Paradigms of Psychiatry: Eclecticism and Its Discontents

Seyyed Nassir Ghaemi

Disclosures

Curr Opin Psychiatry. 2006;19(6):619-624. 

In This Article

The Biopsychosocial Model: Anything Goes?

Without doubt, the primary paradigm of contemporary psychiatry is the biopsychosocial (BPS) model. Historically, it grew out of the internecine conflicts between biological reductionism and psychoanalytic orthodoxy that characterized most of the 20th century. I have discussed this evolution in some detail elsewhere.[2] The roots of this model can be traced to the 'psychobiology' of Adolf Meyer (1866-1950), longtime chairman of the Johns Hopkins Department of Psychiatry. In Meyer's theory, mental illness was seen as an interaction between constitution and environment in which the key role, and the only treatable one, was that of environment. Instead of biological disease terminology, Meyer spoke of 'reactions.'

After Meyer, Grinker (1900-1993),[3] longtime chairman of the Michael Reese Department of Psychiatry in Chicago, can be seen as perhaps the leading thinker in this model. Roy Grinker, being one of Freud's last analysands, had been trained not only in psycyhoanalysis but also in neurology and was an active clinical researcher whose empirical studies focused on the impact of war trauma on soldiers. He was highly critical of the orthodox evolution of the American Psychoanalytic Association and organized a rival group. For years, as the editor of the Archives of General Psychiatry, he had a major impact. He coined the term 'biopsychosocial' and emphasized its link to the then popular biological paradigm of 'general systems theory', a holistic view that saw reductionism as unscientific and that emphasized that the whole of a biological system is greater than its parts and that indeed no part could be understood except in relation to the whole.[4]

The BPS model is most commonly associated with the work of George Engel, who was a contemporary of Grinker. Engel more formally espoused the BPS model in contrast to 'biomedical reductionism'; as a medical internist, Engel did so for all of medicine though he had most impact within psychiatry. Many reasons exist, beyond the scope of this review, for the popularity of Engel's theory after the publication of influential papers by him in Science in 1977[5] and in the American Journal of Psychiatry in 1980.[6] It is perhaps not entirely coincidental, however, that Engel's main psychiatric paper was published in the same year as the publication of Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III). Around 1980, psychoanalytic orthodoxy was clearly in the decline and biological psychiatry in the ascendant (both in the revival of Kraepelinian nosology and with the rise of the new psychopharmacology). The BPS can be seen as a cease-fire between the two groups, one that was especially beneficial for the psychoanalytic/psychotherapy paradigms in that it provided an ongoing rationale for their practice in response to the rising strength of the biological paradigm.[7]

In recent years, the BPS model continues to be seen as mainstream in American psychiatry.[8*] Oral interviews for the US boards are generally approached by dividing a case into three BPS components and saying something about each. Doing this, an applicant will likely pass; if an applicant focuses only on one approach (e.g., a completely biological assessment of a case), he will likely fail. Yet, leaders of American psychiatry have also been decrying a perceived decline in the influence of the BPS model.[9] In 2005, the newly elected president of the American Psychiatric Association, Steven Sharfstein, received much positive feedback when he stated in his presidential address: 'We have let the biopsychosocial model become the bio-bio-model.' Sharfstein[10] went on to lay much of the blame at the feet of the pharmaceutical industry, which many view as pushing biological paradigms so as to sell their drugs.

While such comments assume that the BPS model is a perfectly fine paradigm that is simply being ignored or misapplied, a minority has also begun to express the view that the BPS model itself may be partly at fault.[2,7,11,12**] The main critique here is that the BPS model is excessively broad, trying to be everything to everyone. The BPS model has essentially degenerated, in this view, to an extreme eclecticism, whereby anything goes. This is a scientific analogy, in a way, to theoretical relativism, where no viewpoint can be seen as definitively correct or incorrect. Although this open-mindedness is better than dogmatism, it fails to answer the important questions models should answer and thus fails to provide adequate guidance to the field. A vacuum is then created, of which interested parties (such as the pharmaceutical industry) can take advantage.

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