At the start of every Pain Training and Education introductory course, we talk about dualism, and the problems that it has created for physiotherapists and their patients who live with pain. Dualism is a philosophical model which suggests that the mind and body are separate. Dualism has a long history: the Greek philosopher Plato (approx. 427-347 BCE) was a dualist, and more recently, René Descartes (1596-1650) strongly influenced dualist thinking. So why should a physiotherapist be interested in philosophy, and in particular, in dualism? This blog will explore these two issues, and expand on the ways in which dualism can be an obstacle to successful pain management. I will aim to use straightforward language that a member of the public could understand, because there are already many academic sources of ideas about dualism, for physiotherapists who want to read more.
Why might philosophy matter to a physiotherapist? Philosophy has been defined as “the study of knowledge”, and it addresses a range of questions about the nature of understanding, how we use language and logic, and how we make sense of causality, for example. There are specialist branches of philosophy, such as the “philosophy of science” which considers the way that we develop and test knowledge using scientific methods. The short answer to why philosophy matters to physiotherapists is that knowledge matters to us all: what we think and how we think significantly influences what we do. If we want to be as effective as possible in what we do, we need a clear understanding of the theories which guide our behaviour.
Why does dualism matters to a physiotherapist? To answer this question, we need to know more about what dualism means, and the consequences of this way of thinking. Dualism argues that the physical, tangible body is a separate entity from the mind (also known as the soul, or psyche). I think it helps to understand the origins of dualism to realise that the word “psyche” is a Greek word for breath. Breathing was associated with life: when a person dies, they stop breathing, but the body remains. If we put aside our modern knowledge, it is easy to imagine that the breath leaving the body was the life force leaving the body: the breath was seen as having a separate existence. The belief that the mind can have a separate, ongoing existence after the death of the body is intimately linked with dualism. Dualism has therefore been associated with religious belief: a detailed history of dualism also needs to understand the way in which religious beliefs have changed and adapted to new knowledge over the centuries. Roy Porter’s book, Flesh in the Age of Reason (2004) provides an excellent, detailed account of these changes in Europe since the Enlightenment.
Not all the Greek philosophers were dualists, but as I’m not aiming to provide a detailed account of Greek philosophy, I’m going to skip around 2000 years of philosophy to talk about Descartes. He is known for many reasons, but in particular for using the “Method of Doubt”, which involves putting aside any ideas which cannot be evidenced. He concluded through a process of reasoning that the only thing he did not doubt was his process of reasoning itself. This lead to the famous statement, “cogito, ergo sum” (Latin: “I think, therefore I am”). He was looking for a foundation on which to build knowledge, and his foundation was the very existence of his mind. He did understand that the mind was connected to the body, but he speculated that the connection was via the pineal gland. This speculation led to considerable criticism at the time, and with our current knowledge we can understand that he was struggling to make sense of the way in which the brain “connected” the mind and the body. This model represents the mind as a “thing” or entity, with an existence that is separate from the body. Descartes argued that the body operated like a machine (perhaps influenced by contemporary advances in clock design) and that scientists should be allowed by the Church to find out how the machine worked, using dissection and experimentation. In contrast, he accepted that the mind (the soul) was the domain of the Church.
If we adopt a dualist model, how might that affect the practice of physiotherapy? To start with, it will mean that we will have to divide all health problems into physical health problems or mental health problems. Physical health problems are indicative of a machine that is not functioning properly, and the job of medicine is therefore to identify the faulty part and to fix it. Physical health problems are therefore “real” (tangible), compared to mental health problems, which in contrast are “all in the mind”. This neat categorical divide has facilitated the development of separate bodies of knowledge, and medical specialisms: for example, general medicine and orthopaedics treats the body, whereas psychiatry treats the mind. The job of a dualist physiotherapist working in a musculoskeletal department is therefore to identify the mechanical fault, and to address it. This way of thinking has dominated physiotherapy, and medicine in general, but it is problematic. It is of course an oversimplification, and this simple way of thinking actually makes it more difficult for us to develop a more complex and useful model of health and rehabilitation.
Another obvious pitfall of taking a dualist approach to health occurs when medical science cannot adequately explain a particular health problem. If current scientific methods are unable to identify a physical fault, then the finger of suspicion is pointed at the mind. It is sobering to realise that this problem affected patients with multiple sclerosis, who were once thought to have a psychological disorder, before we were able to identify demyelination. A similar problem holds back our thinking around Chronic Fatigue Syndrome/ME, which is still not widely recognised as a “real” condition because the absence of a clear biomarker has allowed dualist sceptics to carry on thinking that it is “all in the mind”. It should be clear at this point in the blog that the point I made earlier about the importance of philosophy has been evidenced over many decades, at significant cost to the health and well-being of many patients.
It is not just scientists and healthcare professionals who are dualists. Dualism is the dominant philosophical model in Europe, and we have all grown up within a dualist culture. Our patients are therefore likely to think like a dualist, and this can affect their understanding of any health problems that they have, and any management plan that they might undertake. A dualist patient with a pain problem, such as an osteoarthritic knee, may assume that their pain is an entirely physical phenomenon, and may therefore seek a physical remedy rather than learning to take a broader, self-management approach. They may therefore push for knee surgery as the obvious solution to “fix” the problem, which is clearly (in their minds) a faulty part that needs replacing, like a worn bearing. It will be difficult for them to grasp that their pain experience may be mediated by peripheral body chemistry, and sensitisation within the nervous system at different levels. It is likely to be impossible for them to grasp the idea that all pain (regardless of its cause) is ultimately an experience that is mediated by thoughts and feelings, and hence amenable to a much broader approach to management.
If dualist thinking is a problem, what is the alternative? There are a number of approaches, but my next blog will explore a strong alternative known as the “biopsychosocial model”.