Paradigms of Psychiatry: Eclecticism and Its Discontents

Seyyed Nassir Ghaemi

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

Abstract and Introduction

Abstract

Purpose of review: To assess paradigms of psychiatry, assessing their strengths and limitations.
Recent findings: The biopsychosocial model, and eclecticism in general, serves as the primary paradigm of mainstream contemporary psychiatry. In the past few decades, the biopsychosocial model served as a cease-fire between the biological and psychoanalytic extremism that characterized much of the 19th and 20th century history of psychiatry. Despite being broad and fostering an 'anything goes' mentality, it fails to provide much guidance as a model. In recent years, the biological school has gained prominence and now is under attack from many quarters. Critics tend toward dogmatism themselves, usually of postmodernist or libertarian varieties. Three alternate approaches include pragmatism, integrationism, and pluralism. Pluralism, as technically defined here based on the work of Karl Jaspers, rejects or accepts different methods but holds that some methods are better than others for specific circumstances or conditions.
Summary: The compromise paradigm of biopsychosocial eclecticism has failed to sufficiently guide contemporary psychiatry. The concurrent revival of the biological model has led to postmodernist counter-reactions which, though valid in many specifics, promise to replace one ideological dogma with another. New paradigms are needed.

Introduction

Kuhn[1] coined the term paradigm to denote the conceptual structure within which scientific work occurs. All scientific observation is conditioned by preexisting theories or assumptions, according to Kuhn. A paradigm is the sum of those underlying assumptions. Major changes in science happen when the underlying assumptions of a paradigm are thrown into doubt.

Theories and models can either be specific, in which case they are often hypotheses that function within a paradigm, or more general, in which case they can approximate what Kuhn had in mind.

Kuhn felt that the role of paradigms was to provide a coherent overall structure in which specific observations, hypotheses, and theories could exist. In the case of psychiatry, we would expect paradigms or general models to provide information about the following nonexhaustive list: the nature of mental illness, the structure of the mind, the relation of mind to brain, the relation of mental illness to physical illness, the relation of mental illness to society, the nature of mental states and psychological concepts, definitions of specific mental pathologies, the cause of those pathologies, the course of those pathologies, treatments for those pathologies, an ethical framework for practitioners who treat mental illness, guidance on how to cope with mental illnesses for those who have them, guidance regarding how to provide resources to research mental illness, guidance regarding how to conduct research on mental illness, and information to guide politicians and the public regarding creating laws related to mental illness.

Obviously no paradigm can meet all these needs, but an assessment of them should be taken into account.

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.

Biological Psychiatry: Are We Nothing But a Bag of Enzymes?

The biological paradigm in psychiatry follows the traditional biomedical model, seeing severe mental illness as due to pathology in the organ of the brain. This approach can be taken reductionistically, as in a classic paper by Guze.[13] More commonly, however, biological psychiatrists affirm a biopsychosocial eclecticism, yet focus on the biological aspects of mental illness. A marked asymmetry in research and practice has, nonetheless, occurred in the past two decades, whereby far more funding, publication, and practice are given to biological/pharmacological than to psychosocial approaches.[14*] This reality has been criticized, but potential solutions are generally not offered besides returning to, or better applying, the BPS.[9] The fact that this biological reductionist reality has occurred despite mainstream acceptance of the BPS is often left unexplored.

Psychoanalysis: A Kinder, Gentler Freud

Psychoanalytic extremism or orthodoxy is now rather rare. Yet the negative consequences of a half-century stranglehold of this dogmatism on psychiatry, especially in the USA, can hardly be underestimated. The lifework of the late Paul Roazen[15] provides great insight into the tragic flaws of psychoanalytic orthodoxy, as well as its sometimes under-appreciated merits. Today, most psychoanalytic groups adhere to the BPS and tend to be eclectic,[16*] with multiple subtypes of psychoanalysis being acceptable to all, rather than the past experience of insistence on a pure Freudian variety by mainstream leaders in this group.[17] The limits of the 'anything goes' nature of eclecticism have also been raised among psychoanalysts.[16*]

