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biopsychosocial, integration, medieval, mental illness

We appreciate the careful and enriching commentary offered by Kroll and by Radden on our paper about holistic views of mental illness in the writings of the twelfth-century abbess and healer Hildegard of Bingen. Both reviewers are well-established figures in the study of historical perspectives on mental illness, an area that we have just begun to explore. We are glad for the opportunity to respond to their observations and thereby to continue the dialogue.

First, we would like to clarify our purpose in preparing this paper. Nowhere do we claim that Hildegard used a biopsychosocial model of mental illness, either in addressing the needs of the particular case of Sigewiza, or more generally in her writings on illness and health. In fact, we agree with Kroll (2007, 370), when he states that Hildegard did not use a biopsychosocial model. We use the term “biopsychosocial” only three times in the paper, always by contrast with what we see in Hildegard’s writings. The present-day biopsychosocial model focuses on getting a range of perspectives on the table, encouraging the consideration of biological, psychological, and social issues when thinking about mental illness. This is a good thing, but we argue that it does not go far enough. Specifically, there has been insufficient attention to ways these perspectives might interact.

How, then, might we describe Hildegard’s way of conceptualizing mental illness? In place of the label “biopsychosocial model,” Kroll suggests that Hildegard’s approach could be described as a “religious model” (p. 372). Here we disagree. By our reading, Hildegard’s description of mental illness involves religious components, certainly, but also humoral, astrological, interpersonal, community, and intrapsychic components. Radden correctly notes that we are not so much interested in the particular components as we are in their interactions. We are attracted to Hildegard’s writings because she attends to these interactions. Our students, like Kroll’s (p. 371), are curious about mind–body relationships, which represent one example of the interplay between components. Our concern is that the current biopsychosocial model often fails to satisfy our own, and our students’, interest in the nature of those interactions. Our hope is that Hildegard’s writings might help us to think more richly about the interactions.

As Radden (2007, 373) points out, present-day psychiatrists and psychologists do in fact use mul-ticausal accounts of depression. And we agree that such accounts need not be reductionistic (Kroll, 371). But we also recognize that psychology and psychiatry have well-established reductionist (more specifically, materialist) habits. To borrow [End Page 377] Kroll’s phrase, the biological model threatens “to swallow all other models” (p. 371). We must guard against such reductionism, given the habits of our disciplines. As we noted, McHugh and Slavney (1998) respond to that threat by building walls between the perspectives, suggesting that we might use different perspectives when thinking about different sorts of problems. We think that there ought to be more synthetic, holistic ways of responding to that threat, and we are hopeful that Hildegard’s writings can help us to develop those.

At a basic level, we see Hildegard asking different questions than people ask today. On the first page of his commentary, for example, Kroll poses the question of “which of these three modalities [bio-, psycho-, social] may be sufficient” (p. 369) in the particular medieval text. We found that the sufficiency of one modality or another does not concern Hildegard. We are not able to speak to the general point that Kroll raises, that one or another element is emphasized depending on the goal of the medieval text; we can report our experience in reading Hildegard, where we found no sense in which one or another component is privileged. Even though Hildegard operated within a thoroughly religious context, we did not find examples of her subsuming other factors under religion. Everything interacts with spiritual concerns, to be sure, but everything also interacts with the biological, and with the interpersonal, and with the astrological. Although it may seem odd to us post-Darwinian thinkers, Hildegard’s model is essentially noncompetitive—she does not pit different explanations against one another. Therefore, we hesitate to join Kroll in calling Hildegard’s a “religious model.” We believe it is more accurate to describe her approach as “holistic.”

In the paper, we illustrate our points with spe-cific examples concerning depression and alcoholism. Our point in raising the matter of “reactive depression” and “endogenous depression” is simply this: Under the DSM-II, depressions were subtyped based on their supposed primary cause (American Psychiatric Association [APA] 1968). As of the DSM-III, they are not (APA 1980). We suggested this might reflect more complex thinking about depression in the DSM-III, perhaps arising from the significant theoretical advances coming out of Seligman’s research on learned helplessness. Perhaps Kroll’s interpretation is more accurate, that the biological cause effectively consumed the environmental factors in DSM-III, resulting in a more simplistic view. If Kroll is correct, this further illustrates our concern about the strength of the biological model in our present context. But for our part, we are glad for the end of diagnostic language that implies that depressions can be cleanly divided into biologically based conditions and environmentally triggered conditions, and of a system that requires practitioners to attend to such a division.

Kroll also raises questions about our characterization of alcoholism treatment; it appears that our training experiences differ in this regard, but we do not want this to distract from our more general concern, namely that present-day psychology and psychiatry may approach complex mental health problems in too linear a manner. Even when present-day providers use a multicausal approach, we are concerned that causes are discussed as though they are stacked up in layers, and one layer is addressed at a time. Perhaps an illustration around which we could share more agreement comes from common practice in the treatment of schizophrenia.

