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Reassessing biopsychosocial psychiatry

  • Will Davies (a1) and Rebecca Roache (a2)
Summary

Psychiatry uncomfortably spans biological and psychosocial perspectives on mental illness, an idea central to Engel's biopsychosocial paradigm. This paradigm was extremely ambitious, proposing new foundations for clinical practice as well as a non-reductive metaphysics for mental illness. Perhaps given this scope, the approach has failed to engender a clearly identifiable research programme. And yet the view remains influential. We reassess the relevance of the biopsychosocial paradigm for psychiatry, distinguishing a number of ways in which it could be (re)conceived.

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Corresponding author
Will Davies, Oxford Uehiro Centre for Practical Ethics, Suite 8, Littlegate House St Ebbes Street, Oxford OX1 1PT, UK. Email: wkdavies@hotmail.com
References
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1 Engel, G. The need for a new medical model: a challenge for biomedicine. Science 1977; 196: 129–36.
2 Ghaemi, SN. The rise and fall of the biopsychosocial model. Br J Psychiatry 2009; 195: 34.
3 McClaren, N. A critical review of the biopsychosocial model. Aust NZ J Psychiatry 1998; 32: 8692.
4 Gabbard, GO, Kay, J. The fate of integrated treatment: whatever happened to the biopsychosocial psychiatrist? Am J Psychiatry 2001; 158: 1956–63.
5 Davies, W, Roache, R, Savulescu, J. Rethinking Biopsychosocial Psychiatry. Oxford University Press (in press).
6 Kendler, KS. The dappled nature of causes of psychiatric illness: replacing the organic functional/hardware–software dichotomy with empirically based pluralism. Molecular Psychiatry 2012; 17: 377–88.
7 Leff, J, Kuipers, L, Berkowitz, R, Eberlein-Vries, R, Sturgeon, D. A controlled trial of social intervention in the families of schizophrenic patients. Br J Psychiatry 1982; 141: 121–34.
8 Leff, J, Kuipers, L, Berkowitz, R, Sturgeon, D. A controlled trial of social intervention in the families of schizophrenic patients: two year follow-up. Br J Psychiatry 1985; 146: 594600.
9 Chalmers, D, Clark, A. The extended mind. Analysis 1998; 58: 719.
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The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
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Reassessing biopsychosocial psychiatry

  • Will Davies (a1) and Rebecca Roache (a2)
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eLetters

Biopsychosocial model : what do we have to do as doctors?

Manhal M Zarroug, Psychiatry trainee - ST5, South West London and St George's NHS Trust
Dieneke Hubbeling, Consultant Psychiatrist, South West London and St George's NHS Trust
Robert Bertram, Associate Specialist, South West London and St George's NHS Trust
21 February 2017

Davies and Roache asserted that the biopsychosocial model can be useful for classification of psychiatric problems, for establishing causal factors and for developing interventions1. Their editorial suggests that further research should make clear whether classification, causation and treatment for specific conditions can be best conceptualised at social, psychological or biological level. />
Ghaemi expressed a different view, arguing that the biopsychosocial model is too vague. He suggests that it is not clear which interpretation should be prioritised because the available evidence is often not there. He also stated that the biopsychosocial model can lead to ‘mere eclecticism passing for sophistication’2⁠.

The question – not specifically addressed by Davies and Roache – is what to do as a practising psychiatrist. If there is clear evidence supporting the psychosocial paradigm, then it can be applied; however, as Ghaemi stated, there often is not.

We suggest that the positions of Davies and Roache ought to be combined, to a certain extent, with that of Ghaemi by taking the patient’s view into account. Previous studies have found that patients have different ideas about the possible causes of their illness such as current stress, childhood problems and physical illness3⁠. There is also qualified evidence that agreement between patient and health professional is associated with a better outcome4⁠⁠ and higher patient satisfaction5⁠.

Therefore, if there is some evidence for a certain explanation or treatment (despite alternative explanations or treatments possible), the biopsychosocial model can be helpful. This model can accommodate a degree of eclecticism, because it can make it possible for clinicians to offer explanations to patients which are most concordant with their own ideas. This is a form of eclecticism; eclecticism that may be beneficial for patient care.

References

1 Davies W, Roache R. Reassessing biopsychosocial psychiatry. Br J Psychiatry 2017; 210: 3–5.

2 Ghaemi SN. The rise and fall of the biopsychosocial model. Br J Psychiatry 2009; 195: 3–4.

3 McCabe R, Priebe S. Explanatory models of illness in schizophrenia: comparison of four ethnic groups. Br J Psychiatry 2004; 185: 25–30.

4 Stewart M, Brown JB, McWhinney IR, Oates J, Weston W, Jordan J. The Impact of Patient-Centered Care on Outcomes. J Fam Pract 2000; 49: 0–12.

5 Callan A, Littlewood R. Patient Satisfaction: Ethnic Origin or Explanatory Model. Int J Soc Psychiatry 1998; 44: 1–11.

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Conflict of interest: None Declared

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The dynamics of the biopsychosocial paradigm

Saad F Ghalib, Consultant Old Age Psychiatrist, behavioral sciences pavilion,SKMC,Abu Dhabi,UAE
17 January 2017



I read your editorial with interest. In my opinion, what a good number of opponents and proponents of the biopsychosocial(BPS) paradigm have not taken into account is the fact that trying to build a BPS model out of patient’s symptoms is not a passive process but rather, a very dynamic one whereby preconceptions by therapists inadvertently being incorporated into patients’ narratives. For example, a biologically oriented therapist over emphasizing the biological aspects of the BPS model, sadly or not, at the expense of psychological and social aspects. A multidisciplinary approach may help to lessen the impact of the latter approach, but can never prevent it all together. Moreover, and considering the complexity of the BPS model, were causality cannot be ascertained precisely, the order of interactions with the system does matter greatly. For example, when a patient’s condition is initially conceptualized from a biological perspective (explained to patient in terms of receptors and chemicals) to having been subsequently told by another therapist that their defense mechanisms have gone haywire (bad luck if your local psychotherapist has a long waiting list!), the end result may well potentially be quite different had the process been applied in a reverse order, that is psychotherapy first then biological psychiatry second. The latter, may explain as to why the BPS model is so heterogeneous.

For many decades, physicists have understood that the order, in which a complex system has been interacted with, can matter a great deal to the end results (adding vectors). Measuring the position of an electron and subsequently its velocity (doing both at once is forbidden in quantum theory) will give entirely different results had measurements been performed initially on velocity and subsequently on position.

In conclusion: it is by the integration of the role of the observer/therapist into the biopsychosocial model and the precise order of steps that have been taken in the process of building a narrative for patients’ symptoms, that a more operational definition of the BPS model can possibly be achieved, and its only then that a better correlation between the explanatory languages of psychology and that of brain biology can be reached. I doubt if the BPS model, will ever be an ontological one. However, it can certainly be improved at an epistemological level.

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