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

Afterword: Pre-empting the Straw Man

Afterword Pre-empting the Straw Man There is one reaction to this book that I expect to receive, based on my discussions about it with many colleagues. My criticisms of the biopsychosocial (BPS) model may be granted, but it will be argued that these relate only to the “old” model of George Engel; the “new and improved” versions that exist now would survive my critiques. This is a version of the “straw man” argument: weak or simplified versions of an idea are set up and then attacked, thereby seeking to reject stronger versions of the idea indirectly and by association. Engel’s BPS model is not a straw man version; it is the classic version.Being classic , it deserves respect, and so does this critique of it. I have not put words in the mouths of Engel and Roy Grinker; extensive direct quotations are provided, and I have used all of their primary published works, as well as most available secondary sources. It is not exactly the same to claim the straw man argument and to say that newer versions of the model are better. The straw man argument involves actual oversimpli fication: this book documents the classic work of Grinker and Engel such that this criticism cannot apply. The new-and-improved argument implies that what is newer is better and unrelated to what preceded it. Such apologists for the BPS model would have to claim that current views can be upheld completely separate from, and unrelated to, the views of Engel and Grinker. This kind of thinking is clearly apologetics, an attempt to defend an opinion at all costs, and is simply illogical . It would be like claiming that one could be a Marxist and have nothing to do with Marx or a psychoanalyst with no relation to Freud. Obviously, many newer versions of Marxism are different from Marx’s own viewpoint and, similarly, newer (“eclectic”) versions of psychoanalysis may diverge from Freud.Yet the progenitors cannot be completely disowned; the sins of the fathers are visited on the sons. This is not to say that no improvements can be made, or have been made, on the BPS model. Let me be clear: this book criticizes BPS eclecticism but it does not thereby seek to uphold biological dogmatism.I explicitly reject all kinds of dogmatism , whether biological or psychoanalytic, at the same time as rejecting eclecticism . I am seeking an antieclectic, antidogmatic way of thinking for psychiatry. This is what I mean by method-based psychiatry. Someone else may try to improve BPS eclecticism by making it less eclectic: Let us suppose BPS revisionists were to conclude that not all mental illness always has biological, psychological, and social factors; that it is legitimate at times to take a purely biological or a purely social approach to a condition; that simply mixing and adding methods does not inherently improve our knowledge; and that sometimes pure reductionism is appropriate for certain illnesses or conditions. If all these perspectives were accepted, and revisionists wanted to call it a new-and-improved BPS model, they could do so, but why use the term biopsychosocial at all? Why not call it something else, for reasons both conceptual and historical: conceptually, this amount of revision converts the BPS concept into something quite different from what its originators intended (it would be like insisting that the graduated income tax is a type of Marxism);1 historically, this kind of perspective was long upheld, when Engel and Grinker were schoolchildren , by Karl Jaspers. Would not historical accuracy instead support using terms that Jaspers promoted before the notion of biopsychosocial was conceived of, terms related to his “methodological consciousness”? I have come to a conclusion. Many mental health professionals, and others interested in psychiatry (in the social sciences and humanities), are averse to rejecting the BPS concept because they want to reject biological dogmatism. Everybody hates the idea that mental illness can be reduced to the brain and drugs; nobody wants this, perhaps because of some wish to preserve space for the soul, and a larger sense of humanity, in our self-image. Even though I am not sure why this concern should exist (are we lesser humans because much of psychosis turned out to be neurosyphilis?), I can sympathize with it. I want to reject biological dogma212 The Rise and Fall of the Biopsychosocial Model tism, too. BPS sympathizers need to...