Responsible present-day treatment for schizophrenia involves biological, psychological, and social interventions—a biopsychosocial model of treatment—but the way in which those components are addressed is often sequential. When an individual is initially diagnosed with schizophrenia, biology has top priority. Medication is understood to be essential, and it is the form of treatment that is provided first. Psychotherapy is introduced once the medication begins to work. For individuals with schizophrenia, psychotherapy is likely to function primarily as support for the biological interventions, encouraging medication compliance and focusing on coping with implications of the diagnosis. Family education (a social intervention) is emphasized later, to prepare for transition to the community. Such education may focus on social support and stress reduction (in support of psychotherapeutic goals), as well as monitoring for early warning signs of relapse and medication noncompliance (in support of [End Page 378] pharmacological goals). By addressing the biological, psychological, and social issues surrounding schizophrenia, the biopsychosocial model is being applied, in a sense. However, to our minds, this way of “doing” the biopsychosocial model is unsatisfactory, because it fails to integrate the components of the model.

Whatever specific example of treatment we might choose, we think that both reviewers would agree that the current state of affairs in conceptualizing mental disorder is less than ideal. Whether we describe it as a voracious biological model that needs to be “hedge[d] in” to keep it from consuming other developing models (Kroll, 371), or whether we think about it as involving less integration among components than it might, we are left with a need. Like the students Kroll describes, many people who think carefully about mental disorder wonder about interactions between components. But our modern intellectual heritage, with the history of materialistic reductionism, has left us lacking integrative habits of thought. Attempting to create those ex nihilo is not working very well yet, by our estimate. And so, finally, we come to the goal of our paper, which is to explore the possibility that Hildegard’s writings might help us understand what integrative thinking might look like.

Both reviewers raise concerns about this goal. Is it realistic to expect that Hildegard’s writing can assist us in developing our thinking? As Rad-den so well illustrates, the experience of reading these medieval works is humbling. The metaphor of seeing “through a glass, darkly” (I Cor 13:12, KJV) comes to mind. While preparing the paper, how often we wished we could have Hildegard in for a cup of tea, just to ask a few questions! Our efforts to understand the words on the page were so often frustrated by the sense of some deep difference between the assumptions of the writer and our own understandings of the world. Radden describes it as “a different metaphysics” (p. 374). The passages that Radden provides in her review should help the reader grasp what our experience has been like in reading Hildegard. These experiences keep us from presuming on the text, from concluding that we know just what was being said. We hope this keeps us from the sins of “presentism,” about which Kroll cautions us. In any case, we are reluctant to abandon the project of looking for help, for an expansion of our understanding, from Hildegard.

What we wanted from Hildegard was exposure to a way of thinking that is different from our own. With this as our goal, we may be more crassly pragmatic than is prudent to admit in print. Candidly, we are looking for a “useable past,” the very thing that Kroll warns is not there. It is our practical hope, by searching for a way to think about how elements interact or communicate (which we sorely feel need of), and by reading the words of someone who thought so differently from us (a claim about which all four of us can agree), that we might ourselves have some new thoughts, that we might be stretched in new ways. It is for our readers to judge whether that exercise bore good fruit. Through our analysis, we conclude, first, that Hildegard uses narrative to bring diverse components together; second, that she emphasizes the mutual interdependence of components; and third, that balance among components is essential. Given that we are not operating under what Rad-den describes as an associationist metaphysics, we acknowledge that we cannot possibly mean exactly what Hildegard meant when she wrote of these things. For us, though, the more important question is whether these strategies can help us to move forward in our current attempts to understand how the diverse components in a modern, multicausal model might be truly fitted together.

Suzanne M. Phillips

Suzanne M. Phillips (PhD [Clinical/Community Psychology], State University of New York at Buffalo, 1990) is currently Professor of Psychology at Gordon College in Wenham, Massachusetts. She is interested in communitarian models of mental health and mental illness, community-based restorative care of individuals with mental illness, and the impact of religious and spiritual beliefs on attitudes about mental health. Of particular concern is the synthesis or integration of various models of mental illness.

Monique D. Boivin

Monique Boivin (MPH, University of Michigan School of Public Health) is an international public health consultant specializing in monitoring and evaluation. Her work focuses on strengthening health systems and contributing to health and human rights movements throughout East and Southern Africa.

Suzanne M. Phillips can be contacted via e-mail at
Monique Boivin can be contacted via e-mail at:


American Psychiatric Association. 1968. Diagnostic and statistical manual of mental disorders, 2nd ed. (DSM-II). Washington, DC: American Psychiatric Association.
American Psychiatric Association. 1980. Diagnostic and statistical manual of mental disorders, 3rd ed. (DSM-III). Washington, DC: American Psychiatric Association.
Kroll, J. 2007. Medieval holism and ‘presentism’ or, Did Sigewiza have health insurance? Philosophy, Psychiatry, & Psychology 14, no. 4:369–372.
McHugh, P. R., and P. R. Slavney. 1998. The perspectives of psychiatry. 2nd ed. Baltimore, MD: The Johns Hopkins University Press.
Radden, J. 2007. Sigewiza’s cure. Philosophy, Psychiatry, & Psychology 14, no. 4:373–376. [End Page 379]

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