Defending Engel's biopsychosocial model

Linda Gask has an essay in The Lancet Psychiatry entitled 'In defence of the biopsychosocial model'. Progress does need to be made on clarifying George Engel's biopsychosocial model (see previous post).

Engel’s model promotes a holistic psychiatry in the same way as critical psychiatry and is a challenge to biomedical dogmatism. His original Science paper was written in response to a paper published in JAMA by Arnold Ludwig (1975) called ‘The psychiatrist as physician’.

Ludwig was concerned about the state of psychiatry, which he saw as under attack from what we now identify as 'anti-psychiatry'. His response was to accept that modern-day psychiatry is vulnerable to such charges. His solution was to retreat to the medical model. As far as Ludwig was concerned, psychiatry should deal with medical illness, including neuropsychiatric and medicopsychiatric disorders, rather than nonpsychiatric problems, which are more appropriately handled by nonmedical professionals. This position is what has more recently been called a 'remedicalised psychiatry' (see previous post). Ludwig was clear that psychiatry's viability was dependent on an understanding of mental illness as due to known, suggestive or presumed brain dysfunction. Interestingly, he predicted, “I am not optimistic that there will be any sudden and dramatic resolution of these issues” (p. 604). Subsequent history could be said to have proved him wrong in the sense that psychiatry has become more biomedical since the publication of DSM-III in 1980 and the development of brain imaging. Modern psychiatry has become more biomedical than even Ludwig anticipated.

Engel, by contrast, was not happy with Ludwig's proposal for change. As far as he was concerned, all medicine, not just psychiatry, was in crisis. He believed doctors had become insensitive to the personal problems of patients and preoccupied with procedures. In short, medicine is too disease-oriented rather than patient-orientated. For Engel, the biopsychosocial model has real advantages, by taking account of cultural, social and psychological considerations as well as biological. Furthermore, it avoids the polarisation between biomedical reductionists, amongst which Engel would have included Ludwig, and exclusionists, like Thomas Szasz, who deny mental illness. Szasz, in fact, had the same biomedical understanding as reductionists of the nature of illness as physical lesion, but did not believe in mental illness because a biological basis has not been established. I have always tried to be clear that there are aspects of Szasz's views which do not coincide with my views about critical psychiatry (eg. see previous post). My views are more identified with Engel's.

What is of interest is that both Ludwig and Engel were trying to salvage psychiatry in the context of ‘anti-psychiatry’. This is why this situation is relevant to critical psychiatry, which has its origins in anti-psychiatry (see my book chapter). I am suggesting that Engel’s biopsychosocial model is a viable form of critical psychiatry.

Many psychiatrists, like Linda in her essay, would say that their approach to psychiatry is biopsychosocial, taking into account psychosocial factors as well as biological. I agree that most psychiatrists are pragmatic in their approach. However, even though most psychiatrists are not narrowly biomedical, they are still biomedical (see previous post), in the sense that they generally believe that mental illness, or at least major mental illness, such as schizophrenia and bipolar I disorder, is due to brain abnormalities, even though the evidence is against this conjecture. More than the empirical evidence, the philosophical argument about the relationship between mind and body is against such speculation. Psychiatrists now rarely become involved in this conceptual debate because they expect that brain research will find the solution to mental illness.

As pointed out by Linda, the biopsychosocial model has been critiqued as being too eclectic by Nassir Ghaemi, leaving psychiatry with no overall theoretical structure as "all theories are possible and all perspectives are valued" (p.1) (see my book review). I agree that psychiatry can be eclectic with, for example, biological and psychotherapeutic treatments being combined without any systematic theory to support such a therapeutic strategy. There is also commonly a split in the aetiological understanding of mental illness, with major psychotic illness being seen as biological in origin, and more minor, neurotic illness seen as having psychosocial causes.

The real origin of eclecticism in modern psychiatry, though, is not in the biopsychosocial model but in the mainstream response to ‘anti-psychiatry’. Anthony Clare’s Psychiatry in dissent, mentioned by Linda, was a response to anti-psychiatry (see previous post). It eschewed a well-defined theoretical basis for practice. In this way, Clare avoided the worst excesses of reductionism and the objectification of patients that caused particular concern to anti-psychiatry. This approach is what is now often labelled as ‘biopsychosocial’ and I worry that Linda is using the term in this way. Most psychiatry is only semi-critical in this sense (see previous post). The true meaning and implications of Engel’s biopsychosocial model have been diluted.