Reactions Against Biology: Postmodernist, Antipsychiatry, Libertarian, Anticapitalist, and Recovery-oriented Views

Postmodernist interpretations of psychiatry have focused on the power structures that underlie the practice of psychiatry. The most famous of these interpretations can be found in the work of Foucault.[18] Other predecessors, often grouped in the term 'antipsychiatry', include Laing[19] and Szasz.[20] While not overtly rejecting the concept of mental illness, as does Szasz,[20] many of the views of the antipsychiatry movement have been reformulated by contemporary critics. Recent works in this vein have included the writings of Healy[21,22*] who has argued that a 'corporate psychiatry' has developed, heavily influenced by the pharmaceutical industry. A recent editorial along these lines was published in the British Journal of Psychiatry by Moncrieff,[23**] arguing that modern psychiatry has become a handmaiden to conservative (or 'neoliberal' in the British context) political commitments. Treating the unhappiness of the masses, which derives from poverty and racism and other socio-political causes, as if they are biological entities, not only diverts the masses from the real causes of their discontent but also enriches capitalist entities directly (i.e., the pharmaceutical and insurance companies). A particularly influential paper[24] in the UK rephrased this movement in the concept of 'postpsychiatry', with a consequent rise in a group of psychiatrists formed around a 'Critical Psychiatry' Web site (http://www.critpsynet.freeuk.com ). A recent book[25*] seeks to extend this perspective to American psychiatry.

While 'critical psychiatry' represents the reaction of some psychiatrists to the failures of biopsychosocial eclecticism, the patient advocacy movement has begun to coalesce around the 'recovery' movement, deriving from the 12-step approach to behavior.[26**] In this perspective, the goal is full recovery: a complete return to normal mental and physical states, whereby one relinquishes the role of being a patient and resumes simply being a person. The medical model of simply alleviating symptoms is not enough. Recovery requires the active involvement of the person with the illness and not simply passively receiving medical care from professionals. The recovery movement has implied that the psychiatric profession has not appreciated, and thus not sufficiently abetted, the ability of persons with mental illness to get well. Though implicitly critical of mainstream psychiatry, this approach has garnered support from many community psychiatrists,[27**] as well as the leadership of the American Psychiatric Association.[28*] It has also appealed to many in less medically based professions, such as social work, as well as groups generally critical of psychiatry. Ironically, it also received a stamp of approval from the George W. Bush administration's New Freedom Commission on Mental Health (www.mentalhealthcommission.gov ). Apparently, a libertarian philosophy of self-help and thus less need for provision of medical care appealed to American political conservatives. American conservatives and British left-oriented critics appear to agree on a critique of the biological paradigm in psychiatry and on a need for more individual liberties in relation to mental healthcare. This alliance of extremes is surprising and powerful, putting biological paradigms in psychiatry on the defensive. Yet it is not unprecedented; in fact, as recent historical scholarship has shown, antipsychiatry movements have existed for at least 100 years, beginning in Germany in the late 19th century.[29] At that time, too, critiques of mainstream psychiatry came from both left-wing and right-wing perspectives. This observation suggests that it is not political ideology per se that drives these critiques of psychiatry, but rather other factors.

