The Rise and Fall of the Biopsychosocial Model
Reconciling Art and Science in Psychiatry
Publication Year: 2010
Published by: The Johns Hopkins University Press
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Half a century ago, John Kenneth Galbraith developed the concept of conventional wisdom to denote how we often seek acceptability, rather than truth, in our theories (Galbraith 1958). In psychiatry, conventional wisdom today is the biopsycho-social model. It is highly accepted and is generally viewed as innocuous, yet whether...
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This book is a sequel to The Concepts of Psychiatry, seeking to provide a rationale for why the positive program set forward in that book should be taken seriously. Thus, it shares many of the same debts and acknowledgments of that earlier work, to which I must add and repeat a few...
PART I: THE RISE OF THE BIOPSYCHOSOCIAL MODEL
1 The Perils of Open-mindedness: Adolf Meyer’s Psychobiology
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The story of psychiatry is usually told as a battle between two dogmas: those who see mental illness as simply a brain disease and those who view psychoanalysis as the ultimate solution. This simplified analysis explains much: nineteenth-century European psychiatry was...
2 So Many Theories, So Little Time: The Rise of Eclecticism
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In 1954, as new president of the Canadian Psychological Association, D. C. Williams gave an incoming address titled “The New Eclecticism” (Williams 1954). In it he identified the key dilemma in psychology as the wars between behaviorism and psychoanalysis—two incompatible theoretical systems...
3 Riding Madly in All Directions: Roy Grinker’s “Struggle for Eclecticism”
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Adolf Meyer’s psychobiology led to the biopsychosocial (BPS) model that was fully articulated in the 1970s and 1980s by George Engel. But between the two theories, there is a missing link, a part of the tapestry of twentieth-century U.S. psychiatry that historians and psychiatrists have unjustly ignored...
4 A New Model of Medicine: George Engel’s Biopsychosocial Model
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A theory is a reflection of the person who created it. George Engel, the person generally acknowledged as the founder of the biopsychosocial (BPS) model, once described how he, his twin brother, and his older brother, Lewis, were strongly influenced by their uncle, Emanual Libman (1872–1946), a prominent New York physician (whose visitors and patients included Einstein, among others). “All three...
5 Before and After: Precursors and Followers of the Biopsychosocial Model
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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 tohysteria and other psychological syndromes, it was perhaps logical that others...
6 Cease-fire: Ending the Psychiatric Civil War
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In Beirut during the 1970s, Christians and Muslims tore their nation apart in a bloody civil war. There was a boundary that could not be crossed, except at the risk of one’s life-the Green Line; on one side lived Christians, on the other Muslims. For more than a decade, violence ruled...
PART II: THE FALL OF THE BIOPSYCHOSOCIAL MODEL
7 Drowning in Data
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George Engel claimed that the biopsychosocial (BPS) model would provide a blueprint for research, yet the reality of the past two decades has not seemed to follow any particular blueprint...
8 Teaching Eclecticism
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In a 1980 retirement Festschrift, George Engel’s colleagues and former students emphasized that teaching was the most important aspect of his professional life(Ader and Schmale 1980). If the model was to shine anywhere, it should shine here...
9 Psychopharmacology Awry
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The next test is whether the biopsychosocial (BPS) model meets George Engel’s criterion as “a design for action.” Previously, I discussed how the model has been, and continues to be, a means of preserving a space for psychotherapies; yet few would claim success there...
10 The Vagaries of the Real World
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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...
PART III: WHAT NEXT?
11 The Limits of Evidence-Based Medicine
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Some psychiatrists seem more inclined to reinterpret the biopsychosocial model, rather than to give it up, along something like the following lines: “The BPS modelhas not lived up to its expectations, it is true,” they might say. “But it really should not be placed at such high expectations. We view the model as a general framework for our field. It reminds us to pay attention to all three components of human...
12 Osler’s Ghost
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A specter hovers over this debate, the spirit of the person with arguably the greatest influence on medical education in the past century, a man widely viewed as the founder of modern scientific medicine: William Osler. Osler’s ghost reminds us that the biopsychosocial (BPS) approach is not the only alternative to a dehumanized biomedical model. The biomedical model that George Engel set himself against...
13 The Two Cultures
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There is a natural hesitation and resistance against the humanities among scientifically oriented persons, many of whom choose to become physicians.1 To them, the humanities seem not only foreign to, but also of unclear relevance to, medicine. They might even note that William Osler was neither a historian, nor a novelist, nor a poet, yet he acted the part in all these areas. And his exhortation to doctors...
14 Between Science and the Humanities
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The debate between science and the humanities gets at the core of the philosophical problem underlying the biopsychosocial (BPS) model: Is science, valuable as it is, the main road to knowledge? If not, how is the method of the humanities different? This philosophical problem lands us in the real world of the practicing psychiatrist and psychologist. Should we be dualists, with two approaches to the mind...
15 The Meaning of Meaning: Verstehen Explained
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The previous chapter introduced the concept of Verstehen as a key alternative tothe biopsychosocial (BPS) model. Some readers will want more detail, though; so now our thinking caps will really be needed, as we try to deepen our understanding of the meaning of meaning. (This chapter is philosophical and somewhat unavoidably technical at times; it can be skipped by those already convinced of the...
16 The Beginning of a Solution: Method-Based Psychiatry
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In 1965, psychiatrist Roy Grinker, whom readers should now appreciate as the founder of eclectic psychiatry, related a parable that he hoped would explain why psychiatry needed to be eclectic; he called it “the land of human behavior” (Grinker 1965). One might call this story “Grinker’s Dream,” because though so true in many respects, it ended in a fantasy, one that became a reality, and is now a nightmare...
17 A New Psychiatric Humanism
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We may end this book with three key questions that the biopsychosocial model sought and, in my view, failed to answer: What is illness? What is health? What is the proper role of medicine as a profession?..
Afterword: Pre-empting the Straw Man
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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...
Appendix: How Can We Teach It? A Proposal for Education of Psychiatrists
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A Brief Glossary of Concepts
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Page Count: 272
Illustrations: 2 line drawings
Publication Year: 2010