A Critique of the Biopsychosocial Model in Psychiatry

biopsychosocial model in psychiatry

The biopsychosocial model is one of the main approaches in psychiatry. The psychiatrist George Engel formulated this model in 1977, in a paper titled ‘The Need for a New Medical Model: A Challenge for Biomedicine’, published in the journal Science. He did not, however, propose this new model exclusively for psychiatry (which focuses on the treatment of mental disorders) but as a way to understand all medical conditions. Engel repudiated the mainstream biomedical model that sought to understand medical conditions – including psychiatric disorders – only in terms of biological factors (e.g. mental disorders are brain disorders or symptoms of imbalanced brain chemistry), and consequently should be treated solely through medical means.

This model now pervades mainstream views of health, in general, with the World Health Organization (WHO) defining health as an overall state of health on the biological, psychological, and social levels.

Replacing the Biomedical Model With the Biopsychosocial Model

Engel proposed that a new model is needed, which he called the biopsychosocial model, to take into account psychological and social factors in a person’s medical condition. This novel model incorporates, as we can see, three dimensions: the biological (physical pathology, genetics, and physical health), the psychological (thoughts, emotions, and behaviours; such as psychological distress, fear-avoidance beliefs, self-esteem, and coping mechanisms), and the social (socioeconomic, environmental, and cultural factors; including family circumstances and peers). It is an interdisciplinary model that sees these three dimensions as interconnected.

Indeed, it is wise to view mental illness through a more integrative lens; the biomedical model, which focuses only on biochemistry and physiology, seems myopic and reductive in comparison. Social, cultural, emotional, and psychological factors play a critical role in mental health conditions – and by ignoring these, we will fail to fully understand – and be able to adequately treat – people experiencing extreme psychological distress.

In spite of the assumption that all psychiatrists operate under the assumption of the biomedical model, the biopsychosocial model is, in fact, the mainstream ideology of contemporary psychiatry; it has been underpinning standard psychiatric practice, all around the world, for the past 40 years. The biomedical model is still prominent, of course, evidenced by the fact that a great deal of psychiatric research and treatment, and mainstream explanations of mental illness still rely on biomedical thinking (e.g. contrary to claims that psychiatry has never promoted the debunked chemical imbalance hypothesis, which reduces mental illness to imbalances in brain chemistry, the American Psychiatric Association and many top psychiatrists have, in fact, been promoting the idea).

The biopsychososcial model appears helpful in reconciling biological psychiatry – which operates under the biomedical model and views mental disorders as the result of faulty biology – with the psychodynamic perspective, which prioritises the psychological aspects of maladaptive thinking, feeling, acting, and relating. However, while the biopsychosocial model may seem, on the face of things, to be more valuable and sensible for its more holistic approach, it is also flawed in many ways.

The Flaws of the Biopsychosocial Model in Psychiatry

In The Rise and Fall of the Biopsychosocial Model (2010), the psychiatrist Nassir Ghaemi argues that “…the BPS [biopsychosocial] model has never been a scientific model or even a philosophically coherent model. It was a slogan whose ultimate basis was eclecticism.” This model does include more perspectives than the biomedical model, which should better represent the highly complex reality of the individual, but Ghaemi propounds that the model promotes eclecticism for its own sake and that such eclecticism (the philosophy of ‘more is better’) gives a false impression of sophistication. He points out that biological reductionism is not always wrong and that – contrary to the biopsychosocial intuition that medication and psychotherapy combined is always better than either one alone – using one treatment on its own can often produce better results than using multiple approaches together.

Gregg Henriques, a professor of psychology at James Madison University, also highlights this critique:

One of the most generally cited problems with the BPS model is that its inclusiveness results in an unscientific, “fluffy,” pluralistic approach where, in the words of the dodo bird in Alice in Wonderland, all perspectives have won and deserve prizes.

There’s also an issue in trying to clearly define the terms ‘biological’, ‘psychological’, and ‘social’, their boundaries, and their interrelationships. Some consider the boundaries between the three artificial. As Henriques asks:

…consider the question of, what, exactly, is the relationship between biology and psychology? That is, where does biology end and psychology begin? What about the relationship between psychology and behavior—are they the same thing or different? Moving up a level, where does psychology meet the social? Is a family of bonobos a psychological or a social level entity? What about a human family living in Canada?

