Beyond Engel: Clinical Pragmatism as the Foundation of Psychiatric Practice

For many years now, there has been growing recognition of the powerful role of pragmatic reasoning in numerous disciplines, including bioethics, medicine, law, political science, and philosophy (Dickstein 1998; Rosenthal, Hausman, and Anderson 1999). But until recently, philosophical pragmatism was neglected by scholars exploring the clinical challenges and theoretical underpinnings of psychiatry. In his noteworthy article The Biopsychosocial Model and Philosophic Pragmatism: Is George Engel a Pragmatist?, Bradley Lewis offers a significant contribution to the small but gradually increasing literature in this area. Lewis appropriately presents Engel as a major figure in twentieth-century American medicine and psychiatry, a critic and a visionary who dared to question the dominant paradigm of biomedical reductionism (Engel 1977)—a paradigm that led to important scientific advances, but also restricted the physician’s understanding of the patient as a complex individual with an inner world and interpersonal relationships. Lewis argues that medicine and psychiatry a generation after Engel’s seminal 1977 paper can be revitalized by reinterpreting Engel in the intellectual tradition of classical American pragmatism and neo-pragmatism. Placing Engel in the pragmatic tradition, Lewis suggests, could enhance the biopsychosocial model and have substantial benefits for both individual patients and society as a whole.

There is no disputing Lewis’s argument that a pragmatic philosophy of medicine and psychiatry is a noble goal. In fact, in my book Healing Psychiatry: Bridging the Science/Humanism Divide (Brendel 2006), I present philosophical pragmatism as the most compelling theoretical approach to clinical psychiatry in the twenty-first century—the approach that is most likely to empower the clinician and the patient to collaboratively develop a treatment plan that heeds the multidimensional complexity of the patient’s life, recognizes the confusion and uncertainty that grows out of this complexity, and aims for a favorable therapeutic outcome. Drawing on work of the classical American pragmatists and contemporary pragmatic bioethicists, I identify four dimensions of philosophical pragmatism that provide a sound foundation for clinical work, which I call the “four ps”: (1) diagnostic formulations and treatment plans in psychiatry are practical insofar as they focus on results rather than a commitment to any particular theory; (2) they are pluralistic insofar as they incorporate explanatory concepts that span the biopsychosocial spectrum; (3) they are participatory and collaborative, not imposed authoritatively by the clinician; and (4) they are provisional, open-ended, and malleable to newly acquired information and evolution of the patient’s condition.

Lewis casts Engel as a philosophical pragmatist who battled the Goliath of biomedical reductionism that had come to dominate American medicine and psychiatry in the latter half of the twentieth century. Unfortunately, however, regardless of how elegantly Lewis reinterprets Engel, he cannot render him a full-blown pragmatist for the medicine and psychiatry of the twenty-first century. Lewis provides quotations to suggest that Engel valued a results-oriented clinical sensibility, for example “the value of a scientific model is measured not by whether it is right or wrong but by how useful it is” (Engel 1980). But Engel was not fully committed to clinical outcome as the supreme judge of theory in medicine and psychiatry. Lewis notes that Engel understood the biopsychosocial model as less “a matter of compassion and humanity” and more a matter of “rigorous application of the principles and practices of science”; he was a man of his time who could not fully escape the scientism of the day. Working within this scientistic world, he distinguished himself by reintroducing psychological, sociological, and humanistic concepts into clinical medicine, which had become obsessed with the power and robustness of the natural sciences but had neglected the suffering human subject and the social context of illness. Engel undoubtedly hoped the biopsychosocial model would lead to better clinical results but, unlike the classical American pragmatists and contemporary pragmatic bioethicists, he did not make a systematic case for privileging clinical outcome above strict adherence to scientific theory.

In fact, Engel’s biopsychosocial model runs the risk of becoming a reified end in itself; those who unquestioningly espouse its basic tenets are in danger of...