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

In this volume S. Nassir Ghaemi (a professor of psychiatry at Tufts University School of Medicine) has attempted to provide a somewhat unique analysis of the history of American psychiatry. The traditional interpretation, he argues, posits a conflict between those who see mental illnesses as a brain disease and those who hold to a psychoanalytic interpretation. Such an interpretation, although partially justified, is too narrow. Indeed, he concedes that at present psychopharmacology is predominant in treating certain conditions. Yet American psychiatry remains eclectic, which results in a kind of theoretical anarchy and the proliferation of dogmas and perspectives. Nowhere is this more evident than in the biopsychosocial (BPS) model, a model that permits everything and explains nothing. The goal of this book is to provide a historical analysis of the origins and shortcomings of the BPS model as well as to offer a different perspective.

The origins of American eclectic psychiatry and the BPS model began with Adolf Meyer, a Swiss émigré who became chair of psychiatry at the Johns Hopkins Medical School. Trained in German psychiatry and neurology, Meyer was influenced by the philosophy of pragmatism during a brief stay at the University of Chicago. Opposed to Kraepelin's concepts of disease and syndrome, Meyer developed his psychobiology, a system that subordinated biology to the individual. Psychiatric conditions in his eye could be understood only as reactions to life events. The result was a form of pragmatic flexibility that explained nothing, permitted anything, and made research virtually impossible because of its emphasis on the unique life experiences of the individual.

Most of the book is focused on the careers of Roy Grinker, Sr. and George Engel, both of whom played crucial roles in the creation of the BPS model. The model had broad appeal; its eclecticism provided a rationale for almost any kind of intervention. "Such eclecticism," Ghaemi argues, "borders on anarchy" (p. 15). Indeed, the individualization of practice led to an infinite variety of therapies. But if practice consisted of nothing but individualization, the concept of science all but disappeared. Practice under these circumstances could not be informed by scientific evidence, which, after all, "comes only in generalization about groups of people with similar characteristics (samples)" (p. 15). Indeed, the BPS model, which was designed to protect psychotherapies, actually permitted psychopharmacology to flourish. Having given up the medical tradition of identifying diagnoses that reflect diseases and then providing treatments, psychiatrists simply provided medications and then proceeded to psychosocial interventions, thus producing "an anarchic world of practice" (p. 111). The misplaced popularity of the BPS model in part reflected a rejection of biological determinism.

Ghaemi's book is somewhat bifurcated in that it employs both advocacy and historical analysis. In place of the BPS model Ghaemi urges adoption of what he calls a method-based psychiatry that is consistent with both medical science and the humanistic art of medicine. This method-based psychiatry assumes that different methods are available, but the choice of method is based on empirical data. Freud, for example, was treating community patients with neuroses and used the method of free association to listen to his patients to find hidden meanings. Kraepelin, by contrast, was dealing with hospitalized patients with psychoses; he looked at rather than listened to these patients to determine what happened to them. In his eyes diagnosis was prognosis; the course of the patients' symptoms would determine the diagnosis. Both were right within their own spheres. It is "the nature of science," Ghaemi notes, "that all knowledge is partial; no scientific theory can have validity outside of its chosen scope" (p. 189).

As a work of history, however, The Rise and Fall of the Biopsychosocial Model falls short. Unfortunately, the author seems unaware of a rich literature that explores the evolution of American psychiatry. Thus, his discussion of many topics...