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The rise and fall of the biopsychosocial model

  • S. Nassir Ghaemi (a1)
Summary

The biopsychosocial model is the conceptual status quo of contemporary psychiatry. Although it has played an important role in combatting psychiatric dogmatism, it has devolved into mere eclecticism. Other non-reductionistic approaches to medicine and psychiatry such as William Osler's medical humanism or Karl Jaspers' method-based psychiatry should be reconsidered.

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References
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1 Craddock, N, Antebi, D, Attenburrow, MJ, Bailey, A, Carson, A, Cowen, P, et al. Wake-up call for British psychiatry. Br J Psychiatry 2008; 193: 69.
2 Engel, GL. The need for a new medical model: a challenge for biomedicine. Science 1977; 196: 129–36.
3 Engel, GL. The biopsychosocial model and the education of health professionals. Ann N Y Acad Sci 1978; 310: 169–87.
4 Grinker, RR Sr. A struggle for eclecticism. Am J Psychiatry 1964; 121: 451–7.
5 Shorter, E. The history of the biopsychosocial approach in medicine: before and after Engel. In Biopsychosocial Medicine: An Integrated Approach to Understanding Illness (ed White, P): 119. Oxford University Press, 2005.
6 Campbell, W, Rohrbaugh, R. The Biopsychosocial Formulation Manual. Routledge, 2006.
7 McHugh, P, Slavney, P. Perspectives of Psychiatry (2nd edn). Johns Hopkins University Press, 1998.
8 Osler, W. Aequanimitas (3rd edn). The Blakiston Company, 1932.
9 Ghaemi, SN. The Concepts of Psychiatry: A Pluralistic Approach to the Mind and Mental Illness. Johns Hopkins University Press, 2007.
10 Ghaemi, SN. Toward a Hippocratic psychopharmacology. Can J Psychiatry 2008; 53: 189–96.
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The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
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The rise and fall of the biopsychosocial model

  • S. Nassir Ghaemi (a1)
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Response

Nassir Ghaemi, Professor of Psychiatry
18 August 2009

Though I appreciate and value the comments given in Dr Lothane’s personal experience with Dr Engel, I fear that he has made many of those same misinterpretations for which I fault the biopsychosocial (BPS) model.I hope he reads my full book to be published in December where I provide the evidence that contradicts some of his statements. Until then, in brief, here are a few replies:

1. The mainstream ideology of psychiatry is the BPS model. One cannot pass the specialty boards in the US without paying lip service to the bio, psycho, and social aspects of a case. It is widely taught in residency programs. In practice, I agree, biology has taken pre-eminence, but perhaps this is because of the failure of the BPS model to convince?

2.There are many other approaches that provide all the benefits of the “healer” that Dr Lothane describes, without requiring all the other beliefs of the BPS model: Osler’s medical humanism is quite different and more effective in teaching the healer’s role.

3.My critique of eclecticism relates to the harmful uses put to Engel’s ideas in psychiatry, rather than Engel’s work itself, but this is partly because Engel wrote little about psychiatry. Nonetheless, he is not blameless, just as Marx cannot be dissociated from Lenin. Engel’s ideas invite eclecticism in psychiatry as an almost inevitable result.

4.I appreciate and agree with Prof. Scadding’s view, as would Jaspers, but the BPS model does not follow. I urge Dr. Lothane to carefully study Jaspers if he has not.

5.I document in my book why Engel’s BPS model was anti-humanistic. He overtly rejected the idea of humanism, in black and white print. This is a matter of documentary record, not opinion.

6.Engel also, far from being in Osler’s tradition, overtly rejected Osler’s ideas about medical humanism. I describe their clear differences in detail in my book, but one major difference is that Osler accepted the traditional medical disease model, while Engel did not, and Osler emphasized the importance of intuitive art and literary humanism in medicine, which Engel overtly rejected.

One can value George Engel as a man; I do not personally criticize him at all. But his ideas have been more harmful than helpful in contemporary psychiatry, in my view, and it is time that we stopped defending those views that have had half a century to prove their worth, and can hardly be said to have been an unalloyed success.
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Medical model is not as bad; Biopsychosocial model not as good, bid adieu!

