful because it was more objective in research and intervention. It was able to provided more controlled research with clinically relevant questions and the kind of objective assessment and treatment protocols that clinicians found useful.

There is disagreement among authors on the relationship of behavioral medicine and psychosomatic medicine. Some see behavioral medicine as simply an outgrowth of psychosomatic medicine (West, 1982) while others see it as an independently established discipline (Weddington & Blint, 1983). Those authors who view behavioral medicine as an outgrowth and revitalization of psychosomatic medicine seem to do so because of the almost identical definitions and goals of behavioral medicine and psychosomatic medicine (West, 1982). Briefly stated the goals of both psychosomatic medicine and behavioral medicine are the application of the knowledge of the behavioral sciences in medicine (Delprado & Glen, 1986; Weddington & Blint, 1983). Those authors who view them as independently arising fields point to the development of the very different basic postulates and methods of psychosomatic medicine and behavioral medicine.

Behavioral medicine and psychosomatic medicine do share some common antecedents which diverge with the transformation of psychosomatic medicine by Freud’s psychoanalytic thought. Psychosomatic medicine had an established history before psychoanalytic theory became its organizing principle. The term psychosomatic is believed to have been first used by Heinroth in 1818 as "describing the interplay between mind and body in health and disease..." (West, 1982, p. xvi) a definition which can apply as easily to behavioral medicine today as it was to psychosomatic medicine then. By 1843 the first major journal in the field Annales Medicopsychologiques was being published in Germany. In 1872, Tuke was able to cite a considerable literature on psychosomatic medicine in his book Illustrations of the Influence of the Mind upon the Body in Health and Disease. George Groddeck (1866-1934) coined the term "It" which Freud adopted as "Id" (Will, 1997). It was Groddeck who first utilized psychoanalysis in the treatment of the physically ill and who created a theory of psychosomatic medicine integrating the two (Will, 1997). As psychoanalytic theory gained in influence it became the guiding principle of psychosomatic medicine, and psychoanalysis was the mode of treatment.

Psychosomatic medicine as it was known in the 1970’s was based around the psychoanalytic theories of Freud and his subjective data of consciousness (Weddington & Blint, 1983; Engel, 1982; Kazdin, 1978). Verbal therapy was its primary intervention, and was the intervention conducted by liaison psychiatry. Since psychodynamic theory did not provide objectively testable hypothesis it could not be proven or disproven scientifically, creating a dissatisfaction with psychosomatic medicine as a scientific endeavor (Kazdin, 1978). To make matters worse it did not make clear the relationships between behavior and health and illness nor generate empirical research supporting the efficacy of talking therapy as an intervention (Agras, 1982; Kazdin, 1978; Delprato & McGlynn, 1986). Behavioral medicine as it was known in the 1970’s was based largely on behavior modification and the learning theory and the methodologies of objective observations of behavior and physiology which originated with Pavlov and Skinner (Pomerleau, 1982; Weddington & Blindt, 1983; Brown, 1987). In short it is the shared goals and definitions of behavioral medicine and psychosomatic medicine which form the basis of the commonality and shared history between them. It is the difference in basic postulates, scientific methodologies and historical ancestries which form the independent origins and identities of the two fields.

The basic antecedents of Behavioral Medicine can be found in the Hippocratic approach to medicine, and the objective techniques of early learning theory in the observation of physiology and behavior (Weddington & Blindt, 1983; Daniel, 1987). Behavioral medicine eschews reductionism and mind-body dualism in a return to the integrative tenets of Hippocratic medicine, yet two of its strongest roots are in reductionist approaches. These two reductionist approaches are psychophysiology (particularly the branches which evolved into biofeedback and psychoneuroimmunology) and the branch of applied psychology derived from learning theory and behaviorism, behavior modification.

In February 1977 a conference was held at Yale University to define behavioral medicine and to establish goals for the field. The conference included researchers from the fields of anthropology, epidemiology, medicine, psychiatry, psychology, and sociology (Schwartz and Weiss, 1978a.). Fields involved in behavioral medicine not represented at this initial conference but which regularly make important contributions to the field are education, immunology and biostatistics (Schwartz and Weiss, 1978a.). Western and eastern traditions of imagery, hypnosis, and eastern medical traditions have also contributed to the field (McMahon & Hastrup, 1980; Crabtree, 1993; Brown, 1987; Ornish, 1990).

Behavioral medicine had been practiced prior to the Yale conference but it was practiced independently by researchers and practitioners in separate disciplines who did not have a high level of integration or coordination of research and practice (Schwartz and Weiss, 1978a.). A significant goal of the conference was to promote good interdisciplinary communication and discussion by researchers and practitioners in all the sub-disciplines of behavioral medicine for more integrative and effective research and practice. The 1977 Yale conference comes as close as any single historical event in marking the formal inception of behavioral medicine as a coherent and integrated field.

