The Rise and Fall of the Biopsychosocial Model: Reconciling Art and Science in Psychiatry

182 Pages·2009·3.46 MB·English

by  S. Nassir Ghaemi

S. Nassir Ghaemi, M.D., M.P.H.
Professor, Department of Psychiatry Tufts University School of Medicine Boston, Massachusetts
For Leston Havens, who made me think and feel, and in memory of Paul Roazen, intellectual honesty personified
For each of the great problems of life, there is a solution: simple, plausible, and wrong.
H. L. MENCKEN
Preface ix
Acknowledgments xi
PART I: THE RISE OF THE BIOPSYCHOSOCIAL MODEL
1 The Perils of Open-mindedness: Adolf Meyer's Psychobiology 3
2 So Many Theories, So Little Time: The Rise of Eclecticism 12
3 Riding Madly in All Directions: Roy Grinker's "Struggle for Eclecticism" 27
4 A New Model of Medicine: George Engel's Biopsychosocial Model 38
5 Before and After: Precursors and Followers of the Biopsychosocial Model 51
6 Cease-fire: Ending the Psychiatric Civil War 69
PART II: THE FALL OF THE BIOPSYCHOSOCIAL MODEL
7 Drowning in Data 81
8 Teaching Eclecticism 91
9 Psychopharmacology Awry 103
io The Vagaries of the Real World 112
PART III: WHAT NEXT?
11 The Limits of Evidence-Based Medicine 123
12 Osler's Ghost 128
13 The Two Cultures 145
14 Between Science and the Humanities 159
15 The Meaning of Meaning: Verstehen Explained 167
16 The Beginning of a Solution: Method-Based Psychiatry 184
17 A New Psychiatric Humanism 198
Afterword: Pre-empting the Straw Man 211
Appendix: How Can We Teach It? A Proposal for Education of Psychiatrists 217
Notes 221
A Brief Glossary of Concepts 233
References 237
Index 247
Half a century ago, John Kenneth Galbraith developed the concept of conventional wisdom to denote how we often
seek acceptability, rather than truth, in our theories (Galbraith 1958). In psychiatry, conventional wisdom today is
the biopsychosocial model. It is highly accepted and is generally viewed as innocuous, yet whether this is true is
questioned all too infrequently.
I have doubts about the biopsychosocial model. If not untrue, it has at least far outrun the purposes it originally
served. Psychiatry is currently eclectic, verging on anarchic. For all the advances in neurobiology and
psychopharmacology and for all the expertise in psychotherapies, the field has no overarching conceptual structure.
Or, perhaps better said, what passes for a conceptual schema for the fieldthe biopsychosocial model-rose from the
ashes of psychoanalysis and is dying on the shoals of neurobiology.
The current unpalatable psychiatric status quo is not too different from the view decades ago of prominent
American psychiatrist, Roy Grinker, the underrec- ognized founder of psychiatry's biopsychosocial model (Grinker
1970, p. 730): "Modern psychiatry has been extended as a total field as broad as life, giving more and more room for
its mad ride in all directions. Some psychiatric groups attempt to overcome this manic phase by fencing off a limited
space-the isolation of schools and ideologies. Others, as eclectics, wander aimlessly over the entire pasture. A more
common solution, persisting through the ages, has been to assume either a reductionistic or a humanistic position
with some lip service to the other."
The biopsychosocial eclecticism prescribed by Grinker and others has both anesthetized and destabilized this
profession. On the one hand, some are discontented and disoriented; many practitioners as well as the people they
treat are confused about what psychiatry is all about: is it primarily biological, or mostly psychotherapeutic, or a
mix? And, if a mix, what is it a mixture of? The biopsychosocial model pretends to answer these questions, though
unsatisfactorily. On the other hand, many in the field are complacent. Biopsychosocial eclecticism is broad and
benign enough to make everyone feel accepted. Any theory can work and any perspective can fit; hence, there is
little impetus for many to question their own theories or perspectives. Yet before one can seek new answers, one has
to become uncomfortable with past answers. Before we can move ahead and take the next step in approximating
what is true, we need to be convinced that change is necessary.
When I presented this material to a department of psychiatry that had been highly devoted to the biopsychosocial
model for decades, one of the critiques I received was that my analysis was purely negative. I did not provide a
better alternative to the biopsychosocial model, while I admitted that it was an advance over previous dogmatisms.
While you work on a better theory, my colleagues advised me, leave us our biopsychosocial model for now, with all
its faults.
Indeed, a negative critique only paves the way for a better alternative; as George Washington once reputedly
