Psychiatr News January 19, 2007
Volume 42, Number 2, page 30
© 2007 American Psychiatric Association
Wisdom From the 12th Century
Ronald Pies, M.D.
Roanld Pies, M.D., is a clinical professor of psychiatry at Tufts
University School of Medicine and the author of The Ethics of the
Sages (Rowman & Littlefield, 2000).
Modern-day psychiatry undoubtedly has many "fathers" and
"mothers," but one pioneering parent seems to have gone largely
unrecognized.
The physician and philosopher Moses ben Maimon—known as
Maimonides—was born around 1135 in Cordoba, Spain. At that time, Spain
was under enlightened Muslim rule, and scholarship flourished. But when an
extremist sect seized power, Maimonides's family left Cordoba and eventually
settled in Egypt. There, Maimonides completed his best known religious
works—the monumental Code of Jewish Jurisprudence (Mishneh
Torah) and the Guide for the Perplexed (Moreh
Nebuchim).
As detailed by Dr. Fred Rosner in Maimonides: Physician, Scientist, and
Philosopher, Maimonides wrote 10 specifically medical works, including
treatises on hemorrhoids, sexual intercourse, poisons, asthma, and, most
notable for psychiatry, his famous Regimen of Health (Regimen
Sanitatis).
Maimonides undertook this last work in 1198, in response to pleas from the
Sultan Al Malik Al Afdal. The sultan—a dissipated young man given to
bouts of melancholy— complained of constipation, indigestion, dejection,
and "bad thoughts."
Maimonides replied to his royal patient in four chapters, the third of
which is arguably one of the earliest presentations of "psychosomatic
medicine." There, Maimonides presented his view of "a healthy mind
in a healthy body," noting the interdependence of mental and physical
well-being. Maimonides argued that when dealing with the sick individual, the
physician "should place nothing ahead of rectifying the state of the
psyche."
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Maimonides understood that "passions of the psyche produce changes in
the body that are great, evident, and manifest to all...." (Regimen
of Health) and that the individual's mental powers are important in
maintaining health. Indeed, for Maimonides, mind and body together constitute
what David Eisenman calls a "psychosome"—an indivisible and
interrelated unit.
Rather than focusing solely on medication or other physical treatments,
Maimonides propounded an "equilibrium theory" of health. He argued
that a healthy diet, periodic exercise, good climate, behavioral modification,
and self-mastery are all required to maintain a healthy balance in life.
Maimonides insisted that we are responsible not only for our own actions,
but also for our feelings. Like modern cognitive-behavioral therapists,
Maimonides saw a direct causal link between our feelings and our underlying
thoughts and beliefs. He referred specifically to "acts of thinking
leading to depression" and admonished individuals to abandon such mental
habits. For example, he described the person consumed by anticipatory anxiety
and advised that "just as [the individual] becomes distressed and
grieves lest what he expects occur, so too he ought to delight his soul with
anticipation and hope that perhaps the opposite of what he expects will take
place" (Regimen of Health).
Like modern cognitive-behavioral therapists, Maimonides believed that we
can modify our emotional reactions using a kind of "guided
imagery." For example, he prescribed the following procedure for weaning
the mourner from the grieving process: "During the first three days, the
mourner should think of himself as if a sword is resting upon his neck; from
the third to the seventh day as if it is lying in the corner; thereafter, as
if it is moving toward him in the street. Reflections of this nature will put
him on his mettle, he will bestir himself..." (Hilkhot Avel
13:12).
Like modern behaviorists, Maimonides also prescribed various forms of
"exposure" therapy, in which the feared object or situation is
directly confronted by the patient or sufferer. He also applied this principle
to various destructive character traits. For example, "If one is
arrogant, he should accustom himself to endure much [insulting treatment,]...
sit below everyone, and wear old and ragged garments that bring the wearer
into contempt, and so forth, till arrogance is eradicated from his
heart..." (Laws Concerning Character Traits, chapter 1).
Dr. Nassir Ghaemi, in his book The Concepts of Psychiatry,
distinguished between mere "eclecticism" in psychiatric treatment,
and what he called "pluralism." The difference might be summed up
as that between "throwing in everything but the kitchen sink"
versus using a broad-based but selected and validated therapeutic approach. I
believe Maimonides would have applauded this type of psychiatric pluralism. He
clearly recognized that—depending on the case—some treatments were
appropriate whereas others were not. Maimonides took into account the
patient's illness, personality, habits, and even place of residence.
He also recommended joint consultation among physicians—recognizing
that no individual, however wise, has a corner on the truth. In this humbling
observation alone, modern-day psychiatry owes Maimonides a great debt.
"Teach thy tongue to say, 'I do not know,' Maimonides taught
us, "and thou shalt progress." 
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