Raman D Pattanayak, Psychiatrist
18 August 2009

We welcome the selection of a thought-provoking theme for the editorial (1). Till the time we stumble upon the Galileo’s telescope to view psychiatry, a flowing stream of discussion on the key concepts and theories is our insurance against ‘the kind of growth associated with stasis quo’. George Engel with immense contributions to psychiatry remainsa respected figure for present and future students of psychiatry irrespective of the fact that his model may continue to be accepted, revised, reinvented or rejected for a better suited one. We present our take on this fundamental yet controversial theme.

The adherents of Engel’s biopsychosocial model (2),often enthusiastically and ambitiously, pitch it as a replacement of the medicalmodel. The fact that latter has survived the test of time and enjoys a fruitful existence in medicine, not merely by chance, is conveniently overlooked. The medical model has been ‘bashed’ for promoting mind-body dualism, treating mental different from somatic (2). Ironically, it is thebiopsychosocial model which refuses to consider mind as a ‘product and function’ of brain and treats it as different and ‘something more’ than can be accounted by brain processes, thereby leading to a divide of body-mind. With the integration of psychiatry into mainstream medicine, the compartmentalistic view of mental being different from somatic is fading in favor of attempts to explain mental processes on basis of somatic/physical phenomenon. Believers of ‘mind vs brain stance’ object tothe philosophy of reductionism and physicalism. It is noteworthy that recent advances in psychobiology, psychoendocrinology and psychoneuroimmunology also support, rather than contradict these basic philosophical principles of medical model of disease, that is complex phenomenon being derived from primary principles (that is, psychology can be explained based by biology, biology by chemistry, chemistry by physics). We cannot let ourselves into deception of belief that an outwardlife event has the ability to form a subjective experience embedded in ourmind without consequent changes in neurotransmission, neurochemistry and neurophysiology of brain and per se, we don’t see a problem in physicalismas the basic philosophical principle. A virus or bacteria or a dietary deficit has a capability to alter this biological machinery and so can a stressful life event by hampering the ‘hardware’ which may be already weak. McLaren, in a review(3) concluded the biopsychosocial model based onsystems theory and emergentism to be so seriously flawed that its continued use in psychiatry is not justified (3) and not helpful as a construct either (4).

The science of nutrition or say, exercise does play an important and established role in health and illness, but does not generate a debate regarding bio-dietitics or bio-kinetics as being the next explanatory model. It leads us to wonder if the debate regarding biopsychosocial is more of territorial one than scientific.

Often, it is stated that medical model leaves no room for psychological or social aspects which is untrue. Evaluation of personal, familial and social impact of any illness is as much in harmony with medical model as is the use of evidence-based inter-disciplinary management (psychological therapy or physiotherapy).To often dismiss biomedical model as ‘cold and impersonal’ is also factually incorrect as aperson interviewing based on biopsychosocial model can be perceived as ‘cold, mechanical and insensitive’ while asking personal information whilean orthopedician strictly following biomedical model can be perceived as ‘warm and empathic’.A ‘humanistic’ and ‘patient centered’ approach and empathic interviewing style are the determinants rather than the etiological model followed.

The psychological and social factors do play a role albeit to a varying degree in the causation, manifestation, alleviation, exacerbation and outcome of medical diseases. Engel in his seminal paper in Science, a medical journal, made an attempt to sensitize the entire medical fraternity to take into account the psychological factors in clinical approach (‘psychologize medicine’). Unsuccessful in achieving its expectedgoal to the desired degree, it had a collateral impact of ‘re-sensitizing the psychiatry’ to psychological factors. Psychiatry as a discipline in 1970s was justifiably working towards establishing itself as a science trying to shun away the ghosts of largely redundant psychoanalytic theories. Restoration of this faith can be seen as a ‘collateral benefit’ and achievement for the biopsychosocial model (though the lesson learnt is‘to not to swallow the faith pill without an evidence base’).

