Monday, September 30, 2019

Foundations of the biopsychosocial model

Derek Bolton is giving a series of colloquia on Engel's biopsychosocial model, based on his book with Grant Gillett (ebook freely available, and references below taken from it). Gillett and he recognise the need for the biopsychosocial model in the light of "historical prejudices against psychosocial causation deriving from physical reductionism and dualism" (loc 132). Nonetheless, they seem to accept criticism of the model by authors, such as Nassir Ghaemi in The rise and fall of the biopsychosocial model, that its eclecticism makes it "vague, useless and even incoherent" (loc 132).

I have myself reviewed Ghaemi's book (see review and response from Ghaemi and my reply). It critiques psychiatric eclecticism and in my view wrongly blames this on Engel's biopsychosocial model. Ghaemi is correct to note the contribution of Roy Grinker, who appreciated the relevance of general systems theory to psychiatry (see my article). Engel suggested that systems theory provided a suitable conceptual basis for his biopsychosocial model. Bolton & Gillett think this is "fundamentally the right way to go" (loc 563). But they seem unaware that Engel's biopsychosocial model is not responsible for the eclecticism in psychiatry.

As I've said before (see eg. previous post), the real origin of the eclectic view in psychiatry is Anthony Clare's response to anti-psychiatry. As Bolton & Gillett say:
The way Ghaemi tells the story ... [is that] the biopsychosocial model arose in the context of competing general views about illness, favouring one or other of the social, the psychological/psychoanalytic and the biological. ... Ghaemi interprets the biopsychosocial model as an elegant ... solution to these ideological conflicts ... [as] if all participants won, [as] if they were not really in opposition at all, but were in fact all true general accounts of illness and healthcare in all aspects. (loc 237)
This was what Clare argued, not Engel. Clare wanted to avoid the ideological conflict created by anti-psychiatry and proposed eclecticism as a way forward.

Bolton & Gillett do realise that "this line of thought [ie. eclecticism] is not apparent in Engel's main papers" (loc 237). In some of Engel's other papers, he does make the general comment that biological, psychological and social must all be taken into account. Misuse of this statement by Ghaemi to mean that all three are more or less equally relevant in all cases and at all times, seems to convince Bolton & Gillett that Ghaemi has a valid point.

As I’ve said (see eg. my editorial and previous post), Engel’s original paper was in fact written to counter Ludwig (1975), who recommended a retreat to a rigid biomedical model in the face of the onslaught of anti-psychiatry. In the same year as Engel, Manschrek & Kleinman (1977) similarly argued for a critical rationality to replace the hubris (dogmatic biomedical) and semi-critical (eclectic) positions in psychiatry (see previous post).

I'm not convinced that Bolton & Gillett have fully appreciated this context. Engel was aware of the success of biomedicine in explaining physical diseases. As a psychosomatic physician, he was also mindful that many presentations to doctors do not necessarily have an underlying physical disease. He wasn't retreating to vagueness, but accepting of the uncertainties of medicine and psychiatry. I, too, have reviewed the book on Biopsychosocial medicine edited by Peter White (see my review), which Bolton & Gillett reference by quoting from The Lancet review of that book by McManus (2005). As McManus notes, "the broader view [of biopsychosocial medicine] is seen by biomedicine as irredeemably soft, with no clear methodology, measurement, or experimental manipulation". This isn't a reason for dismissing the psychosocial nature of some patient complaints; nor for having a negative assessment of Engel's biopsychosocial model.

Bolton & Gillett try to meet the challenges to the biopsychosocial model by suggesting that it needs to be made "specific to particular health conditions" (loc 456). From their point of view, Engel's biopsychosocial model is not really a general model, and this explains its vagueness. I'm not against looking at examples and specifics, but I don't think this is an adequate reason for undermining the generality of Engel's model. Bolton & Gillett do recognise the connection between patient-centred medicine (see previous post) and the biopsychosocial model and the centrality of this element for Engel (loc 2707). An integrated understanding of the whole person is required for all medical conditions.

Bolton & Gillett suggest that the foundational theoretical constructs of the biopsychosocial model need rethinking and reconceptualising. Again, I'm not convinced this is necessary as such, although I recognise there is a need to develop the biopsychosocial model as a philosophical and scientific theory of health, disease and healthcare. This is the strength of Bolton & Gillett's book. For example, they argue that information processing theory has moved biology on from understanding causes as merely physico-chemical. There is some truth to this view and Bolton & Gillett are correct that psychiatry should not be dualist or vitalist (see previous post). However, the mechanistic perspective remains pervasive in biology. Biology still needs to move onto a processual, organismic philosophy (see previous post), in the same way as indicated by Engel.

Bolton & Gillett argue against physicalism. Persons do need to be understood as biological processes. An integrated biopsychosocial model studies people within the framework of biology. A mechanistic conception of nature fails to provide a complete characterisation of living systems (see previous post). We need a new organismic biological perspective to enrich the integrated mind-brain understanding promoted by Engel for medical and psychiatric practice.

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