The fact that power, economics, and politics permeates society is as old as Aristotle and as recent as Marx. Hence, these aspects of the postmodernist/semi-socialist critique are, in my view, relatively valid. The reduction of mental illness entirely to social constructs, however, is another matter. To be fair, not all of these critics (e.g. Healy) engage in this kind of postmodernist dogmatism but many do. As McHugh[12**] once wrote, it is sufficient to interview and treat a person with schizophrenia over time to realize that postmodernist dogmas are one-sided. E. O. Wilson, pointing out the nihilism of postmodern extremism, commented: 'Scientists, being held responsible for what they say, have not found postmodernism useful'.[30] Nonetheless, ideas have consequences, and postmodernist critiques likely have had both positive and negative consequences: positive in opposing the biological reductionism and capitalist ethos of much of the mainstream psychiatry, and negative in providing, at times, a simplistic alternative that probably adds to the suffering of many people. Clearly there are limitations to science, and science is influenced by socio-political factors; yet this does not invalidate science. Dennett[30] draws this distinction: 'The irony is that these fruits of scientific reflection, showing us the ineliminable smudges of imperfection, are sometimes used by those who are suspicious of science as their grounds for denying it a privileged status in the truth-seeking department - as if the institutions and practices they see competing with it were no worse off in these regards. But where are the examples of religious orthodoxy being simply abandoned in the face of irresistible evidence? Again and again in science, yesterday's heresies have become today's new orthodoxies. No religion exhibits that pattern in its history'. A major danger exists in replacing science, properly understood in all its limitations, with any ideology - be it postmodern, postpsychiatry, antipsychiatry, recovery-oriented, libertarian, anticapitalist, or procapitalist. My own perspective is that any kind of dogmatism, or belief that one perspective has a monopoly on knowledge, is bound to fail in psychiatry, and that dogmatisms of left and right are similar. The problem is how to reject dogmatism while also avoiding the pitfall of eclecticism.

'Darwinian' or Evolutionary Psychiatry: The Science of Everything

Another paradigm involves the application of evolutionary theory to psychiatry, popularized in a text called Darwinian psychiatry.[31] In this approach, mental illness is seen as the outgrowth of the misapplication of mental states initially adapted to the caveman era (evolutionary environment of adaptation [EEA]), which is now dysfunctional in modern civilization. Implications of this hypothesis are drawn for our diagnoses as well as treatments.[32*] For instance, depression can be seen as a plea for help or a means of inducing others to help one because of the passive, helpless stance of the depressed person.[33] Although there are advantages of the application of Darwinian methods to any field,[34] a dogmatic application of this paradigm also would tend to induce some skepticism in those committed to scientific methods. For instance, as Popper[35] long ago demonstrated, evolutionary theory is not a scientific theory that can be assessed properly on the refutation standard, as it cannot be refuted. This leads to the uncomfortable fact that the theory can be twisted to fit any data, a hallmark of the vagaries of other dogmas such as psychoanalytic orthodoxy.

Pragmatism: Being Useful

Pragmatism in psychiatry is often promoted, sometimes by those who use the term colloquially, rather than in the more rigorous philosophical usage. In the latter case, however, this approach often means the willingness to test theories by their results, letting the observed data drive theorizing rather than the reverse. It can mean following James'[36] approach of an insistence on open-mindedness and unwillingness to accept any single system of thought, or it can mean an adherence to Pierce's[37] concept of the community of investigators gradually getting closer and closer to the truth but never perceiving the absolute truth (antipositivism). It also often involves an appreciation for the role of values in human experience and the need to avoid being excessively positivistic and objectively oriented in empirical and clinical work.[38] It finally can mean a utilitarianism of method, seeking to combine different methods based on pragmatic ends and value judgments.[39*]

Although a philosophically rigorous pragmatism has many strengths, including the important virtue of avoiding dogmatism, it can also be excessively loose, seeking to combine methods based on individual whims or preferences, in a manner that can make it quite similar to extreme eclecticism.

Integrationism: The Search for a Single Explanatory Model

Most humans want a single explanation for many things. Indeed, this is a hallmark of classic scientific thought: Occam's razor would pull together many observations in one theory. Thus, the search to integrate different paradigms or methods, to find the underlying theory that would pull it all together, has been a constant in psychiatric history. Where Freud and Kraepelin failed in their dogmatic approaches, modern integrationists seek to succeed by being more flexible. Perhaps the most famous current attempt is that of Kandel,[40] a Nobel prize winning scientist and psychiatrist. Kandel argues that work on conditioned learning in aplysia suggests that the environment can alter brain structure and thus demonstrates the two-way nature of brain/environment interaction. Thus, at some level we should be able to demonstrate what changes in the brain happen with environmental changes (such as psychotherapy); this would then provide a neuroscientific justification for psychotherapies, even psychoanalysis. An approach to such work, called 'neuropsychoanalysis', has been developed.[41]

Although intriguing in principle, there is a long way from aplysia to humans. Kandel may have shown that such translational work might be feasible in principle, but one wonders whether it ever will be practically feasible at the higher order level cognitions of humans, not to mention the complex states of psychopathology.

