Early on, psychiatry accepted the idea that unconscious psychology affected the body to cause disease. By the 1970s, the rise of psychiatric drugs pushed the field in a biological direction, and by the 1980s, psychoanalysis was in full retreat, at least in the halls of psychiatric power. S. Nassir Ghaemi, MD, adds to the debate.
Articles in this set:
Ronald W. Pies, MD: Can We Salvage the Biopsychosocial “Model”?
Awais Aftab, MD: The Nine Lives of Biopsychosocial Framework
S. Nassir Ghaemi, MD: The Postmodern Assumptions of the Biopsychosocial Approach
I appreciate my friend Dr Ron Pies’ thoughtful essay,1 Can We Salvage the Biopsychosocial Model? A Reformulated Biopsychosocial Paradigm Can Be Clinically Useful, where he accepts some of my central criticisms of the biopsychosocial (BPS) model. However, I think the problem goes beyond the issue of whether it was a model in a scientific sense, as opposed to a more general approach to a worldview.
The key problem, if I were to simplify it in one sentence, is that the BPS model for the past half century has served as a postmodernist excuse for eclecticism.2 Let me explain this sentence.
The first half of the sentence:
The BPS of the past half century is not the same BPS of George Engel in 1977, or for that matter Roy Grinker of 1954, when the term was first coined. Grinker and Engel were psychoanalysts who specialized in “psychosomatic medicine,” which meant finding unconscious emotional causes for medical diseases. Engel was a gastroenterologist who specialized in ulcerative colitis and worked on a consultation-liaison psychiatry service. In the 1950s and 1960s, their views were mainstream. Psychiatry was highly psychoanalytic so it accepted the idea that unconscious psychology affected the body to cause disease. By the 1970s, the rise of the new psychiatric drugs was pushing the field in a biological direction, and by the 1980,s psychoanalysis was in full retreat, at least in the halls of psychiatric power (chairmen of departments, funding, organizational leaders). Engel and Grinker were nearing the end of their careers, and Engel’s famous 1977 paper3 was a cri de couer to turn the clock back to 1957. He was, essentially, seeking to preserve a place for psychoanalytic ideas in medicine.
This history may or may not be relevant to current defenses of the BPS model, such as those of my friend Ronald Pies. One could argue, as Dr Pies does, that the BPS model could be revised and accepted on its own merits, irrespective of what Engel intended or its roots. But this would be like saying Marxism can ignore Marx, or psychoanalysis Freud. In fact, all such ideologies evolve, and one can reject many aspects of the founder’s ideas. But not entirely. Or if one goes so far away from the original concept, then why keep the label? Socialists don’t need to be called Marxists. Psychotherapists who accept the idea of unconscious emotions don’t need to be labeled psychoanalysts. Both Marx and Freud have useful insights; that’s what matters, not their ideologies. I would say the same about Grinker and Engel: they had insights which may be valuable, but that doesn’t mean one has to cling to the BPS label.
The second half of the sentence:
Postmodernism (PM), in my usage, is a philosophy, rooted in Schopenhauer and Nietzsche, and expressed most clearly later by Heidegger and Foucault.4 It rejects the Enlightenment heritage in its claim that science can replace religion as the source of independent truths. (There is more to it; but let’s focus on this point). PM in this classic form is relativistic and critical (or cynical) about science in general, and psychiatry in particular (the target of much of Foucault’s ire). If PM is accepted, there are two options: nothing is true—nihilism; or anything can be true—eclecticism.
That is how the BPS model has played out in the past half century. Mental health clinicians do whatever they like, and they claim support for that anarchy in the BPS approach. This attitude leads to over-prescibing of psychiatric drugs (giving drugs for any and all kinds of symptoms); incorrect use of psychotherapies (letting therapists do their favorite therapy for everyone); and unnecessary mixes of both (a common refrain is that both treatments are better than either alone, a statement that is false, or at least unproven, when made generically).
American culture has become highly postmodernist in the last half century (beginning with the 1960s counterculture), and this is why, in my view, so many clinicians are attracted to the postmodernist-influenced PM model.
Postmodernism is not an epithet. I am not sure why so many colleagues are unwilling to accept it. This is a description, not a criticism. There are insights to be had in Nietzsche which are very important. Karl Jaspers, who with Heidegger founded existentialist thought, was able to apply PM insights while not being relativistic about science.5
Ideas are unconscious too. Many of the readers of this article will have postmodernist-influenced ideas without knowing so. For instance, any defense of science is commonly criticized as if one does not know of critiques of science based on PM-related concepts like pragmatism and social constructionism (Pierce, Popper, Kuhn). One can accept those critiques and still defend science.
So I defend science qua science, understood non-simplistically with all its limitations. And that is what psychiatry needs—to be more scientific, like all of medicine, not to hang on to a false eclectic theory. The problem is less with phrasing (model versus approach) but rather with content. What benefit does the BPS approach provide? What does it add to a wise science (e. g, Jaspers’ work in philosophy) informed by a general humanism (eg, William Osler’s tradition in medicine)? There are plenty of good ideas beyond this disproven psychosomatic medicine tradition.
Dr Ghaemi is a psychiatrist and researcher with expertise in depression and bipolar illness, and training in philosophy and public health. He is Lecturer on Psychiatry at Harvard Medical School and Professor of Psychiatry at Tufts University. He also directs early drug discovery at Novartis Institutes for Biomedical Research in Cambridge MA. He is the author of multiple books, most recently Clinical Psychopharmacology (Oxford University Press, 2019) and The Rise and Fall of the Biopsychosocial Model (Johns Hopkins University Press, 2009). He has published over 200 scientific articles or book chapters. He is an associate editor of Acta Psychiatrica Scandinavica, on the editorial board of a number of journals, and active in numerous professional organizations. The views expressed here are solely his own and do not reflect those of his employers or Psychiatric Times.
Dr Ghaemi reports he is an employee for Novartis Institutes for Biomedical Research, Cambridge, MA.
1. Pies RW. Can We Salvage the Biopsychosocial “Model”? A Reformulated Biopsychosocial Paradigm Can Be Clinically Useful. Psychiatric Times. January 22, 2020. https://www.psychiatrictimes.com/couch-crisis/can-we-salvage-biopsychosocial-model. Accessed January 23, 2020.
2. Ghaemi SN. The Rise and Fall of the Biopsychosocial Model: Reconciling Art and Science in Psychiatry. Baltimore, MD: Johns Hopkins University Press; 2010.
3. GL Engel. The need for a new medical model: a model for biomedicine. Science. 1977;196:129-136.
4. Dennett DC. Postmodernism and truth. Contemp Philos. 2000;8:93-103.
5 Jaspers K. Way to Wisdom, An Introduction to Philosophy. New Haven, CT: Yale University Press; 1951.