The need for a new medical model: A challenge for biomedicine

At the end of the last post, I said that George Engel did not define the biopsychosocial model in the eclectic way in which it tends to be used in modern psychiatry. In his seminal article in Science, he proposed his biopsychosocial model as a new medical model to challenge biomedicine. The biopsychosocial model is not only a challenge for psychiatry, but also for medicine in general. I'm not convinced people have often even read Engel's paper when they discuss the biopsychosocial model.

As I said in my article, 

The appeal of Engel’s model was its critique of biomedical reductionism. In his original paper, Engel talked about neutralizing “the dogmatism of biomedicine” (p. 135). He commented on the enormous investment in diagnostic and therapeutic technology that emphasizes “the impersonal and the mechanical” (p. 135). He quoted from Holman (1976),  who argued that:

[T]he Medical establishment is not primarily engaged in the disinterested pursuit of knowledge and the translation of that knowledge into medical practice; rather in significant part it is engaged in special interest advocacy, pursuing and preserving social power (quoted on p. 135).

Engel acknowledged the interest in the biopsychosocial model amongst a minority of medical teachers, but also emphasized the difficulties in overcoming the power of the prevailing biomedical structure.

As Engel explained, “medicine's crisis derives from the same basic fault as psychiatry's” (p.129). By defining disease in terms of somatic parameters, physicians can make the incorrect inference that they "need not be concerned with psychosocial issues which lie outside medicine's responsibility and authority” (p.129). Medicine has tried to correct this imbalance over recent years by attempting to make its training and practice more patient-centred. It hasn’t always been very successful in this aim and medicine still needs to be rethought in the way suggested by Engel (see eg. post on my personal blog). Healthcare has corrupted its mission and still needs to change (see another post on my personal blog).

Historically there have been various culturally derived belief systems about illness and disease. It wasn't so long ago that people in the West still believed in humoural explanations of illness (see eg. previous post). As Engel pointed out, "the biomedical model is now the dominant folk model of disease in the Western world" (p.130). However, even within the West there is still much take up of alternative and complementary medicine. Nor have traditional indigenous views globally been completely colonised by biomedicine (see previous post). 

The problem with trying to conceptualise mental health problems as physical disease is that it leads to polarised positions between biomedical reductionism and a stance which argues that ‘mental health problems should not be seen as illness’. Representatives of the latter view, which Engel called ‘exclusionist’, would be Thomas Szasz (see eg. previous post), Lucy Johnstone (see another previous post) and Peter Kinderman (see eg. yet another previous post). There have even been these Szaszian tendencies within the Critical Psychiatry Network (see eg. previous post). 

As Engel said, “the reductionists are the true believers, the exclusionists are the apostates” (p.130). But, in fact, both biomedical reductionists and the Szaszian position are wrong, as illness is not so much a physical disease as a "person-centered, harmful, and undesirable deviation or discontinuity . . . associated with impairment or discomfort" (p.130 of Engel paper, quoting from Fabrega, 1975). A technical distinction is made in the literature between illness as an experience and disease as physical pathology. In these terms, mental illness should not be reduced to physical brain disease (see eg. my Lancet Psychiatry letter).

Illness is most frequently first identified by people having symptoms or noticing signs. Building on the dissection of the body in medieval Europe, the Cartesian view of disease as the breakdown of the bodily machine did not take an organismic view. This more wholistic viewpoint in fact tended to take an equally erroneous vitalist perspective (see eg. previous post). In the nineteenth century, the application of the anatomoclinical method, relating signs and symptoms to physical pathology, was remarkably successful. But as Engel said, "at a cost" (p.131). From his point of view, “We are now faced with the necessity and the challenge to broaden the approach to disease to include the psychosocial without sacrificing the enormous advantages of the biomedical approach” (p.131).

People may have underlying disease which hasn’t yet presented with symptoms and signs. Furthermore, patients need to be interviewed by doctors to understand their presentation. Broader socioeconomic conditions may well be important. Psychosocial factors determine even whether patients present to doctors. How patients react to treatment options can also affect outcome. The doctor-patient relationship itself is a powerful factor in treatment. All of these factors are outside a narrow biomedical framework which Engel called the “requirements of a new medical model” (p.131).