Behavioral medicine has a shared history with western medicine, but the importance of understanding this history is more than just the shared history of philosophical thought. It is relevant because of the importance of changes in outlook on reductionism and integrative approaches in medicine and the ongoing historical dynamic it represents. It is a history which illustrates the origins of medical perspectives on the mind and the body and the pressures of the times swinging a pendulum to and from a reductionistic/dualistic model and an integrative model. An understanding of the origins of mind-body dualism is needed to understand the historical dichotomy between biomedical sciences and behavioral sciences. To understand the history of behavioral medicine it is necessary to understand the two basic roots of it in the history of medicine and psychology.

Behavioral medicine shares roots with traditional medicine and psychology in humanity’s distant past. A past where the shaman healed with placebos, suggestion, altered states, psychoactive substances, religious faith, herbs, surgeries, behavioral change, diet, and the manipulation of physical and social environments (Ellenberger, 1970; Eliade, 1964; McKenna, 1992). During the time of the shaman’s there was no distinction made between illnesses of the mind or body. The mind/soul and the body were not viewed as discrete things. For that matter man was not viewed as a being independent of his environment, and the circumstances of an individual's physical and social environment were considered integral to both health and illness. The first physicians were integrative healers/priests who used all the behavioral and biological and pharmaceutical knowledge available to them to promote wellness and cure illness.

The first major epoch is represented by Hygeia, the Greek goddess of health, and falls between the 15th and 12th centuries B.C. During this time it was thought that everyone is entitled to health if they lived moderately and did not induce the ills of excess. Illness was treated by going to the temple and praying for health (Roccatagliata, 1997). It was toward the end of this period in the 13th century B.C. that Melampus became the first Greek physician to conceive of illness as a result of organic disorders and try to treat them accordingly with herbs. (Roccatagliata, 1997).

The third epoch is the epoch of Hippocrates which starts in the 5th century B.C. and ends with the "dark ages". Hippocrates was the first physician who was a physician in much of the modern meaning of the word. Hippocrates eliminated the physician’s reliance on the supernatural in diagnosis and treatment. He promoted the use of a more scientific approach to clinical care dependent on well reasoned and systematic methods. He understood the impact of social environments on health and disease and promoted a more biological and psychological understanding of the diagnosis and treatment of disease.

Aristotle lived during the Hippocratic epoch, being born on 384 B.C. and dying on 322 B.C. He belongs in the Hippocratic epoch but he is such a figure of staggering influence in western behavioral and medical thought that he deserves mention in his own right. His book Peri Psyches formed the foundation out of which the empirical study of psychology grew. (Ungerer & Bringman, 1997). His maximum "happy is one who knows the causes of things" (Robinson, 1997, p. 4) forms a basic building block of modern science, namely that the basis for learning and understanding is discovering the cause of the phenomena.

...Aristotle examines the sensory, motor, motivational, and social aspects of animal life. He carefully describes anatomical nuances and shows how these favor the survival and prosperity of different types of animals. He notes the comparability of organs in human and non-human primates; the manner in which types are shaped and adapted to local habitats; the instinctual behavior that serves the interests of herds and flocks and schools. It would not be until the age of Darwin that a more thorough natural history and theoretical explanation of the plant and animal kingdoms would be composed (Robinson, 1997, p. 4).

In the "Dark Ages" the Catholic Church became a powerful political and social force. The mind-body question was deemed a religious one since it was central to the theology of the church that the body is the flawed vehicle of a separate and immortal soul. The church created an institutionalized view of a separation of the body and behavior. Since the mind and behavior were seen as reflections of the soul of a person and thus the domain of the church, medicine was only allowed to research and treat what were clearly illnesses of the body. It was in the 15th century that the Church began to permit the dissection of human bodies as long as physicians limited themselves to the body and not comment on the soul, mind or behavior (Rasmussen, 1975).

In the 17th century René Descartes formalized the dualistic views of the church into a reductionistic and mechanistic biology. He lived in a time of intense persecution of any thought which deviated from church doctrine. This was a significant social pressure which likely influenced his writings. He is known to have suppressed one of his own books to avoid investigation after hearing about the trial of Galileo in 1633; needless to say his writing was likely influenced by what the church would think of it (Carter, 1983). Descartes’ reductionistic and mechanistic approach eventually replaced the Aristotelian views of the body and the soul in mainstream western thought. He created an approach which left the soul and thus behavior to God and medical investigation of health and illness in a purely secular realm free of the threats of mentalistic or religious considerations. Due in large part to Descartes, the human body became conceptualized as mechanistic, reducible to elementary parts and systems for explanations of illness. This position was one which allowed for empirical investigations of theories in safety from having those investigations declared heresy by the church. The approach that the body functioned independent of the mind and was independent of the mind’s control was a sensible position to take given the social environment of the time.