Pluralism: Neither Eclectic nor Dogmatic

A final paradigm is pluralism, which is often confused with eclecticism. The paradigmatic thinker in this approach is Karl Jaspers,[42] about whom I have written in great detail elsewhere.[2] The basic idea here is that no single paradigm can explain all of psychiatry; no dogma is sufficient. Combining all methods on whatever grounds (pragmatic or otherwise) is, however, barely a step forward; more is not better. Anything goes is not sufficient; sometimes some things go, and other times other things go. Unlike eclecticism, there is a truth to the matter and a reason to argue for a certain method in some circumstances but not others.

Thus, pluralism agrees with eclectic paradigms by rejecting any one paradigm as sufficient; yet it also rejects eclecticism as too confused and watered-down. In the pluralist model, each method or paradigm has strengths and weaknesses, and that method or paradigm is best which has the most number of strengths and fewest limitations for the subject under scrutiny. For example, in the case of a primarily biological disease like schizophrenia, the postmodernist paradigm applied purely is simply wrong; the biological paradigm is most effective and appropriate (though again, all paradigms have limitations). For posttraumatic stress disorder in poverty-stricken inner cities, however, the social/political approach is perhaps the strongest, whereas the biological approach explains little. Simply adding approaches does not always necessarily explain more or takes one closer to the truth, although sometimes this may be the case. Examples of works along these lines include that of McHugh and Slavney, Havens, and other recent efforts.[2,43,44**,45] Jaspers[42] proposed two basic methods to psychiatry: Erklären (causal explanation) versus Verstehen (meaningful understanding); McHugh and Slavney identify four perspectives (disease-related, dimensional, behavioral, and on life story); and Havens describes four schools (objective-descriptive, psychoanalytic, existential, interpersonal). These pluralist models give coherence to the varieties of psychiatry, allowing space for different methods while providing a rationale for the use of certain methods versus others in specific conditions or circumstances. Pluralism offers a perspective that can allow us to get beyond our current confused eclecticism, while also rejecting dogmatisms of any kind, be they biological, psychoanalytic, or postmodernist.

Unfortunately, pluralist models have not been as popular as other alternatives. William James once commented that for a philosophy to become popular it must tap into some deep inner need of humanity. The continuing popularity of dogmatism (even in its postmodernist incarnations) speaks to the human wish for easy answers to life's complex problems. Eclecticism is the next simplest alternative, a road of little resistance that allows one to avoid having to think hard about the dilemmas of psychiatry. Pluralism requires a willingness to commit oneself to specific methods while remaining flexible about methods in general. It is, in fact, identical to scientific method, which is a difficult vocation. In the technical definition provided here, it is rarely practiced. Yet one can hope that, as with the progress of science in general, easy but wrong answers will eventually give way to recognition of the conceptual clarity and practical benefits of the pluralist paradigm.

Conclusion

Clearly, biological dogmatism, now resurgent, is under attack from many quarters. Psychoanalytic orthodoxy is defeated, yet psychoanalysis, in softer form, persists. The BPS model, and eclecticism in general, has served as a cease-fire, which has allowed the profession to subsist in the past few decades, yet clearly there is unhappiness with the predominance of biological methods. Unfortunately critics of the biological paradigm tend toward dogmatism themselves, usually of postmodernist or libertarian varieties. Thinkers who have tried to rise beyond eclecticism while rejecting postmodernist dogmas have tended toward three approaches: pragmatism, which tends toward eclecticism with similar drawbacks experienced with the BPS model; integrationism, which is appealing in theory but quite limited in practice; and pluralism. In my view, the pluralist approach can allow us to avoid the vagaries of eclecticism and rise beyond the simple-minded dogmas that have been, and continue to be, the bane of true progress in this complex discipline.