We have to agree that emergentism/holism as a philosophy ‘sounds’ good indeed, but it is equally vague and unverifiable in science, not found to be a helpful construct (4). Not only has it failed to be an effective guide, it has allowed itself to be vulnerable and fallen prey tonumerous quasi-scientific and pseudophilosophical viewpoints. Biopsychosocial model has failed to provide ‘a blueprint for research…and a design for action’. Reductionism as a concept, on the other hand, has undergone further refinements in contemporary theories of philosophy and proved to be practically useful, generate testifiable data and valuable asa research tool for biological sciences.

We wish to conclude by saying that medical model is capable of takinginto account all the factors including psychological and we repeat, including psychological in a more rational way. It can be delivered in perfect harmony with a humanistic and patient centered approach to medicalcare and is not that bad afterall for medicine in general and psychiatry in specific (at least till a suitable and perfect alternative is found). ABiopsychosocial approach can stay but it is about time we bid adieu to a biopsychosocial model and come home to our trustworthy old and often misunderstood friend.
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Biopsychosocial model is there room for improvement?

Athanassios Douzenis, Assit. Prof. In Forensic Psychiatry
18 August 2009

We read Dr Ghaemi's editorial '' The rise and fall of the psychosocial model'' with interest. However, we feel some comments might be necessary.The biopsychosocial model (BPS) has a significant advantage. It demands an inclusive framework for the study of disease a framework which resists dichotomies. Mental disease is seen as a phenomenon- dynamic itself- whichresults from interactive patterns of influence among genetic variables, environmental influences, cognitive appraisals and unconscious influences.Empirical evidence, though limited, has not discredited such conceptualization of disease. Engel and Grinker provided the ontological framework within which disease may be studied. The term holistic is not disadvantageous here. In fact, itdemonstrates that the model may stand as medical as well as psychiatric.

In these terms, there is a hidden strength of the BPS model. A strenth wecan find in functionalist accounts of mental states and the Folk Psychological framework . That is, that it is ontologically non- committal; since it identifies the biological, the psychological, and the social influences by their functional role to the onset and course of disease. Thus, the BPS model offers a way out of the contemporary, ontological perplexities of science. It postulates that -in principle- we should not hold explanations and influences by each of the three levels of understanding as either superior or inferior to each other. This is not a solution to all our problems. But it is the sort of ground which conforms to the needs for a psychiatric model that may integrate different epistemological approaches to disease (i.e. biological or psychodynamic). This is, most probably, the reason why the BPS is a powerful model and hasbeen established as the dominant view among contemporary psychiatrists.

So BPS is more than a label. However, an inclusive, non-hierarchical model is not enough to promote the study of mental illness. Ontological foundations are necessary. The issue, however, is to provide the pragmaticframework that might render the study of disease- cause, diagnosis, prognosis and treatment- more effective. In these terms Ghaemi is quick to identify the inadequacy of BPS. In research (and practice) we may not look at all three levels of understanding at the same time. Research needsprioritization and specificity. Still, the model does not guide us as to which aspect should be prioritized. Grinker, as well, has identified the deficit. He went one step further than Engel: from ontology to methodology; seeing that holism in research may hinder effectiveness he advocated eclecticism. Ghaemi, correctly, suggests that eclecticism is not the answer because it entails the danger that the choice of emphasizing one aspect rather than another lies ultimately on the researcher’s (or the practitioner’s) subjective conviction. He also argues that since the BPS model does not provide the means for the task of prioritizing, it is stagnant and we may abandon it. Might Osler’s “medical humanism” present an alternative option? Osler's contribution was significant particularly to medical education, advocatingthe need for clinical experience as part of the academic curriculum. Through his essays and famous textbook ‘The principles and practice of medicine’ he insists on the qualities the physician ought to posses. It is in these terms that he suggested the notion of art of medicine and the need to recur on humanities. Learning about human beings from other sources may render the physician more capable of using factual knowledge. Though a morally attractive position this is by no means the sort of solution we are looking for. The need to revisit humanities is also found in Jaspers . Though in a different sense and within a diverse, more sophisticated conceptualizationof the epistemological framework that psychiatry ought to hold. Jaspers advocated methodological pluralism. The kind of pluralism that does not degenerate into medical relativism. Significantly, he argues that the way to avoid the latter is to rely on evidence. However, it is worth noting that he advocates two ways of making science: explanation and understanding. Explanation refers to empirical data that can be confirmed statistically. Understanding approaches the hermeneutic tradition, in thatmeaning and interpretation are stressed, but it is different- Ghaemi obscurely positions it ‘midway between explanation and existence’. Jaspersthinks there is place for understanding in science along with explanation.Yet we need to abandon the dogmatic attachment to the positivism of natural sciences and the Popperian falsification criterion. However, and despite Ghaemi’s effort to render the epistemological premise of understanding visible, the position is more mystical than scientific. Moreover, there is a familiar, disagreeable element in it. Just like Osler’s psychiatry, it appears to bear on the ideologically attractive buton practical grounds inept school of humanistic psychology. However, Jaspers’ work brings back an open debate and the need for an answer. He reminds us the need for an epistemology that might render interpretation a scientific endeavor. Despite some inconsistency, his work, in a way complements the BSM model -with the notion of methodological pluralism. Still, we argue, pluralism may easily degenerate to methodological anarchism. Jaspers implies that it is each method itself that might orientate the researcher or practitioner. So it is not the case that again a mechanism of choice is needed. Instead, let us say, this is the case. Ultimately it is evidence based research that can define the boundaries ofmethods or-significantly- falsify them altogether. What each of the relevant methodologies can contribute from within its ontological filed ought to be demonstrated by evidence. Ghaemi suggests that we should either wait for an improved version of the BPS model or revisit other models, as those of Osler and Jaspers. Concluding, it suffices to say that we argue for the first option; given that the functional character of the BPS model may encompass a flourishingresearch program.