The biopsychosocial model does not appear, in itself, to provide any clear answers to these sorts of questions. It assumes an interrelationship between the biological, psychological, and social without advancing how they relate to each other. In line with Henriques’ critique, it also considers these three aspects of equal importance, but why should this be so? Could one dimension not have – in general – more explanatory power than another one? The model is somewhat vague and overly simple in viewing these three dimensions as having the same importance in every situation and for every individual. Are there not specific contexts in which one dimension warrants greater focus than another?

Furthermore, with numerous biological, psychological, and social factors provided in the explanation of mental illness, it seems it would be difficult to decide which factors of each grouping should be appraised. What methods should psychiatrists use to select factors out of so many possible options? Psychiatrists simply cannot examine every possible factor in every dimension. This would be practically impossible. One problem with the biopsychosocial model is thus pragmatic in nature. By having to consider so many different factors, psychiatric treatment could be delayed or become confused. Henriques states:

Medical doctors have so much to learn as is. If knowledge expectations and training become too diffuse, then expertise will inevitably suffer. It is worth noting here that the general trend in medicine has been toward specialization, not in broadening one’s perspective.

These pragmatic issues can also make it difficult to teach the model to psychiatry students. And not all students will be convinced of the credibility and usefulness of the threefold-approach. Then there is a deeper philosophical issue with the model. Henrique underscores that philosophical physicalists “believe that biological, psychological and social levels of analysis are either epiphenomenal or can be fully reduced to the physical,” and from this point of view, the biopsychosocial model is ultimately reducible to the biomedical model. The psychotherapist (and critic of psychiatry) James Barnes argues the biopsychosocial model has advantages over the biomedical model but stresses it has not achieved much progress, precisely because of this issue of the former being reducible to the latter. He writes:

The chief intended purpose of the term ‘biopsychosocial’ is to assert that unlike in the biomedical era ‘social causes’ are now permitted a place in the causal chains that psychiatry sees as leading to its ‘mental disorders.’ And it is true, psychiatry has indeed conceded such a causal role for some time now. To be fair, there is also an increasing emphasis on discussing social factors. But when one understands what the ‘social’ means in this context, the continuing allegiance to biomedical explanation becomes clear.

For a model that purports to integrate social experiences, it is very strange that their lived, meaningful dimensions and idiosyncratic character are absent from the causal explanations. The ‘social’ in biopsychosocial in fact only features in terms of external ‘triggers’ or’ stressors.’ So, when it is claimed that the model accounts for the social world of the person, what is meant is that it acknowledges external pressures that contribute to otherwise biologically determined processes. The actual personal, meaning-pervaded social experiences we are all immersed in are, as such, irrelevant to the model, or at least without any causal efficacy. A ‘social cause’ within this model is simply a quantity of external force on the biological system, which is then where the disorder is located and expressed.

While admitting a causal role to social factors is of course an improvement on the purely biomedical model, if that role is limited to a position in a causal chain that leads inexorably to biological processes, then we have not moved past the biomedical model in any meaningful way. We have just stretched it out a bit. While the biopsychosocial model is not pure biological reductionism or determinism, we are nevertheless talking about experiences that are only relevant in their effect on biological processes which then determine the ‘disorder.’ It is these processes that remain the focus — the main treatments (e.g. drugs, ECT) have remained the same — evidencing the supposed incorporation of the social world is nothing of the sort. The actual meaningful dimensions of our social experience remain absent from the explanations and, as result, from the primary interventions.

