Saturday, February 20, 2021

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).


Richard Gipps said...

Hi Duncan. I found much to agree with here.

Yet I didn't grasp why you say that "third person narratives attempt explanation in terms of brain processes". "Third person" is typically 's/he' rather than 'I' or 'you' or 'they'. We say 'She is going to the shops', 'he is getting on my nerves', etc., and in this way deploy a fully personalistic idiom.

Also, I'm not yet sure I'm with you on the sense in which mental, as opposed to ordinary, illness requires the application of psychosocial concepts. You suggest that this is because mental illness is 'contingent on the person having certain sorts of subjective experience'. So, it seems to me that both ordinary and mental illness essentially involve subjective experience: discomfort, pain, distress, angst, etc. Ordinary illness is, after all, not the same as mere disease (which can be ascribed to someone independently of their subjective experience). Perhaps, though, you mean that genuine mental illness is that which must not only be described, but also *accounted for*, by reference to psychosocial matters? If so then I think I agree with you; I would just say, though, that those who have tried to move the concept of mental illness away from the psychosocial context - so that it could in theory arise not only from reactions to life experience, but simply endogenously, would not agree.

Looking through some of your blog posts I find various accounts of what Engel's biopsychosocial model isn't. Is there one which you could point to, or another text online, which tells us more about what it is?

DBDouble said...

Thanks, Richard. Third person is 'it' as well as 's/he'. Thanks for your clarification. What I'm pointing to what Martin Buber called the attitudes of I-Thou and I-it.

I also agree that illness is an experience. Thanks again for your clarification. Of course this was what Engel was emphasising. Mental illness is of course mediated by the brain. But that does not mean that there is a biological abnormality in the brain. I agree a lot of people find this position difficult to accept.

I think my best post that describes what Engel actually said is Rebecca Roache has actually read what he wrote but to my mind does not go far enough in describing its implications. I'm sure I'm not expressing myself very well, but I'm not sure how to make my position clearer. Perhaps the blog posts need to be brought together into a published article.

Richard Gipps said...

Thanks Duncan. Now I understand better I'm with you on all of this. The 2020/11 blog post does indeed make it clearer.