restricted access 5 Before and After: Precursors and Followers of the Biopsychosocial Model
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chapter five Before and After Precursors and Followers of the Biopsychosocial Model The rise of the biopsychosocial (BPS) model, as exemplified by the careers and works of Roy Grinker Sr. and George Engel, cannot be understood separately from the rise of the perspective of psychosomatic psychiatry (psychiatry related to medical illness), which grew out of Freud’s work. While Freud applied his theory to hysteria and other psychological syndromes, it was perhaps logical that others would apply it to medical syndromes.Among the first to do so in the United States was neurologist Smith Ely Jelliffe. Smith Ely Jelliffe and Psychosomatic Disease At the turn of the twentieth century, Smith Ely Jelliffe wrote perhaps the first paper to specifically argue for a psychological cause for a medical illness (psoriasis; Burnham 1983). Many of Freud’s early supporters were neurologists rather than psychiatrists . For decades, Jelliffe was coeditor of the Journal of Nervous and Mental Disease, the most prominent neurological journal in the United States, with psychiatrist (and long-time head of St. Elizabeths Hospital in Washington, D.C.) William Alanson White. In the 1920s, though, Jelliffe’s journal lost its place of honor to the new Archives of Neurology, partly due to the rift between those who supported an organic approach to neurology versus Jelliffe’s psychosomatic tendencies. Like Freud, Jelliffe was a private practitioner, seeing many patients in his busy Manhattan practice, whom he treated with a mixture of traditional neurology and psychoanalytically informed psychotherapy (in fact, he wrote one of the first technical handbooks about the methods of psychotherapy). Jelliffe had been introduced to Freud and Jung’s ideas at the same time, when the two were still allies, and after Jung’s schism, Jelliffe was always seen by Freudians as vacillating between the two. Ultimately, it is most likely Jelliffe was a true eclectic, unable to fully accept or reject any one Freudian group. He found expression for his eclecticism in the idea of psychosomatic illness, in which Freud’s notions could be mixed even with physical disease. Freud himself was cool to the idea, though he did not actively oppose psychosomatic views. Freud’s closest personal disciple who went in the same direction was Franz Alexander (a mentor to both Roy Grinker and George Engel), who moved to Chicago and formally established psychosomatic training. Franz Alexander’s Psychosomatic School Like Jelliffe, Alexander argued that psychoanalytic constructs were the cause of some physical illnesses. This view led to great opposition from many internists and neurologists. Grinker provides a good example: It was at the University of Chicago where Dr. Alexander was placed in the unfortunate position of giving a seminar concerned with the relationship of psychoanalysis and medicine to members of the Department of Medicine and various invited, but essentially hostile, guests. On one particular day Alexander recounted a case history illustrating the dynamics of constipation. At that time, and perhaps even yet, he contended that constipation was based on a syllogism, “inasmuch as I do not receive, therefore, I do not have to give.” He told the story of a young lady who had developed constipation shortly after her marriage to a man who paid little attention to her. In his management of this case Alexander spoke to the husband and pointed out that her constipation was a reaction to his lack of attention. Whereupon the guilty husband immediately became solicitous, purchased a few red roses and gave them to his wife. Immediately after she received the first gift since their marriage her constipation miraculously disappeared . This was too much for the Department of Medicine and marked the beginning of Alexander’s end at the University of Chicago! (Grinker Sr. 1994). 52 The Rise of the Biopsychosocial Model Those early forays were seen as too simplistic.Grinker,Engel,and others revised Alexander’s approach to emphasize that psychological factors were important, though not solely causative, in physical illness; they contributed to physical illness, along with other important biological factors or mechanisms. Grinker directly analogizes the term psychosomatic to the term biopsychosocial, thus clearly showing how the BPS model grew out of the psychosomatic wing of psychiatry. Just as Grinker argued that the term biopsychosocial was holistic and did not imply the reduction of any aspect of life to another, so too the term psychosomatic did not imply a reduction of somatic illness to psychological cause, as Alexander had implied : “It is indeed a...