As Engel said, medicine has to “take into account the patient, the social context in which he lives, and the complementary system devised by society to deal with the disruptive effects of illness, that is, the physician role and the health care system” (p.132). The boundaries between health and disease are not absolute and both patients and doctors can have views about what counts as the sick role. It is patients and doctors, as far as possible together, that determine what should be regarded as illness/disease.

Debate about models of mental health problems

As Anne Cooke et al (2019) say in their article, "There is considerable debate about the nature and causes of ... 'mental health problems', and therefore about the best way/s to intervene". They juxtapose the frameworks of the 'medical model' and the 'psychosocial model' and point out that there have been attempts to create an intermediate 'biopsychosocial model'.

I think the debate is more complex than this polarisation may suggest. The article defines the 'medical model' as denoting "the idea that mental health problems are best understood as 'illnesses like any other'". Even though there may be people that define and apply the 'medical model' in this way, I think most people do recognise a difference between mental and physical illness. Again, some people may want to minimise the difference between mental and neurological illness (eg. see previous post), but psychiatry is a separate speciality from neurology. The reason for this is that the two specialities deal with different kinds of medical problems. Those that want to work towards merging neurology and psychiatry at least realise we have not got there yet.

The article references Mary Boyle to define the 'psychosocial model' as a "framework that removes biology from the position of privilege in favour of a focus on the relational, interpersonal and social contexts of distress". This is fundamental to a critique of the biomedical model in that we need psychosocial explanations of mental health problems rather than reducing such problems to brain disease (see eg. previous post). 

What worries me is the way the 'biopsychosocial model' is seen as a way of reconciling the 'medical model' and 'psychosocial model' in the senses defined by the article. Engel's biopsychosocial model is is fact the same as the article defines as the 'psychosocial model' (see eg. previous post). True, the people that the article references in relation to the definition of the 'biopsychosocial model', such as Allen Frances (see eg. previous post) and Robin Murray (see eg. another previous post), do use the term in an eclectic way. But this was not what Engel meant.

Changing the medium of psychiatry to relations

Dumas-Mallett and Gonon (2020) helpfully summarise the bias in biomedical psychiatric research. They also describe how these misrepresentations are spread through the mass media and call for the public to receive correct information.

The trouble is that they do not want to go as far as questioning biological psychiatry per se. That's what's really needed to make progress. Biomedical psychiatry holds out the attractions of a predictive and systematic way of understanding and treating mental health problems. No wonder people hope it may be true and psychiatrists act as though we have got there, or at least are not far away from it.

But as the article says we're being misled. It’s not only the message that is wrong but also the expectation about what can be achieved. Do we really think we can solve the problem of consciousness (see previous post), or more generally how life originates from inanimate matter? As Kant said, this is an insight which is denied to us (see another previous post). 

But that doesn't mean that psychiatry is defunct. It should never have had such fanciful notions. Nonetheless people still need understanding and treatment for their mental health problems.

Psychiatry has the wrong biology

Daniel Nicholson (who I’ve mentioned before eg. see previous post) has a paper on ‘Is the cell really a machine?'. As he says, "The conventional mechanical, reductionistic, and deterministic view is gradually giving way to an understanding of the cell that emphasizes its fluidity, plasticity, and stochasticity." Human cognition also needs to be understood in this dynamic, integrated, enactive way as it is embodied in the brain and the body more generally, and embedded in the environment, which is social and cultural, affording various possibilities of action to the person (see eg. previous post).

We need to move on from a mechanistic approach to life in general, including human life, to a more interpretative one (eg. see previous post). The advantage of seeing life as self-organising is that its plasticity is acknowledged without neglecting its ongoing stability (see another previous post). Cells and bodies are not well-defined structures but actually stabilised processes. What persists over time are their form not their matter. As David Nicholson says, “Cells are empirically revealing themselves to be inherently dynamic, self-organizing systems that respond stochastically and nonlinearly to environmental stimuli.” Cells and life in general are not determined spatiotemporal arrangements (see eg. previous post). 

