restricted access 10 The Vagaries of the Real World
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chapter ten The Vagaries of the Real World German philosopher Georg Hegel argued that all theories, if taken logically to their full conclusion, would end in contradictions, producing the opposite of what they intended. The biopsychosocial model suffers from this Hegelian tragedy. It began as a way to avoid dogmatism, but it has ended in a new dogma; due to its broadness and vagueness, it provides no arguments against any dogma and no resistance to other forces in society that propound their particular dogmas. A case can be made that the strongest such forces in contemporary American society are the insurance and pharmaceutical industries. It is in their economic interest to propound a biologically oriented psychiatry, one in which disease labels are used widely and treated with medications (which is cheaper than psychosocial interventions for the insurance industry and a source of profits for the pharmaceutical industry). While it is not itself a cause of these forces, the biopsychosocial (BPS) model has failed to stem the devolution of psychiatry into a more and more biological field. The leaders of the profession proclaim fealty to biopsychosocial eclecticism , but the reality on the ground is biological dogmatism. Patients know this, and they are reacting. Thus, in its role as George Engel’s “design for action,” the BPS model has again failed to fulfill its promise. This revival of dogmatism has occurred despite the model, which has proven powerless to resist it. The weakness of the BPS approach partly has to do with the fact that its adherents have used it in a confusing manner when thinking about its role in understanding etiology (the nature of disease) versus treatment. Engel certainly seemed to emphasize the BPS model as a way of understanding the etiology of disease, yet both he and Roy Grinker Sr. also saw it as a basic model of treating mental illness. This back and forth between seeing the BPS model as one of disease and as a guide to treatment has led to confusion in psychiatric practice, which in time has left the profession unable to adequately respond to the biologically dogmatic biases of managed care insurance companies and pharmaceutical companies, as we will see. Treatment versus Etiology Discussions of the BPS model frequently confuse treatment with etiology. Often it is assumed that all three components must go hand in hand: thus, genetic causes should lead to biological pathogenesis and psychopharmacological treatment, whereas environmental causes should lead to psychosocial pathogenesis and psychotherapy . The matter is much more complex. Often causes are genetic but treatments environmental (even in the most genetic conditions, such as phenylketonuria , the treatment can be environmental: diet restriction).At other times, causes are environmental but treatments biological (a person who eats only Twinkies will develop coronary artery disease, which may require surgery, rather than some kind of anti-Twinkie psychotherapy).The BPS model flounders when a one-to-one correlation between type of cause and type of treatment fails to hold. If an illness is predominantly biological and genetic in etiology and pathogenesis, psychotherapeutic treatment could still be defensible and vice versa. But then, when should we do one or the other or both? The biopsychosocial model itself provides little guidance on this question. Combined Psychotherapy/Psychopharmacology Frequently, clinicians advocate combination psychotherapy/psychopharmacology treatment. This result is to be expected from such a broad theory, because more specific guidance is not forthcoming. (Indeed, Engel did not emphasize the need to prove psychological treatments; he assumed them, and primarily psychoanalytic versions [Brown 2003].) Providing a rationale for combined treatment may be, in Vagaries of the Real World 113 fact, the main reason why this theory has been so attractive (G. M. Abroms 1969). There are drawbacks to combination treatment, though. From the policy perspective , if some therapies (including medications) are sometimes not necessary, then this approach is fiscally wasteful and expensive. One might argue that the rise of managed care in the early 1990s was partly a consequence of the rampant expense of combination therapy in psychiatry in the 1980s, a time when some health insurance paid for daily psychoanalysis (as was the case in Washington, D.C., for federal employees). The psychiatric profession has not been able to counter managed care on costs (partly perhaps because the biopsychosocial model does not provide any rationale on how to limit costs). It seems reasonable to ask of a conceptual model of psychiatry that it provide a rationale, to the public as well as the profession...