It was during this period that the foundations of epidemiology, an important field in behavioral medicine emerged. The word epidemiology originated with Hippocrates (Monson, 1980). Epidemiology began to emerge as a distinct field of study in the Middle Ages in the works of Paracelsus (1493-1541) "the father of toxicology". It was John Graunt who in 1532 started what is now the field of biostatistics in epidemiology. Other epidemiological researchers of the period were Thomas Sydenham (1624-1689) "the father of clinical medicine" and a student of epidemic and endemic disease, and Bernardion Ramazzini (1633-1714) a student of community disease outbreaks and "the father of occupational medicine" (Selleck & Whittacker, 1962; Levin, 1996; Monson, 1980). Despite the works of these researchers, the reductionistic model remained dominant and very successful in providing progress for the field of medicine.

During the Industrial Revolution rapid changes to the structure of society created new health problems which quickly brought a return of a Hippocratic approach to medicine. The new illnesses of urban squalor, and unregulated work conditions called attention to the environmental health problems associated with the new working and living conditions of urbanization and industrialization (Selleck & Whittaker, 1962; Levin, 1996). As a result of the demands of the era, the focus shifted from a purely mechanistic view of disorders of the body to a more Hippocratic integrative view of the individual’s health within the context of the environment and society. There was a surge of interest in public health which resulted in improvements in living conditions, working conditions, public hygiene and sanitation (Weddington & Blint 1983). In his review of the medical literature of the period Falconer provides a sample of the medical views of the time on the crucial importance of the relationships of social-environmental stress and emotions in health and illness (West, 1982; Falconer, 1796).

In the 19th and 20th Centuries medical and scientific breakthroughs made dramatic advances in the curing of acute disease. These advances took advantage of the scientific method to identify and treat individual sources of disease and illness, whether through surgery, medication, vaccination, or other new technologies. The pendulum swung again away from the integrative biopsychosocial perspective toward the reductionistic mechanical model. Disease once again became just a breakdown in the machine, and it was the physician’s job to fix the machine. In a medical era which became obsessed with mechanism and reductionism even the social and environmental factors in the need of human touch for the health of infants was no longer obvious. Physicians were genuinely puzzled by "Hospitalism" where babies in hospital and orphanage cribs died of a wasting away, no matter how sanitary the conditions, yet they recovered quickly if sent home. In 1915 one doctor surveyed 10 institutions and found that in 9 of them every baby died before the age of two, yet the thought was in the "...pediatric establishment that touching, holding, and nurturing infants was sentimental maternal foolishness" (Sapolsky, 1998). The mechanistic reductionism which provided great cures also provided new ills in depersonalization and isolation which are just as fatal as acute illness (Ornish, 1997).

Due to technological advances, the mechanistic model was very effective during most of the 19th and 20th centuries in aggressively addressing the major sources of illness facing western society. It was so successful that the reductionistic approach has become the dominant folk model of disease in the Western world and has attained the status of dogma (Engel, 1977). Unfortunately dogma operates in the twentieth century the same way it did in the middle ages. Individuals (clinicians and researchers) often do not recognize the obvious. They are threatened covertly and overtly for heresy. There is slowing in the response of medicine and society in general to understand and act on what is not predicted and sanctioned by the dogma, such as in the example of hospitalism.

Since the mid 20th century the demands on medicine have changed as chronic disease has replaced acute disease as the primary source of mortality. This change is an environmental one for medicine itself, a functional demand on medicine swinging the pendulum back toward a Hippocratic approach to medicine. Because of the dogma of the biomedical model, twentieth century medicine has not been quick in effectively recognizing and responding to the new demands being placed on it for prevention and management of chronic disease. But as in earlier eras, medicine is responding and changing and behavioral medicine is a growing manifestation of this change.

Behavioral medicine encompasses many diverse fields and thus is heir to the history of these many diverse fields and their interactions. Yet the core of the historical origins of behavioral medicine is the rise and application of behavioral techniques in the 1970’s and the alternating history of Hippocratic and reductionist thought across the history of psychology and medicine. While its own history is short, behavioral medicine is the most recent face of the Hippocratic approach to medicine. Thus while a new field, behavioral medicine is also quite old since it is the aspect of western medicine which is the modern application of the ancient biopsychosocial model of prevention, diagnosis, treatment and rehabilitation of illness.