Valid psychiatric diagnosis is unreliable

It's touching to see Paul Salkovskis & Irene Sutcliffe apparently hankering after DSM-III in their The Mental Elf blog post. For some reason they associate DSM-III with ICD-9, which was actually very similar to DSM-II not III. Surely ICD-9 still had some of the "notoriously unreliable" diagnostic definitions Salkovskis & Sutcliffe seem to so dislike. True, they do recognise that biological research has failed to substantiate reliable diagnostic categories, as in DSM-5 (see previous post).

What I'm objecting to is the way Paul Salkovskis & Irene Sutcliffe seem to follow Robert Spitzer in his view that "assuredly an unreliable system must be invalid" (Spitzer & Fleiss, 1974). As I said in my talk (see powerpoint slides), psychiatry should not be panicked by the unreliability of psychiatric diagnosis. If psychiatric diagnosis is going to be meaningful, there will be inevitable inconsistencies. In fact, paradoxically, increasingly internal consistency may well create an overly narrow measure that does not measure the construct optimally, which is called the attenuation paradox.

I'm not against Salkovskis & Sutcliffe encouraging debate about whether psychiatric diagnosis is finished (see previous post). But they speak against the Division of Clinical Psychology (DCP) position statement encouraging people to give up the disease model of mental disorder, which is actually what I think should happen (see previous post).

Most of The Mental Elf post is about the Power Threat Meaning (PTM) Framework, on which I have also blogged (eg. see previous post). Personally I'm not worried that DCP spent money on the launch of the Framework, as it needs to do something with its money. I agree with Salkovskis & Sutcliffe about the Framework being hard to follow, but I've tended to assume it will get easier once I've got used to it. Maybe though it does need a more user-friendly version.

I actually think the summary by Salkovskis & Sutcliffe of the document is quite good. What worries me though is that they seem to still believe in scientific positivism in mental health. They need to accept more the limitations of psychiatric diagnosis (see previous post), and take the PTM Framework more seriously. Lucy Johnstone, one of the main authors of the Framework, is merely arguing for service users to have more choice as to whether they take on a psychiatric label as part of their understanding of their problems (see my book review). Some service users may well find the PTM Framework helpful.

Maybe Foucault understood critical psychiatry after all

Further to my previous post about postpsychiatry, I have found that I like the view of John Iliopoulos that Foucault was not necessarily for or against the Enlightenment (see his PhD thesis (2013) and subsequent book (2017)). The Enlightenment is not so much about the "principles of humanism, liberalism and positivism" (book p.18) but the point when reason itself started to question "the rational foundations of what is accepted as reason" (book p.7). It was this "critical engagement of reason with itself which brought psychiatry as a discipline into existence, and it is the same conflict, the same battle which fuels current debates in psychiatry" (thesis, p.7).

Foucault draws on Kant's philosophy. "Kant's method of questioning the pretensions of rationality, and reflecting on the limits of who we are through reason, inspired Foucault to analyse the birth of the human sciences, and especially of psychiatry" (thesis, p.21-2). In the late eighteenth century, alienism identified certain individuals who were "agents of an experience whose content eludes understanding" (thesis p.167). The insane were separated from places of confinement and placed within asylums.

Madness thus became separated from where it was within medicine in the sixteenth and seventeenth centuries. At that time, "'[m]aladies of the spirit' existed and theories of humours were used to explain mental disorder" (thesis p. 99). From the middle of the nineteenth century, the idea of madness was then "inserted into positive medical knowledge" (book p.20). But, incorporating positivism led to psychiatry losing "its scientific rigour and its validity" (book p. 22).

Iliopoulous also has an article, from which I have produced a tweetorial, that takes this situation forward to the twentieth century. With the development of community care, psychiatry has become accountable to the public.

What I like about this historical narrative is that it fits with my view that there has always been a critical psychiatry perspective since the origins of modern psychiatry (see previous post). Critical reflection is not confined to a particular historical period. Although it may be unrealistic to expect a paradigm shift in psychiatry (see previous post), "Foucault argues that verification and positivism have excluded, set aside and subordinated other modes of truth production" (book p.123). Such critical perspectives are important.

How does a Cambridge professor of psychiatry get away with this?

As a young doctor, Ed Bullmore did not want senior physicians to start thinking he was bonkers, but now he’s long in the tooth it doesn’t seem to matter. He’s written what his publisher calls a “game-changing book” on depression (see book website).

