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Psychosomatics and psychotherapy

Professor Emeritus Johannes Bitzer, MD, PhD, from the University of Basel (Switzerland) visited Rīga Stradiņš University (RSU) on 20-23 November 2019. Prof. Bitzer is also a guest researcher at the RSU Institute of Public Health. He delivered a series of lectures and seminars for students with the theme 'Research capacity strengthening, including sexual and reproductive health'.

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Research in the field of sexual and reproductive health has become increasingly active driven by a reduction in stereotypes and prejudices in some countries while the opposite dynamics are at work in others. We met before he had concluded this lecture series to look closer at his personal practice, the government’s role in encouraging research in the field, and discussed what an ideal doctor should be.

How did you come to be invited to RSU?

I have known Prof Gunta Lazdāne since she worked for the World Health Organisation (WHO), and I was active in the European Society of Contraception and Reproductive Health (ESCRH). I was president for six years, and in that context we met several times to look into a possible of collaboration between WHO and ESCRH in the field of contraception, abortion, and sexual and reproductive health. Gunta also knew that I’m active in psychosomatic medicine, and since part of psychosomatic medicine is also sexual medicine Gunta invited me to come to RSU as a guest professor to talk about psychosomatic medicine and sexual medicine from a practical point of view.

I am also going to speak about, and encourage, research in the field of sexual and reproductive health, outlining where there are gaps and what types of studies we already have and what type of studies we would like to have. On my last day I will also help students understand how to review a paper as I am Editor in Chief of The European Journal of Contraception & Reproductive Health Care so I want to give an insight into how we review papers and what people who submit papers should be aware of.

What is your specialisation?

Well actually I’m a trained obstetrician/gynaecologist (OB/GYN), and I was the head of department of Obstetrics and Gynaecology at the University of Basel for several years. Quite early in my career I started combining OB/GYN training with psychotherapy, and psychiatry, so I did a sort of double training. This is a combination that has always fascinated me, because I think traditionally medicine is split between doctors for the body, and doctors for the mind. I think we all agree that it is useful to a certain degree to have this separation, because it helps doctors specialise, but at the end of the day you still have to bring it together again, because there is really just one person sitting in front of you as a patient. 

Since you will be encouraging research in this field, could you explain why you think this field is under-researched?

I think women’s health as a part of public health is under-researched and under-served in many countries. We do know what good standard of care for women should be, but when we look into the facts of how services are provided and what women can expect to receive in the field of sexual and reproductive healthcare in different countries, the standard is rather below what we know should be available. This is a question of health policy. It is a question of how important this field is on a national level and in the health care system. It’s not so easy, because a large part of women’s health is prevention and this isn’t so attractive to politicians. Cancer care is a much more impressive issue, so I believe that there is still an imbalance between male and female healthcare – female healthcare is politically less important, although in reality it is even more important.

How can the prestige and funding for this field be raised, and how can we encourage more knowledge in society? Is it up to NGOs, the government, or individual universities?

That’s a very good question. Basically the decision should come from the government. Usually, however, this doesn’t happen, because when it comes to sexual and reproductive rights many governments don’t want to get too involved. They don’t want to commit. As I mentioned, oncology, cancer etc. gets much more attention. When you get into sexual and reproductive health care and rights, then you touch upon people’s value systems and they are afraid of all sorts of things, like sexual behaviour that they don’t understand. I think it’s a field that governments try to avoid to a certain degree. And that makes it important then that either universities or NGOs step in. Universities are crucial because they can still affect the situation via education. I also think that we very much depend on international academic collaboration. 

What are, in your mind, some good examples of government policies that have really worked to raise awareness?

If you look at Germany, Switzerland or France, for example, I think that one of the most important factors to changing attitudes was that women came into positions of power and could influence politics. This is also true regarding the European Commission and the European Parliament. Female politicians are interested in sexual and reproductive health and can raise these issues so that things really start to change. The image that is then produced in the media is important and has a positive political impact.

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One of the topics you will cover in your lectures is emotions and disease. Could you elaborate on this topic?

I think the most neglected issue in medicine is the recognition that the emotional brain is very important for health, and that one of the things making people ill is that they are not able to understand their own, or others’ emotions, how to regulate emotions, and how to make them useful. In recent years we have learned much more about what “good functioning of the emotional brain” looks like, and the interaction of the emotional brain with cognitive functions, without which you wouldn’t be able to cope with stress. What happens when people are unable to cope with stress is that they frequently get into a state of chronic distress that finally makes them sick. I think that is why knowledge about emotions and the competence to deal with emotions in yourself is so important and that is actually in my view the most important part of psychosomatic medicine.