References

1.Engel GL. The need for a new medical model: a challenge for biomedicine. Fam. Syst. Med. 1992 10: 317-331

2.Stich SP. Deconstructing the Mind, Oxford University Press, 1996

3.Stich SP. From Folk Psychology to Cognitive Science: The Case Against Belief. MIT Press, 1983

4.Ghaemi N. The rise and fall of the biopsychosocial model. BrJ Psychiatry 2009; 195: 3-4

5.Grinker Sr RR. A struggle for ecleticism. Am J Psychiatry 1964; 121: 451-7

6.Golden R. A history of William Osler’s The principles and practice of medicine. Osler Library studies in the history of medicine No. 8. Montreal, McGill University, 2004.

7.Ghaemi SN. The concepts of psychiatry : a pluralistic approach to the mind and mental illness : Johns Hopkins University Press, 2003.

8.Jaspers K. General Psychopathology - Volumes 1 & 2. translated by Hoenig J.and Hamilton MW. Johns Hopkins University Press, 1997
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The biopsychosocial concept: relic or reality?

Zvi Lothane, Psychiatrist
29 July 2009

Dr. Ghaemi’s recent (BJP, 195, 3-4) editorial targeting the biopsychosocial model as “played out” is both inaccurate and misleading. It also tarnishes the achievements and memory of George Engel who was my teacher during my residency training in psychiatry at Strong Memorial Hospital in Rochester from 1963 to 1966.

Dr. Ghaemi’s opening salvo -- that the biopsychosocial model is “the mainstream ideology of contemporary psychiatry” – is in error on two counts. First, the mainstream ideology of psychiatry in 2009 is one that defines psychiatric illness as biological, with pharmacotherapy as its first line of treatment. Second, the term biopsychosocial, as Engel used it in 1977, was not an ideology but a bit of shorthand for his entire approach to medicine and psychiatry.

Engel came to psychiatry from medicine and his 1977 paper expressed an approach that he had developed from 1941 onwards. Just as in medicine there is a patient with his/her illness, so in psychiatry there is a person with his/her disorder. In both the patient is a person with a body (soma), a psyche (mind), and with a place in a family and in society. Whether practicing the sciences of disorder or the arts of healing, the physician and psychiatrist both must first and foremost establish an interpersonal relationship with the suffering person -- a fellow physical,psychological, and social being.