Bullmore reminds me of Henry Cotton (1876-1933), an eminent and notorious American psychiatrist, who believed that the cause of mental illness was the systemic effects of largely hidden chronic infections (see my book review). This is because Bullmore has the same enthusiasm for so-called scientific medicine and advises depressed patients to ask their doctor to consider whether there may be a low-grade inflammation causing their depression. For example, he suggests trying a new dentist in case periodontitis (gum disease) has been missed. You might think this advice may well get him into trouble with the GMC. But, at least Bullmore doesn’t advise removal of teeth or tonsils or even the colon, like Cotton.

To give Bullmore his due, he does admit that finding periodonitis will not immediately make much difference to the treatment of depression. But, he is seriously asking us to consider his theory, which is actually about inflammation in general not just periodonitis, if only, because he is currently leading an academic-industrial partnership, whilst working part-time for a pharmaceutical company, to develop anti-inflammatory drugs to treat depression (see Neil MacFarlane’s review). Initially Bullmore wants to use these drugs for depressed patients that also have a physical illness and then for those depressed patients with raised inflammatory markers.

Don’t be confused into thinking that Bullmore is quite the critical psychiatrist. True, he doesn’t believe in the serotonin theory of depression. His history of the origin of antidepressants with Nathan Kline is actually quite good, although he doesn’t mention Roland Kuhn (see previous post). But, then he takes the radical step of saying that “rheumatoid arthritis is not primarily a disease of the joints” (Loc 963). This does sound bonkers, and what he means is that it is instead a disorder of the immune system. By analogy, we’re not really supposed to view depression as a psychological disorder, but as an inflammatory disease.

I’ve already said in a previous post that this hypothesis doesn’t make much sense. To me, Bullmore seems to compound this situation by confusing feeling sick with feeling depressed. He mentions several times that he had a root-canal filling at the dentist in 2013, and this made him feel blue. The link between inflammation and sickness cannot be disputed, but that inflammation causes depression is just plain wrong and not worth investigating any further. I just think Bullmore, like others, wants to develop a monoclonal antibody for depression because anti-TNF antibodies for autoimmune and immune-mediated diseases have made billions of dollars over the years. This is despite the only trial of a TNF inhibitor in depression being negative. Bullmore should be put out of his misery.

Also, don’t think Bullmore is a good philosopher because he makes much of Descartes. Sceptics of his theory like me are dismissed as Cartesian, which I’m not. And he doesn’t spell out that his position is reductionist (eg. see previous post). True, he admits he likes such a point of view because it’s simpler. But I’ve made a point in this blog of emphasising that it’s important to integrate mind and brain (eg. see previous post) and medicine and psychiatry (see eg. another previous post). Bullmore could also learn from the philosophy of biology (see previous post).

Let’s conclude with quotes from Bullmore himself, “[I]mmunology has made no difference whatsoever to any patients with depression, psychosis or Alzheimer’s disease” (Loc 443). Nor should it! As Bullmore also says, “Voltaire and Molière filled theatres with their dark comedies about medical buffoonery” (Loc 1243). Bullmore is laying himself open to similar treatment from a modern satirist.

Taking the Independent MHA Review forward

Akiko Hart has a MIA blog post about the interim report of the Independent Review of the Mental Health Act (see eg. previous post). As she says, it may be difficult to see how changing legislation in itself could necessarily address rising detention rates and racial disparities in detention.

The interim report is disappointing because it does not specifically mention institutional racism (see previous post). Nor is reference made to the rights-based report of the UN Special Rapporteur, which takes into account the Convention on the Rights of People with Disabilities (CRPD) (see previous post). It’s also difficult to know what the interim report means when it says “We are  not  persuaded that CTOs [Community Treatment Orders] should  remain in their current form“, when CTOs probably should never have been introduced in the first place.

What is central is the dignity and respect of detained patients. The Independent Review has heard plenty of evidence of unacceptable, including abusive, treatment. The interim report does not specifically mention the Mental Health Act Commission (MHAC), whose functions have been taken over by the Care Quality Commission (CQC). Its statutory responsibility is to interview detained patients and investigate their unsatisfactorily dealt with complaints, as well as deal with any other complaints in relation to detained patients. I guess it could be said that CQC has not been fulfilling this statutory function and changes need to be made.