Emotions are a link between the mind and the body. Emotions are directly linked to your nervous system, to your autonomous nervous system, to your endocrine system, and they are mainly what we used to call “the unconscious brain”.

What are some common diseases that can result from stress?

I think there is quite a considerable impact on endocrine functions and reproduction. A classic example is anorexia and stress-related hypothalamic amenorrhea, which means that menstruation ceases. It has also been shown that acute stress can induce ovulation, which may become a problem for women who want to become pregnant. That’s one of the problems with fertility treatments – as soon as you start treatments you increase stress, which in turn impacts fertility, and you can get into a vicious cycle.

We now also know that depression is very much linked to chronic stress. And then you also have functional disorders like different pain conditions, or irritable bowel syndrome (IBS). You do not die from these, but your quality of life is considerably reduced.

Similarly to sexual and reproductive health, I feel that psychology is something that needs a push to become more accepted or common in society, rather than being seen as a luxury treatment. Do you see it this way, and what can be done to promote psychology in society?

This is very true. One traditional understanding of mental health is that your wellbeing is up to you as an individual, that if you’re struggling you’re not hard enough, that you should just pull yourself together. The other issue is that there have historically not been any well-designed studies to prove efficiency, so it looked a little bit like a luxury. You can see that a patient has been in therapy for 20 years, but without an outcome study that has followed them from the beginning, you cannot outwardly see the progress. Many psychoanalysts would also never be willing to take part in outcome studies, because the concept is so complicated. How do you even measure something that cannot be seen with the naked eye? So you have to rely on patient-reported outcomes. There are, however, more and more brain imaging studies that nicely show that new neural networks are in fact built up, but these studies are still expensive.

The history of psychoanalysis and female sexuality is complicated, where women would often be dismissed as hysterical. What is your take on this historical development, and where are we today?

Whatever you think of Freud, he was at least honest in saying that he doesn’t understand female sexuality. I think he called it the “dark continent” and thought it was very complicated and confusing. This was, however, in my view rather rapidly corrected by female psychoanalysts. For example, they looked at something that I personally find very interesting, namely the concept of how children perceive the difference between being a little boy and a little girl. This was a very helpful contribution to our current discussion on gender differences. Things developed in a good direction. I especially want to mention Helen Singer Kaplan who researched desire problems, and Masters and Johnson, who brought sexuality into medicine. They took sex workers to the laboratory, and measured what happens when someone gets sexually excited – female and male. They, together with Kaplan, looked at the role of the brain in sexuality.

Could you talk about how you balance your work between being a therapist and a gynaecologist?

I combine both in the same practice – half of the time I do gynaecology and half the time I do psychology. Sometimes with the same patients, which is completely against psychoanalytic rules, but I don’t practice psychoanalysis. The psychotherapy I practice is a mixture, but I am very much oriented towards famous American psychotherapist, Irvin D. Yalom who is an existential psychotherapist. I don’t only listen, but I talk quite a bit to try to bring the session to a certain point.

Do you see this kind of a practice that takes the emotional and the medical into consideration simultaneously as the future of medicine? Is there a demand for something like this?

I don’t know what it’s like here in Latvia, but in my country the wish for more personalised approach to medicine is exemplified by the field of homeopathy – a lot of people go to homeopaths because they have a feeling that this is someone who listens, who wants to understand, to respond, to really learn what’s going on. I addressed this in my lecture. If we keep emotions out of the room, and we really just stick to so-called facts, then doctors can easily be replaced by artificial intelligence. Computers can ask questions, you answer, and then the answers are analysed and according to an algorithm they either work out a diagnosis, or see what to ask next. So you don’t actually need a doctor for this type of rational process of just taking a classical history and getting a list of symptoms. A computer might even be better, because computers have larger databases and can make connections a human might not be able to. I do, however, hope that people in medicine understand that if you want to maintain the profession, you have to also take interpersonal encounters seriously, to develop what we call the “therapeutic relationship”. I cannot have a relationship with a computer, but I can with a doctor.

This is a lot to ask of one person. Is it realistic?

Yes. You have to keep in mind, however that emotional work is work. This work is quite exhausting, so I don’t want to sort of idealise it, or say that there should be this ideal doctor, but it’s important to keep this in mind when practicing medicine.