Engel was not promoting an ideology, nor was he attacking biological or pharmacological treatments, and he certainly was not trying to push “psychoanalysis through the back door,” as Dr. Ghaemi insinuates. Engel did believe that this approach, or method, should be practiced in every doctor-patient encounter, or else the doctor was in danger of failing his calling as healer. If psychiatry, a name which means mental healing (from psyche=soul and iatros=healer), does not embrace this approach, then what is it? This is the relevance of George Engel’s approach, which Dr. Ghaemi sorely missed. He should consult Engel’s 1962 book, “Psychological Development in Health and Disease,” which describes what Engel stood for and how he got there; and Dr. Ghaemi, a Tufts man, might be pleasantly surprised to learn that Engel’s first mentors, when in 1941 he became a Fellow in Medicine at Peter Bent Brigham Hospital, were Soma Weiss, HerseyProfessor of Medicine at Harvard, and John Romano, the distinguished American psychiatrist who as chair of the Department in Rochester appointed Engel as Professor of Psychiatry and Medicine there.

Dr. Ghaemi suggests that the biopsychosocial approach is a disguise for undisciplined “eclecticism”; he argues that attempts to “individualise treatment to the patient” conceal an attitude in which the physician is “allowed to do whatever one wants to do,” resulting in “anarchy.” I cannotevaluate these statements if they are meant to characterize the books by Campbell & Rohrbaugh and by McHugh & Slavney, which Ghaemi cites. However, they are defamatory if applied to George Engel.

Engel was a consummate clinician and scientist, a humanistic physician in Osler’s tradition, who taught a unique interview technique of medical patients which was also applied by the senior Rochester faculty in interviewing psychiatric patients. This technique was based on the determinism of free association, memory, and fantasy which shaped the narrative of the patient. Following the flow of the patient’s narrative, Engel would be able, in the course of a 30 to 45 minute dialogue, to bringout the concerns of the patient in the here-and-now, connect it with significant memories of trauma, loss, helplessness and hopelessness, to show not only the person’s major dynamic issues but also reach a correct diagnosis of the physical ailment. Engel was not just, as Ghaemi alleges, a “specialist in functional gastrointestinal disorders”; his interests ranged over the entire spectrum of health and disease. Rather than turningto Jaspers’ method-based psychiatry as Ghaemi suggests, I would rely more on the late Professor Guy Scadding (1988) who highlighted the issues we face as follows:

“Philosophical discussions about health and disease often refer to a 'medical model' of bodily disease, in which diseases are regarded as causes of illness; diagnosis consists in identifying the disease affectingthe patient, and this determines the appropriate treatment. This view is plausible only for diseases whose cause is known, though even in such instances the disease is the effect on the affected person, and must not be confused with its own cause. But in fact the medical diagnostic processwhich progresses from recognition of patterns of symptoms and signs, through search for abnormalities of structure and/or function, towards knowledge of causation often stops short of this desirable end-point; and at whatever point it comes to a halt, its result is expressed in terms of 'diseases'. Thus in medical discourse the names of diseases are a convenient device by which the current conclusion of the diagnostic process can be stated briefly; and they have widely varying factual implications. This nominalist analysis of the medical usages of the names of diseases has consequences for definitions of health and disease, and for some problems in medical ethics.”

Perhaps the term biopsychosocial, meant as an improvement over its much-abused predecessor, pychosomatic, has its limitations, but it is most unfair for Ghaemi to reach the hair-raising conclusion that it is “anti- humanistic.” What is in a name? It is more important to understand the whole approach and concept, and to apply it thoughtfully and ethically. Rather than belonging in the dustbin of history, the biopsychosocial perspective is here to stay.

References Engel GL. Psychological Development in Health and Disease.Saunders, 1962. Scadding JG. Health and disease: what can medicine do for philosophy. J Med Ethics 1988; 14:118-124. Scadding JG. Editorial. The semantic problems of psychiatry. Psychol Med 1990; 20:243-248.

Zvi Lothane, MD, DLFAPA Clinical Professor Department of Psychiatry Mount Sinai School of Medicine 1435 Lexington Avenue New York, NY 10128 (212) 534 5555 Zvi.Lothane@mssm.edu
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