The nonsense of reductionism in psychiatry

Konstantinos Fountoulakis (who I've mentioned before, see eg. previous post) argues in an Acta Psychiatrica Scandinavica editorial that anti-reductionism in psychiatry is unscientific. He thinks the unavoidable consequence of the argument against reductionism is the affirmation of a "supernatural (divine or paranormal) source of additional properties". The line of reasoning of anti-reductionism from his point of view leads to a "creator with an intelligent plan". 

Even though this view is nonsense, I'm sure many psychiatrists are sympathetic to it. This situation shows how much psychiatry is still trapped in the history of conflict between Cartesianism and vitalism (see eg. previous post). Rather than go along with the stark binary opposition of Fountoulakis between reductionism and believing in a "creator with an intelligent plan", I think it makes more sense to concede that the relation between mind and matter is an enigma that can never be solved (see eg. previous post). Intentionality and directedness is part of the nature of life, not something external to life. Neuronal processes are not meaning making and lack intentionality, so can only mediate intentional acts as part of an overall life process (see eg. previous post). It is absurd to expect to be able to explain life in terms of merely mechanical principles of nature (see eg. another previous post). This situation doesn't justify belief in a supernatural external force. Even Stahl's vitalism did not posit a transcendent soul. Stahl’s anima was an immaterial ordering principle of movement within physiology. Of course I'm not defending vitalism; merely indicating the bizarre way in which Fountoulakis polarises the debate about reductionism. Anti-reductionism can still be a valid explanation without ontological implications (see another previous post). Fontoulakis should accept that our relationship to ourselves is irreducibly ambiguous (see eg. previous post).

Fountoulakis reinforces his argument for minimising the role of the environment in mental disorders by pointing to "the universality of mental disorder manifestations, with only a few culturally bound syndromes of questionable validity". Actually, it is important to recognise the extent to which psychiatric diagnosis is a cultural judgement (see previous post). Fountoulakis questions the WHO cross-national research which is commonly seen as having found a better outcome for schizophrenia in developing countries in comparison with developed ones. Nonetheless, it is important not to minimise the considerable differences in the presentation of psychosis in different countries. 

Fountoulakis says without reference: "Beyond doubt, there is a minority of patients which under strict double-blind placebo-controlled conditions respond absolutely perfectly to medication treatment". He goes on to conclude, "For these patients, there is no doubt that their mental illness can be completely reduced to neurobiological dysfunction." I'm presuming his degree of certainty comes from his own experience, but we do need to see some evidence. I think the lack of references for these claims is telling. Fountoulakis makes clear that if a position like this is not generalisable that his fear is again that it introduces "some kind of supernatural process" into the origins of mental disorder. He actually thinks psychiatrists are "too much psychosocially rather than biomedically inclined". He blames what he calls “'violent' deinstitutionalization since the 1960s" for the current deterioration in the condition of mental health patients who are being deprived of their rights to biomedical treatment. His defence of the biomedical model seems rather desperate. 

Of course, there are organic brain effects, but, despite what Fountoulakis implies, there are also functional mental disorders without biological abnormality (see eg. previous post). He does not seem to accept what he calls a “modified bio-psychosocial model” that sees mental illness as having a “basic neurobiological etiopathogenesis ... shaped by psychological, social, and cultural factors”. I too have difficulties with such an eclectic approach (see last post) but Fountoulakis seems to prefer a radical reductionistic point of view. The brain of course mediates mental illness, but although people may find it difficult to accept the lack of any neurobiological determination of functional mental disorder, such a view is not as “off the wall” as Fountoulakis makes out.

Understanding the biopsychosocial model

Rebecca Roache (who I’ve mentioned before eg. see previous post) in her two chapters of her co-edited book Psychiatry reborn: Biopsychosocial psychiatry in modern medicine considers the implication of viewing Engel’s biopsychosocial model as a Kuhnian paradigm (see previous post referencing Kuhn’s The structure of scientific revolutions). As she points out, there is a dichtomy between understanding (Verstehen) and explanation (Erklären). I tend to prefer the terms used by Thomas Fuchs: personalistic vs naturalistic (see previous post) as two ways of looking at the body. Basically, first and second person narratives provide understanding, and third person narratives attempt explanation in terms of brain processes. 

As Rebecca Roache points out, we need to apply psychosocial concepts to understand mental illness, which is contingent on the person having certain sorts of subjective experience. In this way it differs from physical illness. Psychiatric disorders do not stand or fall with the presence or absence of biological pathology, whereas physical diseases do. Psychological or behavioural considerations in fact cannot be eliminated in characterising mental disorders. Rebecca Roache suggests we should therefore be “cautious in hoping for biological characterizations of mental illness”. I would go further in suggesting it is a mistake to do so (see eg. previous post). At least Rebecca Roache agrees that “it is unrealistic to hope that a purely biological account of mental disorder is possible”. 

As far as the biopsychosocial model is concerned, Rebecca Roache concludes, “Psychological and social explanations are not eliminable in favour of (that is, reducible to) biological ones, largely because of the way that mental illnesses are conceived and diagnosed.” I think this is the message that Engel was trying to convey in promoting his biopsychosocial model. The problem is that this meaning has been lost in eclectic accounts of what ‘biopsychosocial’ means (see eg. previous post).

As Rebecca Roache says in her other chapter in the book, this eclecticism “often involves little more than an acknowledgement that biological, psychological, and social factors are all relevant to understanding mental illness”. As she goes on, in one sense this is “so obvious as to be trivial”. The implication is that psychiatrists often say that the causes of mental illness are multifactorial. Rebecca Roache picks up Kenneth Kendler’s use of the term ‘dappled’ in this respect, although Kendler in fact does not see his empirically based pluralism as being the same as Engel’s biopsychosocial approach (see previous post). 

As Rebecca Roache indicates, it is far from clear that Engel is taking an eclectic position. In fact, I do not think he does (see eg. previous post). I agree with her that his account can be improved, particularly when it has been so often misunderstood as eclectic (see another previous post). I have mentioned that Sanneke de Haan has criticised the biopsychosocial model for being vague about how the biological, psychological and social interact (see eg. previous post). I think her description of enactive psychiatry, seeing mental illness as abnormal sense-making (see another previous post), can help to flesh out the biopsychosocial model. I also think Thomas Fuchs ecological approach to understanding the brain (see eg. previous post) can do the same. Engel himself noted that his biopsychosocial approach links to Adolf Meyer’s Psychobiology (see eg. previous post and my article). I’m sure Engel’s biopsychosocial model can be enriched by accounts such as these. But we first need to understand it as a non-eclectic model, a mistake which I think came about because of psychiatry’s response to so-called anti-psychiatry (see eg. previous post).