Psychiatry needs to take on board this need for a more dynamic biology, not only for clinical practice but also for research (see eg. previous post). The physical disease model of mental illness is outdated because of progress in understanding not only in human cognition, but also more fundamentally about life processes (see another previous post). 

Psychiatry deconstructs itself, wow!

I made a serious attempt in a previous post to deconstruct the American Psychiatric Association in how it presented itself at an annual meeting. Actually I'd already realised (in another previous post) that Stephen Stahl and his NEI Psychopharm had done the job of hilariously self-deconstructing psychiatry, however undeliberate, in its series of videos. Unfortunately the congress opener for the 2011 NEI Global Psychopharmacology Congress that I mentioned in that post seems to have been taken down. As far as I can remember it had Stephen Stahl dancing in it. Anyway, you can laugh at the more recent 2019 NEI Congress Opener. And you can still see Stahl starring and dancing in this video about DSM-5.

More seriously, Stahl explains that he had to take Psychiatra-Gain to deal with the boredom he was feeling in working with patients (see another video). This created his Alice in Wonderland worldview (see video). It leads to trying out lots of medications on patients in a fun way (see video), although the original psychotropics are still the best (see another video). Thank goodness someone at least is taking psychiatry seriously.

The violence of psychiatry

I've said before (see eg. tweet) that it's not surprising psychiatry is controversial when it has the power to detain people against their will on the basis of their health or safety or for the protection of others because of mental disorder, which are criteria that are bound to be open to interpretation. It is the dominance of the biomedical model in psychiatry that causes problems. The criteria in mental health legislation that allow coercive treatment are too wide to prevent abuse (see previous post). The UK government is currently producing a White paper for reform of the Mental Health Act but almost certainly will not go far enough - at least initially - to preserve the dignity and respect of detained patients (see eg. another previous post). There does need to be a campaign to stop psychiatric abuse (see yet another previous post).

More generally psychiatry's tendency to reduce people to objects means that its practices are too restrictive and not therapeutic enough. This tendency has increased over recent years with the overemphasis on risk. Community care has become as bureaucratic at times as the worst institutional practices of the asylum. 

My hope is that the government will produce a green paper to discuss these issues more widely, but I suspect it will go straight to a White paper because of the independent review led by Simon Wessely. There needs to be renewed debate about these issues, as it has been paused by the coronavirus pandemic. My personal hobby horse has been that detained people should have a right to a second medical and non-medical opinion of their choice. Both detention and treatment decisions should be adjudicated by a single judge in the Mental Health Tribunal (doing away with the need for medical and lay members). Second Opinion Approved Doctors (SOADs) will also no longer be needed and anyway have tended to become a 'rubber-stamping’ exercise. The Mental Health Act arm of the Care Quality Commission needs to be given the specific responsibility of preserving the dignity and respect of detained patients. Its role in maintaining basic human rights needs to be reinforced.

(With thanks to a tweet from @Heather28258253)

Embarrassing use of the term ‘anti-psychiatry’

I’ve mentioned before (eg. see last post) that it was David Cooper that first used the term ‘anti-psychiatry’. Adrian Chapman has an interesting article about him. He references a Guardian piece by David Gale, who saw Cooper for therapy for 4 years. 

As Chapman says, “Cooper overreached [himself]”. This is, I think, a rather generous assessment of what happened to Cooper’s anti-psychiatry, which as RD Laing said became rather embarrassing. Chapman also notes that Adrian Laing, the son of RD Laing, in his biography of his father says there was only ever one anti-psychiatrist. That was David Cooper. Those that still use the term ‘anti-psychiatry’ generally don’t mean Cooper when they use the term. Instead they are usually trying to denigrate criticisms of psychiatry (see eg. previous post).

It’s also rather outrageous to include classic works like Erving Goffman’s Asylums and Michel Foucault’s History of Madness within a denigratory use of the work ‘anti-psychiatry’ (see another previous post). As I’ve said before, I think people should stop using the term. It was a historical phase that psychiatry went through, which actually was not as negative as is commonly made out. Psychiatry needs to learn to take on board criticisms of its tendencies to reductionism and positivism.