Defenders of the model, however, believe that these criticisms can be resolved, so that the model can be salvaged. The psychiatrist Ronald W. Pies, for instance, has reformulated the biopsychosocial model in the following way:

Simply stated, the biopsychosocial (BPS) paradigm, as I conceive it, asserts that most (but not necessarily all) serious mental disorders are best understood as having a variety of causes and risk factors–including but not necessarily limited to biological, psychological and social components. (Dr Michael McGee has also emphasized the importance of the spiritual dimension in the origin and treatment of addictions and other psychiatric conditions, arguing for a “bio-psychosocialspiritual” approach)

As I conceive it, the BPS paradigm does not assert that all psychiatric disorders are, like ancient Gaul, divided into three parts: a biological, a psychological, and a social component. Nor does the paradigm assert “tripartite causation” for all or most diseases, though Engel’s 1977 paper briefly alludes to “the role of psychosocial variables in disease causation.” However, the BPS paradigm does encourage the clinician, heuristically, to investigate whether a particular disorder may arise from some combination of these factors; and, if so, whether the condition merits treatment in all three spheres-which will likely not be the case for all psychiatric illnesses.

The BPS paradigm imposes no need to solve the ancient “mind-body” conundrum that has bedeviled philosophy for millennia (eg, “What is the mind? Is it distinct from brain? How does mind interact with the brain?). Those issues, though philosophically important, are at a different epistemic level than that of the BPS paradigm.

Is There a Better Alternative?

There are many alternative models to the biopsychosocial one, but which one is preferable? Barnes is justified in bringing attention to the lived, meaningful dimension of our experiences, as this phenomenological perspective on mental illness is often left out in psychiatry. How can we truly understand and help an individual’s distress without taking into account – and respecting – how their subjective experiences are entangled with their suffering? According to Ghaemi, modern psychiatry will only advance by taking seriously the phenomenological outlook, by seeking to accurately describe a patient’s inner and outer experiences from their first-person point of view.

An alternative model of mental illness should take into account the subjectivity of the individual in a non-reductionist manner. In fact, some researchers, such as Peter Stilwell and Katherine Harman, have proposed that pain should also be understood in this way; the “subjectively lived body” must be considered, a dimension that the biopsychosocial outlook leaves out. One influential psychiatrist who imported this phenomenological approach into psychiatry was Karl Jaspers, who presented an approach that Ghaemi calls “method-based psychiatry”. Jaspers saw two main methods in psychiatry: the objective/empirical and the subjective/interpretive, but he did not posit one method as inherently superior to the other. As Ghaemi puts it:

Rather than advocating one or the other method, Jaspers called for methodological consciousness: we need to be aware of what methods we use, their strengths and limitations, and why we use them. Dogmatists hold that one method is sufficient, biopsychosocial eclectics that methods should always be combined, Jaspers that (depending on the condition) sometimes one, sometimes another, method is best.

Ghaemi references another alternative model, promoted by the Canadian physician William Osler, which he describes as a “medical humanist model”. This approach modernises the Hippocratic approach to illness – it argues a physician should treat illness in a biomedically reductionist way while also attending to the human being who has the illness. “This approach (which captures the Hippocratic aim: to cure sometimes, to heal often, to console always), has all the strengths and none of the weaknesses of the biopsychosocial model,” says Ghaemi. For Osler, medicine was an art based on science. It’s not purely an art, and not purely a science, but a combination of the two. Engel, conversely, rejected this notion of medicine as art. He rejected Osler’s view that physicians should learn about human beings from the humanities, such as through literature and poetry. For this reason, Engel’s biopsychosocial model is anti-humanistic.

There are clearly other scales of explanation to bear in mind when thinking about human distress. Personal meaning and values matter, too. Yet given the complexity of factors involved in mental disorder, will there be any one approach that psychiatrists can practically employ when seeing and treating patients? Does every psychiatrist also need to be an adept philosopher, sociologist, and anthropologist? Or at least have some essential understanding of these disciplines?

Returning to Henriques’ criticisms levelled against the biopsychosocial model, demanding that psychiatrists (or any physician) in training and in practice be well-versed in several disciplines seems unreasonable. Perhaps a more down-to-earth and humble perspective should recognise that no profession (and no practitioner within any profession) can possibly have all the answers to illness. Many perspectives, experts, and specialisations are needed, as is the wisdom in recognising which approaches to apply to individual cases. Jaspers’ more flexible approach to psychiatry at least provides a useful conceptual framework for thinking about human well-being. Issues tend to arise when we perceive a single approach as a panacea, as universally and categorically superior to all others.

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