said, people must feel before they can see. Mental health professionals and the public must come to realize that there
is something deeply wrong with the status quo before they will be open to alternatives. The point of this book is to
make the reader uneasy, to demonstrate the inadequacy of the biopsychosocial model, and to show that it now needs
to be superseded.
As to what should replace it, I think it needs to be a model that is both nondogmatic and noneclectic. I have tried
to describe that alternative in more detail separately, and in part III I expand on it. The main problem, though, is not
the absence of alternatives; the main problem is lack of awareness that there is a problem.
I am convinced now that many in psychiatry and other mental health professions will not listen to any alternative
models because they are too comfortable with their assumptions. For them, Galbraith 's other dictum applies: "If you
cannot comfort the afflicted, you can at least afflict the comfortable."
Perhaps it is time to afflict the comfortable.
This book is a sequel to The Concepts of Psychiatry, seeking to provide a rationale for why the positive program set
forward in that book should be taken seriously. Thus, it shares many of the same debts and acknowledgments of that
earlier work, to which I must add and repeat a few. Any writer is in debt to his family's tolerance for the solitary
work of writing, and-despite having delayed this project after the birth of my son, Zane, in 2003, until the end of his
second year-I am no exception. No person has had more influence on me personally or intellectually than has my
father, Kamal Ghaemi, M.D.
Rudolph Makkreel, at Emory University, a philosopher with expertise in the work of Wilhelm Dilthey, was
generous with his time and helpful in revision of sections of the book. Howard Kushner, of the Emory School of
Public Health, helped me think through how to understand work in the history of psychiatry. Ronald Pies provided
comments on the sections written about the humanities, as did Gareth Owen on selected chapters. The bulk of the
manuscript of this book was presented to a gathered conference of the Department of Psychiatry at the Johns
Hopkins University in January 20o8. I thank the department for its attentiveness to these ideas and the helpful
feedback I received from its faculty and staff, in par ticular current chairman Raymond DePaulo and past chairman
Paul McHugh. Phillip Slavney deserves special thanks for extensive discussion of these themes and his suggestion
that I delve more deeply into Verstehen.
Versions of the book were also presented in numerous conference settings, leading to valuable feedback that
helped guide the book along its way. Those who heard these ideas and helped me think about them include the
audience at a symposium of the American Psychiatric Association annual meeting and the departments of psychiatry
of Northwestern, Case Western, and Yale Universities, the Cleveland Clinic, and the Universities of Tehran, Chile,
and Sao Paolo. At Northwestern, I especially benefited from meeting and learning from Sidney Weissman, a former
pupil of Roy Grinker, who introduced me to the relevance of Grinker's ideas at a point in the manuscript where I had
not come across his work. Toward the end, I debated the book's main themes with the local Boston chapter of the
Association for the Advancement of Philosophy and Psychiatry, led by Jennifer Radden; the gentle peer review of
one's friends is invaluable. I also thank Brett Mulder, a psychology graduate student, for thinking through my ideas
about Verstehen with me. The appreciation I express for the input of my friends and colleagues is not meant to
imply their assent to some, or even most, of the ideas I express here.
Wendy Harris has remained a supportive and helpful editor at the Johns Hopkins University Press, and I thank
her and her staff for all their efforts. Major portions of this book were written in the bohemian but welcoming
confines of Aurora Coffeehouse, in the Virginia Highlands neighborhood of Atlanta, Georgia; if I could also thank
the coffee that kept me going, I would.
Leston Havens has been the most formative intellectual influence I have had among psychiatrists. He also
introduced me to the late Paul Roazen. Paul was a man whom I knew from his books and whom I grew to love as a
man. He passed away suddenly, and I have felt the void ever since. After our wonderful conversations (and after
reading his books even more intensely), I realize what a pioneer he was and how forthright he had always been
about seeking the truth, despite personal or professional cost, a characteristic that most of us do not possess. I tried
in this book to live up to his standard of intellectual honesty.