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

1 The Perils of Open-mindedness: Adolf Meyer’s Psychobiology

chapter one The Perils of Open-mindedness Adolf Meyer’s Psychobiology 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 predominantly biological and twentieth-century American psychiatry was mostly psychoanalytic, and now the pendulum is swinging back in the biological direction, at least as far as treating major mental illnesses is concerned. But the story of this battle does not explain the dilemmas of psychiatry today. For even though psychopharmacology is so predominant in treating certain conditions , we live in an eclectic era, a time when all theories are possible, and all perspectives are valued—and yet no sense is made of it all. Our eclectic psychiatry is a flawed attempt at solving the conflict between the two dogmas, a failure that began in the early twentieth century, when a diminutive, goateed Swiss immigrant took over the most prestigious psychiatric post in the United States. When Adolf Meyer became the chair of psychiatry at the Johns Hopkins University, he brought with him not only a classical training in nineteenth-century Germanic psychiatry but also a firm resolve to enact the ideas of American pragmatism. By this I mean not only the practical how-to attitudes of American culture but also the formal philosophy of pragmatism, which Meyer had learned at the feet of its leading advocate , John Dewey (Meyer 1948, p. 152). The result was Meyer’s “psychobiology” (Meyer 1948), a precursor of today’s biopsychosocial (BPS) model. But Meyer was not only the chair at Johns Hopkins; he was the president of the American Psychiatric Association. As such, he was the leader of the field of psychiatry in the first half of the twentieth century. Meyer ultimately failed as a leader, and his eclectic approach continues to fail today, because, when the profession needed a democratic leader, one who guided without tyrannizing, it got nothing but anarchy. The reasons for drawing this conclusion are based on a story that begins with Meyer a hundred years ago and ends where we are today. The Rejection of Disease The first important aspect of Meyer’s approach was that he opposed the concepts of disease and syndrome, such as those used by Emil Kraepelin (the main leader of nineteenth-century German biological psychiatry). Meyer proposed viewing psychiatric conditions as “reactions” to life events. His psychobiology was meant to incorporate the importance of biology, while subordinating it to the individual person. We study behavior not merely as a function of the mind and of various parts of the body, but as a function of the individual, and by that we mean the living organism , not a mysteriously split entity. When we see somebody eating or drinking too much or too hurriedly, or overworking, with inadequate recreation, we want to know why and how this occurs, and we modify it not merely as a state of mind but as behavior. That is what we imply by psychobiological—undivided and direct attention to the person and to the function, health, and efficiency of the person as a living organism. . . . We study the facts (a fact is anything which makes a difference) for what they mean in actual life, and by that we mean the life of a “somebody.” He is to us an organism with a life history, a biography. (Meyer 1948, pp. 434–36) In practice, Meyer’s psychobiology was hostile toward biological approaches: one could not, in the prepsychopharmacology era, change biology. The biological component of mental illness was seen as equivalent to genetics, and hereditary constitution was inherently unchangeable. Being a pragmatist, Meyer wanted to focus on what would produce results—biology was a dead end. Thus, Meyer’s psy4 The Rise of the Biopsychosocial Model chobiology was a psychosociology of mental illness.In Meyer’s own hands,this approach had some benefits: he focused on the social aspects of mental illness, was a founder of the field of psychiatric epidemiology,1 coined the term mental hygiene, and was a key figure in the early advocacy movement of those experiencing mental illness. Holism As far as individuals seeking treatment are concerned, the consequence of Meyer’s approach was a pragmatic flexibility that, in its negative connotation, involved a willingness to do anything,even if...